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Organization, planning and control of the oncology theme in the AMC
and VUmc alliance
COMPANY PROJECT MBA Healthcare Amsterdam Business School Eefje van Kessel, 10733566
Version 1. 27 November 2015 Submitted to internal supervisor M. Kramer Version 2. 24 December 2015 Submitted to external supervisor J. Kraaijenbrink Version 3. 11 January 2016 Final version Dutch
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Management summary
This research project is conducted as part of the Amsterdam Business School MBA Healthcare. It identifies solutions for the organizational embedding of the oncology theme at location Boelelaan in the proposed alliance of AMC and VUmc. Based on literature, international best practices and Dutch cases we see the following: More and more hospitals developing centers of excellence with the organization of patient groups in separate units. This is possible when the patient group has sufficient volume in order to efficiently be organized in a separate organization.
In order to organize the usage of departmental owned or shared resources in an efficient way, there are various planning and control methodologies that can be used. In today’s information society it is possible to assign resources and budgets to different groups of patients efficiently based on available process information.
In the Netherlands wesee that not onlyVUmc and AMC,but also the sixother university medical centersare working on theformationofoncology centers. We see that these six centers make very different choices for the organizational embeddingof these centers. Groningen and Utrecht have chosen for the establishment of separate organizational units for the theme Oncology (called Comprehensive Cancer Centers), whereas Nijmegen has chosen for a matrix model with strong influenceforthe oncology center, while in LeidenandRotterdam,the oncology centers are organized without any budgetauthority and with less influence.
Based on needs and requirements of stakeholders in the oncology theme and the internal medicine divisions at AMC and VUmc, it has become clear in this study that the oncology theme should be given a more clear position in the new organizational structure. Currently the most desirable scenario for the organization appears to be the scenario in which departments and sub-departments continue to stay part of divisions. Divisions and departments remain responsible for budgets. The departments with relatively high weight because of strategic considerations and usage of expensive drugs, Oncology and Hematology, are part of the internal medicine division, but also directly have a link with the Executive Board in the strategic theme Oncology. This theme is organized in this model as a separate layer over the divisions. The theme is given a formal place in the organization chart with a managing board appointed by the Executive Board. The theme oncology has the task of aligning plans across divisions. This occurs at two levels: at the level of departments in the meeting of heads of the oncology departments and at the level of multidisciplinary care pathways. Coordination with and approval of proposed oncological strategic policy is carried out by the daily board which is done on a structural basis with the divisional boards. For planning and control the introduction of the themes indicates an additional level of planning: annual plans for cancer care are identified by the theme and confronted with the strategic objectives of the organization.
Prerequisite for the proposed organizational structure with themes is that other divisions and themes implement the same model. Prior to further development of this model in process descriptions, tasks and duties, it is recommended to exploretheopportunities forthismodelalsofor other themesanddivisions.
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Contents
Management summary 2 Contents 3 1 Introduction 4 2 Theoretical framework 8 3 Case descriptions 22 4 Results 345 Conclusions and recommendations 41
Literature and sources 43
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1. Introduction
VUmc and AMC, the two university hospitals in Amsterdam, intend to combine their activities and to enter into an alliance. Both university medical centers provide regional and national health care to virtually all patient groups, conduct research and train students for various professions, in particular medical specialist. When the medical centers will start collaborating, the core activities (care, research and training) will be redistributed over the current two locations in Amsterdam. A profile has been created for both sites, which indicated that several medical themes will be centralized on one of the two hospital locations.
Cancer care, associated research and medical training will be concentrated in the alliance on the location De BoelelaaninAmsterdamZuid.In severalexploratorystudies the existing support for this option is mapped and various possibilities for convergence ofthe expert groupsfromboth houses
are explored. In these studies, a lot of attention is given to the principle of interdependence: the activities of thethemeoncology,as well asthe activities of otherthemes, exist notin itself:thereis a lot ofcollaborationwithnon-oncologicalplayersrequired forquality of care, research and education.
Ifnotalloncologicalcoredisciplines requiredare available on one location, the key questionis how
care, research andtrainingcan be guaranteedwithout giving in on quality standards.
In this research project the focus is on whether a specific organizational model and an accompanying planning & control system may provide a solution for this. Associated with this is the question which organizational model should be implemented given the needs of the organization and what arrangements are necessary for the planning and control system.
Oncology
Oncology is the medical skill and knowledge of the treatment of cancer. Cancer is a disease that occurs when body cells are starting to multiply independently with the proliferating cells spreading to surrounding tissues and cause damage. In a next phase, the proliferating cells spread to other parts of the body. This is called metastasis.
An internist who specializes in oncology is called a medical oncologist, a surgeon who specializes in oncology is an oncological surgeon. Radiation therapists are doctors who specialize in the treatment of cancer using radiation. Also other medical specialties have sub-specialties regarding the knowledge and treatment of cancer.
Commonly, there are multiple medical and paramedical disciplines involved with the diagnosis and treatment of cancer. Depending on the location and staging of the disease, the multidisciplinary team may include the following specialists: medical oncologist, surgical oncologist, radiation oncologist, pathologist, radiologist, nuclear medicine physician, pulmonologist, thoracic surgeon, gynecologist, urologist, head and neck surgeon, oral surgeon, neurosurgeon, neurologist, surgeon, orthopedic surgeon, dermatologist, endocrinologist, hematologist, gastroenterologist and liver doctors, pediatric, clinical geneticist. Also oncology nurses, physiotherapists and rehabilitation specialists, psychologists, psychiatrists, dieticians, medical social workers, could be part of the team that provides care to patients with cancer. Various supportive departments take part in the care
5 process. In total, the professionals from more than 25 different disciplines in the hospital are involved.
In the Netherlands cancer is still the largest cause of death with nearly 45,000 deaths caused by cancer in 2014. 1 The incidence of new cancer cases is also tracked exactly in the Netherlands: The
incidence of cancer was in 2014 almost 104,000. 2 Cancer research has already led to better cancer prevention (by means of limiting excessive exposure to UV light, not smoking, no excessive consumption of alcohol and certain foods, exercise and by vaccination such as preventive vaccination against HPV), cancer is discovered in an earlier stage (early diagnosis and screening), cancer can be better diagnosed (including new imaging techniques), can be treated better (more targeted with less side effects) and also in the aftercare and in the treatment of metastatic cancer we already see significant improvements. Yet there is currently no medical solution to cure cancer and the question is whether that will come. Much research focuses on the clinical questions related to diagnosing and treating cancer, which is why close cooperation between researchers, doctors and other healthcare professionals is important, and subsequently bench to bedside testing results (translational research) are needed.
Oncology in the AMC VUmc alliance
Approximately 15,000 new patients with cancer are being treated annually in VUmc and AMC. In addition, a large group of patients is referred to one of the two hospitals with suspected cancer or similar complaints. These patients are diagnosed and treated, if necessary, by the same health professionals who treat patients with cancer. When this benign group is included, oncology covers approximately 20% of the overall patient population of VUmc and AMC together. In research and training, usually not only the issue of cancer (malignancies) is addressed but also the benign groups are included because it is so closely related with the malignant group and is often studied or taught by the same people. The choices for locations in the alliance of AMC and VUmc means that all oncology and all related benign care has to be concentrated as much as possible at one location. Exceptions are a) pediatric oncology and b) benign subjects which are more consistent with a theme other than the theme of oncology. Figure 1 shows how the oncology and other themes in the end vision of the alliance (2030) will be distributed over the two locations of the current VU University Medical Center (Boelelaan) and AMC (Meibergdreef).
1 source CBS:
http://statline.cbs.nl/StatWeb/publication/?DM=SLNL&PA=7052_95&D1=a&D2=a&D3=0&D4=0,(l-20),(l0),l&HDR=G2,G1,G3&STB=T&VW=T
2source IKNL:
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Fig. 1 Schematic representation final picture alliance AMC VUmc 2030 (Source: Rapport Alliantie AMC-VUmc Op weg naar excellentie)
The consequence of this is that some disciplines such as internal medicine, surgery, pulmonary medicine, ENT, orthopedics, urology and many others never will be able to fully concentrate their core tasks on one location; there is need for a model that guarantees quality of care at both locations.
Patient research groups / Tumor Workgroups Main groups distinguished in the oncology center:
• Patients with diseases of the digestive organs (Gastroenterology) • Patients with tumors in the head and neck (Head and neck oncology) • Patients with tumors in the brains (Neuro-oncology)
• Patients with breast abnormalities (Mammacare) • Patients with hematologic diseases (Hematology) • Patients with urological malignancies (Uro-oncology) • Patients with gynecologic malignancies (Gyneaco-oncology) • Patients with skin tumors (Dermato-oncology)
• Patients with endocrine and neuroendocrine tumors ((Neuro) endocrine tumors) • Patients with lung tumors (Lung Oncology)
7 Within these main groups all common forms of cancer among adults and the associated benign diseases are covered: The combined oncology center of VUmc and AMC still provides care to all potential patient groups and does not exclude groups. It has to be mentioned that for some main groups the research will be limited and for some groups (eventually) care will be offered in collaboration with other (peripheral) partner hospitals at other locations. This development is in line with the national development of oncology3
Each of the main groups has various subgroups of tumor types, with specialists who specialize in research, diagnosis and treatment of one or more of these tumor types. These subspecialties are one of the reasons why the Foundation of Oncological Cooperation (SONCOS) has issued guidelines for minimum amounts of patients to be treated in one hospital to ensure quality of care. Also for VUmc and AMC the size of the specified patient populations and the size of the dedicated group of (sub-)specialisms involved with each patient group is one of the reasons for a better position when AMC and VUmc join forces. This is one of the credentials for the cooperation that certainly holds true in the cancer theme.
Research questions
Traditionally, hospitals are functionally organized; medical specialty being the organizational unit. In order for multidisciplinary patient care to run smoothly, coordination between departments is required. It could be decided to formalize this alignment either in working arrangements or in financial agreements. A further development is to consider the multidisciplinary teams as organizational units with associated financial frameworks. This we call thematic organization. There are several international examples of functionally equipped hospitals, thematically organized hospitals and hybrid forms. In this research project the characteristics of these various organizational choices are mapped. The focus is on organization and planning & control.
Based on the theoretical, objective standards and subjective preferences in the organization, recommendations will be given for an optimal organizational structure and related planning and control system for the oncology center in the UMCA, the alliance of AMC and VUmc. The main question of this research is:
Which organizational structure and related planning and control system is the best choice for the new oncology center on site De Boelelaan?
Sub-questions:
1. Which organization types for hospitals exist and what are their organizational and financial characteristics? Which (objective) criteria determine the choice of an organizational structure? 2. What preferences and expected developments exist? Which are legitimate and must be
considered when choosing an organizational structure for the alliance of AMC and VUmc?
3. What is the most appropriate organizational structure based on literature, best practices, Dutch case studies and other requirements?
4. How will the embedded organization and the planning and control cycle be structured for this organization?
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2. Theoretical framework
In order to answer the research question, literature about organizational development (governance) in hospitals has been studied and international best practices in the field of organizational development of hospitals have been consulted. In addition the developments in the field of planning and control in hospitals are investigated.
2.1 Literature about organizational development in hospitals
Over the past centuries hospitals have evolved into complex organizations. In the second half of the nineteenth century medicine grew as a profession, specialisms arose and hospitals developed into independent organizations. We see the development of specialized care or collaborations of medical specialists focusing on care for certain parts of the human body, certain diseases or life events or certain age groups. In addition, the distinction between general and teaching hospitals developed. In Western countries hospitals usually developed a functional organizational structure. The divisions are divided among functions, decision and authority are decentralized and the organization is managed hierarchically. Department heads in this kind of hospitals will typically result from the functional field and have thorough knowledge of the function of the department. (Lega, F., DePietro, C., 2005) Functional organizations into product-oriented organizations
In the organizational literature we see that the last few decades, more and more organizations have implemented other organizational structures as a result of both the increasing opportunities to share knowledge within the organization and on the other hand changed product-market combinations. In addition to the functional structure, where products are being transferred from department to department along the processes of value creation, we know the process- or product structure, the job shop structure and the project- or matrix structure. Across the functional structure, in which departments are formed according to function or specialization, workmanship or production processes, we see the product-oriented organization: In this model, departments are formed towards customers, products or markets. This model is useful with large volumes and limited variation in demand, variants of a standard product can be produced in small or large series with little variation. The job shop and project structure are examples of structures where smaller volumes are produced in fixed or alternating teams. Figure two shows the functional organization model and a model for division organization.
9 The basis of all types of organizational structures is the line organization. This is represented by a hierarchical vertical "line" and a horizontal division of labor in units. This horizontal division of labor can be based on four characteristics: function, geography, product or market. These activities increasingly find place across the borders of these organizational units: we call this a matrix organization. An example is multi-disciplinary care. AMC and VUmc essentially work like a matrix organization, however this is not embedded in the structure. Within a matrix organization there is much variation possible. The question is how should be dealt with the department-spanning activities. How are they managed and coordinated? What is the first level of planning and what is the second planning level? How are the resource allocation process and the planning and control organized? What is the mandate of the leadership? Who is ultimately responsible and accountable for the care?
From Business Unit structure to matrix structure
The Standard Model for Internal Governance in the 21st century is called the M-shape, a business unit organization. In this organization, the Executive Board organizes the organization through
1. The mission and shared values of the company 2. A strategy
3. Determining the business scope of each of the operating units (= structure, decision rights) 4. The determination of the resource scope of each of the operational units
5. To appoint, evaluate, reward and dismiss the management of the units 6. The funding of operations, the resource allocation process
7. Appoint strategic and financial goals
8. The performance of the control tasks, market trends and criteria for efficiency (KPIs) 9. Imposition of policies (e.g. Accounting standards)
This organization is based on a lot of assumptions, many of which no longer apply in today's society. The assumptions that are no longer valid are:
1. Each business unit or division has its own production function or business model and it is organized autonomously
2. The resources unique for product / market / customers are tangible and complementary 3. Absence of cross-selling opportunities
4. Products or divisions are not complementary
5. Value is entirely created within the organization, not outside
6. Profits generated in the divisions to the benefit of the organization as a whole 7. Information is costly
8. Initiatives from the divisions are embraced by the management division, responsible for managing opportunities in the market and utilization of the available resources.
9. Communication is costly, slow and communication channels are limited
Because the circumstances have changed, the business unit model is basically obsolete. In its place comes the Matrix or Project model, a model where (situational) teams will be formed for customer segments in order to offer the best mix of value. The figure below shows the business unit model and the model for a matrix or project.
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Fig. 3 Business unit organization versus Matrix- or project organization
Organizational configurations
In addition to the description of the organizational model as an organization chart, it is customary to describe the organization on the basis of certain characteristics. The organizational configurations that Mintzberg (1992) describes are familiar archetypes that operate as a common language in the conversation about organizational design. According to Mintzberg, there are six types of configurations and in addition there is an overall organization structure, where several types of configurations are covered. The seven basic configurations are:
• Entrepreneurial organization, an organization with a flat structure and little standardized systems
• Machine organization or bureaucracy, where everything is standardized. Processes are defined as a system, and are regularly analyzed for improvement opportunities. Machine organizations are vertical organizations with low-skilled repetitive work.
• Professional organizations are like the machine organization but the basic consists of highly skilled professionals who want to determine their own work.
• Division organization consists of several divisions with central headquarters with support functions. Decision making is more decentralized than in the machine organization. The disadvantage is that the divisions may have conflicts of interest both towards the markets and towards headquarters.
• In an innovative organization professionals with the necessary authority are brought from different parts. In this type of organization flexibility is the largest, which can be switched quickly into new markets.
• Political organization is an organization in which no real coordinating system is available. What characterizes the organization is the lack of one of the other organizational structures. • Missionary organization is an organization that focuses on organizational ideology. An
example is Apple: Apple is following Steve Jobs’ ideology of an integrated system of products, where the customer does not have to configure (no configuration can be real), is ideal. This is leading to Apple's way of organizing and producing.
Within a division organization multiple configurations can exist. Inside the hospital we see that hospitals traditionally can be characterized as a professional organization. The division organization
11 has been added here when hospitals became so large that because of span of control and decision-making a more comprehensive structure was needed. Currently we see that authors such as Christensen (2009) distinguish between different types of care where different configurations apply.
Different types of care
For the sake of optimization of the organizational model of a hospital, it is valuable to distinguish between different types of care. Christensen (2009) distinguishes between intuitive care where the availability of resources is important, empirical care where processes have to be standardized and precision care where results should be regulated. Theoretically over time all care changes through research and development from intuitive (little predictable and repeatable) via empirical towards precision care (straight forward). With these different types come different regulatory regimes and other forms of organization. Fully protocolized care fits for example well in a focused factory (with the organizational model of the job shop or product-oriented organization, in terms of Mintzberg a machine organization) while intuitive care really belongs in a university medical center, an innovative organization with a matrix or project format. The intermediate area of empirical care can be organized typically in large clinics, professional organizations according to Mintzberg.
Christensen distinguishes between three different organizational models: solution shops, value-adding process businesses and facilitated networks. Solution shops are departments that are equipped to diagnose and to find solutions to unstructured problems. Important asset for an organization as solution shop are the professionals, the employees. Christians calls care that asks for a solution shop Intuitive medicine. Value-adding process businesses are organizations where input is being transformed into output with greater value. Value Adding Process Businesses perform repetitive tasks, the methods are for this purpose laid down in processes and task-specific tools. A third business model are the Facilitated Networks. This model uses knowledge and connects customers and suppliers together in a network. We see more and more companies that owe their existence to organizing, facilitating and maintaining such networks. In care this business model offers opportunities for new and better (disruptive) solutions at lower costs because patients and professionals can easily share ideas with each other.
Integrated Patient Units
Michael Porter has published a lot of research about hospitals that are equipped as Integrated Patient Units: In this model, activities are clustered within the hospital to the patient group where they contribute to. In this model, volume is a key success factor: After all the resources are assigned exclusively to the IPU and this must be effectively deployed. It is interesting to see the formation of an IPU as the application of the Set Theory in which various collections exist that have minimal overlap and form a larger set. Figure four illustrates this principle.
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Fig. 4 Venn Diagram of two subsets with common elements (colored)
Conclusions literature about organizational development in hospitals
The development of business unit organizations to matrix organizations and the distinction between full protocoled care at one end of the spectrum and intuitive care at the other side, implies that in several variants for hospital organization come forward from literature. The model of the Integrated Patient Unit can be used for both intuitive and for protocoled care, volume is a determining success factor. If the care of a specific group still has many links with other groups a matrix model can be the better choice; here, it is important that processes are well documented, and management or control information is available.
2.2 International best practices from literature
An example of a hospital which is organized in IPU's is the Cleveland Clinic in the state of Ohio in the United States. This university hospital has been completely reorganized in 2007. Led by the Director, Dr. D.M. Cosgrove all hospital services were reconfigured in multidisciplinary teams, from the perspective of the patient, around diseases and/or organ systems. These new units were called institutes. It was possible to form these teams because of the large investments in information technology Cleveland Clinics had made since the 90s of the last century. The knowledge that was available within this information system made it possible to distinguish which institutions had sufficient size and appearance to create efficient teams. In the course of the years not only the cancer institute was formed, but also for example a Wellness Institute, an institute for cardiovascular care, an Eye Institute and many other institutes. These institutes are the budgetary units in the hospital. (source: Porter and Teisberg, 2013)
Johns Hopkins Hospital in Baltimore is another example of a hospital organization structured to groups of patients. The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center is an academic institution with great autonomy with a matrix structure. Since opening in 1973, the Cancer Center has an internationally leading role in understanding the mechanisms of cancer and the discovery of new treatment methods. It was one of the first centers that was recognized by the US National Cancer Institute as a "Center of Excellence". Within the Comprehensive Cancer Center over 30 specialty centers and clinics are realized. The JH SK CCC has its own structure. The size is of great importance (source: Lega, F. DePietro, C.), profitability and quality of research, education and care are the basis of the valuation of the departments. Within departments, the department heads are held accountable for profitability and quality delivery and have to define their own strategy. Departmental administrators (administrators role) have a connecting role between the hospital and university. The main coordination mechanism is the budget negotiation on the contribution margin.
13 The department management is responsible for the direction of nurses, support staff and all logistics performance.
When we look outside the Netherlands to leaders in the field of oncology it is striking that three leading centers, Mayo Clinic, Johns Hopkins and Cleveland Clinic are very similar organization wise. These three centers have organized care and research in Centers of Excellence, which are organizational units.
European Centers of Excellence
Kings Health Partners, London, United Kingdom and Karolinska University Hospital, Stockholm, Sweden both have the same system as Johns Hopkins: Care and research are organized in Academic Health Science Centres (AHSC). Within an AHSC collaboration is encouraged, with an increased focus on the patient group in the field of basic and translational health research, clinical care and education this creates better opportunities, regardless of organizational barriers in order to create faster improvements in health care.
Imperial College Healthcare, London, United Kingdom is a merger of three hospital sites, organized in four divisions:
• Internal Medicine • Surgery and Oncology • Research and Support • Woman and Child Health
In its clinical strategy for 2015-2020 Imperial College Healthcare also provides for formation of seven AHSC Centers for Translational Medicine:
• Metabolic diseases • Brain
• Heart and vascular disease • Infectious Diseases
• Inflammatory diseases
• Surgery and technology, oncology and hematology • Women, child- and birth care
How these departments have to be arranged and implemented has to be developed further in accordance with the strategic plan.
Charité University Hospital, Berlin, Germany consists of four locations and more than 100 departments and institutes. From the point of view of patients focus, 17 centers are formed, the Charitécenters. The Comprehensive Cancer Center is one of these centers, all relevant interdisciplinary activities are organized here. The figure below shows the organizational model of Charité.
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Fig. 5 Organization chart Charité University Hospital Berlin (Source: http://www.charite.de/)
Care focus hospitals
The observation that more and more major hospitals are organizing their care and research the same way in centers of excellence is consistent with the findings of Lega and Depietro (2005). Based on a comparative study of large (over 300 beds) multi-specialty hospitals they conclude "These hospitals in different countries move towards the same organization architecture although they have to deal with different historical internal and external organizational and environmental factors". Lega and Depietro call this governance model the care focus hospitals. They identify four general international developments where this architecture comes from. Firstly, there are financial reasons, secondly the institutional and social influences, thirdly clinical developments (including still continuing specialization) and the last reason they give is professional development (among others new jobs and functions in care). To go along with these developments, hospitals around the world are adjusting through integration, redesign and other adjustments. Especially in organizational redesign this involves organizational mechanisms such as planning, programming, budgeting and controlling, human resource management etc.
Lega and DePietro examined a large number of hospitals in Nice (France), Ticino (Switzerland) Palermo, Milan and other Italian hospitals, Johns Hopkins (USA) and hospitals from England, Spain and Germany. The trends they see in the field of Governance are:
1. Clinical integration by the formation of organizational units for patient groups. This involves the development of functional organization units to a division or business unit organization. Inside, the development of multidisciplinary teams is an international trend, where it is established that responsibilities and competencies within the team compared to individual patients should be clearly agreed upon.
15 2. Integration of resources: the development that resources are no longer permanently
assigned to traditional groups / disciplines but based on new criteria are assigned to different groups of patients. Other characteristics (such as expected length of stay: short-medium-long) can be thought of to guide the allocation of shared resources. This trend is also observed internationally.
3. Patient focus and patient groups is mentioned separately: Not the knowledge and skills of the specialist (supply-driven care) but the needs of patients (demand-driven care) are increasingly the basis on which care is being redeployed.
4. The developments that caregivers are more involved in the organization of work and not only in implementing care implies new organizational mechanisms and new roles.
Functional descriptions and planning and control mechanisms are needed to sustain this new care system. It is recommended to use the Balanced Scorecard, which not only monitors financial goals but also quality and development objectives.
Clinical Pathways
Richard Bohmer has published frequently on the subject of organization of hospital care through clinical pathways or care processes of diagnosis related groups. Amongst others, he sees examples at Intermountain Health Care, one of the largest healthcare providers in the western US. Intermountain Healthcare is a healthcare conglomerate in the US which is nationally recognized for its highly structured approach to the management of quality of clinical care. Organizations like Intermountain Healthcare and University College Hospital in London have developed an organizational model in which leadership in combination with explicit expectations provide explicit quality of care. The core of this system consists in the care processes they have defined including explicit goals. This leads to both high efficiency as well as quality care. In organizations where this theory is applied a second alignment level is added to the old structure of departments of disciplines, This second level follows the customer or production line. Bohmer (2010) states that "Decisions, tasks, and workflows crucial to optimizing patient care must be the organization's primary focus." In this model, the horizontal bars are patient care paths, research, education, general services and other shared tasks. These horizontals are appointed the first level of planning of the organization. This model needs detailed information on the resources required by horizontal planning and evolves into another form of budgeting.
Vanheacht (2007) has performed research in KU Leuven on clinical pathways and their impact on the organization of care processes. He suggested that clinical paths, are in the first place used to optimize the quality and efficiency of care processes. He concludes that clinical pathways are one of the key methods for the organization and coordination of care processes but the methodology should be further improved. A pathway is a complex intervention which should be developed and constantly monitored by a team of clinicians, managers and patients. Teams that work with clinical pathways have a more logical view of the organization of the care process. Clinical paths are more than the development and implementation of a new document or structure of the care process. Clinical pathways are complex interventions that structure processes and monitor the outcomes of care in motion. They should be used as a method to achieve a particular goal. Vanheacht states that clinical pathways are increasingly being used to give structure to the organization. Figure six shows
16 schematically how clinical paths or themes are positioned as horizontal bars in the organizational model with respect to the vertical departments or divisions. Both report to the governing body.
Fig. 6 Clinical pathways
Conclusions about international best practices from literature
When we take a look at the international best practices in literature we see that organizations that are renowned in the field of oncology care and research often chose for an organizational structure in which the theme of oncology is a unit of organization, with budget and accountability functions. Within this department specific groups are responsible for parts of oncology, but the bond between the components that make up the oncology is greater than the connection with organizational units outside the oncology domain. The volume of the oncology is in these examples so large that the department could be a standalone organization on itself.
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2.3 Planning and control
Budgeting or financial planning is primarily one of the processes performed from the perspective of financial management in organizations of any size. Control then means that activities are carried out in accordance with the plan. The budget of an organization or organizational unit is often a short-term plan (<1 year). To perform activities in accordance with that plan is clearly a way to show that an organization is in control. In a broader sense, the budget process can be usefully deployed on four organizational areas namely operational planning, performance evaluation, communicating goals and strategy (Hansen and Van de Stede, 2004). The role of budgeting as a performance indicator instrument is described most in literature; often the four applications take place simultaneously. Practice shows that the management control function / resource allocation process is of decisive importance for the realization of the strategy / policy / objectives and the necessary changes. A good resource allocation process implies more than budgeting: it takes good leadership to make a difference.
History of management control
In 1954 Peter F. Drucker introduced for the first time the term "Management by Objectives". This perspective came in place of Management by Instruction and central planning. Management by Objectives implies that organizational goals are translated into local objectives in order to generate better use of knowledge that is available in the decentralized organization. With this concept vertical information asymmetry is reduced. In 1965 RN Anthony introduced the concept of management control and management control systems as a method to translate strategy into jobs / assignments mainly through the budgeting process. Bower transformed Management by Objectives in 1970 into bottom-up resource allocation process, this remains the most widely used system for strategy execution. The balanced scorecard, introduced by Kaplan & Norton in 1992, is an alternative that also allows more abstract features to be included in the valuation of organizations.
Resource capacity planning in hospital care
Van Merode (2004) advocates the use of Enterprise Resource Planning for hospitals. In his opinion, integrated hospitals cannot function without a central planning and control system in order to plan the required processes and capabilities. The ERP system is in his view the best information product with which this function can be performed. ERP systems make it easier for organizations to respond to fluctuating environmental variables: because all processes have been mapped and recorded in a uniform manner, it is relatively simple to translate changing demand and adjust targets in the underlying plans. The planning framework of Vissers et al (2001) recognizes five levels of planning and is the basis of the ERP system for hospitals. The five levels appointed here are: Strategic planning, patient volume planning and control, resource planning and control, patient group scheduling and patient scheduling and control. This only concerns the pre-planning levels (also called offline planning). Reactive planning (also referred to as online planning) and monitoring are not included in such a system. This model however assumes that the care in the hospital is organized in more or less independent business units.
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A model for planning and control in health care
Hans et al (2012) present a model for planning and control in health care in which extra dimensions are added to ensure that the entire scope of planning and control in health care is covered. The following dimensions are developed:
1. Medical (technological) planning: decision making by clinicians related to protocols, treatments, diagnostics and triage
2. Resource capacity planning: planning, scheduling, monitoring and control of renewable resources (facilities, equipment and people)
3. Materials planning (such as consumable materials, medicines, blood, food)
4. Financial planning: how the organization should manage costs and revenues to achieve the
objectives of today and tomorrow.
These dimensions are completed at the strategic, tactical, operational and executive level. This leads to a complete but complex framework that enables both individual departments, organizations and even complete transmural chains to be controlled, as shown in figure seven. The primary goal of this framework is to structure the different functions in the field of planning and control. It can be used to determine which features are missing, underdeveloped or insufficiently coherent or even are conflicting with other functions.
Fig. 7 Application of the framework for health care planning and control in a hospital (Source: Hans, Van Houdenhoven, Hulshof, 2012)
Relation between budgets and performance
King et al (2010) examined the budget practice in small healthcare organizations. In the Australian study 144 respondents were interviewed. They found a relation between the characteristics of the considered budget and the performance practice of the organization. Amongst other results, the researchers found a connection between the usage of budgets and performance. Although the comparability of this research with the Dutch university medical centers is limited, it is an interesting fact that working with budgets in healthcare positively influences performance. The researchers are very cautious about their findings and calling especially for further research.
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Performance Indicators and Balanced Scorecard
Previously I discussed the role and usefulness of budgeting in health care organizations. It is important not only to look at budgets but also at the other parameters which individuals or teams are held responsible for. Obviously, these are not only the financial parameters (cost) but also other dimensions in which the goals of organizations are measured: quality, speed, reliability and flexibility. The consecution of these five Key Performance Indicators determines the objective of the organization. The figure below shows schematically how the five key performance indicators, cost, quality, speed, reliability and flexibility behave towards each other.
Fig. 8 Five key performance indicators and their interdependence4
Kaplan and Norton (1996) developed the Balanced Scorecard with this in mind. The Balanced Scorecard contains financial indicators, customer-focused indicators, process indicators and indicators in the field of development and growth. They all originate from the vision and strategy of the organization. In 2008 Kaplan and Norton came with a model for planning and control in which the strategy of the organization is linked to the planning and control of the operational processes. Extra attention is given to strategic themes besides resources. One could state that in this model the knowledge- or information view is connected to the resource based view or production, although organizational structure is not explicitly appointed. In the model of Kaplan and Norton, strategy, planning and control are linked along the following steps:
1. Develop corporate strategy
2. Select strategic themes and make annual plan 3. Plan resources of producing departments 4. Link department budget and theme budget 5. Control, learning organization
6. Measure and adjust strategy
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Fig. 9 Strategy, planning and control, Kaplan & Norton
In 2005 Bower and Gilbert presented a revised version of the resource allocation process: Based on years of studies, they conclude that the strategy in organization is achieved through an emergent process and to a lesser extent derives from the formal objectives of the summit of the organization. They demonstrate that the realized strategy stems from a pattern of statements about the use of resources that occur at all levels of the organization. This supports the idea that the structure of the organization determines the achievement of its strategic objectives.
Conclusions planning and control
A transparent organizational structure, clear agreements on how budgets come about, clear processes and key performance indicators and well defined roles and responsibilities: All this is necessary in order to achieve the organizational objectives. The diagram below of Strikwerda (2014) illustrates how developments in the resource allocation process can be implemented through the increasing availability of (planning) information in the healthcare sector.
21 The framework of Hans et al can be used as a format to outline the various planning and control functions. When this framework is used the following tasks can be appointed:
1. Strategic medical: strategic agenda for research and development (research) 2. Strategic Resources Strategic HR policy
3. Strategic resources: Strategic supply chain management and purchasing strategy 4. Strategic Financial Strategic multiannual budget
5. Tactical medical: medical policy portfolio choices
6. Tactical resources: staff plan for each department / group 7. Tactical resources: supplier selection and procurement tenders 8. Tactical finance: budgeting and cost allocation
9. Offline operational medical: logistics planning of care pathways 10. Offline operational resources: staff scheduling
11. Offline operation means: Ordering and order sizes
12. Offline operation financially: Weekly production planning, cash flow / cost analysis 13. Online medical operations: triage and scheduling consultations, OK, etc.
14. Online operational resources: monitoring and corrective hiring staff 15. Online operations means: deliver, rush orders
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3. Case description Dutch University Medical Centers
To develop a good model for organization, planning and control of the oncology center of AMC and VUmc, we described in the previous chapter the developments in the field of organizational development in hospitals and international best practices described in the literature. Since all Dutch university medical centers are struggling with this topic I continued to examine what choices the other Dutch university medical centers are making. I focused this part of the research on the structuring of these organizations in general and the positioning of the oncology theme in particular. To this end, websites and publications of the various UMCs were consulted and thereafter discussed with program managers oncology from five out of six of the other oncological university centers. The questionnaire of this semi-structured interview is included in Appendix I.
3.1 Current situations
Situation AMC
AMC is a teaching hospital with a mixed divisional structure. Besides the divisions Internal specialties, Surgical specialties, Women and children, Neuro and psychiatry, Laboratory specialties, Imaging & diagnosis and treatment center and the Clinical methods and public health division there is a Division operation center, an Intensive care division and an Outpatient division. There is also a division Cardiovascular center. Collaboration in oncology is aligned since a few years in the oncology board. This is a funded project with limited support by policy advisors. A special part is GIOCA: Gastro-Intestinal Cancer Center Amsterdam. This center of excellence in the field of gastrointestinal tumors supports collaboration between specialists from different disciplines; patient care is coordinated within strict protocols and working arrangements. GIOCA's objective is not only to offer excellent care, but also innovative care. The GIOCA Board formulates and monitors annual objectives in the three academic tasks: patient care, research and education. AMC has one research institute in which all scientific research is organized in seven themes.
Situation VUmc
VU University Medical Center is an academic medical center with a divisional structure in which departments are clustered according to specialties. VUmc consist of six divisions. The divisions all have their own budget responsibility and engage in patient care, teaching and research. The division is headed by a Division Board. Besides the divisions VUmc designates five research institutes where management and support of research and education are performed. VUmc Cancer Center Amsterdam is one of these research institutes, but also the virtual organization in which care, research and teaching in the fields of oncology and immunology are linked. The research institute VUmc CCA is organized into five programs. Patient care and clinical research have been structured in multidisciplinary pathways, which guide cooperation in the field of health care and research. These pathway teams have a chairman who is not appointed by the Board; there is informal, historically grown leadership in each team. VUmc CCA has a small staff department of policy advisors who support research, education and multidisciplinary cooperation. The board of the institute has a small budget with which limited tasks can be performed. Thanks to a rich external foundation, the VUmc
23 Cancer Center Amsterdam Fund deploys funds for care, scientific research and research infrastructure and external profiling.
3.2 Case description Erasmus MC, Rotterdam
Departments at Erasmus MC are grouped into nine themes: partnerships of departments that support processes within their departments and cross-departmental processes. A theme manager and a medical specialist are heading each theme. In total, Erasmus MC has 51 departments. All executive support tasks that do not need to be organized on the theme level, are grouped in two Service Organizations (SOs): a service organization and a SO Knowledge. All tasks in support of strategy, policy development and accountability are organized within the department Strategie Beleid & Verantwoording where the group controller contributes to the realization of strategic objectives. The group controller also has an independent position (directly under the Board of Directors) to fulfill the assessing, monitoring and consulting role properly. To perform this task the company controller is in charge of Finance & Control.
Fig. 11 Organization chart Erasmus MC (Source: http://www.erasmusmc.nl)
The Erasmus MC Cancer Institute is managed by the Council Cancer Institute Erasmus MC. In addition, there is an executive committee (dagelijks bestuur) composed of two physicians (chairman and vice-chairman), a project secretary, theme advisor and administrative support. Theme Daniel (den Hoed) is one of the themes within the cancer institute. The department of Internal oncology is situated within the Daniel (den Hoed) theme, Internal medicine is another department that is situated within a different theme. The general tasks within the domain of general internal medicine also stand alone.
24 The cancer institute does not hold budget responsibility: the financial structure remains to the medical departments. It has been examined whether it is possible to give budgets to the cancer institute: this is not an option now because of the administrative burden which this entails, as it involves the distribution of capabilities and resources. Plans are to realize an overarching budget for the institute through distribution. Accountability does take place in a limited way by means of reporting biannually in spring and fall.
The Institute is well embedded in the organizational structure. This was a good step in the organizational development and has become a must too. Matters such as choices of portfolio are a responsibility of the institute. It is a very large institution, therefore multidisciplinary cancer centers are formed within the institute. Examples are the bladder center and the brain tumor center, centers for other patient research groups will follow in the future. Research is leading within the specialized centers under the Erasmus MC Cancer Institute. It is thus quite a difficult, complex, four-dimensional structure in which it is a challenge to establish a good balance between power and responsibilities. It is important to note though, that the transition from a monodisciplinary to a multidisciplinary approach is a model in development.
Another institute, neurosciences is more hierarchically organized. Whereas the cancer institute has evolved organically from the workplace, thus from health care, the neuroscience institute was conceived from research. Other institutes have not yet been formed. In the future a single location for oncology Erasmus MC will be constructed. Currently it is still organized in different locations. The institute ensures alignment across locations and departments. Coordination of departmental activities finds place on the departmental level and in the staff convent.
3.3 Case description LUmc, Leiden
The LUMC oncology center is currently configured based on the following principles:
• Current structure and control is leading. (Departments <-> Division <-> Board of Directors) • Tumor Work Groups (TWG) co-ordinate and, together with specialists from departments,
they are responsible for implementation of agreed policies.
• The board of department heads formulates and evaluates annually an oncology policy (science and health) based on the contribution of the TWG.
• Prior to approval of the oncology policy by the chairman of the board, it is discussed with the divisions and finalized. Policies are part of the regular P&C cycle as KPI's. The TWG carries out the policy.
• Board of Directors ratifies the appointment of chairman of TWG and appoints the chairman of the board of department heads.
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Fig. 12 governance center for oncology LUMC5
1. Regular planning and control cycle including KPIs for oncology;
2. Alignment with and approval of the proposed oncological policy by divisions in the inter-divisionair consultation;
3. The Chairman of the Board of department heads is appointed by the Board of Directors of LUMC. TWG and Board are jointly responsible for achieving results (KPIs). TWG is responsible for making policy and coordination of care and science. TWG has a chairman, appointed by the Board of Directors.
Board of department heads: board consists of oncology involved department heads and leaders of the relevant profile areas (Board determines relevant profile areas in consultation with the Executive Board).
To stay embedded in the division structure of LUMC is important for acceptance. Therefore they have chosen to focus on Tumor Work Groups. The creation of centers of excellence, research and regional partnerships are targets of our strategical plan. Leadership is important: functional requirements and profiles for leaders of tumor groups, are set by the Executive Board. Radiotherapy and Clinical Oncology are part of the same division. Internal medicine is part of a different one. This section is subdivided into subsections as endocrinology, nephrology etc.
Budget Responsibility: There is no budget responsibility in the oncology center. The Divisions remain budget responsible, though the chairman of the oncology center will join discussions with division boards in budget rounds. Responsibility for translating plans into capacity, specialists, etc. lies with the divisions and departments. Only a limited budget for case management is likely to be part of the oncology center in the near future. There is no formal consultation but there are regular informal discussions with the Executive Board of LUMC. The Link between care and research is not yet properly developed in LUMC, this is part of the task of the new oncology center LUMC.
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Fig. 13 Organization chart LUMC 2015 (Source: https://www.lumc.nl/)
3.4 Case description Maastricht UMC+
The Maastricht UMC Oncology Center is one physical unit within the Maastricht University Medical Center where all outpatient care and knowledge -such as education and research - in the field of cancer converges around the patient. Since 2009 all outpatient cancer care houses in the Maastricht UMC Oncology Center. The Oncology Center will evolve into a clinic with an outpatient center that can offer patients everything they need from prevention to aftercare. Therefore it is envisaged to include the following in the Oncology Center: a medical day center (chemotherapy), clinical examination of GROW (the trial office) and laboratory research focused on whether or not giving a subsequent treatment.
The current position of the oncology center in the organizational chart has not yet become clear.6
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Fig. 14 Organization chart Maastricht university medical center 20147
3.5 Case description UMCG Groningen
University Medical Center Groningen has its oncology center for years: this is the clinic where outpatient care for several oncological groups is provided "polikliniek 20". This center is controlled by the different sectors where the oncological disciplines belong to. This center houses the following specialties:
• Hereditary Tumors (Clinical Genetics) • Medical Oncology
• Hematology • Lung Oncology
• Surgical Oncology (melanoma / sarcoma)
• MOC-poli (Mammae, Ovarian Cancer). This is a special clinic for the diagnosis of hereditary breast and / or ovarian cancer
Also the combined intake of patients by the Head and Neck Oncology finds place in this clinic.
Since 2011 UMCG has an oncology committee with representation from all tumor groups. On October 1, 2015, the UMC Groningen Comprehensive Cancer Center was established: this is a center with the following features: UMCG has a sector structure, the comprehensive cancer center is anchored in this structure, departments such as radiotherapy, medical oncology and hematology are
28 part of sector D oncology. The sector consists of more than 500 FTEs and is responsible for the entire production budget of the departments and the business office. Periodic meetings find place with the Executive Board as well as with other sectors. The board of the Comprehensive Cancer Center, also known as the chain board consists of four members: the heads of radiotherapy, the department of medical oncology, the sub-heads of oncological surgery (this subsection remained part of general surgery) and a managing director with a business background. A program manager supports organizational change aspects (change management).
Fig. 15 Organization chart UMCG8
The comprehensive cancer center has overall responsibility for care, research and education. Tumor Work Groups have their own specialized role within the Center. Quality aspects such as ISO certification is situated in the comprehensive cancer center. How the comprehensive cancer center will function as a sector is still under development. A thorough preparation by designated staff made the transition easier. Probably the surgical care will also be concentrated in the comprehensive cancer center in due time. Similar developments in UMCG can be seen in the areas of transplant medicine and acute care.
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3.6 Case description UMC Utrecht
UMC Utrecht has recently opted for a separate division for UMC Utrecht Cancer Center. Here a large proportion of the cancer care is concentrated. This division is designed along the lines of the only Dutch categorical cancer center Antoni van Leeuwenhoek, the planned merger partner of UMC Utrecht between 2011 and January 2015. UMC Utrecht and Antoni van Leeuwenhoek have expressed the ambition to work together to further improve diagnosis and treatment for patients with cancer. A uniform structure can facilitate this cooperation.
A division at UMC Utrecht is usually led by a four person division board. The division leadership consists of a medical manager (almost always professor), a manager research and education (professor), an operations manager and a care manager (often someone with nursing background). Divisions have their own budget and division policy. The policy within divisions will be written down in management contracts. These management contracts are concluded with the Executive Board. Within the oncology division care pathways and care chains (tumor working groups) come together in the oncology committee.
Fig. 16 Governance Cancer Center UMC Utrecht (Source: UMC Utrecht)
Before the UMC Utrecht Cancer Center became a division, it was appointed as a project: Within the UMC Utrecht, the divisions are dominating in terms of organizational principle, there was a need for more connections and a more uniform profile. Therefore, six priorities were appointed at the
30 crossroads between the divisions. One of these priorities was cancer. To achieve this virtual matrix in 2006, finances up to € 5 million were used to fund the Project Cancer Center. With this project it was possible to make a large development beyond the division structure. The first five years the focus of the cancer project was on care, while research and education developed independently. In 2012 the project cancer was transformed into a program and in 2014 to a profit center. From 2015, the oncology division functions independently: In concrete terms this means that all cancer care in 2020 after refurbishment will take place in one of the clinical towers (Tower B). In the past two years the necessary so-called unbundling of oncology occurred in the other divisions, this has been an extremely complicated process. Many professionals not only provide cancer care; Physicians work for a certain percentage of their week in the oncology division and not all relevant disciplines are part of the new division. Surgeons are still doing general services as well. Medical oncologists were already a separate department alongside internal medicine and did not do services for more general internal medicine. The general departments themselves had to reorient their objectives. Multidisciplinary clinics will be set up. Oncological wards and operations, including finance are housed in the Division of Oncology. Research is still part of the research institute, whereas clinical research is part of the departments.
Budget Responsibility: the division of oncology has overall responsibility for the entire budget. There is a management contract for the division with the main component being the division budget. The three members of the Board of Directors each have a number of divisions in their portfolio. The holder of the portfolio consults the division management every two months. In addition there is half yearly coordination between division management and the full Board.
The structure chosen is still under development but a sincere improvement from the previous fragmented structure. The gain is at the level of the patient and at the level of the employee. Important is the development of a vision on care that provides clarity for patients and directs the actions of employees. The Brains Division is somewhat similar; there we see concentration of specific patients and professionals of UMCU.
3.7 Case description Radboudumc, Nijmegen
The organizational structure of the University Medical Center Nijmegen Radboud has changed completely in 2007 under the leadership of a new CEO who took office in 2006 after a severe crisis at the heart center for adults. Mr. Lohman had good experiences in Amsterdam OLVG with setting up a hospital with departments as Business Units (BUs). Radboud University Nijmegen Medical Center has chosen for departments as profit centers (Resultaat Verantwoordelijk Eenheden (RVE)) that report directly to the Board of Directors. This is important in this model: no interlayer or clustering of departments but direct accountability of departments to the Executive Board. The Board is supported by a small, high-quality corporate staff. There is a clear distinction between line and staff; All support services are merged together in a service business. The 50-60 RVEs are headed jointly consisting of a doctor and a manager. The RVEs are fully responsible for care, research and education and are optimally facilitated for this purpose with all relevant data properly administered, finance must be transparent in income and expenditure. Strategy and annual agreements make part of this. The end result is that market thinking is encouraged throughout the organization.
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Fig. 17 Organization chart Radboudumc 20159
The oncology center RUCO within Radboud University Nijmegen Medical Center started as a project of 35 collaborating departments resulting in 13 multidisciplinary care chains (consisting of one or more clinical pathways). In 2015, the RUCO transformed into Radboudumc Center of Oncology with the aim to enhance cross-departmental policy making and to improve and implement the regional network strategy. The organizational structure chosen for this is the following:
• One person in the Executive Board accountable for all relevant matters related to oncology (care, research and education)
• The Center for Oncology also has two heads, one physician and a center manager.
• The Center reports as the departments of Radboudumc directly to the Executive Board. Every month there is a meeting with the Chairman of the Executive Board.
• The leadership of the Center is part of the top100 of the hospital, a meeting that discusses policy issues.
The executive committee consists of the central leadership and some permanent members (heads of department / chain owners in the fields of radiotherapy, medical oncology and hematology and research) and some rotating members (representing oncological or other care chains or departments). The executive committee takes strategic decisions beyond the level of departments. There is a management team for operations consisting of the central leadership and a project manager, a representation of the chain owners and employees who are operational responsible for projects. The oncology committee consists of the center leadership, a program manager and all chain owners. A general board consists of representatives of all departments involved in oncology, oncology committee and other representatives (primary care, oncology nursing, and network). There is also an advisory board including patients and other stakeholders. Besides the Center of Oncology, there is also a research institute (Institute for Oncology). In the future, all research will be more integrated into the center; research is already being integrated as a pilot in a selected chain.
Budget Responsibility: a year plan is created annually by the center for oncology. To this end, the departments submit their plans to the center leadership and issues are aligned. The plan is submitted
9
32 by the center to the EB. From top-down perspective, if for example 2% growth is allowed for the whole UMC, then 1% may be granted to oncology. The budgets are allocated directly to the departments.
In addition to the Center for Oncology, the Radboudumc has a pediatric center and a heart-vascular center. For Radboudumc working with a matrix organization is still relatively new and difficult. Departments were accustomed to be in the lead themselves. Through the establishment of these centers and by support of the Executive Board, which gives priority to the interests of the chain and propagates working in centers, results are improving and targets in terms of quality, collaboration and visibility / appearance are being achieved.
3.8 Conclusions case descriptions Dutch UMC’s
In summary we can state that several choices are made: UMCU and UMCG opted recently for the establishment of a separate oncology division, which combines as many components as possible of oncology. In practice, these are pragmatic scenarios where each specialty can prevail various arguments whether or not to be part of this division. With the current sizes of the different university oncological centers it also means that different mother specialties are divided into an oncological and non-oncological part and that this split concerns often also medical specialists in person. In Radboudumc, Eramus MC and LUMC the organization is not structured into themes but a more or less guiding role for the oncology center is defined. In these models the multidisciplinary tumor workgroups play an important role in addition to the heads of the departments involved in cancer care. Process descriptions and protocols describe the pathways along which patients travel across departments and divisions. The following conclusions can further support our thinking about the establishment and management of cancer care:
• Leadership is important, job requirements for the leadership of tumor workgroups have to be clear, they have to be appointed by the Executive Board and embedded in the organizational structure;
• Different principles for design are possible, an executive committee has been appointed in every organization, the responsibilities of this committee differ;
• For collaboration it is essential to initiate similar structures and to decide on the importance of the chains, and support this with process descriptions and information;
• Internal medicine; In every UMC studied, there are separate departments for medical oncology and hematology;
• Budget Responsibility can be addressed in several ways: Dialogue between Management and the Executive Board is important to ratify choices made;
• Collaboration is by definition without hierarchy; chains function preferably without executives, through development of clinical leadership;
• There is a preference for concentration in one physical place for better coordination within the oncology and profiling.
• Development of theme organizations is a long lasting process in which the organization's willingness to change plays an important role.
33 • No judgement can be made yet on the performance of the different organizational models based on the information gathered: it could be a subject for further research to monitor the various models and the outcomes on the long-term.
