Competition in the market for home care : an anlysis of Buurtzorg versus Florence

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C o m p e t i t i o n i n t h e

m a r k e t f o r h o m e c a r e

A n a n a l y s i s o f B u u r t z o r g v e r s u s F l o r e n c e

Student: Janine Goumans (10973125)

Contact: janinegoumans@yahoo.com

Supervisor: dr. M. Rademakers

Datum: 25 January 2017

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Summary

In the last decades a lot of changes haven been executed in the Dutch health care system, such as new legislation in the insurance system and the introduction of limited free market system. A recent change is the transfer of various care tasks from the central government to the municipalities; a process called decentralization. The constantly changing healthcare

landscape influenced the home care market and had an enormous impact on the care suppliers. Several large existing organizations came in to serious trouble and at the same time an

increase of new players in the home care market, mainly small and medium companies, occurred. A relative new player, “Stichting Buurtzorg Nederland”, succeeded in getting a place in this market and even its market share is still growing. These developments in the healthcare landscape and especially the effects in the home care sector are the objective of this thesis, where two research questions are investigated:

 Which elements, apart from the business’ operating model based on autonomous teams, were critical and most important for the “Stichting Buurtzorg Nederland” with respect to its success as a new player in the home care market?

 Which pro’s and con’s are related to the operating model of the “Stichting Buurtzorg Nederland”, this compared to existing (traditional) companies and with respect to the continuity of the company?

In this study the existing organization “Stichting Zorggroep Florence” and the relative new player “Stichting Buurtzorg Nederland” are analyzed, compared and contrasted by using the theory and models described by Porter and Zott and Amit, regarding the activity system and activity system based business model. The theory described by Meyer regarding the

‘organizational context’ is used to get a better insight in the way companies are organized and how this interacts with leadership. Documents available in the public domain are used and structured in an organized way by using a developed tool.

The basis of success of “Stichting Buurtzorg Nederland” to get and to hold a place in the market lies in the choice for a unique client oriented business model working with

autonomous teams, participation in innovative projects, excellent public relations and a good functioning ICT based information system. Their system resulted not only in small overhead with low costs, but also in the delivery of high quality care for an acceptable price in the market. Given the outcomes from this research project, it is recommended that working with autonomous team in the home care sector, a topic much discussed in the literature, needs careful implementation and is not an easy implantable “best practice”.

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Preface

In order to finalize the MBA in health care management, this thesis about competition in the market of home care in the Netherlands, has been made. The subject of this thesis has been chosen because of my broad interest in the Dutch health care. In the health care system many developments are going on, such as new legislation and changes in the financial

arrangements, which affects both the cure and the care sector. These developments also influence the home care market. This thesis aims to give insight in the factors, which are

important for having success in the home care sector. At this point I like to thank my supervisor dr. M. Rademakers for his feedback and expertise.

And I like to thank prof. dr. J. Strikwerda for being my second reader. Finally I like to thank my husband and parents for their patience and support the last two years.

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I Introduction

A Background

In the Netherlands the costs of the health care system showed an increasing trend for the last decades. Successive cabinets have tried to cope with this problem by developing various policies. For instance in 2014 cost showed an increase of 1.8 %, amounting to 95 billion Euro (Persbericht (2015)). A general policy statement, broadly agreed upon, is: “betere zorg tegen lagere kosten”, meaning: better care for a lower cost. However, this policy proved to be very difficult to realize. These everlasting problems were the direct cause for a stringent

reorganization of the Dutch health care system.

The most recent reorganization being the transfer of various care tasks from the central government to the municipalities. This process is called decentralization. The tasks involved are: juvenile care, employment and social services care for the elderly and long stay care. As of January 2015 the municipalities are responsible for these activities. The decentralization comprises of 2 types of processes: transition (rules, legislation, financial arrangements and responsibilities) and transformation (different behavior of professionals, other ways of working, other relations between workers in the field).

A huge reorganization as this must have effects on both processes and the people involved. The process of decentralization also has impact on the home care sector in The Netherlands; it influences amongst others the way of financing and the organization of the sector. Home care is now paid for by municipalities within the framework of new legislation, called the WMO (home care and daily activities) and/or by insurance companies (personal care and cure, extramural treatment, palliative care) as part of the basic general health insurance. Often the client has to pay an income depended contribution.

This changing care landscape has influenced the market for home care and had an enormous impact on organizations in the field. Several large organizations for home care came into trouble, resulting in bankruptcy for e.g. TSN and Thebe. A relative new player is the “Stichting Buurtzorg Nederland”, which succeeded in getting a place in the market and its market share is still growing.

These interesting developments have been the direct cause for the study described in this thesis.

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B Brief history of home care in The Netherlands

Home care is the general name for all types of care and cure delivered at the clients’ home. It consists of a broad arsenal of services, such as (specialized) nursing and care, personal care and care for newborns and taking care of household activities. These activities are the domain of the first line extramural care. Home care as we know it these days, is a result of the fusion of several older local institutions, so called ''cross societies”. At the end of the ninetieth century the relation between bad

hygiene (e.g. contaminated drinking water) and health problems was discovered.

Municipalities took up the task to improve matters. Social initiatives also came into place e.g. supervised by Jacob Penn (inspector for health care in the province of North Holland), in the beginning of the twentieth century a network of local societies was formed (named

“kruisverenigingen”) to fight and trying to prevent epidemics (Steyaert (2009)). In The Netherlands at that time there was a strong division along the lines of religion, also valid for the local care societies. As time got by, these institutions got more and more tasks. Care for mother and child, but also taking care of the sick people was done, as well as social support for families with all kind of problems. Around 1950, also due to changes in subsidies from the government to the “kruisverenigingen”, the accent in the tasks from these institutions changes more and more to individual medical care, especially for the elderly and chronic patients. In the sixties, religious barriers were in general removed and the first social legislation was put into place; both factors stimulated cooperation between the

”kruisverenigingen”, even resulting in up scaling. In 1977 this resulted in the forming of a national “kruisvereniging” (Van Elteren et al. (2006)). In this period the basis was laid for further professionalism and official registration of the function of district nurse (Van der Boom et al. (2004)). However, also the influence and control of the sector by the central government increased. Secretary of State Hendriks laid the basis for a strict central control on quality and efficiency in the health care sector. Amongst others, the government decides which services in the home care sector will be subsidized (Bertens (2015)). In the eighties and nineties of the last century, up scaling and professionalism goes on, resulting in the formation of a national society for home care out of the national “kruisvereniging” and the national council for social family care (NtvG (1989)). Accompanying this process is an increase in bureaucracy.

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C Development of the legal framework

In 1968 a law for special costs for health care, entitled the AWBZ, was put in working. This law was an obligatory insurance for the whole population, aimed to pay for all health care costs not paid for by the health insurance. In first instance the AWBZ was meant for long stay intramural care in nursing homes. However, due to increasing market pull combined with the rise of the costs, accent changed to relative cheaper extramural care. This was in agreement with the policy for people (mostly elderly and chronic patients) to stay as long as possible in their own living environment (Van Gorp et al. (2009)). This implied that home care also has been put under the regime of the AWBZ. The cabinet introduced a so-called dedicated care policy (client oriented care) combined with a marketing approach for the sector. The aim of this policy was in essence an attempt to get grip on the ever-rising costs for care.

These developments resulted in changes in the tasks of the district nurse. Differentiation in functions was formed, resulting in a background position for the all round district nurse and all kind of new functionaries came on the market. A side effect was the decrease in salary costs for these new laborers (Van Weelderen et al. (1998)). In order to implement societal developments, the AWBZ was modernized, thereby changing from the supply of care to the request of care. This resulted also in broader care package (Van Gorp et al. (2009)).

By making the health care system market depended, insurance companies and accompanying bureaucratic institutions got control over the costs of care delivered by health care suppliers. As of 2005 the indication for the delivery of care is centralized and performed by a

governmental related institution, the center for indication of care delivery (CIZ). In this way one office (counter) system was created, being responsible for home care and long stay care (Van Gorp et al. (2009)).

The Law for insurance of health care (Zvw) has been introduced in 2006, which is obligatory for each citizen falling under the AWBZ. However, due to years of adjustments, the AWBZ proved to be very difficult in practice. This initiated the policy options to transfer tasks from central to local authorities. A first result was the in 2007 introduced legislation for social support (WMO). Local communities were given the task to organize the work, e.g. home care (mainly cleaning etc.). Finally in 2015 the AWBZ was abolished and replaced by a Law for long stay care (Wlz), taking care of personal care and nursing at the home as well as in an institution (provided that an indication has been given by the CIZ). This centralization has great impact on the way home care is organized in The Netherlands, as well as for the financing.

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Within the framework of the WMO local communities only pay for work in the household or modifications of the housing. Various policy goals, like the elderly staying longer in their houses and budgeting the costs for care by local communities, were put into work.

Communities are allowed to decide upon the height of the contribution of the client, the client has the possibility to apply for a so-called “personal budget”. This budget enables the client to decide what kind and amount of care to buy from suppliers.

The above-mentioned CIZ and the insurance companies are as of now responsible for the implementation of the Wlz, thereby responsible for the care functions from the basic package, like personal care and nursing at home. They also must administrate clients’ contributions, up to the legal maximum.

In general the contributions to be paid by the citizens for all parts of the health care system are income dependent and controlled by the tax authority.

D The problem of the cost development

In the recent decades, the total cost for health care in The Netherlands showed a steady increase, in 1972 amounting to 8% of the gross national production (GNP). In 2010 this already has risen to over 13% (Van der Horst et al. (2011)). The spending on care, both health and social, in 2015 had risen with 1.8% to around 95 billion Euro (Persbericht (2015)). The last three years a decline in the rise of health care cost has been seen, the rise being 0.9%. Combined with an increased growth of the Dutch economy, total costs of the healthcare system amounts to over 14% of the GNP, showing now an over all trend to decrease (CBS (2016)).

In order to get a hold on the rising costs in the last decades, the government has introduced various policies, reorganizations of or new legislation (see also above under C). The first big reorganization was the forming of a national health insurance system, thereby abolishing the existing systems (De Minister van Volksgezondheid, Welzijn en Sport, J. F. Hoogervorst (2004)).

The second big reorganization was the introduction of the two laws Wlz and WMO, which implicated transfer of responsibilities and budget to local communities and insurance companies (Movisie (2012)).

These great system changes have an important impact on the way the system is financed. The cure sector is still consuming about 50% of the total budget. Health care costs for the elderly showed a decline with 2%, to around 17.7 billion Euro. Cost for welfare and juveniles also decreased. In 2015 costs were, compared to 2014, 3 billion more financed via the Zvw, via the

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Wlz 8 billion less and the government (the local communities included) had to increase their budget with 5.5 billion Euro (CBS (2016)). It is important to mention, that with these system changes, the government has now 4 crucial points in the system where they can influence the financing of the sector: basic costs to be paid by the citizens, health care tax via the income, own risk to be paid by the citizen and of course the clients contribution for certain services. In addition to this it is possible, based on the height of the income, for citizens to get a refund via the tax system. It is obvious, that these arrangements make the financial part of the system very complex and bureaucratic. As mentioned, insurance companies are via the Zvw and Wlz partly responsible for financing of the home care (NZA (2014)). Every year budget arrangements are made between insurance companies and care suppliers. Per type, or care function, a national standard tariff is defined. Because of the fact, that the by the government made available budgets for home care are to low, several suppliers are reaching the limits long before the end of the budget year. This resulted in financial problems for several care suppliers and thus in clients getting not the amount and quantity of care that was agreed upon. Both the sector organization

(Branchebelang Thuiszorg Nederland), as well as the insurance companies recognizes this problem (Skipr (2015)). Even some care suppliers had to reduce the amount of personnel or stop their activities in the sector completely.

E Tension between quality and policy

In the home care sector three interests, corresponding with general trends in the society, are important (see figure 1). Firstly there is the interest of the client, who wants more control over the type and amount of care and he wants to make his own choices. A consequence of this aspect is, that care must be more client-oriented and has to be delivered on time.

Secondly comes the interest of the care supplier. Due to the every increasing cost it was a societal concern to organize the health care system more (cost) effectively (see above under D). This presses existing organizations to improve delivered care and change company management in this way (Almekinders (2006)).

Then we have the interest of the professional, who actually delivers the care to the client. For delivering work of good quality, it is important for personnel to be motivated and that, based upon his expertise, he or she is allowed to work independently. This makes it possible to develop a pride for the function (Van den Brink et al. (2011)).

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Figure 1. Three interests in home care (Ten Have 2011 p. 11). The three interests are the interest of the client, the employee and the efficiency of the organization.

It is obvious, that in order to fulfill all three interests, a balance must be reached. Figure 1 illustrates this, also indicating their interrelation and consequently the resulting constraints and obstructions (Ten Have 2011 p. 11).

The in the system introduced function differentiation makes it possible for clients to obtain only a certain service, which means that “zorg op maat” is now possible. The in 2003 introduced modernization of the AWBZ, defined seven functions in home care: cleaning, personal care, nursing, activating activities, supportive activities, treatment and long stay (in certain institutions like a nursing home). In 2009 the functions supportive and activating activities were skipped. One new function supporting activities was defined, while another part was incorporated in the function treatment (Cokema (2011)), (Ten Have (2011)). A positive aspect from function differentiation is, that suppliers offering only a few functions are now allowed on the market.

As of 2009 home care is paid for by the AWBZ (see above under C). The content of

extramural nursing and care is changed also, resulting in nursing tasks now being defined as care. The level of expertise required is thus lower, resulting in a lower payment and a larger amount of available workers. This aspect is called downgrading of the professional nurse (Ten Have (2011)).

All these changes resulted, as said in the delivery to the client of “zorg op maat”, thereby introducing competition in the market. Already from the nineties the government has put effort in improving the quality in the home care sector. The responsible department and the sector organizations have made agreements concerning management and performance in the sector. Also it is investigated which “best practices” can be described and agreed upon. As such, the home care sector is a spear point in governmental policy aiming at the introduction of market systems in the health care system (Almekinders (2006)). The government hopes to

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make savings through competition between smaller and bigger home care companies. Via the aimed up scaling the expectation is to make more money available for amongst others

innovation. Large home care organizations however developed a lot of bureaucracy, thereby making rules, procedures and protocols leading aspects in management. The satisfaction of the clients as well as the motivation of personnel loses importance (see figure 1). This leads to organizations in the sector, which have grown relatively fast, with a complex and hierarchical organization structure. Recent research has shown, that smaller care firms perform above the average. Lower company costs and applying best practice principles might be important in these cases. In addition they also show a good result regarding satisfaction of clients and personnel (Almekinders (2006)).

F Result: new players on the market

In The Netherlands the last years the amount of companies operating in the service sector is growing. For over 90 % this is due to starting of single person firms, or of small and medium enterprises up to 20 personnel (Small MKB). In the care sector this growth has been

enormous. Traditional companies have problems in following up the speed of changes in the sector moreover bankruptcies are a thread. They have problems following changing

economics, e-innovations, fast to market products and smart data handling. In addition, if they succeed to keep place, there is the thread of being sold to foreign investors (Kamer van

Koophandel 2015 p. 2). Recently in The Netherlands suppliers like Thebe, TSN and Diafaan got bankrupt, leaving many employees without a job. Also fragile clients had to look for new firms able to supply care. Increase in new enterprises in the health care sector is mostly seen in the market for home care and paramedic services. Last five years 7000 new companies started in the sector, whereas the number of companies with over 250 personnel has relatively decreased (CBS (2015)). At the end of 2016 around 2500 home care suppliers are active on the Dutch market (www.zorgkaartnederland.nl/thuiszorg). As was previously described, the market has changed and it is interesting to note, that new players have adopted the new policies and ways to deliver the requested service. Also they communicate that they are cost effective and put the client’s wellbeing as their focus point. These developments are in line with the general marketing theory, stating that new players on the market stimulate innovation and decline of costs. In the health care sector new players in general are better in quality aspects and efficiency. This has also a positive effect on existing players, through a mechanism of substitution of the cost efficiency of the sector as a whole improves. Recent research shows that this effect takes place, however the effect is relative

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small, because of the fact that the substitution is only partly. This indicates, that new players have to confront the market with entrepreneurship and a clear additional value (Poortvliet et al. (2012)). In addition, this is in accordance with the assumptions, that market oriented companies show better financial results. An aspect that is stronger under the thread of new players coming on the market. Thus market orientation has four important aspects: client orientation, awareness towards competitors as well as for suppliers and functional management. One of the relative new players in the Dutch home care market is the “Stichting Buurtzorg Nederland” (StBN), which was founded in 2007. StBN makes it clear in their communication that satisfaction of clients and personnel is their main concern. The last years StBN showed a clear trend of growth. This in view of the fact, that the number of one person companies en small businesses increase on the expense of large firms (Winkel (2015)). End 2016 there are around 780 home care suppliers operating under the StBN flag.

(www.zorgkaartnederland.nl/thuiszorg).

Based on public information from StBN compared to public information from an existing care supplier (Stichting Zorggroep Florence), the central questions in this limited research, as concluded from the overview and the context description above, are:

1. Which elements, apart from the business’ operating model based on autonomous teams, were critical and most important for the “Stichting Buurtzorg Nederland” with respect to its success as a new player in the home care market?

2. Which pro’s and con’s are related to the operating model of the “Stichting Buurtzorg Nederland”, this compared to existing (traditional) companies and with respect to the continuity of the company?

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II Framing

A Conceptual framework

In order to find answers for the research questions, as formulated at the end of Chapter I, the conceptual framework described below is used. The existing player “Stichting Zorggroep Florence” (StZF) and the relative new player “Stichting Buurtzorg Nederland” (StBN) will be compared in a systematic way and an analysis will be made using the theory and models described by Porter (1996) and Zott and Amit (2010), regarding the activity system and activity system based business model. The part of theory described by Meyer (2007 chapter 10), regarding ‘the organizational context’, will be used to get a better insight in the way the companies are organized and how this interacts with leadership.

Porter (1996) defines activities as the basic elements with which companies can gain advantage in a competitive market. Describing his theory about fitting of activities and strategic positioning, he developed the method of mapping activities in activity systems (see figure 2).

Figure 2. Example of an activity map of the company Southwest Airlines according to Porter (Porter 1996 p. 14).

Zott and Amit (2010) describe, based on the concepts and the work of Porter on the activity system, a design framework with which company activities can be structured in an activity system based business model. They define an activity in this business model as the

engagement of a human, physical and/or capital resource that serves a specific purpose towards the fulfillment of the overall objective of the organization. The activity system to be

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constructed is than defined as a set of interdependent organizational activities conducted by this organization, including external oriented activities (Zott and Amit 2010 p. 217).

Their design framework used to develop an activity based business model consists of the two major items: design elements and design themes. Three design elements are defined: content,

structure and governance. In addition the design framework contains design themes, for

business improvement and sustaining the obtained competitive advantage (Zott and Amit 2010 p. 222). They consider these design themes as important drivers for value creation of the systems activities. Their theory assumes, that a business performs better when the various business activities are interrelated in a systematic way.

Porter (1996) has already described these interrelations with the word “fit”. If there is

consistency between the activity and the strategy of the company this is called “first order fit” and when various product lines reinforce each other, he used the name “second order fit”. In maps of the activity system, these relations are shown in a graphical way (Porter (1996)). According to Porter (1996) competing companies in the market have a habit of looking at each other and are constantly busy to improve their operational effectiveness. Best practices are copied and used by all competitors. This results in the forming of a productivity frontier (figure 3).

Figure 3. Productivity Frontier (Porter 1996 p. 4). The frontier illustrates the development of the costs as a function of the introduction of best practices in a sector.

The productivity frontier concept can be applied to single defined activity or to a group of activities and also to linked activities in a company. “When a company improves its operational effectiveness it moves towards the frontier. The productivity frontier is thus constantly shifting outward as for instance new technologies and management approaches are

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developed and/or new inputs become available. Operational effectiveness means performing similar activities better then a competitor performs them”. Therefore operational effectiveness includes but is not limited to efficiency and refers to various practices to improve outcome. This has led to several management instruments used in the last decades, such as change management, outsourcing and the concept of the learning organization (Porter 1996 p. 3). A way for a company to escape from this behavior in the competing market is to choose for a new strategic positioning and try to get a unique position in the market. Elements necessary for designing a strategy are: to define a unique value position, to customize a value chain, to make a clear choice of activities and trade-offs, to look for activities that fit together and reinforce each other and finally how to support innovation activities (Porter (2008)).

According to Porter (1996) leadership and strategy are clearly linked. In addition leaders must be aware of the “growth trap”, which is a danger for strategy development. The theory

described by Meyer (2007), especially the part about the organizational context, gives insight in the way organizations respond to a changing environment. Figure 4 illustrates the relations between strategic issues and their polarities (Meyer 2007 p. 39).

Figure 4. The relations between strategic issues and their polarities as taken from Meyer (2007 p. 39). In this study the emphasis given to the strategic tension control versus chaos.

Clearly the recent governmental induced changes in the health care market, puts pressure on companies to take actions in response to new market requirements and societal needs. This makes it necessary to perform better then competitors. Company processes must be up to date, but the organization must also be flexible in order to comply with new developments and market demands (Zijlstra (2005)). The style of leadership is of great importance with respect to the way a company reacts to often conflicting strategic demands, as is the case in todays home care market. This can lead to tensions between executives and various levels of

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management in the company. Strategic control is necessary for an organization to develop, while chaos is important for renewal and motivation of the personnel. According to Meyer (Meyer 2007 p. 178) “control is defined as the power to direct and impose order, whereas chaos is defined as disorder or the lack of fixed organization”. Moreover he defined this specific tension as the paradox between control and chaos in is overview of the main differences between the organizational leadership perspective and the organizational

dynamics perspective. As Meyer stated as a paraphrase of Shakespeare “to control or not to control, that is the question” (Meyer 2007 p. 179, 184).

The above described conceptual framework has been chosen for analysis, comparison and contrasting of the organizations used in this study, because it will illustrate where company performance and management differences can be found between new and existing players in the home care sector. Using this framework a comparative case study between two different organizations serving the same market is performed. Moreover it gives insight in the way companies react to the changing market demands and the various new market tensions. The concepts of activity system and the here upon based business model are used to answer the question on the success of StBN as a new player to acquire a position in the home care market. The question on how StBN succeeded in staying in the market and even to grow is analyzed with the concept of the productivity frontier and by the theory on the organizational context. In addition interrelations and dependencies may show up and may give information related tot the aspects of interest discussed in Chapter I, section E and shown in figure 1.

B Tool for data analysis

In order to apply the analysis on the organizations of the case in this study, it is necessary to process the information available in documents in the public domain in such a way, that usable input data is obtained. The four categories (financial, clients, operations, development / growth) described in the balanced scorecard (BSC) methodology are used to derive a, for the home care sector modified and dedicated, tool that can be used to process all information from the selected sources of information. The original BSC methodology comprises of a set of coherent financial and non-financial indicators, used to characterize the realization of

company strategy, including critical success factors (Kaplan et al. (1993)). Non-financial factors are for instance innovative performance or motivation of personnel. A drawback is the fact, that these factors are more difficult to compare or are less reliable because of fewer hard data available, making them more qualitative indicators then quantitative.

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Taking these aspects into account, the developed modified tool was tailored to the way of working in the home care sector and brought in line with the usual management information in the sector. The chosen and modified categories (financial, organization, quality and

innovation) are divided in issues and then in sub-items. In this way hard data on performance parameters of an organization, obtained from various sources and documents, can be

appointed to the corresponding sub-item. Also information related to the organization or the other mentioned non-financial factors can be appointed. Figure 5 below, shows the general layout of this modified tool, while a detailed list of the issues and sub-items is given in Appendix I.

Figure 5. Modified Balanced Scorecard Tool (MBST).

The modified tool, further referred to as MBST, is used to process the available information of both organizations, StZF and StBN. It is at this point interesting to note that also consumers and potential clients have most times only access to public data.

The MBST has been chosen for this study because it is very useful as an instrument to process and organize data, and so making it possible to compare the obtained results for companies active in the same market. Numerical data from the several categories and sub-items can be compared in a direct way. The aspect of valuation of sub-items is therefore important and is especially relevant for performance related parameters. The results of this data processing step are shown in Appendix II for both StZF as for StBN.

IssIssu e )SS u b item s C osts o f ca p ital g ood s B u ild in g s, IC T h ard w a r e C osts o f p er son n el T ota l costs, % overh ea d

F in a n c ia l

S ou r ce o f in com e C osts, in com e R a tio pr ofit / costs

Issu e S u b item s Issu e S u b item s

IC TIC T IC T system s S a tisfa ction of

p er son n el M otiva tion ,tea m w or k Q u a lity

im pr ovem en t s ystem s

S a tisfa ction of

clien ts D ed ica ted car e,com p la in ts

E -h ea lth C lien t p ortal In tern a l d em ocra tic

s ystem C ou n sel of clien ts,O R

In n o v a ti o n G en era l

d ev elop m en ts Q u a lity c on tr ols ystem s M IP r ep or tsN ea r a ccid en ts T r ain in g an d

sch oolin g L e vel, p lan n in g S tan dar d iz ation P r otoc ols

Q u a li ty Issu e S u b item s

D ecision m a k in g T op d ow n / bottom u p, sp eed R esp on sibility an d a u th or ity P la ce in th e or g an iza tion In for m a tion tran sfer R ep or ts, m eetin g s

T erm s of em p lo ym en t H R M , collectiv e la bor agr eem en t

In te rn a l o rg a n iz a ti o n

D iffer en tiation in car e

fu n ction s T yp e an d n u m ber, ser vice ar ea ,tar g et gr ou p

M is s io n V is io n

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III Case description

From Chapter I it was concluded, that the governmental induced changes in the health care sector had a huge impact in the home care sector. More over, this sector has been placed in the forefront of the transition of the whole care and cure sector to a more market oriented business. The pressure of this transition affected all parties in the sector and resulted in two main effects in the market for home care: existing home care suppliers had to respond to the changes and the new demands and new players evolved and started to compete for their share of the market.

As described in Chapter I in this, more or less created, turbulent market both existing companies and new players in the market survived or got bankrupt. At the end of 2016 the number of small and medium organizations in the home care market is still increasing at the expense of large organizations. Therefore it is interesting to investigate how new players in the market, in comparison to existing companies, have operated and to get insight in the factors enabling them to perform in such a way that they could stabilize their market share or even grow.

In this study two organizations will be analyzed, compared and contrasted. As existing organization is chosen for the “Stichting Zorggroep Florence”, who had to adapt to the new market demands. This supplier is a conventional organization with a rather long history in the health care sector and is also active in the home care market for a longer period. As new player in the home care market the “Stichting Buurtzorg Nederland” has been selected. This relative new player in the market started with only activities in the home care sector, survived the turbulent competition phase and is still growing. The “Stichting Buurtzorg Nederland” used a market approach and strategy different from the usual concepts.

In order to obtain information suitable for analyzing and comparison these organizations, documents available in the public domain were used as sources. The available information had to be processed first, as a necessary step, to obtain comparable data for the selected parameters. Processed numerical data is presented in the form of tables and contains both quantitative and non-quantitative information, while other relevant information is given in text. The thus obtained dataset and additional detailed information about both organizations is given in Appendix II. With this data set the performance of both organizations is analyzed and compared.

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IV Results

The analysis of the information and data for the organizations StZF and StBN obtained from the processing step, which are presented in Appendix II, starts with applying the conceptual framework described in Chapter II and gives the results and implications for both companies. Zott & Amit formulate a design framework with which an activity map based business model can be made. Various elements in this business model are important in order to be competitive and to be able to increase value. This indicates that the performance of the activities of a business must preferably be measured on the basis of chosen or defined performance drivers. The data given in Appendix II from both organizations are analyzed with the aim of getting hard data on performance drivers that were selected, such as client satisfaction, costs and satisfaction of personnel.

The category Quality of the MBST, presenting both qualitative and quantitative information, is used to derive data for the selected performance indicators. An important aspect is the satisfaction of the client for the service delivered. StBN has on all aspects a higher score than StZF. Figure 6 below clearly shows, that StBN shows a better performance on all measured elements of client satisfaction.

Figure 6. Graph of client satisfaction measurements, for both StZF and StBN, based on standard quality index (QI) parameters with scale from 1-5 (Delnoij and Sixma (2006)). The five measured scores are: care, quality of personnel, information received, treatment by personnel and consultations.

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Remarkable are the relative high scores of StBN for the parameters quality of personnel and consultation, because these parameters are strategic choices of the company. In addition StBN had (almost) no complaints by clients. The results in figure 6 show, that the company strategy of StBN with respect to client satisfaction is successful in the market. This result is also qualified by the research of KPMG / Plexus regarding the costs / quality ratio. They conclude that StBN delivers a high quality care for costs just below mean values (see Appendix II, figure 6).

The parameter satisfaction of personnel can also be looked upon as a performance driver. The company StBN has a relative low percentage of 5,3% for sick leave and a high score for satisfaction of personnel. This shows a good fit between company and employees. In this respect the unique concept and work model of StBN is positively accepted by all parties. StZF, however, clearly has to deal with problems, probably due to (governmentally induced) changes in the care sector and the thereby caused reorganization of the company. StZF has a higher percentage of 7,75% for sick leave, 20% leaving of personnel after the reorganization and showed a decrease on the listing of “Best employers”.

The way the organization functions has an impact on the overall performance, thus relevant information presented in Appendix II, can partly be appointed to the performance of the company activities, restricted to services in the home care sector. For StZF it is clear that the organization has the design of a top-down, bureaucratic system. Decision-making is a slow process and innovation is not much supported in daily operations. Furthermore StZF works with a large amount of volunteers, who not necessarily have a personal relationship with the client. Financial results are one of the important management tools.

For StBN the organization is designed to support the autonomous teams, who are fully responsible for delivering the services to clients. The CEO operates mainly on the strategy level and is responsible for decisions on company level, while the autonomous teams manage their daily business. In addition, participation in innovation activities is strategic choices of StBN. Results of such projects are implemented in the organization when possible.

StBN (see table organization in Appendix II) has a flat organization based on the strategy, that the organization is designed to support the primary process: deliver high quality care close to the client. Fast decision making processes, primarily based on a high degree of autonomy of the employee (autonomous teams), allows StBN to act fast in the market. In comparison StZF is a care supplier with a slow, vertically structured and top down way of decision-making, accompanied with a culture of meetings. The employee is confronted with a

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management structure of several layers and various levels of reporting. This may result in a less competitive operation in the market.

StBN had as a new player the advantage that they could restrain their activities to the market for home care only. In contrast, for a company as StZF the market for home care is just one of their many activities. The complex organization of StZF works as a brake on the flexibility required in a changing environment.

There is a huge difference between the autonomous teams of StBN and the working with result oriented teams (ROT) of StZF. Autonomous teams are self responsible for content and planning of the work, decisions on work level and having enough work force (including getting new employees). The central and remote (coaches) parts of the organization are supportive to their work. A ROT is in many aspects depended on the company. A typical example is the quality and amount of personnel of a team. StBN sticks to a high quality level of the teams, at StZF however such a strategic element is difficult to realize and is a task of the management.

StZF is an organization with a complex structure and several layers of management. This makes the distance between the primary process and the top of the company large, resulting in slow decision-making and many layers of responsibility. At StBN most responsibilities and authorities are placed low in the organization, namely at the level of the autonomous teams, resulting for a lot of work situations in fast decision-making. In addition internal knowledge and know how is fast accessible for all employees by means of a sophisticated ICT system like “Buurtzorgweb”. At StZF the company is working on the improvement of their systems and introducing new developments.

To get insight in the activities of StBN an activity map according to Porter is derived from the available information (Appendix II), see figure 7.

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Figure 7. Activity map of the home care department of StBN based on Porter (1996). Two main activities are shown: in the hart of the map is the client oriented activities and in the right upper corner are the supportive company activities.

In order to stay competitive it is important for companies to work continuously on the improvement of their value and to start innovations. StBN has a special department for

research and innovation. According to Porter it is important for companies to try constantly to improve their efficiency, because all the competitors are doing so. Partly this results in the application of best practices by all suppliers. In this respect StZF is planning to implement working with ROT’s in the whole company. Also has StZF made a strategic plan, including the financing, to get more control on cost for instance housing and energy. With these initiatives StZF might be able to cope with the decreasing trend in the ratio profit/costs. StBN still has an increasing trend in this ratio and has thus an advantage with respect to the performance driver costs. Partly this is due to their policy of leasing housing and transport, but also there are no historical debts.

On the terrain of ICT and Quality there are many activities in The Netherlands. Both StZF and StBN are active in this field, but StBN has the advantage of participating in governmental supported projects, such as the development of the OMAHA system. This system for amongst others the administration of interventions at level of service to clients will most probably be

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introduced as the standard system. Both StZF and StBN are working on or with E-health systems aimed at the client and his or hers network.

As described by Almekinders (Almekinders (2006)) (see Chapter I, section E) and by Poortvliet (Poortvliet et al. (2012)) (see Chapter I, section F) it is clear that StBN operates according the general observations they made, like client orientation, cost efficiency and entrepreneurship. Also it is clear that StZF is pushed in a positive way towards market-oriented operations. As an organization StZF is, due to changes in the market, working hard on keeping their share of the market, amongst others by reorganization, appointing process managers to support a more process oriented way of working with ROT’s and cutting in costs and overhead. StBN on the contrary has possibilities to develop new activities in the care market, such as household support and care for mother and child. In principle StBN applies its unique working model for all new activities, thus making use of the existing fit. StBN must be aware of possible problems related to a quick growth. The span of control of the existing management, including the CEO, can easily be exceeded. In addition the risk of dilution of organizational values can exist.

Table I shows characteristic aspects related to the performance of StZF and StBN in relation to the five strategic elements described by Porter. It is clear from the comparison of both companies, that StZF is an organization in transition, while StBN is operating according to a new strategy and is in the frontier of the market.

Strategy element StZF StBN

Value proposition Broad range of services offered Unique operation model with high client orientation

Value chain Bureaucratic operation model (top-down, vertical organized)

Autonomous teams with support of the central organization

Choice of activities Due to historical position no specific

choices made Home care market as main business

Fit Company is busy with reorganization Activities support each other

Innovation Improvement of existing information

system Participation in several innovation projects Table I. The five strategic elements as described by Porter (Porter (2008)).

Looking at the concept of productivity frontier as described by Porter, StZF can be described as an existing company working hard to get a shift to the frontier, while StBN as a new player is at the upfront of the market and working to hold this position or even to improve it. The figure below (figure 8) shows an indication of the position of both organizations in the productivity frontier in the market.

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Relative positions: StZF StBN

Figure 8. Estimated positions of both organizations on the productivity frontier (Porter (1996 p. 4)).

The important elements of the vision and mission as stated by StZF are, that they offer a broad range of services provided by professional employees and that it is important for the client to have many choices. However, from the point of view of the client you observe quite a distance between the care needed and the service offered and the client still needs to shop to get his services. StBN is more client-oriented and has in its vision and mission the client placed in the core. The central organization supports all activities aimed at improving the position of the client and his network. The services are a result of the interaction between the client and the professional employee (see Appendix II, figure 2).

At a macro level it can be observed that the government with several actions as described in Chapter I, has opened the market in the health care sector. In agreement with the theory described by Meyer, this was necessary because existing structures were a hindrance for competition and innovation. The government took the lead and has indeed been able to force a process of change by creating the so-called “chaos” in the market. This action forces existing companies to act and gives new players an opportunity to start in the market. It is interesting to note that the home care sector has been chosen as an experimental market.

StZF responded to these stimuli of the government by hooking on to the developments, but not by a major change in governing and managing the company. Although process managers were introduced, decision-making stayed top down and control and management of the company is still focused on input control.

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The relative new player on the market, StBN, started with the strategic choice for a company with a flat structure, where autonomous teams have a high degree of independence.

Management is more on output control and support and facilitation of services. Top management (CEO) controls the company strategy, but highly stimulates bottom up innovations. The CEO originates from the work field and is as such highly accepted by the employees, he is looked upon as ‘one of us’. According to the control / chaos paradox StBN succeeded in finding the right mix for the specific market situation, to cope with the societal and new market demands. Moreover, StBN proved to be a successful new player in the forefront of the sector.

StBN has made a choice for an opportunistic approach of the market. The actions of the company in the field of PR and working to achieve a well-known name in the field, is an illustration of this observation. In addition the top of the company spends time to be active in various arenas. They participate in general communication activities such as TV programs, but also in studies and projects. This made the way for StBN to participate in various quality investigations and ICT projects, like the development of OMAHA.

According to the high satisfaction of employees, the style and way of working of the CEO of StBN is motivating for personnel. The choice to work as close to the client as possible, making use of the network of the client and to make use of added value by first line care services, all elements of the developed unique work / care model, are a good answer on the “new market requirements and societal needs”. On the contrary StZF is still struggling with the implementation of the recent reorganization and has a lower satisfaction of personnel as well as of clients and also they have problems in finance and amount of work. Leadership in StZF is still conventional and the bureaucratic way the company has been organized is not changed. Thus decision-making is still a top down activity. Distance between personnel and decision makers is still large.

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Looking back at figure 1 given in Chapter I and the remarks made by Ten Have (Ten Have (2011)), it is clear that at this moment StBN is in the center of the triangle, because all three aspects are fulfilled (see figure 9). The three interest used in this figure, are respectively the interest of the client, the employee and the efficiency of the organization. These interest are also important in the market strategy of StBN. StZF on the contrary is an organization with a lower score in all three elements of the triangle and has still a lot of work to do in order to improve their performance on these aspects.

Figure 9. Position of StBN (red dot) regarding the three interests in home care (Ten Have 2011 p. 11). The three interests are the interest of the client, the employee and the efficiency of the organization.

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V Conclusions and Recommendations

A Conclusions

As described in the introduction (Chapter I) in The Netherlands the health care sector suffers under a constantly increase of costs and a strong political pressure to deliver “better care (meaning also better quality) for lower costs”. These points were the motivation for the government to start with huge changes in the sector. Typical examples were the new

legislation in the insurance system and the introduction of (limited) free market system in the health care sector. These changes had a great influence on both insurance companies as well as care suppliers, indeed leading to increasing legal pressure and fusion of enterprises. The most recent reorganization being the transfer of various care tasks from the central government to the municipalities. This process is called decentralization and is aimed at the three social domains: juvenile care, employment and social services, care for the elderly and long stay care. As of January 2015 the municipalities are responsible for these activities. This was achieved by changing the legislation, the AWBZ was skipped and replaced by the WMO and the Wlz. The home care sector is now paid for by municipalities within the framework of this new legislation, called the WMO (home care and daily activities) and/or by insurance companies (personal care and cure, extramural treatment, palliative care) as part of the basic general health insurance.

This changing care landscape has also influenced the market for home care and had an enormous impact on organizations in this field. Several large organizations for home care came into trouble, sometimes resulting in bankruptcy. At the same time we saw an increase in new players in the home care market, often small and medium enterprises. A relative new player, “Stichting Buurtzorg Nederland” (StBN), succeeded in getting a place in this market and even its market share is still growing.

These interesting developments in the home care sector have been the direct cause for this study and resulted in two questions, which were the central focus of this study:

1. Which elements, apart from the business’ operating model based on autonomous teams, were critical and most important for the “Stichting Buurtzorg Nederland” with respect to its success as a new player in the home care market?

2. Which pro’s and con’s are related to the operating model of the “Stichting Buurtzorg Nederland”, this compared to existing (traditional) companies and with respect to the continuity of the company?

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The first question deals with the aspects, which were important for StBN to get access to the market. The second question looks at the factors, which are important for StBN to hold its place in the market and to be able to grow.

In order to get information for the answers to the questions, StBN was compared with an existing and traditionally organized company. StZF was selected for this comparison, because this supplier could be characterized, based on its organization structure as a traditional

company.

Information, obtained from documents and other sources in the public domain, was processed using a tool obtained by a modification of the BSC methodology. The thus structured

information was analyzed by applying the theory and the model activity system, as firstly described by Porter and the activity system based business model from Zott & Amit (see Chapter II). The competitive advantages of a company can be deduced from data and

information regarding the vision and mission, the strategy and the activities of the company, which are linked in a network. The position of home care suppliers in the market is illustrated by productivity frontier by Porter. In addition the theory described by Meyer, regarding the influence of societal changes on companies and the role of leadership to deal with this, was used.

With respect to the first question, it can be concluded that StBN has reacted adequately to the “chaos” in the home care sector created by the government. Also StBN has made use of the shifting needs of potential clients and the feelings of dissatisfaction of the professional workers in the field, to design a client oriented business model. Very early in the process of a changing market and soon after its foundation, StBN succeeded in getting involved in

activities supported by the government. In this way they participated in all kind of projects aimed at transition and innovation in the home care market. In this way, StBN has not alone captured a place in the forefront with respect to new developments, but also they operate in a transparent and quantifiable way, because results of such innovative projects are made public. A welcome side effect of these activities is a continuous PR and advertisement of their name. The CEO of StBN is a man from the work field; therefore he has a good feeling for what is happening in the sector and what the problems are. He is familiar with the needs of clients, but he also knows why the professional workers are so dissatisfied. So he is looked upon as “one of us”, which makes him a natural and accepted leader in his organization.

The restoration of the autonomy of the professional and the flat organization structure with low hierarchy, but also the purposeful operating concept, are factors for the success of StBN.

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Their operating concept makes use of the network of the client and has structured options for necessary up scaling of care and is supported by a clever and good working information system (“Buurtzorg Informatie Systeem (BIS)”) accessible for everyone involved and it gives StBN a unique tool and position to develop further.

The choice for investing in an easy accessible information system for clients and personnel (recently transformed to the OMAHA system with a client portal) and for ICT systems, like “Buurtzorgweb” for exchange of information and know how, resulted in an organization with no problems regarding information asymmetry.

Also the management strategy to invest in and work only with highly qualified personnel proved to be a good choice in the market.

In general it must be noted, that StBN had no organizational heritage to overcome, like expensive buildings, old debts, lots of employees or old deals with stakeholders or insurance companies. This gave StBN the opportunity to develop the company and their organization along the lines and ideas of the management. As is concluded from the performance drivers’ cost and quality StBN has done a good job in the changed market for home care.

Question two is answered by collecting the pro’s and con’s of the StBN operating model, deduced from the data and the analysis described in Chapter IV (see also the tables and text of Appendix II), in table II. The topics having influence of the position of StBN in the market of home care, as given in the table below, are also related to general developments in the home care market, which also influence the existing organizations (StZF), as well as general aspects of management like for instance span of control.

PRO’S CON’S

Unique client oriented operating concept, using the existing network of the client, first line care systems and options for up scaling when needed.

Crucial role of the CEO in the organization, but also outside for PR actions, giving the company identity and color. This is also a point of concern because of high dependency on one person.

Organization based on a flat structure with autonomous operating teams with low overhead.

The operating concept is being copied by competitors. Thus giving traditional or new organizations the chance to move upfront in the productivity frontier of the market (see figure 3 and 8 and table I).

Excellent relation with the government and its organizations and participation in innovative projects. A special research department develops

The undertaking of various new activities, like e.g. “Buurtdiensten” and acting on new markets, like health insurance, has an impact on the span of control of the

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innovations. management. Also the legal structure gets more complex and the pressure on the organization increases. This may lead to additional layers of management. StBN must be aware of the “growth trap” lurking around the corner (Porter).

Due to intensive PR StBN is a well-known name in the market. This opens doors for new activities.

The enormous increase in individualism in the modern society can be a danger with respect to the important role for the client’s network in the operating model. Excellent (ICT) structure and systems for exchange

of information, knowledge and know-how, for clients and personnel. No information asymmetry.

Application of developed best practices by all players in the market is a thread to the front position.

Appealing leadership style and stimulating and supportive company culture, resulting in high scores for satisfaction of both clients and employees. Stimulation of bottom up innovation.

Maintaining the low overhead costs is increasingly difficult in a growing organization. Also the legal structure is getting more complex and may lead to additional costs and management layers.

Almost no long-term debts giving pressure on the year balance, combined with a good, positive costs / quality ratio.

Maintaining coherence within the organization can be a problem due to fast expansion, resulting in dilution of assumed values (social and communication) in the way the company operates.

Table II. Overview of the pro’s and con’s having influence of the position of StBN in the market of home care.

From the observations summarized in the table above, it is concluded that StBN is still in a comfortable and leading position in the home care market. However, looking at the list of con’s, they must be constantly alert and working hard to maintain its leading position. For instance the developments in E-health and information systems in the home care sector are fast, as well as improvements in efficiency, so StBN must be aware of the competition in these fields. Competitors do not sleep, but try to improve constantly. The pressure on the market, both by the government and stakeholders is still strong.

B Recommendations

The study presented is based on data and information, which was available in the public domain, both for StZF as well as for the relative new player StBN. The performance analysis made of both organizations and the conclusions drawn are based on the analysis of this information. It is interesting to note that consumers and potential clients also have mainly access to this type of information. The information used in this study consists of company documents and of reports from results of consultancy bureaus and independent researchers.

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Hard data on the performance drivers, such as data on client satisfaction, obtained from validated measurement reports indicate that these data are significant information for client and other stakeholders. Having made these observations, the following recommendations are given:

 Further improvement and usage of quality measurement systems on several

parameters. Because this can have a significant influence on the working of the limited free market system of the Dutch health care sector. Moreover publication in the public domain of such information has a stimulating effect in a competitive market.

 Application of the method used in this study (structured data analysis and comparison in combination with the application of a conceptual framework such as the activity map) on other new players in the market is recommended. This may reveal interesting information, for instance for other performance drivers such as intra- and extramural care paths, in the still developing health care sector.

 StBN works with autonomous teams and its success in the market has led to many discussions. However, from this study it is clear that copying working with

autonomous teams as a “best practice”, is not effective. It is recommended, that such a “best practice” is embedded in a companies operating model together with other relevant measures and activities. See for instance the StBN activity map (Chapter IV, figure 7), which shows the relation between the various activities. Then it gives opportunities for success.

 The style of leadership (control versus chaos) and consequently how a company is structured and organized, is important for its performance. A flexible operation of the CEO, within the scale between chaos and control, is the best option: control when it is necessary to take a decision and more of chaos when the organization needs to be stimulated, for instance in the case of participation in innovative projects. This goes hand in hand with a company culture where feedback is accepted and the delegation of authority is a standard procedure.

 Participating in innovation projects is important for care suppliers in order to acquire the newest developments in the competitive market. In addition it helps the company in its networking activities.

 Investing in personnel, for instance in quality and schooling, but also in restoration of the autonomy of the professional are important elements to improve the performance of the company.

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