Innovation Barriers
in the Dutch home care industry
F.H.M. (Rob) Weerts 11112530
MSc. in Business Administration – Entrepreneurship & Innovation Track Amsterdam Business School, University of Amsterdam
Supervised by dr. W. (Wietze) van der Aa Co-reader: dr. A.S. (Alexander) Alexiev
1 Statement of originality
This document is written by F.H.M. (Rob) Weerts who declares to take full responsibility for the contents of this document. I declare that the text and the work presented in this document is original and that no sources other than those mentioned in the text and its references have been used in creating it. The Faculty of Economics and Business is responsible solely for the supervision of completion of the work, not for the contents.
2
Table of contents
Abstract ... 3
1. Introduction ... 4
2. Literature review ... 6
2.1 Home care in the Netherlands ... 6
2.1.1. Intermediate conclusions ... 10
2.2 Theoretical perspectives in innovation research and healthcare innovation research ... 11
2.2.1. Intermediate conclusions ... 18
2.3 Towards a conceptual framework ... 19
2.3.1. Tailoring the conceptual framework ... 19
3. Methodology ... 22 3.1. Research design ... 22 3.2. Case description ... 22 3.3. Method selection ... 23 3.3.1. Conceptual framework ... 24 3.3.2. Interviews ... 24 3.3.3. Survey ... 26 3.4. Analysis ... 26 3.4.1. Qualitative analysis ... 26 3.4.2. Quantitative analysis ... 27 4. Qualitative Results ... 28
4.1. Classical content analysis ... 30
4.2. Qualitative comparative analysis ... 33
4.3. Conclusions on the Qualitative Study ... 36
5. Quantitative Results ... 38
5.2. Survey design ... 38
5.2. Survey results ... 39
6. Discussion ... 49
6.1. Answer to research question #1 ... 50
6.2. Answer to research question #2 ... 52
6.3. Practical implications ... 55
6.4. Theoretical contributions ... 56
6.5. Research limitations and recommendations for future research ... 56
7. Conclusion ... 58
References ... 59
3
Abstract
Purpose – The aim of this thesis is twofold and can be extracted from the two research questions: 1. What are potential innovation barriers in the Dutch home care industry?
2. How are specific barriers perceived at the level of home care providers?
Methodology – A mixed methods approach is adopted. To answer RQ1: Semi-structured interviews with a group of 11 interviewees, representative for the industry. To answer RQ2: Follow-up survey among 22 respondents working for home care providers and involved in the innovation policy and processes of the organisation.
Findings – 24 potential innovation barriers applying to the industry of home care. 7 barriers are selected and analysed on the level of individual home care providers, resulting in in-depth and specific barriers. Practical implications – The 24 potential barriers serve as concrete entries for improvements in the process of innovating, not just for home care providers but also for other actors in the field. The 7 selected and in-depth analysed barriers serve as guidance for individual home care providers for undertaking the right actions to become more innovative.
Value – Home care is an industry that affects or will affect every Dutch citizen and there is a large call for innovation. At this time there is not much known about innovation processes in the industry. According to theory, understanding of the process of innovation must begin with an in-depth analysis of its challenges.
4
1. Introduction
“To ensure that our future healthcare meets our quality standards while simultaneously being affordable, innovations are of utmost importance” (Nederlandse Zorgautoriteit, 2017). This call for innovation applies to the industry of healthcare as a whole, delivering 14.5% of the Dutch GDP (Rabobank, 2017). The sector is under pressure, amongst others because of an increasing demand for care (Actiz, 2016) that suffers from growing labour shortages (NOS, 2016; Van Essen, Kramer, Van der Velde, & Van der Windt, 2015). As healthcare organisations attempt to control their spending, the need for innovation has become critical to enhance quality of care (Omachonu & Einspruch, 2010).
Within the industry of healthcare, home care has increasingly gained attention in the last few years as a response to demographic trends and several impactful changes in the sector. These trends and changes are explained later in this study. Actors in the field agree that good future home care has to come from innovations (Care Innovation Center, 2017).
Despite this agreement and the indisputable need, there is in fact a lack of innovation in the entire healthcare industry and in home care specific (Deloitte, 2016; Herzlinger, 2006; Hwang & Christensen, 2008). There are however significant possibilities to innovate (Genet, Boerma, Kroneman, Hutchinson, & Saltman, 2013) and these innovations have proven to be successful as well (Grady, 2014; Grol & Wensing, 2004; Mann, Ottenbacher, Fraas, Tomita, & Granger, 1999). Some examples of these successful innovations are presented in this thesis. But, even when there is proof of innovations working in one particular location, further diffusion is said to move slowly or not at all while “the opportunity to revolutionize the healthcare industry has never been greater” (Omachonu & Einspruch, 2010). When it is so obvious, evident and promising to innovate in healthcare and home care, then how is it possible that this is not happening accordingly? More specific, what withholds home care providers from innovating? Like any other industry, home care has its own unique challenges and any attempt to understand the process of innovation within the industry must begin with an in-depth analysis of its challenges (Omachonu & Einspruch, 2010). Therefore, this study first investigates the potential barriers in the industry of home care in the Netherlands, before these potential barriers are deeply analysed on the level of individual home care providers.
Barriers and challenges can concern a broad spectrum of dimensions (Länsisalmi, Kivimäki, Aalto & Ruoranen, 2006; Omachonu & Einspruch, 2010), this study takes on a holistic perspective, meaning that all possible barriers and dimensions will be taken into account and investigated. Eventually the barriers are presented from an organisational perspective.
5 The remainder of this thesis follows the research design which is the following: First, based on prior contributions to literature, a conceptual framework containing items that possible form an innovation barrier in home care is drawn. This framework forms the theoretical backbone of the study and opens the dialogue with field experts. Semi-structured interviews with a representative reflection of the industry enable to uncover potential barriers in the industry and, additionally, to determine which specific potential barriers are further investigated. Then finally a survey among home care organisations is used to deeply analyse these specific potential barriers.
The outcomes of this study are interesting to both practice and theory. Next to mapping an extensive list of potential barriers to innovate in an industry that affects or will affect every Dutch citizen, this thesis presents a selected number of deeply analysed barriers on the level of individual organisations. In addition to these practical implications, theoretical contribution is made. So far, in literature there has been a substantial amount of research to innovation barriers as well as more specifically to barriers in the industry of healthcare, as the literature review clarifies. However, only a few contributions have been made to the home care sector and that is where the present study adds value. Lastly, the in-depth analysis of specific barriers on the level of individual organisations provides concrete and interesting avenues for future research.
6
2. Literature review
The literature review consists of two parts. First, the industry of home care in the Netherlands is defined and characterised by presenting relevant facts and figures, together with its most notable challenges and key developments. Hereafter a closer look into the subject of innovation barriers is provided. This is done via reviewing previous academic contributions on innovation and innovation barriers– both from a general perspective and healthcare and home care specific. Eventually this leads to a conceptual framework that forms the theoretical backbone of this thesis. First, a definition of home care is given.
Defining home care
This study takes on a definition of home care as it is presented by the World Health Organization (Tarricone & Tsouros, 2008): “Home care aims at satisfying people’s health and social needs while in their home by providing appropriate and high-quality home-based health care and social services, by formal and informal caregivers, with the use of technology when appropriate, within a balanced and affordable continuum of care” (p.1). As ‘home care’ appears to be a term with many variations (Wikipedia, 2017a; World Health Organization, 2000) and because the industry is in motion as will become more clear in the subsequent parts of this study, a deeper analysis of what exactly the industry represents is needed. Therefore, a description of the context of the Dutch home care industry is the first part of this literature review.
2.1 Home care in the Netherlands
Home care in the Netherlands is provided via different organisations. Nursing homes with home care as one of its services and agencies with home care as its only business are just two examples. In recent years it became possible for commercial cleaning companies to offer home care services as well and there currently is a revival of neighbourhood-centred home care services, called Buurtzorg (Genet et al. 2013). These and all other forms are included in the study’s definition of home care providers. Home care in the Netherlands represents 146.810 jobs (Deloitte, 2016) with the entire industry of healthcare delivering 14.5% of the Dutch GDP (Rabobank, 2017). The Netherlands is considered to provide home care with relatively extensive services (Genet et al., 2013). On the next page a table containing some more relevant facts and figures about the Dutch health and home care industry is depicted.
7 Table 1. relevant facts and figures about Dutch health and home care industry
Topic Illustration Source
National healthcare expenditures 2016: €75 billion
2021 estimated: >€80 billion, about 1/3 of the total governmental expenditures - above EU average
(Rijksoverheid, 2015) (Mot, Stuut, Westra, & Aalbers, 2016) (OECD, 2009)
Percentage of Dutch versus EU-average people who feel that taking care of dependent elderly is a task for close relatives
13% versus 34% (TNS Opinion & Social, 2007)
Percentage of Dutch versus EU-average people who believe it is best that elderly people receive professional care at home
>50% versus 27% (TNS Opinion & Social, 2007)
Amount of home care providers 1,200 organisations. Number is growing, because of an increasing demand for home care.
(Actiz, 2012)
For profit or non-profit Most of these organisations are still non-profit but the share of commercial organisations is growing.
(Van der Boom, 2008).
People working in the sector 146.810 - they take care of about 2 million people.
(Deloitte, 2016)
Ratio retirees-working population in the Netherlands
1956 - 1:6.4 2016 - 1:3.3
2040 - 1:2.6 *forecast
(Stoeldraijer, Van Duin, & Huisman, 2016; CBS, 2016)
It can be concluded that healthcare represents a large share of the Dutch GDP already and that this amount will grow further. Within that health care sector, home care is increasingly attracting attention – and funds- resulting in a more commercial oriented sector with more providers involved. Compared to other EU citizens, Dutch people believe taking care of elderly (relatives) is a job that should be professionally undertaken. So far so good, but, as mentioned in the introduction: “to ensure that our future healthcare meets our quality standards while simultaneously being affordable, innovations are of utmost importance” (Nederlandse Zorgautoriteit, 2017). Regarding that future, by 2040 the ratio retirees-working population is expected to be 1:2.6. That is, while the amount of people that demand health care is already rapidly growing (Actiz, 2016; Eggink, Oudijk, & Sadiraj, 2012). Partially based on these figures, Jonker et al. (2007) predict a sharply increasing use of home care between 2006 and 2030: +39%.
Previous research on healthcare innovation presents several other interesting insights: innovation is needed, but complicated and therefore there are not enough innovations that are actually being implemented in the industry. This is one of the most important outcomes of a study by Länsisalmi et al. (2006) who used a multidimensional coding process to review 31 empirical studies on topics such as
8 the generation, adoption, and / or diffusion of innovations, or determinants of innovativeness in healthcare organisations. These authors emphasize that healthcare systems in general have a large amount of varying challenges to deal with, such as its retiring workforce, increasing number of elderly patients, and cost-efficiency demands, combined with expectations of high quality care that exploits all the latest advances in technology and related knowledge. These findings are supported in many other publications (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004; Hwang & Christensen, 2008; Omachonu & Einspruch, 2010) and when these are complemented with reports from actors within the Dutch home care sector (such as NZa and Actiz), the severe need for innovation in the Netherlands can be traced back to the ageing population, labour shortage, change in legislation and not fully making use of technological opportunities. This will be explained in more detail in the subsequent paragraphs.
Aging population and labour shortage
The increase in demand for home care comes with a global trend of a shortage of well-qualified nursing personnel (Omachonu & Einspruch, 2010). This trend applies to the Netherlands as well: the current shortage here is expected to increase heavily in the coming years (Care Innovation Center, 2017; Van der Aalst, 2015). Therefore this growing demand for home care may unlock severe problems in the future. Statistics Netherlands (CBS, 2016) and Actiz (Deloitte, 2016) acknowledge these trends and developments and sum it up as an increasing demand for higher educated staff leading to imbalances in the labour market.
New legislation, regulation and funding
In addition to these trends, the home care industry has to cope with a change in legislation and regulation – both affecting its funding. Namely, as of 2015, home care got transferred from the Exceptional Medical Expenses Act (AWBZ) to the Health Insurance Act (Zvw). This change brought regulated competition to a market that has been locked for years. This development led to a tension between demand for care and the available budget that home care providers can spend on providing the requested amount of care. This eventually resulted in a continuing reduction of tariffs for care (Actiz, 2016).
Technological possibilities raise expectations
Expectations about the possibilities for home care have grown as new technology facilitates care coordination and enables distant monitoring and more complex treatments in the home situation. Prior research predicts an increase in the use of supportive technology, such as telecare and video-communication in home care settings (Genet et al., 2013). However, a challenge is the fact that technologic advances in health care have often outpaced the ability to integrate the technology efficiently, establish best practices for its use, and develop policies to regulate and evaluate its effectiveness (Grady, 2014).
9 An industry-report, published this year, on trends and figures in healthcare confirms an increasing amount of innovations that are being established in the industry. Mainly innovations concerning eHealth, domotica and robotica are attracting more attention (Rabobank, 2017). One example of a successful eHealth innovation is a simplified computer with software designed to help elderly people and other patients monitor and manage their conditions at home. It connects to medical devices such as scales, blood-pressure monitors and glucose readers, recording information that can be shared with health professionals over the internet (Omachonu & Einspruch, 2010). Many more examples of successful eHealth innovations exist, but home care innovations are not restricted to just the domain of technology.
Maybe the best example of an organisational innovation comes from Buurtzorg Nederland, founded in 2006 when former home care nurse Jos de Blok introduced an innovative concept: with autonomous, so-called self-governing teams consisting of a maximum of twelve nurses, the goal of Buurtzorg is to deliver better, sustainable and effective care for its clients. For the administrative work, nurses are assisted by customised software while coordination and regulation by the head office is minimized, resulting in among other overhead costs half as high compared to traditional home care providers. Does it work? Considering the grade clients give to Buurtzorg, which is the highest of all home care providers, it does (Buurtzorg Nederland, 2017; Kennisbank sociale innovatie, 2009; Vos, 2008).
Investment in innovations halved
These trends and developments led to an increasing sense of urgency within the industry and as mentioned, an increasing amount of technological innovations is recorded in a 2017-industry report. However, investments in innovations have been more than halved in recent years. In 2012, innovation related expenditures relative to turnover was 1.08%, in 2015 only 0.36% (Deloitte, 2016). What impedes more investments is subjected in this thesis.
10
2.1.1. Intermediate conclusions
Some conclusions can be drawn based on what is discussed in this section on home care in the Netherlands.
One very simple conclusion is that the demand for healthcare and especially home care is growing significantly faster than the supply of well-qualified personnel, confronting home care providers with serious challenges and a need for innovation;
A second conclusion is that there is more pressure on the budgets that home care providers have for meeting this growing demand for care. Again this leads to a confrontation with major challenges, but there are opportunities to grasp the nettle;
Namely, conclusion 3: technique to innovate is available and previous reports show that innovations are being successfully implemented, not just restricting to such technological innovations.
All this together asks for further exploration of what withholds the industry of home care of becoming more innovative.
11
2.2 Theoretical perspectives in innovation research and
healthcare innovation research
The second part of this literature review starts with defining home care innovation and subsequent sections present an overview of relevant literature, consisting of academic contributions on the topics of corporate innovation issues and potential innovation barriers viewed from different angles – general perspectives are complemented with more healthcare specific views. Together this forms the theoretical backbone of the present study, captured in a conceptual framework serving as the basis for the empirical studies that are conducted.
Defining home care innovation
Conceptualising home care innovation starts with a definition of innovation in regard to healthcare. Many definitions exist, some take on different perspectives. The widely accepted definition and reasoning presented by Goes and Park (1997) is central in this study: “We defined an innovation in health care as a medical technology, structure, administrative system, or service that is relatively new to the overall industry and newly adopted by hospitals in a particular market area” (1997, p. 674). Furthermore, Goes and Park explicitly focus on service innovations: innovations that incorporate changes in the technology, design, or delivery of a particular service or bundle of services. The latter is relevant to home care because it is considered a service industry (Greenhalgh et al., 2004).
Innovation as an end-to-end process
The purpose of this study is to present an in-depth analysis of potential barriers in the innovation process of home care providers. To achieve this, the Innovation Value Chain by Hansen & Birkinshaw (2007) is adopted and serves as an initial tool for investigating potential barriers. Namely, Hansen & Birkinshaw (2007) argue that every company has unique innovation challenges and to unveil explicit bottlenecks, innovation should be viewed as an end-to-end process and investigated accordingly. That process, captured in the Innovation Value Chain, consists of the phases generation, conversion and diffusion. Länsisalmi et al. (2006), in their article Innovation in Healthcare – A Systematic Review of
Recent Research, acknowledge these possible stages but they use slightly different names: generation, adoption and diffusion. These authors found that healthcare innovation research seems to focus mainly
on the adoption phase of innovation, but the described reasoning of Hansen & Birkinshaw (2007) fits the goal of this study better and therefore the Innovation Value Chain (IVC) serves as an initial tool for investigating potential innovation barriers at Dutch home care providers. IVC consists of three phases:
1. The first part of IVC is about getting new ideas, possible innovations into the organisation; 2. Part two of IVC consists of two sub-parts: (1) screening and funding new ideas, (2) and
12 3. The third and final part of IVC is about spreading developed ideas within and outside the
company.
Subsequent sections enrich IVC to draw a tailored theoretical backbone for the present study, captured in a conceptual framework serving as the basis for the empirical studies that are conducted.
Why implementing corporate innovation is so difficult
Kuratko, Covin and Hornsby (2014) argue that there are four key issues when it comes to implementation of innovations. These issues are neither well recognized, nor effectively responded to, while “effective recognition of and response to these four implementation issues may represent the difference between those companies that create a successful corporate innovation strategy and those that do not” (p. 647). Understanding and accordingly addressing the issues helps creating an effective innovative ecosystem within the organisation. The four proposed issues are:
(1) Understanding what type of innovation is being sought, (2) Coordinating managerial roles,
(3) Effectively using operating controls, (4) Properly training and preparing individuals.
These four issues are reviewed and in some cases supplemented with other relevant academic contributions.
Understanding what type of innovation is being sought…
…should always be the first step in developing an innovation strategy (Kuratko et al., 2014). Namely: “When there is no clear articulation of the specific innovation being sought by the organization, the actions needed by every level in the organization remain unclear” (p. 648). To classify the possible types of innovation that can be sought, this thesis follows a model covering the six possible dimensions of service innovation, as proposed by (Den Hertog, Van der Aa, & De Jong, 2010). This integrative model is built on an extensive amount of contributions from various disciplines and backgrounds and since home care is considered a service industry, this model is more relevant to the present study than for instance a rather general classification of innovation types. The six dimensions are presented and explained in table 2.
13 Table 2. Adapted from Den Hertog et al. (2010)
Dimension Explanation
New service concept New service concept or offering describes the value that is created by the service provider in collaboration with the customer. The innovation is often a new idea of how to organize a solution to a problem or a need of a customer. Example: small retail outlets at high traffic locations such as “AH to go” in The Netherlands.
New customer interaction
The interaction process between the provider and the client is an important source of innovation – more so when the business service itself is offering support for innovation. The majority of innovations here are variations on the introduction of “self-service”.
New business partner The new value system or set of new business partners, i.e. actors involved in jointly co-producing a service innovation. As the example of the iPhone in combination with the iStore shows, important new services are developed in large communities linked through platforms and networks of businesses. New revenue model Many new service ideas fail as the distribution of costs and revenues do not
match. Example of a new revenue model: a document service management firm shifting from a hardware and product-based revenue model towards a much more customized service-based revenue model where profits made on client-specific service-contracts count rather than selling machines and copies.
New delivery system: personnel, organisation, culture
This dimension refers to the organisational structure of the service company itself, to innovations that typically start at the human resources and/or organisation side of the firm. Examples such as JC Decaux empowering its personnel to clean public transport in combination with using this for advertisements, illustrate that also through the soft elements of the service delivery system one can differentiate oneself from the competition. New delivery system:
technology
This dimension pinpoints the observation that ICTs (predominantly, but not exclusively) have enabled numerous service innovations ranging from electronic government and e-health, to advanced multi-channel management, customization of services, introduction of self-service concepts, virtual project teams and so on.
According to Den Hertog et al. (2010), a service business can innovate in a single dimension or it can combine several dimensions, whereas the prevalence of individual dimensions may vary across different organisations. Regarding innovating the business model it is argued that (almost) every dimension will be included in such a process, whereas it is possible to combine several business models into one corporate strategy.
In addition to categorizing by type, innovations can be classified by the trajectory that it takes; incremental, radical or disruptive (Kuratko et al., 2014). Incremental innovations are the ones that seem less ambitious in scope and they offer the organisation less potential compared to radical or disruptive innovations, but at the same time the associated risks are accordingly reduced. Such innovations are often “systematic evolutions of a product or service into newer or larger markets”, while a radical innovation is “the launching of inaugural breakthroughs such as personal computers and overnight mail
14 delivery” (p.649). Radical innovations take place in existing markets. Disruptive innovation is defined as follows: “In contrast with sustaining innovations (which both incremental and radical are), a disruptive product is actually not as good as what existing customers are already using, and hence it does not appeal to many customers in the existing market. However, because the new product is usually simpler, more convenient, and more affordable, it enables the participation of a new set of customers who were previously ignored by the market or shut out completely” (Hwang & Christensen, 2008, p.1330). The same authors suggest there is haziness about this issue. They argue that because healthcare costs are always being discussed from a wrong perspective, technological innovations are brought to market through existing business models while they should be implemented through disruptive innovations. In addition, Chesbrough (2010) argues that, to managers in general, it is far from clear what the right business model would be for commercializing on technological innovations. These findings call for deeper investigation of what types of innovation are dominant in the industry of home care, what trajectory they are likely to take and if there is understanding or consensus about what business model to embrace.
The issue of (lacking) coordinating managerial roles…
…is the second impediment to successful implementation of corporate innovation. Appropriate managerial coordination throughout all levels of the organisation is a necessary condition for an innovation strategy to work and to sustain within a company. This issue applies to the entire process of corporate innovation, from generating to maintaining and diffusing an innovation strategy. According to Kuratko et al. (2014), the role of a senior manager includes two distinct parts:
Recognizing the value in specific ideas arising from team members and subsequently directing those ideas in appropriate directions;
More important, the articulation of an innovative strategic vision and encouraging a work environment that is open and conducive to innovation.
De Jong & Den Hartog (2007) also stress the importance and potential impact of the management on its workforce; arguing that enhancing individual employees’ innovativeness provides another opportunity for organisations to become (more) innovative. These authors found 13 relevant leadership behaviours that influence employees’ individual innovative behaviour. The behaviours are all related to
idea generation or idea application or both, which is in line with Kuratko et al. (2014), emphasizing the
importance of recognizing and translating ideas coming from inside the organisation. The second part of the role Kuratko et al. (2014) describe, carrying out a clear an innovative vision together with stimulating an environment that is open and conducive to innovation, is underlined in other studies as well, for example by Bommer, Rich & Rubin (2005), who present six transformational leadership
15 behaviours starting with articulating a vision of the future. Therefore, based on the these studies, three overarching important leadership behaviours can be argued, these are:
Articulating an innovative strategic vision Stimulating idea generation among employees
Recognizing and implementing ideas coming from employees
Articulating an innovative strategic vision is separately included because its importance is emphasized
in multiple studies, the second and third behaviour apply to both the theory of Kuratko et al. (2014) and De Jong & Den Hartog (2007). These three behaviours are further explored and refined in the present study.
Effective use of operating controls…
…is the third issue presented by Kuratko et al. (2014). The alignment of operating control processes and mechanisms with a strategy of corporate innovation is a prerequisite for corporate innovation to flourish (Kuratko et al., 2014). In other words, successful corporate innovation activity is contingent upon a firm’s ability to adequately make use of operating controls that select, guide, and possibly terminate innovative actions and initiatives (Morris, Allen, Schindehutte, & Avila, 2006). Selecting,
guiding and possibly terminating corresponds to the processes of recognizing and implementing ideas
as described in the previous paragraph. Therefore, and to remain a clear overview, this item is merged as such in this study.
Individual training and preparation…
Is the fourth and final issue presented by Kuratko et al. (2014). The importance of this item is described as follows: “Without awareness, encouragement, and nurturing, the entrepreneurial behavior that is linked to corporate innovation will not surface or be used consistently throughout the firm” (p. 653). In short, management is responsible for creating awareness and understanding among employees to make sure that they will enact upon the corporate innovation strategy accordingly. According to Kuratko et al. (2014), this process of training and preparing individuals for corporate innovation a responsibility of the management, therefore issue will be added as a fourth part of the previously described coordinating managerial roles and will be included in the conceptual framework as such. Having reviewed the four issues of Kuratko et al. (2014), they will all (in adapted form), return in the conceptual framework that is used and presented later on in this study.
16
Sector Specific External Factors
A final part of the conceptual framework is formed by the external factors surrounding a home care provider. This addition is made because previous contributions to the subject of healthcare innovations show that the external environment and its contingencies indeed significantly affect healthcare institutions’ ability to innovate (Grol & Wensing, 2004; Herzlinger, 2006; Hwang & Christensen, 2008). Every corporation has an external context including factors such as governmental regulations and policies. In the industry of healthcare this includes for example policies on reimbursements. In the subsequent section dominant and relevant contributions to this issue are discussed. Most of these stem from USA, but it is nevertheless relevant to further investigate the role of the external context in the Dutch home care sector, since the core players in both the Dutch system and the American system are the same: the government and providers, insurers and recipients of care. These sector specific external factors are in the remainder of this thesis referred to with External Factors.
Different perspectives on external factors
Hwang & Christensen (2008) present external challenges to innovation in health care and while they are very much focused on the American healthcare market, fragmentation of care, lack of a retail
market, regulatory barriers and reimbursement issues do all, to a certain extent, apply to the Dutch
home care industry as well, as can be found in various publications about the Dutch health and home care industry. (Actiz, 2017; Kieskamp, 2017; PWC, 2016). These challenges might be different in detail, this is investigated in the present study. Table 3 presents them.
17 Table 3. Adopted from Hwang & Christensen (2008)
Challenges To New Business Models In Health Care
Fragmentation of care Carving focused facilities and user networks out of today’s mixed models of health care delivery might indeed capture unrealized efficiencies and cost savings, but they also might fragment the delivery of care. Coordination of care in such a system is critical, and the importance of interoperable health information technology (IT) cannot be stressed enough.
Lack of a retail market Disruptive innovation requires that a market of consumers carry proper incentives to shop for products and services that best meet their needs. Regulatory barriers For the sake of higher profits, the status quo makes impassioned claims that
disruptive change could jeopardize public safety, leading to barriers in the regulatory context.
Reimbursement Regulators and payers often direct their attention to cutting reimbursement rates as the primary solution. However, cutting reimbursement in an attempt to force the solution-shop business models of hospitals and physician practices to somehow figure out a way to become more efficient does little to improve health care delivery.
According to Herzlinger (2006), six forces influence innovations in healthcare, all of them are external and can be both a barrier and a facilitator. Again, these are written from an American perspective and therefore details may vary but the overarching forces are applicable to the Dutch market as well and are therefore suited for further investigation. The six forces clearly take on a wider perspective than the challenges proposed by Hwang & Christensen (2008) and are presented in table 4.
Table 4. Adopted from Herzlinger (2006)
Six Forces That Can Drive Innovation—Or Kill It (in healthcare)
Players The friends and foes lurking in the health care system that can destroy or bolster an innovation’s chance of success.
Funding The processes for generating revenue and acquiring capital, both of which differ from those in most other industries.
Policy The regulations that pervade the industry, because incompetent or fraudulent suppliers can do irreversible human damage.
Technology The foundation for advances in treatment and for innovations that can make health care delivery more efficient and convenient.
Customers The increasingly engaged consumers of health care, for whom the passive term “patient” seems outdated.
Accountability The demand from vigilant consumers and cost-pressured payers that innovative health care products be not only safe and effective but also cost-effective relative to competing products.
A third contribution is made by Bitner, Faranda, Hubbert, & Zeithaml (1997), who fully focus on customers; the recipients of home care. Herzlinger (2006) already argued that nowadays the term patients seems outdated: consumers of healthcare actually became customers. Therefore and since home care delivery is a service, the customers have significant influence on the effects of an innovation.
18 Bitner et al. (1997) describe this phenomenon as follows: “In contributing information and effort in the diagnoses of their ailments, patients of a healthcare organization are part of the service production process … Thus, the quality of the information patients provide can ultimately affect the quality of the outcome” (1997, p.197). The level of customer involvement influences the extent to which an organisation can innovate. This is explained as follows: customer involvement can be low, moderate or high, all options have certain consequences. When there is low involvement, customer presence is required during the service delivery. A moderately involved customer should provide input for service creation and if highly involved, the customer co-creates the services product. The exact level of involvement for home care recipients can be a point of discussion, but will at least be moderate, emphasizing that the customer itself could be a barrier to innovation. Therefore the role of the consumer will be further investigated in this study. It can also be discussed whether customer is part of the external factors of a home care provider or that customers belong to the internal factors, but in this thesis they are investigated as part of the external factors. Although the research by Bitner et al. was published in 1997, the described relationship still applies to contemporary home care since the core relationship between the care recipient and care provider has not changed.
2.2.1. Intermediate conclusions
In this second part of the literature review home care innovation is defined and it is explained why this thesis views the entire innovation process from to end-to-end, instead of just one of the three phases (generation, conversion, diffusion). Hereafter four impediments to corporate innovation are discussed in the light of this thesis and certain choices are made to tailor these insights by Kuratko et al. (2014) to the present study and finally multiple perspectives on the external factors surrounding a home care provider are described. All this together forms the fundament for the conceptual framework, presented in the next chapter
19
2.3 Towards a conceptual framework
The Innovation Value Chain (IVC), containing the phases of generating, converting, and diffusing ideas (Hansen & Birkinshaw 2007), serves as the first part of a conceptual framework that is used to investigate potential innovation barriers in the Dutch home care industry. Every company or industry has unique innovation challenges and the use of IVC makes sure that the end-to-end process of innovation is reviewed. This gives the opportunity to unveil explicit bottlenecks that impede innovation somewhere in the process. A brief overview of the IVC model is explained earlier in this literature study and is yet again presented below.
Innovation generation
The first part of IVC is about getting new ideas, possible innovations into the organisation. Ideas can originate inside the organisation or come from outside the organisation – such as customers, competitors, inventors, and other external parties.
Innovation conversion
Part two of IVC consists of two sub-parts: (1) screening and funding new ideas, (2) and developing ideas into viable products, services, or businesses. This is the stage where potentially good ideas are assessed, and, moreover, where the money comes in. The conversion stage limits itself to the boundaries of one single organisation.
Innovation diffusion
The third and final part of IVC is about spreading developed ideas within and outside the company. In the present study this applies partially to sustaining an innovation within the home care organisation but mostly to the process of scaling up local initiatives nationwide.
2.3.1. Tailoring the conceptual framework
The conceptual framework starts with IVC, but then three dimensions are added to tailor the framework to the present study. This results in a conceptual framework consisting of the following four dimensions:
I. Process of Innovation: II. Type of Innovation III. Leadership Behaviours IV. External Factors
There is overlap between several dimensions within the framework, this overlap is anticipated and deliberately included because of the additional articles that are reviewed. The next section presents in more detail which overlap issues occur.
20
Sequence and overlap within the conceptual framework
The reason for including and starting with IVC is to make sure that no possible barrier somewhere in the process is being overlooked. However, because IVC covers the end-to-end process of innovation, there is overlap with the two subsequent dimensions in the framework: Type of Innovation and
Leadership Behaviours. This overlap is anticipated and deliberately included since Kuratko et al. (2014)
and the complementary articles that are reviewed made clear why it is important to put more focus on these items:
Kuratko et al. (2014) argue that clarity about the Type of Innovation that is being sought by an organisation is the fundamental first step related to corporate innovation. To classify the possible types of innovation, this study follows a model covering the six possible dimensions of service innovation as proposed by Den Hertog et al. (2010).
Leadership Behaviours entails several parts of the study by Kuratko et al. (2014). Articulating a
strategic vision is considered essential for providing guidance internally and encouraging a work
environment that is open and conducive to innovation. This item, as well as the next two (stimulating idea generation; recognizing and implementing ideas) is underlined in other studies as well (e.g. Bommer et al. (2005); De Jong & Den Hartog (2007)). The fourth item is training employees accordingly. In the original study by Kuratko et al. (2014) this item was separately included, but in this thesis it is included under the dimensions Leadership Behaviours because just like the other three items, training employees is the responsibility of the management and it is investigated as such.
External Factors is the final dimension in the conceptual framework and is separately included because previous contributions to the subject of healthcare innovations made clear that the external environment significantly affects healthcare institutions’ ability to innovate. The next page presents the conceptual framework in detail. The subsequent chapter describes the methodology of this thesis.
21 Figure 1. Conceptual framework
22
3. Methodology
The following chapter presents the methodology and therefore contains the following sections: Research design
Case description Method selection Analysis strategies
At the end of the chapter, the research process is visualised and displayed in a graph.
3.1.
Research design
The aim of this thesis is twofold: to uncover potential industry-wide innovation barriers in the Dutch home care sector while subsequently investigating how specific barriers are perceived at the level of individual organisations. This approach led to the following research questions:
3. What are potential innovation barriers in the Dutch home care industry? 4. How are specific barriers perceived at the level of home care providers?
This study uses a mixed methods approach in a holistic cross-sectional design with multiple cases. A key advantage of mixed methods research is that its methodological pluralism frequently results in superior research (Johnson & Onwuegbuzie, 2004). In addition, by combining qualitative and quantitative methods, differences in the extent to which barriers are perceived by individual companies might be found (Thomas, 2011). Such differences would serve as interesting avenues for future research. Desk research resulted in a list of companies that are approached via email first, and later via phone. This form of purposive sampling is said to increase transferability and achieve representativeness of the findings (Teddlie & Yu, 2007). In addition, it positively contributes to generalization of the findings (Yin, 1999) which is important for uncovering industry-wide barriers. Cases are selected carefully so that either similar results are predicted or contrasting results for anticipatable reasons, this is in line with the replication logic of Yin (2013).
3.2.
Case description
Before selecting the cases it is needed to define what exactly is the case, the unit of analysis; a step that is as important as it can be difficult (Eisenhardt, 1989; Ragin & Becker 1992). More than in other fields, difficulties are likely to arise in health services research because of the ambition to investigate rather abstract cases (Yin, 1999). Another argument for an explicit definition is the fact that the term ‘home care’ is understood very differently across countries and sectors and home care can be provided via
23 different types of organisations (Genet et al., 2013). In this study the case is: Dutch home care industry and providers of home care, consisting of the terms home care and home care providers which need to be defined.
The present study follows the definition home care of the World Health Organization (Tarricone & Tsouros, 2008): “Home care aims at satisfying people’s health and social needs while in their home by providing appropriate and high-quality home-based health care and social services, by formal and informal caregivers, with the use of technology when appropriate, within a balanced and affordable continuum of care” (p.1). Hence, it includes not exclusively care for frail elderly people, but also patients in need of home care after hospitalization and adults with disabilities, because this definition is most congruent with the way home care is defined and organised in the Netherlands: “Care and nursing being delivered at clients’ homes. Home care is considered extramurally, primary health care. It contains various services of which nursing, personal care and domestic-aid services are among the most renowned (Wikipedia, 2017b).
Providers of home care come in different forms. Nursing homes with home care as one of its services
and agencies with home care as its only business are just two examples. In recent years it became possible for commercial cleaning companies to offer home care services as well and there currently is a revival of neighbourhood-centred home care services (Buurtzorg) (Genet et al. 2013). These and all other forms are included in the study’s definition of home care providers. In addition, an overview of other actors in the field of home care is included in the appendices.
3.3.
Method selection
This study takes on a mixed methods approach. After the literature review, a qualitative and exploratory approach is applied to gain a thorough understanding of what possible barriers exist within the industry of home care. It can be argued that it is appropriate to work inductively, because not much specific literature about innovation barriers in Dutch home care exists (Saunders, Lewis & Thornhill, 2009). However, a substantial amount of literature on difficulties for innovation (also in healthcare) does exist and in such cases qualitative methods are advocated for their ability to discover the underlying nature of the phenomenon in question (Strauss & Corbin, 1990). Using the theories that are known, is requisite for the replication logic (Yin, 1999) and they therefore form the foundation of the present study. The initial theories are refined and extended, not tested, through exploratory research.
Hereafter a quantitative approach is pursued in order to specify potential innovation barriers to the level of individual organisations. This approach is considered advantageous as an addition to the qualitative research, not least because managers are familiar with deduction and therefore much more likely to trust the conclusions coming from a quantitative approach (Saunders, Lewis & Thornhill, 2009).
24 The combination of these methods is chosen for its ability to fulfil the research purpose: uncovering barriers– as perceived by home care providers – to innovate in the Dutch home care industry. First, potential barriers are explored and subsequently it is investigated how these barriers are perceived by home care providers. The research then consists of three stages as is depicted in table 5 on this page. Hereafter the conceptual framework, interviews and survey as discussed in more detail before a description of the analysis strategies is presented.
Method Explanation Why
Composing a
conceptual framework
Based on academic publications on corporate innovation and innovation barriers, in general and in healthcare.
To describe the context and to provide the foundation for the research (Saunders, Lewis & Thornhill, 2009). To improve accuracy and enable stronger theoretical grounding (Eisenhardt, 1989), tailored to the present study.
In depth interviews with 11 industry experts
Interviewees are managers of home care providers that are directly involved in corporate innovation, academia, insurers, governmental institutions and innovation platforms.
To refine the framework through empirical exploratory research: the fundament for answering the research question and input for the content of the survey.
The list of interviewees is a representative reflection of the industry, in order to get the most complete view of how the industry perceives its barriers to innovate. Survey administered
to 22 respondents
Respondents are
(innovation) managers and other employees involved in the innovation process of home care providers.
The survey allows for specifying the potential barriers and describing them to the level of individual organisations.
Table 5. Research Design
3.3.1. Conceptual framework
Composing a framework is important, even when the study would be fully exploratory (Yin, 1999). The present study contains academic contributions that are reviewed to either enrich or remove parts of this theoretical foundation, resulting in a conceptual framework tailored to this study. Such an approach is also used in other studies on innovations in healthcare (Herzlinger, 2006; Grol and Wensing, 2004). The conceptual framework that is used in this study can be viewed on page 22, figure 1.
3.3.2. Interviews
In-depth semi-structured interviews containing open-ended questions are conducted with a total of 11 respondents coming from a variety of organisations. Regarding interviewees representing home care providers, individuals are selected that have a managerial position, are involved in or mandated to decide on corporate innovation. This criterion was chosen following the aim of the study to eventually uncover barriers at the level of individual organisations. Regarding interviewees not representing home care providers, individuals are selected for which the subject of this thesis is a core part of their jobs
25 while the group as a whole should form a representative reflection of the core actors in home care industry. An overview is presented in the table below.
# Type of organisation Organisation Position Duration (min)
1 Home care provider Woonzorg Flevoland CEO 45 2 Home care provider Woonzorg Flevoland Executive secretary 45 3 Home care provider De Wever Program manager 45 4 Home care provider Icare CEO 35 5 Home care provider Zorgspectrum Nieuwegein Advisor innovation 60 6 Home care provider Cordaan Director Strategy,
Innovation & Quality
60
7 Home care provider Thebe Information manager 35 8 Research Tilburg University Senior Researcher eHealth
and Social Innovation
45
9 Innovation platform Proeftuin voor dementie Program manager, former innovation manager insurer
60
10 Government Ministry of Health, Welfare and Sport
Innovation & Healthcare improvement
55
11 Insurer Zilveren Kruis Care vendee 35
Table 6. Overview of interviewees
Interviews were aimed to last 45 minutes, in some cases this timeframe was not reached or overreached. In the cases of <45 minutes, it was known beforehand that the interviewee had less time, therefore during the interview it was ensured that all items of the protocol were touched upon. In the cases of >45 minutes the respective interviewee had more time to elaborate on certain topics. The interview protocol containing the interview questions is included in the appendices. Before the start of the interview, interviewees were provided with some introductory information about the specific subject, approach and goals of the study. Hereafter acopy of the conceptual framework including an explanation of items was handed out and the items are briefly explained verbally. Then, the items in the framework are discussed one by one. Interviewees were asked how they perceive the items in the framework and if some items are more prevalent compared to others. For the exploratory nature of the study, interviewees were asked to identify any additional items of which they think that are missing from the framework. Interviewees were asked to illustrate by providing specific examples. An example of how an item of the conceptual framework is translated and operationalized in an interview question:
Type of innovation: Dimension: It is possible to innovate in six innovation dimensions. There can be ambiguity about these dimensions, which could hinder the process of innovating. Do you recognize the six innovation dimensions? Which do or do not apply to your organisation? Is there one innovation dimension that you generally pursue?
26
3.3.3. Survey
The survey respondents are selected by again purposive sampling; the initial pool of candidates is similar to the candidate interviewees representing home care providers. This is combined with snowball sampling, which means as much as that the selected respondents are asked to spread the survey among their relations (Goodman, 1961). Snowball sampling can be chosen when the target population is rather complex or specific and there are no (or not enough) financial resources to obtain an ideal sample (Welch, 1975). While snowball sampling can have strong possibilities for bias, this mainly applies when it is the only approach pursued, which is not the case in the present study. Bias is additionally reduced when the original sample resides in different networks, which is strongly the case in the present study. The described approaches increase the external validity of the study (Teddlie & Yu, 2007). To fill out the survey, respondents had to meet one condition: to be involved in the innovation process or policy of its organisation. This resulted in a total of 22 respondents. The next sections present more information about the analysis of both the interviews and the survey.
3.4.
Analysis
3.4.1. Qualitative analysis
The interviews are recorded with permission and systematically analysed and coded. The interview transcriptions are examined for patterns or relationships with a deductive coding approach: using a set of codes obtained from literature or theory to examine the data to find instances of these codes (Tashakkori & Teddlie, 2010). In this case, code-categories are similar to the items in the conceptual framework. This is called analytic induction and together with purposive sampling of interviewees it benefits the generalisability of qualitative research (Andreassen, Kjekshus & Tjora 2015).
Interview transcriptions are then analysed via classical content analysis (counting the number of codes) and qualitative comparative analysis (systematically analysing similarities and differences across cases (…) to test and develop the categories further) (Tashakkori & Teddlie, 2010, p.409-410). Data that could not be coded in the initial categories was identified and analysed later to determine if it represents a new item or a sub-item of an existing code. Such (sub)items either offer a contradictory view on innovation barriers or they further refine, extend, and enrich the theory (Hsieh & Shannon, 2005). Both qualitative strategies are briefly described in the next paragraphs, before the quantitative analysis strategy is presented.
Qualitative content analysis
Academic literature defines qualitative content analysis as “a research method for the subjective interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns” (Hsieh & Shannon, 2005, p. 1278). This strategy comes in three
27 alternatives and in this study the directed approach is adopted (Hsieh & Shannon, 2005). This approach is chosen because of its main strength that existing theory can be supported and extended; fitting the approach of taking the conceptual framework as a starting point of the thesis. One possible pitfall is an overemphasis on theory, blinding to contextual aspects of the phenomenon. This is tackled by including the IVC as a starting point for the framework. Namely, by doing such, the end-to-end process is reviewed which naturally leads to the inclusion of contextual aspects throughout the entire process.
Qualitative comparative analysis
Systematically analysing similarities and differences across cases to test and develop the categories further (Tashakkori & Teddlie, 2010, p.409-410) is what is done in the qualitative comparative analysis section. This means the results are compared, however not yet interpreted, in order to uncover what items interviewees agree and or disagree on.
3.4.2. Quantitative analysis
Analysis of the interviews leads to an overview of potential innovation barriers in the Dutch home care industry. The follow-up survey is used to analyse specific potential barriers in more detail at the level of individual organisations. The decision to make a selection of potential barriers and to deeply analyse these potential barriers follows the purpose of the study; to get an understanding of how barriers are perceived by home care providers. As already described in the introduction, the understanding of an innovation process must begin with an in-depth analysis of its challenges (Omachonu & Einspruch, 2010). Selection of the potential barriers is based on the qualitative comparative analysis of the interviews.
The survey has room for additional input from the respondents. This allows for more detailed barriers and potential avenues for future research. Results are presented in the same sequence as they are in the survey. Full results are included in the appendices. Items are analysed one by one, looking at both the statistical outcome and its illustrations. For example: the percentage of respondents that feel the client needs to be involved from the generation phase is presented together with arguments provided by the respondents. Results are presented in a clean form, meaning that interpretation of the results is left out. This comes in in the subsequent chapter, where theory, qualitative results and quantitative results are compared.
28
4. Qualitative Results
Classical content analysis resulted in table 6 – containing frequencies, examples and sample comments.
The frequencies of the mentioned items need additional explanation and the reasoning and illustrations by interviewees is actually more important and disclosing than just displaying the frequencies. This is partially because of the nature of the items in the framework. For example, regulatory context is likely to receive more attention than customer, because this item includes multiple different actors and parties while the customer represents just one group; care receivers. Another reason is that the semi-structured and exploratory nature of the interviews allowed interviewees too elaborate more on specific items, without mitigating the prevalence and potential of others. For example training is not among the most frequently mentioned items, however, the interviewees that did mention this item strongly emphasized the importance of it.
After the classical content analysis and a brief explanation of these results, qualitative comparative
analysis is applied: systematically analysing similarities and differences across cases to test and develop
the categories further.
Table 6 is displayed on the subsequent page, together with the actual analysis of the results. Aim of the qualitative study is to uncover potential innovation barriers in the Dutch home care industry, building on and refining existing theory –captured in the conceptual framework-, so that hereafter the quantitative study can analyse specific barriers more in-depth on the level of individual organisations. This chapter, containing the results of the qualitative study, is ordered as follows:
1. Per item of the conceptual framework results are presented; 2. Some additional relevant items are found and introduced; 3. Similarities and differences across cases are discussed; 4. An overview of potential barriers to innovate is depicted;.
29 Item
Mentioned in total (% of total)
Examples and sample comments
Pr oc e ss of I nn ovati on Generating 20 (8%)
Sources of innovation mentioned: clients, developments in the market, intuition, data, frustrated employees, annual plan. “Innovation starts with the profile, vision and courage of the management. An innovative climate is very important”
Converting 24
(9%)
Difficulties regarding conversion mentioned:
Fragmentation of care and funding, haziness about responsibilities, wrong focus on efficiency, lack of commercial approach, no financial relationship between provider and recipient of care.
“There is a negative vicious circle regarding the funding of innovations in home care.”
Diffusing 27
(10%)
Difficulties regarding diffusion mentioned:
Lacking cooperation, sharing knowledge, abundance of pilots. “We suffer from pilotitus”
Ty p e of Inn ova ti on Dimension 15 (6%)
Most interviewees argue for combination of the possible innovation dimensions. Some say that in general there is too much focus on eHealth.
“Regarding innovation in home care, people mistakenly think of eHealth 9 out of 10 times. There is so much more”.
Trajectory 9
(3)
General sentiment is that it is very difficult to innovate radical or disruptive.
“Risk taking in home care is difficult”
Lea dersh ip B eh av iou rs Strategic vision 29 (11%)
The importance of a strategic vision on innovation is heavily underlined.
“Leadership is crucial for the right innovation climate”. Stimulating
generation
18 (7%)
A vision on stimulating the workforce is important. At the same time, employees lack time to think of innovations.
“Do you want your employees to control processes or discover improvements?”
Recognizing & implementing
8 (3%)
Less attention is being paid to actually doing something with ideas coming from the workforce.
“We don’t have a process for that”
Training 7
(3%)
If mentioned, interviewees emphasize its importance.
“IT-skills of employees is the biggest challenge for implementing eHealth” Ex ter n al F ac tors Customer 24 (9%)
Mainly about the extent to which a client is responsible for its own care, social acceptance of eHealth, and the place clients have in the innovation process.
“The client is increasingly responsible for its own care”.
Regulatory context
55 (21%)
Shared discontent about the way home care is regulated, referring to funding which is organised via different streams – all separately organised and belonging to different actors such as the government or the insurer. Potential role of partnerships is emphasized. “The current system has a chronic lack of incentives for innovation” “We must work together with all the involved actors” and
“Competitors are a chance to innovate, but most people see it as a threat”
Technology 24
(9%)
Mismatch between available technologies and the actual needs of the field.
“Technologies are looking for demand”
Table 7. Classical Content Analysis.Every interview was coded with the items of the conceptual framework as initial codes. The
number in the third column represents the frequency of mentioned items, in absolute numbers and percentages. The items are mentioned 260 times in total. The full coding scheme is included in the appendices.
30
4.1. Classical content analysis
The following paragraphs discuss every item of the framework by briefly showing how interviewees reacted to these items. These are all mere descriptions of the findings, subsequent sections illustrate the results more in-depth. The end of the section presents four new sub-items.
Generating
Interviewees signal many sources of innovation as well as many conditions or requirements for generating innovations. One interviewee declared that home care providers are too less aware of the possibilities to innovate, but this statement did not get approval in the other interviews where the general sentiment is that enough opportunities exist. Why these are not grasped is discussed in this thesis. The role of the client is frequently associated with the item generating, but client returns later on as it is a separate item. The general sentiment among interviewees is that generating innovations concerns a broad spectrum of conditions and can reside in a large amount of sources.Examples are presented in table 6.
Converting
Interviewees elaborate on the difficulties they face when trying to convert potentially successful innovations and again, a large variety of possibilities are presented. Find these examples in the table. What stands out is that the majority of examples provided by the interviewees are considered with money. One interviewee declares that the absence of a monetary relationship between the provider and receiver of care, is the most important barrier to innovate. There are however also interviewees that shed a different light on this item by arguing that it is not so much about the financial conditions and regulations, but about the choices an organisation itself makes. “There is a collective lack in making choices and subsequently enacting upon them”, is one of the remarks, “Don’t look at others or external factors, the way an organisation can organise itself is key to the extent an organisation is able to innovate,” is another example underlining the focus on the individual organisations. The meaning of these different viewpoints is discussed later on.
Diffusing
Regarding difficulties for diffusion of innovations, less varying examples are given compared with generating and converting. If one thing is made clear by the interviewees, it is that the industry has a lot more to gain when it comes to scaling up from pilots or local initiatives to nation-wide diffused and sustained innovations. Partnerships are referred to as a means to catalyse this process of scaling up. Interviewees emphasize the importance of cooperation between actors in the field and a severe lack of such partnerships, while they also perceive a lack of sharing knowledge in the industry. ‘Money’ is also mentioned as a problem, but interviewees themselves are not unanimous when it comes to what
