A STUDY ON THE ESTABLISH AND EVALUATION OF ADULT DAY CARE SERVICE CENTERS Jui-Ying Hung, Chao-yang University of Technology

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1 GLOBAL JOURNAL OF BUSINESS RESEARCH VOLUE 6 NUBER A STUDY ON THE ESTABLISH AND EVALUATION OF ADULT DAY CARE SERVICE CENTERS Ju-Yng Hung, Chao-yang Unversty of Technology ABSTRACT The purpose of ths paper s to ad n plannng for the provson of adult welfare and care servces, and to ensure that strateges are n place to effectvely cope wth the agng socety. Ths nvestgaton ams to revew an operatng assessment system for the executon of long-term care wthn Nantou County, Republc of Chna. Based on theoretcal consderatons and a herarchcal model of perspectves, the Balanced Score Card (BSC), was used to evaluate management. We also used a fuzzy Delph method, and a Fuzzy Analytc Herarchy Process (FAHP), to assess nonproft organzatons whch manage senor day care centers. The model ncludes fnancal, customer, nternal busness process, and learnng and growth perspectves. The results show the level of mportance of the perspectves was: Internal busness process perspectves; Customer perspectves; Learnng and growth perspectves; and Fnancal perspectves. The performance assessment system provdes an accurate representaton when used to assess long-term care servces. The varous ndcators can gude organzatons to contnuously mprove ther servces, n order to provde the best possble servce for the adults. JEL: I; L3 KEYWORDS: Adult Day Care Servce Center, Balance Score Card, Fuzzy Delph ethod, Fuzzy Analytc Herarchy Process INTRODUCTION A ccordng to fgures released by the statstcs department of the nstry of the Interor (OI), as of the end of 200 Tawan had over 24.8 mllon people older than 65 years. Ths equates to 0.74% of the total populaton. Executve Yuan of the Councl for Economc Plannng and Development (CEPD) forecasts 4,98,000 ctzens aged over 65 by 2026, equatng to 20.90% of the total forecast populaton at that tme (Department of Health, nstry of the Interor, Economc Plannng and Development, Facng an ageng populaton, the Tawanese government has actvely promoted health care strateges ncludng a plot program for the development of long-term care systems, the new century health care plan, the aged ntensve care servce, the plan for the development of the care-servces and welfare ndustry, and a ten-year plan for long-term care n Tawan. In addton, the government s devoted to establshng a complete long-term care system, to plan for the welfare of the elderly, and to satsfyng the welfare needs of the elderly, ncludng caterng to ther probable future needs. The ageng populaton trend s common to many countres. The Unted Natons proposed ther Proclamaton on Ageng n early 99, dsclosng 5 unversal prncples that elderly should have access to: ndependence, partcpaton, care, self-fulfllment, and dgnty. They declared 999 the Internatonal Year of Older Persons, n apprehenson of world natons adaptng to the needs of elderly people. In addton the WTO proposed an actve ageng polcy framework, defnng actve ageng as provdng the greatest chance of health, socal partcpaton, and socal securty durng the ageng process so as to enhance Qualty of Lfe (QOL) n old age (World Health Organzaton, 2002). A polcy framework proposed by the WHO, shown n Fgure, suggests that an actve ageng polcy should be bult upon the three pllars of health, partcpaton and securty. In addton to fosterng the mental health of ndvduals and ther connecton to socety, all plans and polces possess an mportant goal of prolongng the healthy lfe expectancy of ndvduals, and mantanng good QOL durng the ageng process. 9

2 JY. Hung GJBR Vol. 6 No Fgure : Polcy Framework of Actve Ageng Actve Ageng Partcpaton Health Securty Ths fgure sows the polcy framework of actve ageng from World Health Organzaton n Resource: World Health Organzaton, 2002 The government needs to ensure that ther polcy management encompasses supply, demand and management aspects to ensure the elderly receve an actve and frendly servce envronment. In order to combat the currently nsuffcent and dmnshng staffng levels, the use of communty resources to jontly promote welfare servces has become a popular strategy(hsu, 998), whch s also the prmary method beng utlzed to promote the Ten-Year Plan for Long-term Care n Tawan. However, the lack of competton n partal markets, where welfare servces are entrely prvatzed, reduces the consumer s choce and results n operatonal rsks. Ths leads to a stuaton where the government s requred to create standards for the management of welfare servces to ensure ther qualty. As a result, prvate organzatons must adapt to these standards to obtan approval to supply welfare servces. Ths results n the need for a cooperatve model between the government and the prvate provders for the delvery of welfare servces. Inevtably, ths system wll lead to challenges for both government and prvate organzatons. Experence n the executon of welfare servces, an understandng of the nsuffcency of the current system, and a wllngness to mprove upon the current system are not only closely assocated wth the topc of servce qualty, but are also elements whch should gude partnershps between prvate and publc sectors, and the case for utlzng a passve or habtual use of the exstng performance management system. Therefore, the government should use nspectons for practcal operatons, and effectvely utlze performance revews for any changes n the general natonal envronment ncludng poltcs, economcs, socety and technology. In addton they should propose related mprovement measures, and assst under-performng organzatons to maxmze socal welfare for all ctzens whle usng the least resources. Utlzng emprcal research of adult day care centers, ths study ams frstly to revew the current stuaton of long-term care executon wthn Nantou County from a supply and demand perspectve. Ths wll enable dscussons surroundng performance evaluaton ndcators for such centers. We also am to apply a performance management tool, the Balanced Scorecard (BSC), to consoldate the executon process and trends for future development. Secondly, due to lmted government resources, the outsourcng of evaluatons has become more popular. There s an ongong dscusson surroundng the best methods of performance evaluaton n the socal servce feld. Whle performance evaluaton s an mperatve tool to ensure government effectveness for those who support prvatzaton, t s also an mportant tool to ensure socal rghts for advocates of socal democracy. Performance evaluaton must be connected wth both servce targets and servce demand. Balancng varous performance ndcators from the perspectves of the publc, expertse, organzatons, and poltcs requres government nput. The benefts of day care servces for the elderly can serve as a reference for the mprovement of government admnstraton, and ts outsourcng process. Therefore, the purpose of ths study can be summarzed to analyze and establsh performance evaluaton ndcators for adult day care centers. 20

3 GLOBAL JOURNAL OF BUSINESS RESEARCH VOLUE 6 NUBER LITERATURE REVIEW The type of care that a partcular care servce ndustry provdes can vary sgnfcantly. There are many terms used to descrbe the dfferent ndustres, such as long-term care, communty care, home care, day care, or respte care. Accordng to Yeates (2005), care s defned as the provson of socal and health care servces by ether a prvate or publc servce, whch can be pad or unpad. Accordng to ths defnton, t s not smply caterng, cleanng, ronng, and mantenance of household affars. Ths defnton s generalzed, and s not lmted to elderly ctzens. In addton, whle lvng assstance and nursng care s essental, t cannot replace or mmc the care-gvng abltes of famly members, such as the physcal contact and long-term close nteracton that they generally provde. The provson of care s a servce ndustry, and whle an ndvdual may be able to experence the qualty of servce, t s dffcult to detect poor servce, due to ts ntangblty. oreover, the heterogenety of avalable servces sets the care servce ndustry apart from other servce ndustres. Accordng to both Yang (2009) and Zhuang (2008), the care servce ndustry has the followng characterstcs:.) It has a hgh degree of customer contact. Unlke standardzed products, n the provson of elderly care the formaton, contents and mode of delvery vares wth the ndvdual s needs, and therefore a hgh degree of contact s requred to enable a suffcent understandng of ther preferences. 2.) There s a need for customer partcpaton n the servce offerng. Consumers of products are not usually nvolved n the producton process, and ther prmary concerns are the product s cost and value. Conversely, elderly people and ther relatves are normally nvolved n talorng care to the ndvdual, ncludng the selecton of a servce, ts contents, and the draftng of a care plan. 3.) There s dffculty n servce and performance standardzaton. The demands and requrements of servce vary wth the ndvdual, whch has led to dffcultes n both standardzng the care servce ndustry, and n the measurement of performance and qualty of servce. It s dffcult to judge whch provders are more effcent and whch provde superor servce qualty, whch has caused ssues n the management and supervson of such servces. 4.) It s not possble to pre-produce servces. Unlke the provson of goods, there can be no pre-producton n the servce ndustry, as the servce and producton happen smultaneously. Ths causes dffcultes n capacty management. 5.) It s labor ntensve. Unlke automated producton seen n the manufacturng ndustry, the care servce ndustry s labor ntensve. Servces largely need to be provded by people, and cannot be mass produced. As such, a reducton n staff, equpment, or costs can often lead to a reducton n qualty. 6.) There s a relatvely hgh degree of rsk. The recpents of care are nvarably weak or vulnerable. Ths means that when offerng home based care, whch s usually n a prvate settng, there s an ncreased rsk of complants. It s dffcult for the care-gver to defend themselves aganst these complants. Ths s especally true of llegal actons or msunderstandngs between careers and care recpents. 7.) There s a publc cultural beneft to ther provson. Care servces to the elderly are not smply the provson of essental servces, there also needs to be some attenton gven to ther cultural and socal needs. Ths ncludes servce phlosophy, and the creaton culture specfc strateges, whch can enhance customer satsfacton n a more natural way. Day Care Currently, long-term servce organzatons are categorzed nto nursng homes, nursng, mantenance, and long-term care. Care methods can be categorzed as: home care, communty care, and nsttutonal care, all of whch form a contnuum between care and comprehensve care, varyng by age, health, and dependence as can be seen n Fgure 2. The scope of communty care ncludes home based care, day care, and caterng servces. Accordng to current regulatons, day care s consdered a form of socal care, as opposed to nursng homes, nursng, and communty care. 2

4 JY. Hung GJBR Vol. 6 No Fgure 2: Long-term Care odels Insttutonal care Communty care Famly care Acute medcal hosptals Long-term chronc nursng nsttutons Home servce, day care and caterng servce Home care, home nursng Ths fgure shows the long-term servce organzaton categorzed from department of health n Tawan. Source: Department of Health, nstry of the Interor, Economc Plannng and Development(2009) Day care servce s normally provded durng the day n fxed locatons, wth recpents usually returnng home durng the nght, or sometmes to respte care. The servces provded vary between professonal and sem-professonal provders. Day care servces can nclude recreaton, caterng, transportaton, nursng, health promoton, occupaton competency language rehabltaton, and memory retenton therapy. These servces not only releve the pressure and burdens on prmary caregvers, but also enable socal nteracton, whch some researchers beleve s ts bggest advantage (Hooyman and Kyak, 2008). Prmary care gvers can then contnue workng (Crewe and Chpungu, 2006). Dependng on the specfc provder, day care and nursng centers can be dvded nto 3 types(naleppa, 2004).) Socal-based where the socety-based day care center manly provdes socal contact, creatve classes, educatonal actvtes, caterng, nutrton management, and other such servces. 2.) The medcal-based day care center manly provdes nursng, medcal care, and servces such as physcal therapy or occupatonal therapy. 3.) The hybrd-based day care center provdes a mxture of the two above day care center types. In the Ten-Year Plan for Long-term Care n Tawan t was stated that centers wll be categorzed by servces offered. Those governed by socal admnstratve unts wll be termed day nursng centers (Crewe and Chpungu, 2006). The ten year plan mostly deals wth the management of dsabled people, whle day care centers usually deal wth a more dverse range of patents who can be categorzed by ther care needs under the terms dsabled, health, and comprehensve. The term dsabled s used to descrbe people who requre help wth more than two actvtes of daly lvng (ADL), and the term comprehensve s used to descrbe people who requre help wth one or more ADL. Currently, day care centers establshed domestcally are mostly socety based, ncludng prvate communty carng centers, whch are operated by communty groups and communty development assocatons and are hghly advocated by the OI, and day care centers. Day care centers under the commsson of varous cty or county governments use communty or unt volunteers to provde care, and health care professonals to plan the educatonal and recreatonal actvtes for those patents who are relatvely healthy. These centers usually operate at hours whch sut the needs of the patents and ther care plans, whch usually concde wth normal workng hours. These centers allow patents to engage n actvtes and educatonal sessons whch deal wth strateges to reduce the mpact of ageng, and provde an opportunty for socalzaton. In addton, some centers engage volunteers to conduct phone calls and home vsts, to allow for those who cannot be present at the center to receve the same care. Case background- Adult Day Care Center n Nantou Country As of the end of 200, Nantou County reported a populaton of 7,366 people over 65 years of age, comprsng 3.56% of the total populaton. Ths s hgher than the natonal average, of 0.74%. Nantou County has the fourth largest populaton of ctzens aged over 65 n the Republc of Chna (ROC). Owng to the hgh rato of the ageng populaton n Nantou County, t s mportant to provde an effectve welfare 22

5 GLOBAL JOURNAL OF BUSINESS RESEARCH VOLUE 6 NUBER delvery system. As such, snce 2000 there has been a tral of adult day care centers n three centers n Nantou County. These tral centers provde daytme lfe care servces, programs to recover functons, nursng and health care servces, educatonal sessons, counselng, caterng, and recreaton actvtes. These centers target ctzens aged over 65 who resde n Nantou County(Sun, Xao, Zhang, Kuo, and Hung, 2009), and who have a physcal or mental health problem, but are stll able to care for themselves. In recent years, the Nantou government has contnuously commssoned the establshment of multple day care communty centers and day care centers to educate the elderly on dsease preventon and health promoton, and to provde support and socalzaton to renforce health, socal partcpaton, and securty, all of whch further enhance ther QOL. The current performance revew program for these day care centers, run by the Socal Welfare Dvson of the Nantou County government, ncludes evaluatons of the admnstratve management, lfe care servces, caterng servces, exercse programs for functon recovery, nursng and health care servces, educatonal sessons, counselng servces, staff qualfcatons, staff tranng and job requrements, strategc and nnovatve management, ntegraton of communty resources, and satsfacton surveys. The satsfacton surveys cover 28 evaluaton tems. Balance Scorecard(BSC) Performance ndcators, usually derved from prvate enterprse, are generally used to evaluate the actvtes of an organzaton so that organzatonal performance can be supervsed(challs, Clarkson and Warburton, 2006). Kaplan and Norton (999) jontly announced The Balanced Scorecard: easures that Drve Performance n the Harvard Busness Revew, whch has aroused attenton from varous crcles. Fnancal performance s often the key consderaton for an enterprse, whch s true for non-proft organzatons as well. However, there are two major flaws n evaluatng performance management by fnancal means alone:.) research shows that fnancal ndcatons are not good predctors of success, and 2.) t s normal for the current market value of an enterprse to exceed ts market value. Tobn's q-value calculates the rato of company market value to assets, whle addtonal market value can be found from ntangble assets. Fnancal reports do not reflect these assets. As far as future busness performance s concerned, fnancal statstcs are not a partcularly good ndcator. Kaplan and Norton summarzed the three major advantages of the BSC method as:.) t focuses on the most mportant affars of the busness, whch enables other areas to enhance ther value once the key functons are controlled; 2.) t helps busness ntegrate multple project plans, such as qualty versus quantty management, work flow reform, and customer servce plans; and 3. t removes any ambguty from the strategc targets of the organzaton, whch ensures that managers and staff understand the key goals and requrements of the organzaton, and how ther performance wll affect them. The BSC s a tool for strategc plannng, and also a performance management tool whch enables busness to execute ther vson and strateges. Busness performance s measured based on four perspectves: fnancal, customer, nternal busness processes, and learnng and growth. These four perspectves are not nvarable, as, for example, a non-proft organzaton can be evaluated by ther satsfacton of communty needs. The BSC s scored n terms of the followng four observatons for each perspectve:.) the prmary purpose of the organzaton, for example proft or growth; 2.) the parameters whch wll be used to measure the achevement of goals, for example usng net margnal proft growth to measure proft growth; 3.) the targets for achevement, for example a 7% annual reducton rate n dsconnected busness producton; and 4.) oton ndcatng concrete tems or plans whch ensure goals can be realzed. The modern busness reles on the measurement and montorng of performance. easurement methods must relate to busness strateges, and provde nformaton regardng work flow, outcomes and products. There are many possble statstcs, ncludng: customer retenton, product or servce performance, operaton effcency, market poston, comparsons wth competton, suppler prcng, employee satsfacton, cost mnmzaton, and fnance goals. The process of statstcal analyss ncludes utlzng trend analyss to 23

6 JY. Hung GJBR Vol. 6 No precede predcton and other ad hoc analyss. It s mperatve to have correct nformaton, as statstcs and data analyss support many busness actvtes, such as strategy plannng, performance evaluaton, operaton mprovement and performance comparsons wth compettors and benchmarks. ETHODOLOGY Ths study nvestgates the problem of achevng consensus n group decsons when utlzng the fuzzy Delph method (FD) and Fuzzy Analytc Herarchy Process (FAHP) and uses the followng approaches:. The study utlzes FD not only to save money and tme, but also to fathfully represent of group vews, 2. The study utlze FAHP to reverse the program, 3. The study adopts a straghtforward process of buldng fuzzy numbers, 4. The study uses smple procedures to handle mult-level, mult-attrbute and mult-program decson-makng problems. Consequently, ths nvestgaton uses FD and FAHP as a research methodology. The fuzzy theory was proposed by Zadeh(965) at the unversty of Calforna at Berkeley. Dr. Zadeh was of the opnon that tradtonal scentfc methods often gnored the uncertanty and ambguous exstence of human lfe, so he set out to use fuzzy sets theory and adopt the fuzzy logcal concepts to process. Buckley(985) ncorporated the fuzzy set theory nto the tradtonal AHP. FAHP thus became a sutable tool for solvng real-world mult-crtera decson- makng (CD) problems (Buyukozkan, 2004; Huang and Wu, 2005). Ths study ntroduces fuzzy theory nto the Delph method by ntegratng the ponts of vew of many scholars, ncludng Hsu(998) and Chen (997). In order to mprove the problems faced by the tradtonal Delph method, ths study uses the b-trangular fuzzy arthmetc to ntegrate the advce of experts and has then tested the convergence effect recognzed by experts that refers to the gray zone test method. The fuzzy Delph method s establshed by means of the followng steps: Step) Each expert respectvely offers a possble nterval value to each assessed tem. The mnmum value of ths nterval number represents the most conservatve perceved value gven by the expert to the quanttatve score of the assessed tem and the maxmum value represents the most optmstc perceved value gven to the quanttatve score of the assessed tem. Step2) nvolves performng an analyss of the most conservatve and optmstc perceved values gven to each assessed tem by all of the experts. After the extreme values fallng outsde the two tmes the standard devaton are elmnated, the mnmum value C, the L geometrc mean C, and the maxmum value C of the most conservatve perceved value that has not U been elmnated, as well as the mnmum value O, the geometrc mean L O and the maxmum value O U of the most optmstc perceved value are determned. Step3.) Through the foregong steps, the trangular fuzzy number C = ( CL, C, CU ) of the most conservatve perceved value and the trangular fuzzy number O = ( OL, O, OU ) of the most optmstc perceved value of each assessed tem can be establshed. Step 4.) Fnally, the followng methods can be appled to verfy the degree of consensus by experts. In some nstances the Grey Zone does not exst. If C U O, namely, the b-trangular fuzzy number has L no overlap, the nterval values gven by the experts share the common secton. That s the most conservatve perceved values gven by each expert to the assessed tem tend to move towards the secton scope of the trangular fuzzy number of the most conservatve perceved value, and the most optmstc perceved value gven by each expert to the assessed tem tends towards the secton scope of the trangular fuzzy number of the most optmstc perceved value. Ths mples that the most conservatve perceved values and the most optmstc values gven by all of the experts have reached a consensus as far as the assessed tem s concerned. Therefore, the value G regardng the mportance of the degree of consensus of the assessed tem shall equal the mean value of C and O, and ts operatonal formula s seen as follows: 24

7 GLOBAL JOURNAL OF BUSINESS RESEARCH VOLUE 6 NUBER G = ( C + O ) / 2 () In other nstances the Grey Zone exsts, and a small dfference exsts among the experts advce. If C > U O, namely, the b-trangular fuzzy number has an overlap, and when the gray zone of the fuzzy relaton L Z = C - U O s smaller than the nterval value = L O - C between the geometrc mean of the optmstc perceved value and the geometrc mean of the conservatve perceved value gven by the experts to the assessed tem, although the nterval value gven by each expert produces a fuzzy secton, the extreme values gven by some experts do not greatly dffer from the ones gven by the other experts, and so no dfferences and dvergences n terms of the value are caused. Therefore, the value G of the mportance of the degree of consensus of the assessed tem shall equal the fuzzy set F ( χ j ) resultng from the ntersecton (mn) operaton for the gray zone of the fuzzy relaton of the b-trangular fuzzy µ χ owned by number, and the quanttatve score of the maxmum value of the membershp grade ( ) the fuzzy set shall then be fgured out. Its operatonal formulas are seen as follows: ( x ) { [ C ( x ) O ( x )]} F j = mn j, j dx (2) x G χ j µax µ ( χ ) F (3) = j In yet other nstances the Grey Zone exsts, and bg dfferences exst among the experts advce. If C > U O, namely, the b-trangular fuzzy number has an overlap, and when the gray zone of the fuzzy relaton L Z = C - U O s bgger than the nterval value = L O - C between the geometrc mean of the optmstc perceved value and the geometrc mean of the conservatve perceved value gven by the expert to the assessed tem, t means that the nterval value gven by each expert wll be seen to produce a fuzzy secton, and the extreme values gven by some experts greatly dffer from the ones gven by other experts, so dfferences and dvergences n the values are caused. Therefore, the geometrc mean of the optmstc perceved value and the geometrc mean of the conservatve perceved value of the assessed tems that have not reached convergence must be provded for the experts as the references. Then, Steps to 4 shall not be repeated to conduct the next questonnare survey untl all the assessed tems reach convergence, and the value of the mportance of the degree of consensus G s calculated. The hgher the value of the degree of the mportance degree of each tem fgured out respectvely n the foregong paragraphs, the hgher the degree of consensus among the experts t stands for. The arthmetc mean could then be calculated by usng of the geometrc mean of the most lkely sngle value for each tem, and be taken as the threshold value for the research to select a sutable number of assessment crtera featurng the consensus reached by of the experts. In ncorporatng the Fuzzy Theory nto the Analytc Herarchy Process developed by Saaty (980), we evaluate the weght attached to varous assessment crtera and dentfy ther mportance through whch more objectve and reasonable key success factors could be nduced. Ths analytcal process combnes the concepts of several scholars, ncludng Buckley(985), and Hsu (998). It has the advantage n that experts need to fll n only one defnte value when makng pared comparsons, wthout fallng nto the dlemma of not knowng how to specfy the fuzzy number or the need to understand ts defntons. Step) Establsh the Herarchy Structure. Based on the assessment crtera screened out by the Fuzzy Delph ethod and the sequence of the termnal target, secondary target, and assessed tems, the herarchal structure s establshed, and each level has seven elements at most. Step2.) Establsh the F j 25

8 JY. Hung GJBR Vol. 6 No Parwse Comparson atrx. The opnon of expert K at Level L on the relatve mportance of any two assessed tems at Level L+ could be obtaned through the questonnare survey, by whch the parwse comparson matrx A, A = a could be establshed. Step 3.) Establsh the Trangular Fuzzy j Number. Ths study has adopted the geometrc average to represent the consensus of most experts as the model of the trangular fuzzy number. Afterwards, trangular fuzzy numbers were establshed based on the FD to ntegrate experts fuzzy opnons on the relatve mportance of pared elements. It may be expressed as follows: a = ( a j, δ j, γ j ) j L R, α j δ j γ j,, j=,2,n (4) α j = n( B jk ) k =,2,n (5) / n n δ j = B (6) k = jk γ j = ax( B jk ) k =,2,n (7) a j : Trangular fuzzy number α j :nmum from expert counterng the relatve mportance of both of crtera and j δ j :Geometrc average from expert counterng the relatve mportance of both of crtera and j γ j :axmum from expert counterng the relatve mportance of both of crtera and j B jk :Expert K s subjectve opnon on the relatve mportance of attrbutes and j, whch s a defnte value. L R :Fuzzy nterval of trangular fuzzy numbers Step4.) s to establsh a Fuzzy Postve Recprocal atrx. Trangular fuzzy numbers are establshed to express the phenomenon of assessng experts fuzzy opnons. Hence, a fuzzy postve recprocal matrx à could be establshed. a a2 a n A a a2 a22 a = 2n j =,, j =,2, n an an2 ann (8) a a j δ j j j j j (9) Step5.) Fuzzy atrx: à Consstency Verfcaton. We assume A a s a postve recprocal matrx and a = j as well as a = j A s the correspondng fuzzy postve recprocal matrx. Hence, A = j a = j A s consstent,, by whch we can judge the valdty of the questonnares. If experts thnk crteron s more mportant than j, then the fuzzy pared comparsons are: a = ( a, δ, γ ), a, δ, γ {,2,, 9} j j j j j j j,whle (, δ, a ) j = a j = j j j a [,, ], a a, =,2, n j = γ, γ (0) 26

9 GLOBAL JOURNAL OF BUSINESS RESEARCH VOLUE 6 NUBER If experts thnk crtera and j are equally mportant, the fuzzy par wse comparsons are aj (,, ) Step6.) Calculate the Fuzzy Weght of the Fuzzy Postve Recprocal atrx. =. n...,, j =,2, n Z = aj an, () W = Z Z... Z n (2) Z :Geometrc average of trangle fuzzy numbers α α2 ( α α 2, δ δ 2, γ γ 2 ) (3) α α2 ( α + α 2, δ + δ 2, γ + γ 2 ) (4) Z (, δ α ) L R = γ, (5) n a n n a, δ, γ (6) = n Step7.) Defuzzfcaton. Snce the weght of every element and assessed tem s a fuzzy value, the sngle fuzzy weght must be obtaned by the defuzzcaton process. Ths study has adopted the gravty method for defuzzfcaton and t s expressed as follows: Wα + Wδ + Wγ W = (7) 3 W α :the left end fuzzy weght value of trangular fuzzy numbers, namely the mnmum. W δ :the value of the grade of membershp of the trangular fuzzy numbers fuzzy weght whch s. W γ :The rght end fuzzy weght value of trangular fuzzy members, namely the maxmum. W :Convert the fuzzy weght of the trangular fuzzy numbers nto a sngle value. Step8.) Normalty Weght values obtaned are normalzed to compare easly the mportance of varous major structural dmenson crtera and secondary assessment crtera so that ther sum s. The formula for weght normalzaton s as follows: NW = n W = W (8) NW :normalzed weght W :sngle fuzzy weght Establshng a Herarchcal Structure of Performance easurement Indcators for Day Care Centers n Nantou County Ths study evaluates the use of the four major perspectves of the BSC method, fnance, customer, nternal busness flow, and learnng and growth, as a performance ndcator for day centers n Nantou County n The performance evaluaton system s establshed by herarchcal methods, utlzng focus groups, a 27

10 JY. Hung GJBR Vol. 6 No fuzzy Delph, and a fuzzy FAHP appled to varous performance ndcators. Ths study wll comprse of a questonnare targetng desgnated personnel of adult day care centers n Nantou County. The prmary purpose of ths research s to establsh performance measurement ndcators whch can be used to evaluate day care centers. Frst we examne the related performance of domestc and overseas adult day care centers, whch we utlzed n the questonnare desgn through a fuzzy Delph method. We also examne benchmark screenng, to facltate the subsequent emprcal study. Fgure 3 detals the prmary perspectves and the 28 performance evaluaton ndcators whch wll be used n ths study. RESULTS As of 200, there are eght day care centers n Nantou County. Also, due to the vast geographcal sze of Nantou County, the poor transportaton system, and other reasons, these eght centers were dvded nto 6 sub branches, based on organzatonal resources (ncludng HR resources, fundng, market expanson ablty, and other factors. In the frst stage, 5 fuzzy Delph expert questonnares were dstrbuted between February 5 and 27, 20. There were 3 vald questonnares returned representng an effectve response rate of 86.7%. Durng the second stage, a further 3 fuzzy Delph expert questonnares were dstrbuted between arch 7 and 8, 20. There were 2 vald questonnares returned, mplyng an effectve response rate of 92.3%. Ths nvestgaton proposed a program based on the fuzzy Delph operaton model n the statstcal software EXCEL Expert Choce 2000, to calculate the relatve number. Our study utlzed a b-trangle fuzzy number to dentfy evaluaton crtera, and then analyzed the outcomes. We utlzed a threshold value of 7.6, meanng that f the value of G for each crteron exceed 7.6 then they would be retaned. We deleted 9 evaluaton crtera and retaned 9, gvng an effectve rato of 67.86% as shown n Table. Based on the results obtaned durng the frst stage, n the second stage we desgned a FAHP questonnare. We utlzed the retreved questonnares to construct the fuzzy postve recprocal matrx, and used consstency verfcaton to measure the consstency ndex (C.I.) and the consstence rato (C.R.). Next, we calculated the fuzzy weght and normalty weght values of the evaluaton crtera for each concept. Fnally we utlzed these results to rank the mportance of the weghts, and adopted the FAHP analytcal software, run n Expert Choce 2000, to calculate the key judgment values. Statstcs from the Second Stage Questonnare Durng the second stage, a further 30 fuzzy Delph expert questonnares were dstrbuted between Aprl 2 and 3, There were 22 vald questonnares returned, for an effectve response rate of 73.3%. Frstly, a trangle fuzzy number s appled to establsh a fuzzy postve recprocal matrx as shown n Table 2, whch s then regarded as the calculaton base of the fuzzy weght number shown n Table 3. Ths allows us to conduct consstent examnatons of the fuzzy postve recprocal matrx upon the crsp value gven on the expert questonnare. As can be seen n Table 2, the consstent ndcator values are CI=0.07 and CR=0.08, both of whch are wthn an acceptable error range of CI 0.. Therefore, the reports of our expert partcpants show consstency. Accordng to the results of the weght analyss, the level of mportance for the four evaluaton perspectves was: 26% weghted value for nternal busness process, 25.3% weghted value for customer perspectve, 24.7% weghted value for learnng and growth perspectve, and 24% weghted value for fnancal perspectve. The results show, the expert partcpants consdered the nternal busness processes of the day care centers to be subject to fnancal cost control and proper funds management ndcators, servce locaton rsk management ftness, lason and communcaton capabltes, complete supervson management systems, and a focus on developng capabltes wth regards to long-term care polcy n Tawan. Addtonally, the ndcator hghlghts that an emergency medcal referral system must 28

11 GLOBAL JOURNAL OF BUSINESS RESEARCH VOLUE 6 NUBER be establshed for day care centers. The nternal busness process perspectve s more focused on ndcator revews of software elements than operaton management perspectves wthn the organzaton. Fgure 3: The prelmnary Herarchcal Structure Fnancal perspectve. Care beneft (rato of servce recevers and professonals) 2. Reduce operaton cost 3. Renforce marketng functon nsde and outsde the organzaton 4. Increase overall fnancal beneft (ncome ncrease) 5. Dverse products and servce (pcture book of lfe stores of the elderly) developed by organzatons The performance evaluaton ndcators of Nantou County day care center Customer perspectve Internal busness process perspectve Learnng and growth perspectve. Effectve management and applcaton of case studes 2. Regular coachng, trackng and flng of case studes 3. Applcaton dfferentaton of specal case study and ts management by project 4. Internal space and movement desgn plannng n overall 5. Safe and convenent transportaton vehcle and servce plannng 6. The meal-makng envronment comples wth hygene prncple 7. Provde specal case wth dfferentated caterng servce 8. Caterng plannng and counselng provded by professonals (detcans) 9. Provde functon recovery exercse. Complete management system n organzaton 2. Fnancal cost control and funds management 3. Proper rsk management of servce locatons 4. Actvty promoton ablty 5. Communcaton and coordnaton abltes 6. Complete supervson system 7. Establshment of emergency medcal referral system. Servce personnel are all related departments graduated or lcensed practtoners. 2. Servce personnel to regularly take on-the-job tranng and to take part n educaton actvty 3. Cooperate wth government s polcy to provde consultaton of elderly welfare servce welfare servce 4. Provde professonals wth a workng envronment wth good job welfares wthn the organzaton 5. Organzatonal nnovaton plan and ntegraton of communty resource 6. The outcome of servce recever satsfacton and effcacy survey 7. Servce recever complant dealng and feedback mechansm Ths fgure shows the prelmnary herarchcal structure forms from the Fuzzy Delph ethod n ths research. 29

12 JY. Hung GJBR Vol. 6 No Table : Fuzzy Delph Questonnare Analyss Concept Evaluaton crtera The most optmstc perceved values ( O L, O, O U ) Care beneft (rato of servce recevers and professonals) Fnancal perspectve Customer perspectve Internal busness process perspectve Learnng and growth perspectve The most conservatve perceved values ( C L, C, CU ) Geom etrc mean Z Interval value of expert opnon ο 7.6 Reduce operaton cost Renforce nternal & ext. mkt. functon Increase overall fnancal beneft (ncome ncrease) Dverse products and servce (pcture book of lfe stores of the elderly) developed by organzatons Effectve management & applcaton of case studes Regular coachng, trackng and flng of case studes Applcaton dfferentaton of specal case study and ts management by project Internal space and movement desgn plannng n overall Safe and convenent transportaton vehcle and servce plannng The meal-makng envronment comples wth hygene prncple Provde specal case wth dfferentated caterng servce Caterng plannng and counselng provded by professonals (detcans) Provde functon recovery exercse Complete management system n organzaton Fnancal cost control & funds management Proper rsk management of servce locatons Actvty promoton ablty Communcaton and coordnaton abltes Complete supervson system Establshment of emergency medcal referral system Servce personnel are all related departments graduated or lcensed practtoners Servce personnel to regularly take on-the-job tranng and to take part n educaton actvty Cooperate wth government s polcy to provde consultaton of elderly welfare servce welfare servce Provde professonals wth a workng envronment wth good job welfares wthn the organzaton G Organzatonal nnovaton plan and ntegraton of communty resource The outcome of servce recever satsfacton and effcacy survey Servce recever complant dealng and feedback mechansm Threshold value 7.6 Ths table shows the relatve number from the method proposed a program based on the fuzzy Delph operaton model n the statstcal software EXCEL Expert Choce 2000 n ths research. ndcate CU O that experts opnons n the consensus secton, and utlzes L G = (C + O)/2 to calculate. ndcate C U > O, and Z = L C - U O = L O - C that experts opnons not dfference. It mght calculate fuzzy set by mn and get G. Grey-regon ndcates the evaluaton crtera are deleted. 30

13 GLOBAL JOURNAL OF BUSINESS RESEARCH VOLUE 6 NUBER Table 2: Consstency Verfcaton of Prmary Perspectves Fuzzy Postve Recprocal atrx Perspectve Fnancal Perspectve Customer Perspectve Internal Busness Process Perspectve Learnng & Growth Perspectve Fnancal perspectve (.00,.00,,00) (0.,.38,9.00) (0.3,.52,9.00) (0.,.36,8.00) Customer perspectve (0.,0.72,9.09) (.00,.00,.00) (0.,.74,9.00) (0.4,.3,9.00) Internal busness (0.,0.66,7.69) (0.,0.57,9.09) (.00,.00,.00) (0.,0.59,8.00) process perspectve Learnng & growth (0.3,0.74,9.09) (0.,0.76,7.4) (0.3,.69,9.00) (.00,.00,.00) perspectve Ths table shows the consstency verfcaton between the four prmary perspectves. λ max=4.2 C.I.=0.07 C.R.=0.08 Secondly, the customer perspectve should be the hghest prorty, and should nclude the provson of the hghest qualty servce as well as attenton to ndvdual needs. Ths should also nclude the provson of ndvdually managed cases based on each patent s needs, as well as effectve trackng and revew to ensure that ther care remans approprate. Ths may also nclude dfferentated and professonal servces for specal cases. Furthermore, there should be an ablty to delver nutrtous meals, and to educate patents on how to hygencally prepare ther own meals. In addton there should be the provson of convenent and safe transport plannng, and the ablty to provde exercse classes to recover functons. These performance ndcators wll assst the elderly to attan the goal of successful ageng, whch s the key purpose of the day care centers n Nantou County. Importance rankng of Performances Evaluaton Indcators for Day Care Centers n Nantou County We calculated a 0.07 consstency rato herarchy (CRH) that constructs varous performance evaluaton ndcators of Nantou County day care centers, whch s wthn the acceptable range of CRH<0.. Ths value shows that the herarchcal structure establshed by our study demonstrates a proper allocaton of relatedness between varous performance evaluaton ndcators, and hence the consstency of our archtecture model s acceptable. Lastly, our study conforms to relatve comparatve and relatve prorty (local proprety) generated from the performance evaluaton ndcators of varous perspectves. The key am was to understand the weght rato of varous performance evaluaton ndcators n the overall structure, and to select the mportance rankng of varous performance evaluaton ndcators for the establshment of day care centers n Nantou County. Ths would be done n terms of absolute weghted value and the mportance rankng of varous performances evaluaton ndcators as shown n Table 3. Table 3: Weght Analyss of Prmary Perspectves Perspectve W α W δ W γ Normalty Weght Value Importance Rankng Fnancal perspectve Customer perspectve Internal busness process perspectve Learnng & growth perspectve Ths table shows the weght analyss of the four prmary perspectves n ths research. W α the left end fuzzy weght value of trangular fuzzy numbers, namely the mnmum, W δ the value of the grade of membershp of the trangular fuzzy numbers fuzzy weght whch s, W γ The rght end fuzzy weght value of trangular fuzzy members, namely the maxmum. CONCLUSION AND COENTS Ths study ntroduced the concept of the BSC to construct a performance evaluaton herarchcal system for Nanto County day care centers. In addton, t analyzed of the elements of the herarchcal structure, and provded weghted ratos of the varous performance measurement ndcators n order to create a 3

14 JY. Hung GJBR Vol. 6 No structure for the performance evaluaton ndcator system. The performance evaluaton system truly shows the performance and dfferentaton of servces provded by the varous day care centers, whch are regarded as the best ndcators of self-mprovement by assessng ther mechansms and outcomes. In order to revew and dscuss the performance evaluaton ndcator system, we used a fuzzy Delph s method, as well as a FAHP, as the analytcal methods to re-construct the assessment ndcators of exstng day care centers n Nantou County. Accordng to our research outcomes, the level of mportance for the assessment of varous perspectves of day care centers n Nantou County s as follows:. nternal busness process perspectves, 2. customer perspectves, 3. Learnng and growth perspectves, and 4. fnancal perspectves. The nternal busness process perspectves of day care centers covers fnancal cost control, proper funds management ndcators, servce locaton rsk management, lason and communcaton capabltes, complete supervson management, and a focus on the development of capabltes wth regard to long-term care polcy n Tawan. The latter capablty hghlghts that nternal busness processes are more focused on revews of software elements. The customer perspectve refers to the vews of the recpents of care at the day care centers. The provson of the hghest qualty care and attenton to ndvdual needs should be the hghest prorty. Ths should nclude ndvdual case management, as well as effectve trackng and evaluaton to ensure that the care remans approprate. In addton, ths may nclude the provson of dfferentated and professonal servces n specal cases. Furthermore, ths may nclude professonal plannng of meals, as well as educatonal sessons devoted to the preparaton of hygencally prepared, nutrtous meals. Also, there should be the provson of convenent and safe transport for patents, as well as exercse sessons to ad n the recovery of moblty. All of these steps wll ensure that the goal of successful ageng wll be acheved through the day care centers. The learnng and growth perspectve refers to the expertse and contnued tranng of employees. Ths perspectve ncludes nnovatve ntegraton wth other communty resources. Fnally, n respect to the fnancal perspectve, most day care centers are run by non-proft organzatons. Ths means that nstead of actvely seekng fundng, they must wat to receve funds from the governments or through donatons. Therefore, ths s a less mportant assessment ndcator. The Performance assessment system was an accurate measure for long-term care servce. The system could be combned wth performance ncentves to ncrease cooperaton between government and ndustry, as well as encourage nnovatve solutons and management. The Tawanese government evaluates the servce outsourcng process through a system analyzng nput-process-output-outcome. The outcome s not usually a concern for the government, as ther polces are often lmted to an analyss of ratos of nput to output. The assessment of day care servces s the prmary tool for governments to take control of the ndustry, and the results of assessments can affect who wll be granted contracts to provde such servces. However, most of the evaluaton ndcators refer to admnstraton, fnance, personnel, envronment, and servce perspectves, whch manly measure qualty of care, nstead of QOL. Accordng to WHO polcy, actve ageng should enhance QOL for senors, whch has also been shown n past studes(kane, Klng, Bershadsky, Kane, Gles, Degenholtz, and Cutler, 2003). Recently, more studes have consdered the concept and measurement of QOL wth regard to long-term care, and have concluded that they should adopt a customer perspectve. Peper and Vaarama(Peper and Vaarama. 2008) argued that QOL should be the key feature of health models. Currently, a report on the home care subsdy user condton survey, publshed by OI(Department of Health, nstry of the Interor, Economc Plannng and Development, 2009), found that current measurement tool to mprove QOL s relatvely nsuffcent when appled wthn the care servces commssoned by varous local governments. They state 32

15 GLOBAL JOURNAL OF BUSINESS RESEARCH VOLUE 6 NUBER that the reason for ths was a long-term preference for the outsourcng of servces wthn the publc sectors, as well as a shortage of local manpower. Due to complextes assocated wth demandng qualty servce for elderly ctzens durng the process of care servce prvatzaton, health professonals need to argue for effectve reform. Effectve management of outsourced care servce, whch are evaluated by lfe qualty ndcators. wll not only guarantee benefts to the elderly, but also for the government. It wll show accountablty, enable partnershps between prvate and publc sectors, and extended the use of exstng management assessment tools. REFERENCE Buckley, J.J. (985). Fuzzy Herarchcal analyss, Fuzzy Sets and Systems, 7, Buyukozkan, G. (2004). ult-crtera decson makng for e-marketplace selecton. Internet Research, 4(2), Challs, D. P. Clarkson and R. Warburton(2006). Performance Indcators n Socal Care for Older People. Aldershot: Ashgate. Chen, W.C.(997).Prvatzaton of the promoton of socal welfare practce and polcy development of specfc. Communty Development Journal,80:4-9. Crewe, S. E. and S. S. Chpungu(2006). Servces to Support Caregvers of Older Adults, n Berkman, B. and S. D Ambruoso(eds.), Handbook of Socal Work n Health and Agng. New York: Oxford Unversty Press. Hooyman, N. R. and H. A. Kyak(2008) Socal Gerontology: A ultdscplnary Perspectve. Boston: Person Educaton. Hsu, T, H. (998). The Fuzzy Delph Analytc Herarchy Process, Journal of Chnese Fuzzy System Assocaton, 4(), Huang, L. C. & Wu, R.Y.H. (2005). Applyng FAHP n the manageral talent assessment model An emprcal study n Tawan s semconductor ndustry. Internatonal Journal of Technology anagement, 30(/2), Kane, R. A., K.C. Klng, B. Bershadsky, R. L. Kane, K. Gles, H.B. Degenholtz, J. Lu & J.J. Cutler(2003). Qualty of lfe measures for nursng home resdents. Journals of Gerontology Seres A: Bologcal Scences & edcal Scences, 58(3), Kaplan, R.S., & Norton, D.P. (999).Balanced Scorecard - strategc management tool for the Informaton Age.Harvard Busness Revew. Naleppa,. J.(2004). Adult Day Care, n ezey,. D. et al.(eds.), The Encyclopeda of Elder Care. New York: Prometheus Books. Novak,.(2006). Issues n Agng. Boston: Person Educaton. 33

16 JY. Hung GJBR Vol. 6 No Peper, R. &. Vaarama(2008) The Concept of Care-Related Qualty, n. Vaarama, R. Peper and A. Sxsmth(eds.) Care-Related Qualty of Lfe n Old Age: Concepts, odels, and Emprcal Fndngs. New York: Sprnger. Satty, T.L. (980). The analytcal herarchy process: plannng, prorty settng, resource allocaton. New York: cgraw-hll. Sun, C.L., Xao, W.K., Zhang, H.C., Kuo, X.Y. & Hung, J.Y.(2009).The assessment report n 2008 of the adult care servce n Nantou County Government. Nantou: Nantou County government. Yang, J.C.(2009).Servce qualty: from theoretcal to applcaton.tape. Yeates, N.(2005). A Global Poltcal Economy of Care, Socal Polcy & Socety, 4(2): Zadeh, L. A. (965). Fuzzy sets, Informaton and Control, 8, Zhuang, X..(2008).Changes n long-term care servces, the development of research nsttutons: unt care, group practce of the house concept and forward-lookng analyss of trends.tape. Department of Health, nstry of the Interor, Economc Plannng and Development(2009).The ntal plannng of long-term care nsurance system and concepton of the results (presentaton verson). Tape: Department of Health, nstry of the Interor, Economc Plannng and Development. World Health Organzaton (2002). Actve Agng: A Polcy Framework. Geneva: WHO. BIOGRAPHY Dr. Hung s a doctor of management graduated n She s an assstant professor and also the charman n the Department of Golden-Ager Industry anagement, Chao-Yang Unversty of Technology, Republc of Chna. Her expertse s n consumer behavor, organzaton performance management, senor educaton and nonproft management. On the part of professonal servce, she undertake NSC plans n Tawan and perform a number of ndustry-academc cooperaton program, total amount of up to 400 mllon Tawan dollars snce