Organization of stroke care in two Academic hospitals in amsterdam, the Netherlands

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Organization of Stroke care in

two Academic hospitals in

Amsterdam,

The Netherlands

Caroline de Ridder

December 2015

De

Supervisor MBA-HC :

Prof. dr. ir. J. Kraaijenbrink,

jk@kraaijenbrink.com

Supervisors AMC / VUmc:

Prof. dr. I.N. van Schaik,

i.n.vanschaik@amc.uva.nl

Prof. dr. B.M.J. Uitdehaag,

bmj.uitdehaag@vumc.nl

Prof. dr. W.P Vandertop,

w.p.vandertop@amc.uva.nl

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Organization of Stroke care in two Academic hospitals in Amsterdam 1

Preface

This thesis explores the organization of stroke care in two academic hospitals, Academic Medical Center (AMC) and Free University medical center( VUmc) in Amsterdam, the Netherlands. This is the final thesis being submitted for the MBA Health Care program from the University of Amsterdam. In the context of patient care, the primary goal of the

collaboration is to improve quality of care. My main motive, as head nurse of the

Neurocenter, is improving the quality of care. Neurocenter is a clinical department at AMC that treats neurological and neurosurgical patients.

After two years of intensive study, literature search, and listening to fascinating speakers and valuable classmates, I have obtained new perspectives and knowledge. I am grateful for the opportunity given by the board of the AMC to follow this MBA program.

I thank all persons who participated in this thesis, especially the supervisors. I thank Prof. dr. ir. Kraaijenbrink for his help in achieving rigor and relevance. I thank Prof. dr. I.N. van Schaik, Prof. dr. W.P Vandertop, and Prof. dr. B.M.J.Uitdehaag for their support during the study, critically reviewing texts, and sharing their insights and experiences.

I am grateful to my colleagues at the Neurocentrum, Dr. A.J. van der Kooi and Dr. I.H. Folkersma, and my colleagues in the management team for their support over the past two years.

None of this could have been realized without the support of my family and friends. My husband Otto and my children, Rachel, Eva, Matthijs, and Jasmijn, and their partners deserve a special word of appreciation for their moral support, patience, and love.

He who stops being better, stops being good

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Executive summary

The Academic Medical Center (AMC) and VU University Medical Center (VUmc) plan on forming an Alliance. In the context of patient care, the primary goal of this collaboration is to improve the quality of care for patients, especially those in need of highly specialized care that can only be delivered in an academic center. The plan is to concentrate emergency care in the AMC and elective and chronic care in VUmc. Currently, acute stroke care is delivered at both the AMC and VUmc, but the main center for care is located at the AMC, which also serves as a referral centre for the region. In this thesis, the organization of Stroke care will be examined. Given the separation of emergency and elective/chronic care over two locations, I look at ways to optimize stroke care.

Main question: What are the feasible scenarios for combining stroke care within the alliance

of AMC and VUmc, and which of these scenarios is likely to result in the best patient outcomes against acceptable costs and use of resources, under the constraint of the policy choice?

A search and critical appraisal of the literature on organization forms, applicable to this situation, was carried out. In semi-structured interviews with stakeholders, their ideas, opportunities, threats, and chances were explored and used as input to develop future

scenarios. Data was collected on the diagnoses, patient volumes, number of staff, beds used, “horizontaal verkeer” (i.e., costs incurred by other departments such as radiology, laboratory, and operating facilities), and use of other resources. The results of this research were used to constitute three scenarios for the organization of stroke care in the context of the alliance:

- Acute neurovascular care at AMC and other neurovascular care at VUmc - All neurovascular care at AMC

- Academic neurovascular care of referred patients at AMC and other neurovascular care at peripheral hospitals

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On basis of this research, the most feasible scenario is: Referred academic neurovascular care at the AMC and other neurovascular care at peripheral hospitals. This scenario results in the best patient outcomes against acceptable costs, and leads to the following recommendations:

1. Describe (operational) processes which are important for the sustainable design of the organization of stroke care. Current care paths can used to start this description and align the procedures in both hospitals. For employees and patients, treatment and information should be clear and transparent.

2. Create partnerships with ambulance-services and establish formal agreements to deliver specific patients to the hospital where they will be given the best treatment for their condition.

3. Create partnerships with general hospitals for the follow-up care and establish

agreements with all other chain partners such as rehabilitation centers, nursing homes, and home care organizations.

4. Develop a timeline to implement this scenario to achieve the best patient outcomes against acceptable costs and use of resources.

5. Use the excellent position of two academic hospitals in consultation with the healthcare insurance companies.

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I. Introduction

Two academic hospitals in Amsterdam, the Netherlands, are preparing for an alliance. In their vision statement (AMC-VUmc, 2014), the hospitals have described an

anticipated/desirable/potential end state in 2030 in which their clinical services will be delivered at the two present sites, Meibergdreef and De Boelelaan. At one site, the oncology center will be located with elective neuro-care services, musculoskeletal services, public health care, and other elective care services. At the other site, the emergency care,

cardiovascular center, acute neuro-care services, mother and child care, and other acute care services will be located. Dutch Health Insurance companies are pursuing concentration of complex acute care in fewer hospitals to increase efficiency, reduce costs, and improve the quality of patient outcomes through higher volumes.

The AMC is a leading research center in the academic and scientific medical world, searching for new and better stroke treatments. Stroke is the most common cause of death worldwide after cancer and cardiovascular diseases (National Kompas volksgezondheid, 2015). Every year about 50,000 people in the Netherlands suffer from a stroke, and it is the most common cause for disability in older age (National Kompas volksgezondheid, 2015). It is challenging to improve patient outcomes in stroke against acceptable costs and use of resources. This is the most important reason to optimize the organization of stroke care within the Alliance AMC\VUmc.

Stroke care is intended for patients with all stroke types:

 ischaemic stroke (cerebral infarction)

 transient ischemic attack (TIA)

 intracerebral haemorrhage (ICH)

 subarachnoid haemorrhage (SAH)

 vascular malformations of the central nervous system.

For acute ischaemic stroke, intravenous thrombolysis with recombinant tissue plasminogen factor (iv-rtPA) is the standard treatment, which is delivered in numerous hospitals throughout the country. Recently, intra-arterial treatment (IAT) has been shown to be effective for

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Flevoland, AMC is currently the only center where IAT is available.

IAT is performed by a team consisting of a neurologist, an interventional neuro-radiologist, and an anaesthesiologist. This team has to be available round the clock. For SAH, coiling has become the standard treatment over the past 10 to 15 years. Coiling is a highly specialised treatment for which a team consisting of a neurosurgeon, an interventional neuro-radiologist, and an anaesthesiologist is needed. This team also has to be available round the clock. The annual figures of AMC show that neurovascular care is an important part of the in- and out-patient care delivered by the Neurology and Neurosurgery departments. At least 12% (numerically the 3rd place) of the diagnosis treatment combinations (DTC) for Neurology and 21% (numerically the 1st place) for Neurosurgery in AMC are neurovascular in origin. In in-patient care, 1/3 of the admissions to the neurology ward and ½ of the admissions to the neurosurgery ward at AMC are for neurovascular1. In order to optimize acute stroke care and improve patient outcome, it is necessary to create high volumes of patients, which can be achieved by concentration of this care at one location. The relationship between labour, management, and supporting departments should be described in order to have a clear system of roles and authorities within the organization. Employees, the human capital of every organization, are the most important players to persuade when reaching out for a successful and efficient change in the organization. The organizational structure is the engine to realize strategic goals. In restructuring an organization, many factors should be taken into account, such as the political adaptation, culture changes, strategic refocusing and structural

adaptation. Organizational structure can be described as:

“The allocation of tasks (to realize goals), and the related decision-making rights conferred, to which must be attached budget rights, performance measurement, accountability and supervision and dismissal. That allocation of tasks can be done in several ways, from simple, the unit organization, in which the allocation of tasks etc. is equal to the configuration of resources, to complex, where the span of accountability is not equal with the span of control over resources (Strikwerda, 2014).”

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The main question of this thesis is:

What are the feasible scenarios for combining stroke care within the alliance AMC/VUmc, and which of these scenarios is likely to result in the best patient outcomes against acceptable costs and use of resources, under the constraint of the policy choice?

The AMC and VUmc went through a two-year process in which they assessed the potential alliance through a bottom-up approach. As a result of this process, they described the clinical services to be delivered in each hospital in their vision statement (AMC-VUmc, 2014). The elective services and public health will be located at VUmc, and the acute care service and mother and child care will be located at AMC. The care for neurological and neurosurgical patients will be split over both locations, necessitating a functional redistribution of

organizational parts. Lateralization of groups of diseases (such as strokes) to either location will also be performed, with the distribution of people and resources in an efficient way.

In the following chapter, the main theoretical concepts concerning organizational structure will be presented, based on a search and critical appraisal of the literature. A description of organizational structures and the role of the employees and management in the changing environment will be part of the research. In chapter III, the methodology used will be described. In the next chapter, findings of the qualitative research by semi-structured interviews will be presented and analyzed.

Based on these chapters, the current situation will be rendered based on recent data (chapter V) and possible scenarios for the organizational structure of stroke care in the context of the alliance between AMC and VUmc are described (chapter VI). In chapter VII, conclusions of the whole study are summarized the results will be integrated, and, based on those integrated results, an organizational structure will be proposed to facilitate high quality of care and efficiency for all neurovascular care in the departments of Neurology and Neurosurgery.

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II. Theoretical background

In this chapter, a literature review will be conducted on organization structure/design and value proposition. Search of the literature, offered in the MBA program and internal documents, was used to define organization structure related to the main question and the value proposition for the organization of stroke care in AMC and VUmc. Our society is made up of organizations, whereby and wherein strategic goals can be realized. An organization consists of people and resources. In paragraph II.C, the role of human factor in the 21e century and the influence of this factor in an efficient organization. The theoretical background of value proposition of the hospitals and customer value measured in patient outcomes is described in paragraph II.B and II.C. Traditional management and organization practice and theory primarily focus on structure, but the development of organizations does not affect the results in efficient structures. Processes that connect structure, strategy, and business model are the primary focus of business administration and organization design in the 21st century (Christensen, 2009) (Strikwerda, 2012). In the last paragraph II.D, the types of organization structures and role of information management to achieve involvement and transparency is described.

A. Organization structure/design

Organizations are created and sustained in order to accomplish a goal. They exist for a purpose that may be related to an overall goal or mission. Different parts of the organization establish their own goals and objectives to help meet the overall goal of the organization. The overall goal describes the value system of that organization and gives legitimacy to the organization (Daft, 1998).

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Figure 1: Interacting Contextual and Structural Dimensions of Organization Design (Daft, 1998)

This model of Daft is abstract and conceptual, and, for that reason, is difficult to use in practice. The aim of designing or structuring an organization is to make it efficient. An

efficient organization can be defined as an organization structure in which the highest possible sets of outcomes are produced against the smallest possible sets of inputs over the life time of the organization (Strikwerda, 2012). A strong organization of stroke care is related to good patient outcomes. An organization which succeeds in adapting new strategies has to

understand the impact and role of the structure and the consequences on employee behavior and the organizational culture. The environmental conditions, strategies, and structures shape the environment through the weight of the organization's resources (Hal and Saias, 1980). One of the goals of the alliance between VUmc and AMC is improve the quality of care for patients with the focus on complex care, measured in patient outcomes. The focus on improving health care value for patients requires continuous improvement in processes and efforts to sustain those improvements (Lazar, 2007). A hospital that focuses on a specific value proposition can integrate its resources and processes in a unique way (Johnson, 2008). The value proposition for the organization of stroke care is customer value, in terms of patient outcomes. Environment Goals and Strategy Culture Technology Size Structure 1.Formalization 2.Specialization 3.Standardization 4.Hierarchy of Authority 5.Complexity 6.Centralization 7.Perfussionalism 8.Personnel Ratios

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In this thesis organization structure (or design) is described as follows:

The allocation of tasks (to realize goals), and the related decision-making rights conferred, to which must be attached budget rights, performance measurement, accountability and

supervision and dismissal. That allocation of tasks can be done in several ways, from simple, the unit organization, in which the allocation of tasks etc. is equal to the configuration of resources, to complex where the span of accountability is not equal with the span of control over resources (Strikwerda, 2014).

B. Value proposition

The business model of a firm serves as a building plan for designing the business structure and systems that constitute the company’s form (Osterwalder, 2005).

A business model is an interdependent system composed of four components as illustrated in the figure below (Christensen, 2009) (Osterwalder, 2005):

Figure 2: The four box business model ( Johnson, 2008)

The strategy of the firm should express what value the organization has and for whom. Cleveland Clinic has used customer value to organize their stroke care in an integrated

practice unit and now has one of the highest stroke-related patient volumes in North America.

Customer value Proposition Key Resources Key Resources Profit Formule urces

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High patient volume allow the specialists to develop vast experience with stroke patients, which results in a team dedicated to the care and management of strokes (Cleveland Clinic, 2014). Porter and Teisberg (Porter M. T., 2006) describe the impact of increasing patient volumes for the patients and the organization in the figure below.

The virtuous circle in a medical condition

Figure 3: the Virtuous circle of value (Porter M. T., 2006)

C. The role of the human factor in organization structures in the 21e century

Mintzberg (1983) describes the organization structure as involving two fundamental requirements – the division of labor into distinct tasks and the achievement of coordination among these tasks. To divide the labor, a distinction between management and executive employment needs to be made, the vertical expansion. Additionally, decision-making should also be allocated between employees of the same level in the hierarchy, the horizontal expansion. The formulation of tasks that will be chosen needs to fit the strategic positioning (Keuning en Eppink, 1992).

A well-described organization structure is important for progressive management and good performance (Keuning en Eppink, 1992). In addition to the aforementioned formal

organization, there is also an informal organization.

Deeper Penetration (and Geograpic Expansion)

In a Medical Condition

Rising Capacity for Sub-Specialization

Improving Reputation Rapidly Accumulating Experience

Rising Efficiency Better Results,

Adjusted for Risk

Faster Innovation Better Information/ Clinical Data

More Fully Dedicated Teams Spread IT, Measure-

ment, and Process Improvement Costs

over More Patients _{More Tailored Facilities}

Greater Leverage in Purchasing Wider Capabilities in the

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The informal organization is the organization as employees experience it. Work in a good organization is effective and efficient, and the employees are satisfied, motivated, and committed (Keuning en Eppink, 1992).

An effective organization structure meets the following criteria (Keuning and Wolters, 2007):

 fit to economy, technology, and resources

 fit to people

 fit to clients and stakeholders

 fit to strategy

 Previously fit to market was considered a criterion, but is now overtaken by processes (Strikwerda, 2014), providing more flexibility to create and preserve fit to market.

For the organization of stroke care in AMC and VUmc, fit to stakeholders, clients and employees, is meaningful for an effective organization. Fit to other stakeholders, such as chain partners, nursing homes, and rehabilitation centers, ensures a quick flow after the acute phase. Fit to the strategy is described in the internal document ‘Op weg naar Excellentie’ (AMC-VUmc, 2014), and included the fundamental choice to concentrate emergency care in the AMC and elective and chronic care in VUmc.

Several processes for stroke care are described; however, the organization in these hospitals underlines the need for attention to an effective and efficient stroke organization.

To adapt the structure of an organization is never a goal in itself but should always be done in the context of other factors.

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Figure 4: Model Keunink en Eppink, 1992

For successful implementation of a new structure, attention to all four items in the figure above is required.

In the twentieth century, agents like shareholders, suppliers, and customers were separated from managers and employees of the internal organization (Strikwerda 2013). In today’s open business models, the boundary between the legal and internal organization seems to have faded. During the Second Industrial Revolution (the latter half of the 19th_{century), the}

internal organization provided life-time employment and social status.

Life-time employment is replaced by job-hopping, self-employment, and job-hopping; the labor market has become mobile (Strikwerda, 2013). For most employees, work is no longer the main part of their life. Identification is multiple with professional peers instead of

historical peers within the organization. This evolution is an important part of the structural design of an organization, because the human capital, i.e. the employees, is the most important factor for successful and efficient change in the organization. Most people are motivated by a sense of responsibility and the ability to decide for themselves, so decentralization is related to empowerment in today’s organizations.

In an organization, such as hospital, where the focus is on improving health care value for patients, physician leadership is essential (Porter M. E., 2007).

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D. Types of organization structure and information management

The most common approaches to structural design of organizations are functional and divisional grouping (Daft, 1998). In a functional structure, human knowledge and tasks are grouped together from the bottom to the top. This structure operates well in stable

environments, but there is often a high level of bureaucracy, which makes quick response to changes in the market difficult. This structure is most effective when in-depth expertise is critical to achieve organizational goals (Daft 1998).

Divisional structure grouping is based on organizational output and can be organized in several parallel teams focusing on a single product or service line. The functional structure is centralized, and the divisional structure is decentralized. Therefore, the divisional structure is more flexible and can adapt much quicker to needs of the environment.

The matrix structure combines the characteristics of functional and divisional structure.

Figure 5: Matrix organization, Wikipedia

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Strikwerda and v.d. Heuvel (Strikwerda J. &., 2015) describe the role of operational processes as the basic element for organization design as follows: Organizational structure assumed a predictable and controllable environment of the firm, and high costs of (self) coordination, processes organized within the structure and interfaces between divisions being of a transaction nature.

The movement of process re-engineering and process management in the nineties shows that quality & efficiency are to be achieved through cross-divisional processes, because costs of self- or horizontal-coordination have declined.

Redesigning information management by combining clinical and financial information gives transparency for all employees and results in innovation and involvement of physicians for the organization (Bezstarosti – van Eeden, 2014) (Bohmer, 2003). The role of information for the organization of stroke care is important because transparency about this topic can help to reduce costs and involvement of the employees in the achievement of an efficient

organization.

E. Summary and implications

Organization structure is defined on the basis of operational processes in the organization. The role of the human factor has changed in the last century and involvement of employees is essential to realize strategic goals. For that reason, transparency of information and a sense of responsibility for employees are necessary. Physician leadership in hospitals will contribute an efficient and effective organization

Based on the theoretical background the following topics will be examined further in qualitative and quantitative data collections:

 Stroke care in the alliance of AMC/VUmc wants to realize such a structure that the most effective and highest quality is reached. An efficient organization is an organization in which highest possible sets of outcomes are produced against the smallest possible sets of inputs. For the organization of stroke care is it necessary to define the set of patient outcomes, this will be part of the qualitative data collection.

 The focus on improving health care value for patients requires striving for continually improvement in processes but also strategies to sustain those improvements.

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Organization of Stroke care in two Academic hospitals in Amsterdam 17  In the qualitative data collection, the interviewees will be asked which factors or conditions important are to improve customer value. Evident conditions help to describe necessary processes and care paths.

 Quantitative data collection will be used to determine the patient volumes (Porter), staff employed and other resources to answer the main question.

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III. Methodology

The search and critical appraisal of the literature on organizational structures in chapter II, has resulted in qualitative data collection, in this thesis in the form of interviews. The connection between value proposition and the human factor is used in the qualitative data collection. Quantitative data collection gives input for answering the main question in case of an efficient organization in which highest possible sets of outcomes are produced against the smallest possible sets of inputs.

A. Qualitative data collection

Qualitative data were collected by means of 33 interviews with employees (Appendix A) as well as the client councils of both hospitals. Stakeholder interviews were used to get them involved and committed to the planned changes and to use their valuable input to describe the new organization structure.

In vision statement “Op weg naar excellentie” (AMC-VUmc, 2014) the client councils of AMC and VUmc point out that for them the most important criteria is quality gains in care an experience for the patient. Fit to the strategy is described in this internal document, and fit to employees is examines in the interviews. The customer value proposition expressed in patient outcomes is part of the data collection.

The client councils were interviewed to give the patient a voice in the planned changes.

The recruitment of interviewees was achieved through two means. Respondents were

recruited through my own personal and professional networks in my position as head nurse of the Neurocenter at AMC. I sent an email to the most involved people to introduce myself and to explain the goal of this thesis. The appendix to this email contained the interview questions. At the end of each interview I asked if there were other people or parties which could be important to interview. If this was the case I sent an email to that particular person.

Preferably, interviews were held face to face with the questions being sent in advance to all the interviewees.

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With one manager of the VUmc and with the department chair of the Intensive care unit of the VUmc the interview was held by phone because it was very difficult to meet face to face due to time-constrains.

Because of the size of the group nurses (around 100 people), they were asked to answer by email. The members of client councils were interviewed as a group.

The interviews with employees consisted of four questions and all answered these. The interviews with the client councils were more a semi-structured conversation of one hour with three members (AMC) and the chairman (VUmc) of the council.

The interviewees, except the members of the client councils, are employees of AMC and VUmc and are involved in stroke care. The coming alliance between the two hospitals will have a significant influence on their work. For some employees the alliance will change the location where they perform their daily tasks for others the patient mix will change. It is important to note that I have tried to minimize the risk of selection bias by recruiting respondents from different positions and locations.

On base of the literature and the main question, interview questions were formulated.

The first question aims to answer which diagnoses have to be taken into account in the quantitative data collection and is determined by the chairs of the both departments at AMC and VUmc.

1. Which neurological and neurosurgical diagnoses are part of stroke care?

Given the vision of the board of directors of AMC and VUMC namely dividing acute and elective/chronic care, the interviewees were asked to describe their vision of stroke care to optimize the care for these patients. The human capital is the most important factor to bring over when reaching out for a successful and efficient organization. Moving around with people and resources is inevitably in an alliance so their involvement and commitment is essential. When stroke care will be concentrated, greater patient volumes will have effects described by Porter and Teisberg (2006). As a consequence better utilization of capacity is possible (Porter M. T., 2006). These aspects will be explored in question two.

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Organization of Stroke care in two Academic hospitals in Amsterdam 20 2. What is desirable in terms of distribution employees and resources on both

locations?

One of the goals of the alliance between AMC and VUmc is to improve quality of care as measured in patient outcomes. An efficient organization is an organization in which a highest possible set of outcomes is produced against a smallest possible set of inputs (Strikwerda, 2012). Customer value in stroke care is patient outcome and patient experience. In question three interviewees were asked which patient outcomes are relevant for stroke patient and how to improve customer value in an efficient way.

3. Which factors or conditions are important to improve customer value in an efficient way?

In an effective organization employees are satisfied, motivated and committed (Keuning D. E., 1992). With question four, information about the possible treats and chances as well as issues that must be taken into account will be collected and displayed. The answers are expected to give a sense of the scope of the feasible scenarios.

4. Which threats and chances do you foresee to achieve an effective and efficient organization and high quality of care?

The answers given during the interview with the members of the client councils, the voice of the patient, are related to question three and four. The results will be presented separately because of the different way they look at the alliance, namely as a user of care instead of a provider of care.

The data collected by these interviews will be outlined and analyzed in chapter IV.

B. Quantitative data collection

To answer the main question, collecting all financial, resource, and production parameters is essential. Patient volumes, staff employed, number of admissions and other resources were compiled and analysed for 2014, which is most recent information of one year and

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Because of the enormous increase of IAT treatments in 2015 and the impact of this increase on personnel and resources, the extrapolated figures for 2015 have been taken into account. The figures and other information of 2014 are not yet published and public, for that reason it is not allowed to present the outcomes as raw numbers so percentages will be used in this thesis.

The financial responsible persons and the medical chairs of the neurological and

neurosurgical department of both hospitals verified the total numbers. Which parameters were collected was determined in consultation with the chairs of neurology and neurosurgery and the neuro intervention radiologist of both hospitals. The department chairs send a request to the controllers of the division of both hospitals to assemble all necessary parameters and other available information. The data and its interpretation are given in chapter V.

C. Data integration and synthesis

The results of the interviews were used to design the scenarios, under the constraint of the policy choice. Their various visions to optimize stroke care and named opportunities to improve customer value and an effective organization was combined with the collected data. Together with the theoretical background, continuous improvement of processes and

healthcare value for patients, three scenarios have been established. In chapter VI the development of the scenarios will be presented. Followed by chapter VII where the most feasible scenario for the organization of stroke care is described.

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IV. Findings and analysis of interviews

As part of the qualitative data collection this chapter represents the findings and analysis of the interviews with the stakeholders concerning stroke care in both academic hospitals AMC and VUmc. Employees are the most important players to bring on board when reaching out for a successful and efficient organization and are essential to realize the strategic goals. The ideas, opportunities, threats and chances mentioned by the employees during the interviews gave input for the development of future scenarios for the organization of the joint

departments of Neurology and Neurosurgery to facilitate optimal stroke care and improve customer value in an efficient way. Thirty-three people have been interviewed (Appendix A), among which are doctors, nurses, managers, and the client councils of both hospitals. The response rate of the e-mail questionnaire addressing the nurses was 12%, despite two

reminders. The results of the interviews with the client councils will be presented separately.

A. Which neurological and neurosurgical diagnoses are part of stroke care?

The neurological and neurosurgical diagnoses that should be considered a part of stroke care within the alliance were discussed with the chairs of the neurological and neurosurgical departments. With their answers the frame of what is stroke care within the alliance is evident for all parties. There was broad consensus between the three chair people which diagnosis treatment combinations (DTC) should be included. This information has been used for quantitative data collection on stroke care in the two hospitals.

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Neurology Neurosurgery

1201 Conservative Treatment + / - coiling 1101 Subarachnoid Hemorrhage (SAH) 1205 Operative treatment of single not

complex aneurysm

1102 Intracerebral hemorrhage 1210 Operative treatment of complex

aneurysm

1103 Intracranial hemorrhage, epi- or subdural hemorrhage

1215 Operative treatment of Arteriovenous (AV) malformations / dural AV fistula

1111 Ischemic stroke 1220 Desobstruction extra / intracranial

arteries

1112 Transient Ischemic Attack (TIA) 1230 Intracerebral hemorrhage

supratentorial

1121 Stroke related Attack 1235 Intracerebral hemorrhage

infratentorial

1199 Other miscellaneous cerebrovascular disorders

1240 Decompressive craniotomy for stroke

9925 Working diagnosis subarachnoid hemorrhage, not Established

1315 Epidural / subacute subdural hematoma

9927 Working diagnosis transient ischemic attack, not Established 1321 Chronic subdural hematoma /

hygroma

1510 Intracranial operation for cranial nerve compression syndrome

2201 Spinal epidural / subdural hematoma 2205 Vascular malformation spinal cord 2210 Vascular abnormalities spine / spinal cord; conservative treatment

Table 1: The Diagnosis Treatment Combination with numbers

Given the vision of the board of directors of AMC and VUMC, namely dividing acute and elective/chronic care, the interviewees were asked to describe their vision to optimize stroke care for these patients.

B. What is desirable in terms of distribution employees and resources on both locations?

As stated before at one site the oncology center will be located with elective neuro-care services, musculoskeletal care services and public health care, together with several other elective services. At the other site the emergency care, cardiovascular care, acute neuro-care services, mother and child care and all other acute care services will be located.

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Figure 6: Distribution of stroke care, based on answers interviewees

Almost 50% of employees preferred to concentrate stroke care at AMC and not divide it to the two locations. In the current situation, the neurosurgical stroke care is already lateralized at AMC. For that reason, there are more interviewees from the AMC than form the VUmc (Appendix A). It is possible that concentrating all stroke care at AMC, as described above, may have led to the higher number of interviews from AMC than VUmc.

The chair and manager of the emergency department described that the new design of the emergency department which is currently refurbished, will be sufficiently large to

accommodate 24/7 acute care with higher volumes because of the alliance. They think that there will be a doubling of acute stroke care. Porter and Teisberg (Porter M. T., 2006) describes the effect of greater patient volumes, like rapidly accumulating experience, better information clinical data and costs of IT, measurement and process improvement spread over more patients.

The nurses are less concerned with where stroke care should be delivered, as long as the quality of care is high.

Isn’t relevant for me, most important is to give high quality of care. (Nurse)

0 5 10 15 20 25 30

Total interviewees All the acute care to AMC and all elective

care to VUmc

All stroke care to AMC Other anwers

Distribution of Strokecare AMC \ VUmc

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Organization of Stroke care in two Academic hospitals in Amsterdam 25 I do understand that centralizing diagnoses is better for the quality of care, for that reason

concentrate acute stroke care at the AMC (Nurse)

All stroke care at the AMC will lead to better quality of care, at the AMC they have the ambition and experience”

(Neurovascular surgeon)

One of the managers named patient movements between the two hospitals a risk. This may lead to unsatisfied patients and possible loss of patients to another hospital. When all stroke care is located at AMC, the ambulance service should be aware that all stroke patients have to be delivered to AMC.

The chain of care is mentioned by three employees in terms of quality of care, but also as a chance and a threat for the cooperation with other care providers outside the hospitals.

Pay attention at the chain of stroke care, this will cause time- and quality profit for all the people, especially for the patient.

(Coordinator traumanet)

For the new structure the choice has to be made whether all stroke care or only the acute stroke care should be concentrated at the AMC. The chain of stroke care is an important item in terms of quality of care. To help the hospitals to create such a care continuum they will have to ally with other care providers as well. This issue has to be considered in the design of the new structure for stroke care.

For all interviewed nurses (N=12) the location of their daily work is an important item. If the vascular and acute care would be concentrated at the AMC, they emphasize that nurses should get a choice where they want to work. For the stroke neurologists and neurosurgeons this is different because there are specialized physicians in stroke care and they think that it is logical to work at the AMC. On the other hand it is evident that there are not enough specialized stroke physicians to cover a 24/7 stroke service. A solution for this problem would be that all the neurologists and neurosurgeons need to participate in the on call schedule for the stroke care. This solution is currently employed at the AMC already and works well.

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Organization of Stroke care in two Academic hospitals in Amsterdam 26 No stops or denials in the stroke care and always accessible and available.

(Manager Emergency department)

One of the interventional neuro radiologists denoted that in foreign countries the intervention procedures and diagnostic procedures have been separated contrary to the situation in the Netherlands.

The neurologists, neurosurgeons and interventional neuro radiologists stressed the

consequences for the emergency departments of both hospitals when all the acute care will be located at one side. Most of the patients enter the hospital through one of the emergency departments and the number of patients is expected to grow by further development of endovascular stroke treatments2.

There wasn’t consensus between the interventional neuro radiologists about the place of neuro interventions, just at the AMC or to keep the possibility to do this also at the VUmc.

The interventional neuro radiologists of the AMC were in favor of concentrating all this care at the AMC, whereas the interventional neuro radiologist of the VUmc wanted to keep a possibility to perform these procedures also at the VUmc. A lot of expensive materials and equipment are needed for neuro interventions. Major concern of the interventional neuro radiologists at the AMC is how these resources should be divided between the two locations as this highly complex and high qualitative care is to be delivered at two locations against minimal costs.

The neurologists and neurosurgeons from AMC and VUmc argue that the whole chain of care should be decisive, to concentrate all neuro-interventions at AMC. Concentration will lead to higher volumes which in turn facilitates availability of a dedicated anesthesiology team 24/7 for acute (stroke) care. Such a team could support the neuro interventions as well as the neurosurgical interventions (Porter, 2006: The virtuous circle of value, better utilization of capacity).

The whole development of the stroke care in Amsterdam must be considered. (Interventional neuro radiologist)

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All interventional neuro-radiologists (N=3) mentioned that the number of neuro radiologists should increase, because interventions take a lot of time resulting in a high workload. The three interviewees declared that intravenous thrombolysis treatment is not academic care.

In fact this part can be done by other hospitals and the intra-arterial and endovascular treatments should be developed further in an academic setting. In this way the academic hospital can intensify the collaboration with local general hospitals.

Summary and conclusion

There are several arguments to concentrate all stroke care at the AMC. The benefits of higher patient volumes, concentrate the highly complex and high qualitative care of the intervention neuro radiologists with optimal use of the expensive resources, scheduling the physicians at one location and the possibility of a dedicated 24/7 anesthesia team for acute (stroke) care. Increasing of stroke patients will lead to more necessary intervention neuro radiologists. Quality of care is named as a very important reason for concentrate stroke care also for the chain of care with all the different partners. The collaboration with local general hospitals can be intensified to an extent that non-academic care takes place in these hospitals and not in the AMC and VUmc.

C. Which factors or conditions are important to improve customer value in an efficient way?

Providing good and timely information is mentioned by 80% of the interviewees. This should be information about treatments, waiting time, procedure of admission to and discharge from the hospital. Not only patient but also families, referring doctors and other care providers in the stroke care continuum should be well informed.

In my opinion a professional team of physicians and nurses that support information and supervision is extremely important.

(Neurologist)

Capacity and flexibility to move along with the variable influx and demand of patients is mentioned by 50% (N=7) of the physician.

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Capacity is mentioned by several employees (Porter, 2006: The virtuous circle of value, better utilization of capacity). With capacity interviewees mean: resources, like beds and materials, but also waiting time and refusals of patients when there is no room at the wards anymore. Porter and Teisberg (Porter M. T., 2006) describes that dedicated teams and transparent information about patient outcome and costs leads to customer value improvement. Also Bohmer (Bohmer, 2003) indicates that transparency of information, the involvement of employees and innovation stimulates and has a positive effect on customer value. One of the interviewees mentioned that sufficient staffing is paramount for the further development of the intra-arterial treatments as most important in the capacity question. Quality of care must be a leading factor in all decisions taken with regard to the organization of stroke care. As stated by one interviewee:

Quality of care must be leading, the patient is number one (Neurosurgeon)

All the nurses (N=12) and 50% of the physicians (N=7) described the level of training as an important condition. Education and exchange of knowledge at all levels in stroke care and treatment is needed. Collaboration with partners in the chain of care is mentioned by 60% of the interviewees. The flow of patients over the chain of care from the acute phase to

rehabilitation facilities requires dedicated arrangements with all chain partners. Ideally, these arrangements should also be made with e.g. the ambulance services, to optimize and shorten the pre-hospital phase. Other partners are the general regional hospitals with which clear agreements need to be made about referring patients for intra-arterial treatments and about taking them back swiftly afterwards.

In the internal document: “Advising group stroke care 2013”, the members of the group (all interviewed) argue for 24/7 availability of specialized neurologists. Good leadership is named as well as maintaining job security.

The head of the neurological department at AMC emphasized that an administrative merger between two departments is essential for the success of this concentration of care.

The focus should be on creating a single neurology and neurosurgery department each, both in terms of the budgetary and organization.

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If the stroke care is placed at the AMC without a departmental merger, the neuro-wards at the AMC will have to expand with a large number of beds including nurses and the “horizontal verkeer” (i.e. costs incurred by other departments such as radiology, laboratory etc.) will increase together with all other additional costs. This means that the AMC department needs more budget from the total fixed AMC budget.

Given the fixed AMC budget this will deplete other AMC departments of budget. If you merge the budgets of both departments, they can function together and allow free movement of resources, income, and expenditure. The combined budget of both departments should be sufficient to cover the costs to provide all necessary care.

Summary and conclusion

To improve customer value, capacity of employees and resources, dedicated teams and transparent information are important conditions named by the interviewees as well as described in the examined literature. The flow over the chain of care requires dedicated arrangements with all chain partners, like ambulance services and rehabilitation institutes. A combined budget for the neurology as well as the neurosurgery department, across borders of the hospitals, is essential to require an effective organization of stroke care.

D. Which threats and chances do you foresee to achieve an effective organization and high quality of care?

In an effective organization employees are satisfied, motivated and committed (Keuning D. E., 1992). An efficient organization can be defined as an organization structure in which highest possible sets of outcomes are produced against the smallest possible sets of inputs over the life time of the organization (Strikwerda, 2012). These items together are the base of this question for the interviews. The different answers reflect strengths, opportunities, threats and weaknesses to achieve the desired high quality of care. Simultaneously the answers emphasize issues that must be taken into account (SWOTi).

Table 2 shows the strengths, opportunities, threats, and weakness of the administrative merger according to the interviewees. The administrative merger is the most important condition because without this, there will be no alliance between AMC and VUmc.

The answers about the threats are issues to be taken into account by further development of the organization.

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The growing research opportunities were named by all the physicians as a great opportunity, also in an international way. The nominated answers give input for feasible scenarios for combining stoke care at AMC and VUmc.

Strengths

 Already a lateralization of vascular Neurosurgery at the AMC

 Commitment chairs of neurology and neurosurgery departments AMC and VUmc

 Evident described processes for the acute stroke patient in AMC, dedicated resources at the emergency department and agreements with the intervention neuro radiologists

Weaknesses

 No administrative merger between the two departments

Opportunities

 Increasing quality of care because higher volume of patients results in growing experience and skills and optimization of knowledge.

 Expected high volume of patients will justify the permanent availability of a dedicated anesthesia team for trauma and neurovascular care.

 Rare diseases will be concentrated, again growing specialized knowledge.

 Growing research opportunities.

 Better position in benchmarking, national as well as international

Threats

 Developments in the region with regards to stroke care

 Financial structure

 Monotonous activities for the physicians, just acute or just chronic / elective care

 Physicians can lack specific knowledge

 Clear communication, also for external partners

 Too much time for the whole process can lead to cynicism, resignation and investments will not follow through

 Distance of traveling and parking facilities for employees

 Different cultures

 Inadequate leadership

 Bulk production

Issues

 One and one are not always two. When we organize stroke care different, for instance everything at the AMC, it is not automatically said that all patients are brought to this location.

 There are more facilities to choose from in Amsterdam and distance can play an important role

 The relationship between the physician and the patient has to be changed in some cases

 Relationship with general regional hospitals and other facilities as nursing homes and rehabilitation centers

 Communication to all the collaborative parties is needed to ensure that they understand the background of any decisions behind a concentration of stroke care

 Scheduling of physicians in the new structure

Table 2: SWOTi to achieve an effective organization, interview staff stroke care

It is necessary to make choices, what are we going to do as an Academic Center and what not. We need a shared vision and the goal is an optimal situation for the patient.

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The focus on quality of care has to be measured in patient outcomes, the interviewees nominated some of these outcomes.

The nurses are not accustomed to describe patient outcomes and named the patient

satisfaction and door to needle time while the physicians immediately gave a list of outcomes. The answers are listed below:

- Door to needle time

- Door-to-reperfusion-time (IAT) - Functional outcome at 3 months - Complications

- Patient satisfaction - Net promotor score - Score of daily autonomy - Mortality

For all the outcomes, standardized and linear outcome measures need to be used (Medical chair neurology)

In such complex treatments frequent contact between patient, family and physicians is extremely important, patient safety outcome is the final test for us

(Nurse)

E. Interview with client councils AMC and VUmc

The client councils of both hospitals are looking after the interest of patients in general and not for one kind of group. They didn’t prefer to concentrate the stroke care at one or two locations. For the council it is leading that there are no disadvantages for patients. The interviewed members think that the distance between the two hospitals is irrelevant. Leading argument should be the guarantee for good quality of care described as: qualified, motivated and sufficient personnel and resources.

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As condition to achieve the alliance between the two academic hospitals they first named the administrative merger through which the interest of patients will be secured. Switching between both hospitals during a single treatment for a patient is not desirable and need to be avoided. Clear communication to patients, patient associations and referrers (idem) is very important. They stress that all care providers should understand the background of any decisions behind a concentration of care.

The client council is very content in the way they are involved in the whole alliance process and named that the voice of the patient is heard.

Strengths

 The position of the hospital is stronger in their relation with the insurance companies because of the higher patient volumes

Weaknesses

 Information about hospital admission and discharge have bad results in the patient safety questionnaires, when this becomes much better, it can be an opportunity

Opportunities

 Improving quality of care by higher patient volumes

 Better position in benchmarking, national as well as international

 Growing research opportunities

Threats

 Incomplete and ambiguous communication and information

 Loss of patients which choose for another hospital

 Different cultures

 The familiar partnerships with referrers need to change

Issues

 Evident communication about the primary provider of treatment

 Clear signage in both hospitals

 Awareness form patients for top referent care in academic centers and other care in peripheral hospitals

Table 3: SWOTi to achieve an effective organization, interview client councils

It is important to talk with the patient and not just over the patient (Member client counsel)

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F. Comparing SWOTi staff and client councils

When comparing the answers of staff and client councils there are some marked differences.

Strengths

The client councils pointed at the stronger position of the hospital after the forming of the alliance, because of the higher patient volume. The item of the position of the hospital because of the alliance is not part of the answers of the staff and an important subject for the negotiations with the Health Insurance companies. The benefits of the higher patient volumes are addressed by both for several reasons at the opportunities. The strengths nominated by staff are internal items, not known for outsiders.

Opportunities

The opportunities specified by all the interviewees are almost the same, whereby the staff the growing specialized knowledge about rare diseases mentioned as an important opportunity for patients.

Weaknesses

Both parties described one different issue. The staff pointed out as a weakness that there is no administrative merger between the two departments, which is an internal matter. The client councils named the bad results in the patient safety questionnaires on hospital admission and discharge. This point is important for patient safety and as a consequence important for the Net Promotor Score.

Threats

The possibility of loss of patients because of the developments in the region, different cultures and incomplete communication is named by both parties. Besides the internal issues

mentioned by the staff, inadequate leadership was described as a threat. This is already described by Porter (2007) as an essential requirement when an organization focuses on improving health care value.

Issues

There are issues already mentioned by S,W O, of T. Table 2 and 3 presents two other striking findings. Firstly, the relationship between physician and patient has to change in some cases. Secondly, awareness from patients that switching between hospitals is sometimes unavoidable because top referent care should be delivered in academic hospitals. Whereas other more standard care should be taken place in general hospitals.

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The first item required clear communication and flexibility. The awareness for the right kind of care on the right place is important for the most feasible scenario for the organization of stroke care.

G. Summary of the interviews

None of the interviewees that I have spoken to is rejecting the idea of lateralization of specific neurological and neurosurgical diseases to one of the two academic hospitals. The focus of this discussion is whether all stroke care should be concentrated to one side or whether acute stroke care, and chronic and elective stroke care should be lateralized to both sides. This has to be reflected in feasible scenarios for the combining of stroke care within the alliance AMC/VUmc. The chain of care comes back in more answers to different questions and is important to bring along in the organization structure. This means making evident agreements between departments, other hospitals and outside care providers. For the service of

neurologists and neurosurgeons outside office hours it is necessary to work with all available neurologists and neurosurgeons from both locations to cover a stroke service 24/7.

The resources for the intervention neuroradiology, especially the equipment, are very

expensive. The client councils are involved in the whole process and satisfied about their role. They emphasize the role of communication and information for the patients and other

partners.

Essential for the success is an administrative merger between the two departments (or hospitals whatever can be reached earlier), for the organization change.

For a successful lateralization of disease groups between the two locations there has to be one budget for the neurology department and one for the neurosurgery department.

There can be more or less unexpected consequences after specific care services have been lateralized because patients could choose not to follow the lateralization but choose for another hospital. Flexibility and adaptability are essentials during the whole process. The financial structure and strong leadership are both threats and chances, so they are important parts of the organization structure. There are a lot of chances for the patients in terms of improved quality of care and there are many opportunities for research. For the employees growing knowledge, experience and skills are potential benefits. The whole organization may benefit from a better position in the benchmark national and international and from growing research opportunities.

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V. Analysis of data of involved departments of AMC and

VUmc

Data pertaining to stroke care delivered at AMC and VUmc in 2014 were compiled from the BI-systems of both hospitals. These systems are different in both hospitals and do not always contain the same parameters with the same details. In general, the data obtained from the AMC system were more detailed and complete. For this reason, in consultation with the medical chairs of the departments, missing data were imputed or calculated based on estimates and two ratios. The ratio to allocate generic costs for inpatients was calculated by dividing the total number of admission days for patients with stroke by the total number of admission days for all diagnoses. The ratio to allocate costs, e.g. salary costs of residents, was calculated by dividing the total number of Stroke DTC’s by the total number of all DTC’s. Descriptive statistics were used to analyse the data. Data are presented as percentages.

A. Diagnosis Treatment Combination

Currently, for the neurology departments 63% of the total stroke patients are treated in the AMC and 37 % in the VUmc. For neurosurgery, 89% of stroke patients are treated in the AMC and 11% in VUmc. This was expected and in line with the lateralization of specific neurosurgical diseases between the two hospitals which was carried out some years ago. At least 12% of the neurology DTC’s and 21% of the neurosurgery DTC’s in the AMC are neurovascular in origin. For VUmc this is 7% and 11%, respectively.

B. Production parameters

The collected parameters are listed in the following table: Production parameters Consultations at the emergency

department Inpatient hospital

First outpatient clinic appointment and NP

( New Patients) Daycare including difficult cases

Repeated appointment outpatient clinic Number of patient days IC days

Telephone consultation Hospital days

ICC Operation room duration

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Consultations at the emergency departments and outpatient appointments for stroke are numerically higher at the AMC for both specialism compared to VUmc. The total number of admission days for stroke patients is a significant part of the total admission days. For

example, 55% of all admission days at the neurology and neurosurgery ward are dedicated to stroke care at the AMC. Due to the lateralization of acute neurosurgical stroke patients some years ago, these patients were seen already at the AMC. Acute neurological stroke patients are seen at both hospitals. The number of hospital days for the neurosurgical patients of stroke care at the AMC is more than five times the number at the VUmc. Also, the IC days for neurosurgical patients are 50% higher in AMC than VUmc. The figures for the clinical neurological stroke patients were similar at both hospitals.

C. Treatments

Neurosurgical stroke treatments are, as expected, almost completely lateralized at the AMC. As a consequence, the operation room (OR) usage at the VUmc is just a couple of hours per year for stroke care in contrast to more than 600 hours of OR usage at the AMC.

Intravenous thrombolysis (IVT) has been carried out approximately 85 times per year per hospital over the last two years, in both hospitals whereby in 2014 a noticeable growth of IVT has been seen in the AMC. This kind of care requires an effective infrastructure, because “TIME IS BRAIN”. In AMC and VUmc the whole logistic process is detailed described in a standard operating procedure and all necessary equipment, like a state-of-the art CT scan and a point-of-care INR measurer, is available.

At this moment there are four hospitals that perform IVT in Amsterdam.

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The required medicine for IVT, recombinant tissue plasminogen factor (iv-rtPA) costs more than €60,000 per hospital and with growing IVT numbers these costs will increase but the medical insurance covers the costs of treatment.

Neuro interventions are only performed incidental at the VUmc, but are frequently carried out at the AMC, almost 200 times in 2014. As a consequence among others the use of

angiography equipment and MRI for stroke care is more than at the VUmc. Since May 2014 intra-arterial treatment (IAT) is part of stroke care. In the region, IAT is currently only available at the AMC. In 2014 IAT was carried out 26 times, but in 2015, until 1th of December, this number was more than tripled already. Increase of necessary personnel and equipment, like intervention neuro radiologists is needed and an increase of expensive device usage is expected given these growing numbers.

D. ‘Horizontal verkeer’

There are two cost drivers, with regard to “horizontal verkeer”, within stroke care: the costs for radiological activities and the costs for laboratory tests. The magnitude of these costs between the two hospitals differs in line with the different production numbers. The use of equipment, after lateralization of stroke care, will be discussed below. Due to the introduction of IAT the radiological involvement and activities for stroke care are already increasing at the AMC. Another important aspect of stroke treatment is the use of speech-, physio- and ergo therapy, and consultations by a rehabilitation physician, which are all employed by the rehabilitation department. The extent to which physio- and ergo therapy is used, is different between both hospitals. In the AMC, physio- and ergo therapy is used for most of the stroke patients, in the VUmc this is not the case.

E. Equipment

For the care of stroke patients, weight beds or stretchers and lifters are essential and are now sufficiently available in both hospitals. The yearly costs for these materials are approximately € 20,000 per hospital. Currently the number of CT-, MRI-scanner and angiography equipment is sufficient to accommodate the stroke care at both hospitals.

Organization of stroke care in two Academic hospitals in amsterdam, the Netherlands