Managing the flexibility of hospital real estate

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Master Facility & Real Estate Management

Title assignment : Thesis - “Managing the flexibility of hospital real estate” Name module/course code : M Thesis C / BUIL - 1230

Name Tutor : Mrs. Hester van Sprang Name student : Otto Lenderink

Full-time / Part-time : Part-time Greenwich student nr. : 001006179 Saxion student nr. : 456204

Academic year : 2018-2019

Date : 02-08-2019

Word count : 19984

(Excl. front page, table of contents, references and appendices)

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Managing the flexibility of hospital real estate

A multiple case study

Master thesis

Msc. Facility and Real Estate Management programme Saxion University of applied sciences / Greenwich University

Author: H.W.O. Lenderink Date: 02-08-2019

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Summary

Substantial changes in the Dutch health care landscape have led to new ways of funding and designing hospitals. Flexibility in the design of hospital real estate provides options to adapt to changing circumstances. FREM plays an important role in managing hospital real estate and the utilization of these options. This research aims to contribute to a better

understanding of the role FREM plays in utilizing flexibility options of hospital real estate and the influence of market regulation on hospital building design.

The most important conclusion of this research is that hospital organisations occupying modern buildings, with more flexibility options than older ones, are not necessarily better equipped to utilize those options. A well-aligned real estate strategy, good objectivation methods and the proficiency of the organisation to ensure proper use of the real estate, are equally, or perhaps more important to utilize the provided flexibility options.

Hospital FREM departments are recommended to develop well-alligned real estate strategies to serve as a compass for all real estate decisions. In addition, it is advised to develop methods to objectify space demand and agree upon manageable rules to ensure proper utilization of the flexibility options provided.

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Foreword

The Msc. Facility and Real Estate Management programme has proven to be a challenging experience. Although managing time for family, work, studying and (occasional) social activities was not easy, overall I really enjoyed the programme. This thesis report serves as the final chapter and I am confident it is a good representation of the knowledge that I have acquired in the last two years. The report consists of my own work, except where stated otherwise. That being said, I could not have written the report without the help and participation of several people who I would like to acknowledge.

First and foremost, I would like to thank my employer, the Deventer Hospital and in particular Mr. Frans Luttmer for enabling me to pursue the endeavour of obtaining a master’s degree. In addition, I would like to express my appreciation to all interview respondents for their willingness to participate and their valuable insights.

I would also like to thank all teachers and staff of the FREM-programme and especially my tutor Mrs. Hester van Sprang for her support, optimism and guidance throughout the entire process.

Ofcourse a special thank you is reserved for my lovely wife Karen and beautiful daughter Cato for their patience and support. Finally yet importantly, my one-year-old son, Willem deserves a big thank you for not giving us too many sleepless nights and his cheerfull nature in general.

Otto Lenderink

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1. Introduction

In the last decennium, the Dutch health care landscape has changed dramatically. Before 2008, hospital real estate was funded by the government whereas hospital organisations nowadays are responsible for financing their real estate from revenue generated by the treatment of their patients. This results in the need to make efficient use of space in order to stay competitive and financially healthy.

A brief history

In 1971 the “Wet ziekenhuisvoorzieningen (WVZ)” was introduced. When this law was introduced the “College voor Zorgverzekeringen” (CvZ) was formed: an independent legal entity tasked with giving advice in regards to efficacy of health care facilities. As per the year 2000, the CvZ was transformed to an independent governing body consisting of independent consultants and experts; the “Bouwcollege”. Next to advisory tasks the organisation was also able to make decisions, meaning the “Bouwcollege” was authorized to independently give out permits to develop hospital real estate based on programme requirements and

preliminary designs. (AAG,2017)

Until 2008 the costs for interest and amortization of hospital real estate were compensated by the government as long as there was a permit provided by the “Bouwcollege”. This compensation was based on standardised norms for building surface based on the number of potential patients in the hospitals service area. (CBZ,2002) The compensation was not dependent on actual occupancy rates of the real estate. Therefore, the costs of real estate were no issue for health care organisations as the risk of underachieving real estate was carried by the Dutch government.

This all changed as of 2008 when, as part of the introduction of performance related funding by the Dutch government, the “Bouwcollege” was shut down. As of January 2012,

compensation for real estate costs became part of the cost price of care products and, therefore, a responsibility of health care organisations instead of the government. (Klink, 2008). The amount of compensation for real estate costs is dependent on the number of patients that are treated by the organisation. As a result, real estate costs have become a risk for health care organisations. If actual real estate costs exceed the compensation generated by the treatment of patients and/or if patient numbers decline, the hospital may not be able to cover its real estate costs as they are fixed and will remain on the same level regardless of the volume of patients treated. (RVZ,2006)

This development has led to new ways of designing hospitals with sustainability and flexibility in mind. Since future developments in health care are highly unpredictable, the hospital organisations and the real estate that supports them need to be flexible in order to cope with whatever scenario will unfold.

The role of FREM

FREM plays a large role in not only the design of new hospital real estate but also the utilisation of new highly adaptable and flexible hospital buildings. As the Dutch health care

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3 sector continues to struggle with high costs, an increase in demand and government and insurance company pressure on tariffs, costly real estate is a regular item on boardroom agendas. FREM organisations within hospitals are expected to manage the valuable real estate assets in a professional way by being in control and adding value. In complex organisations like hospitals this can be a daunting task.

A flexible hospital building makes it possible to adjust real estate to new circumstances or new ways of health care delivery. This helps to improve productivity, reduce running costs and as such, reduce the price of health care products and services. (van der Zwart, 2014)

Problem statement

Existing theory about flexibility of hospital real estate is widely available. However, if and how it is utilized remains under explored. This raises the question whether the flexibility options of hospital real estate are actually used as intended and how FM/CREM

departments manage the flexibility provided. As insights in terms of flexibility change through time, each hospital building has its particular flexibility options. The introduction of market regulation and the shutdown of the “Bouwcollege”, gave the sector more freedom in developing real estate but also increased financial risk, possibly leading to other design choices than those made before 2008.

Objective

This research aims to contribute to a better understanding of the role FREM plays in utilizing flexibility options of hospital real estate and the influence of hospital building design after the introduction of market regulation in 2008.

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2. Literature review

This chapter will provide insight in theory that is relevant to answer the research questions. It aims to do so by describing findings from academic literature and other sources. The literature review serves as a tool to give meaning to the findings of the in-depth interviews and document research.

2.1. External factors influencing demand in hospital real estate

In this chapter, the most prominent external factors influencing the demand in hospital real estate will be discussed, providing insight in macro developments by which hospital

organisations are confronted.

2.1.1. Politics

“Hoofdlijnenakkoord specialistische zorg 2019-2022”

In 2018, an agreement was reached between the Dutch government, the Dutch hospital association (NVZ), Health care insurers (ZN), the Dutch federation of University Hospitals (NFU), the Dutch Patient Federation, Independent Dutch Clinics, Dutch Nurses en Carers (V&VN) and the Federation of Medical Specialists (FMS). As part of the agreement a number of goals were determined, most prominently; zero growth of costs as of 2022, delivering care in the right place, reduction of rules and regulations and the search for answers concerning employment challenges. The agreement is a combination of trying to reduce health care costs and keeping health care easily accessible for everyone in the Dutch society (Rijksoverheid, 2018).

Transition of the health care landscape

In line with the “hoofdlijnenakkoord specialistisch zorg 2019-2022” trying to deliver the right care in the right place, in recent years there has been an increase in focus of hospital

organisations on networking and cooperation with care-suppliers on different levels in the care-landscape. On a horizontal level there is integration through cooperation and mergers between hospital organisations and on a vertical level the cooperation is taking place between care-suppliers that exist on different levels in the landscape. Vertical integration between hospitals and other care suppliers, like general practitioners and nursing homes, has seen major increases during recent years. In order to create true integrated care, it will be necessary to intensify the vertical integration of care-suppliers in search for a seamless care pathway for patients (KPMG-Plexus, 2013).

In order to achieve successful vertical integration, KPMG (2018) is promoting the creation of three levels of health care that will support the integral vision. In their vision, a paradigm shift and a dramatic breach with the current Dutch care-infrastructure, that is based on physical infrastructure and organisational chimneys, are necessities to achieve durable (cost)efficient health care.

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Low complex specialist care will be organized close to the home of the patient in local

care-centres with easy access to a medical specialist. This eliminates the necessity of a large hospital with expensive facilities.

High complex care will be delivered by approximately 30 modern and efficient high-complex

intervention centres. These will provide acute care, mother and child care, high-complex interventions and specialized oncology. By centralizing these (large) centres it is anticipated that optimal volumes and efficiency can be reached.

Low complex elective care will be provided by specialized (private) clinics that excel in

quality service and efficiency through experience (KPMG, 2018). ING is expecting radical

changes in the Dutch health care landscape in the coming years.

According to their report there will be more focus on self-management

accomplished by

prevention of illness and e-health (Dantuma, 2015). Similar to KPMG a prediction is made that there will develop a landscape in which there

will be far more integration between care and cure organisations. In integrating

care-processes a shift will take place from 2nd_{line (hospital) care to 1}st_{line (healthcare cente, gp)}

and self-care. In addition, it is expected that a focus on prevention instead of curing/caring will help in reducing overall health care expenses. The visions of KPMG and ING and the health care agreement made by the government and the industry are all aligned. Therefore, it’s not a question if, but rather when, the effects of this transition will be of influence on traditional hospital real estate.

2.1.2. Demographic influences

One of the most profound demographic changes in Dutch society is without a doubt the greying of the population. This is not only due to the rising age of the baby-boom

generation, but also because of an increase in life expectancy for the total Dutch population. As a result, health care demand is rising because patients suffering of heart, lung diabetes and other serious diseases, like cancer are dying in a much later stage than before. This is causing an increase of patients with chronical diseases and an increase of health care demand (NVZ, 2016). This increase in demand does not necessarily mean an increase in hospital real estate as the Dutch government and health care insurance companies are actively promoting the shift from hospital care to first line health care providers like general practitioners and independent treatment centres. Due to technological advances, more patients can be treated from the comfort of their own home. As a result, the nature of the hospital real estate may very well change, causing need for adaptability of the real estate to accommodate different forms of health care delivery (Rabobank, 2017).

Hospitals 2nd line Intergrated 1st line Intergrated 1st line

Self-management Self-management_{E-health / prevention}

2nd line

Easy acces Close to home

A shifting center of gravity from 2nd to 1st line health care

Now

Future

Based on: ING, verbeteren door te verbinden, 2015

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2.1.3. Economy

Health care in the Netherlands is financed by insurance premiums paid by all citizens through mandatory basic health care insurance and in addition, the government finances a part with tax money. Dutch health care costs are constantly increasing, from € 53,5 billion in 2011 to € 61 billion in 2017 (Intrakoop, 2019). The government agency of RIVM (2018) is predicting an increase of health care costs to € 174 billion in the year 2040. The causes for this predicted increase are an ageing population, developments in medical technology, increased prosperity and population growth (RIVM, 2018). Market regulation and efforts to accomplish a re-structuring of the Dutch health care landscape are amongst the measures that are taken to reduce the cost increase.

Market regulation

The introduction of market regulation has a profound influence on hospital organisations. Since the “bouwcollege” was shut down per 2008 and with it the guarantee of

reimbursement of real estate costs by the government, hospital organisations have to acquire the funds to pay for real estate costs through providing health care services. To make market regulation possible, the “Diagnosebehandelcombinatie” (DBC) system was introduced in the Dutch health care industry. DBC freely translates to diagnosis treatment combination and is a code that contains all different elements of a treatment that together determine the price. There are approximately 4400 different DBC’s, 30 % of these

(a-segment DBC) have a fixed price determined by the government. The prices of the remaining 70% (b-segment DBC) are determined by negotiation between health care insurance

companies and hospitals (Zorgvisie, 2018). Within the cost price of each DBC a so-called normative capital cost component (“Normatieve Kapitaallasten Component”) is incorporated to ensure the coverage of real estate and other capital costs. Therefore, the more patients are treated, the more DBC’s are opened, the higher the coverage for real estate costs. This system forces hospitals to see their real estate in a different perspective. Before market regulation, over-dimensioning was seen as a flexibility-measure to ensure additional space when the need should arise. Since market regulation, the over-dimensioning of real estate could pose a threat to the organisation as space that is not used, still costs money but does not generate revenue. That’s why hospitals are forced to take a more strategic perspective on real estate and aim for the best fitting buildingwith minimum risk. The best fitting

building for the organisation will change over time as different future scenarios can develop. This is why flexibility should play a large role in determining what is best suited for the organisation. (Paworiredjo, 2013)

External financing

Dutch health care, hospitals and other care and cure organisations are increasingly judged on the basis of business criteria. As a result of increased financial risk, the external financing of the health care sector, without government compensation, is no longer obvious. This has led to a decrease of investments by health care organisations that previously resulted in overcapacity.

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7 From a financial perspective, health care organisations are dealing with two parties; care-buyers, like insurance companies and municipalities that finance the core business and financial institutions that finance real estate and inventories.

Care buyers like insurance companies are responsible for contracting the best care for the best conditions and do so by negotiating on dbc-prices and volumes. Although contracts are increasingly negotiated for longer periods, most of them are only valid for a few years. These short contracts pose a problem in relation to the long running financing constructions that need to be negotiated with banks. For capital intensive investments like buildings, machines, installations and high-tech inventory, health care organisations and banks close financial contracts that require pay back periods of multiple decades. On top of that, the uncertain cash-flow due to short term contracts with parties on the buying side of the spectrum, results in negative consequences for cost of capital and solvability (NVB, 2019).

2.1.4. Technology

With the use of modern technology care, cure and support processes are becoming

increasingly time and place independent and more efficient. These technological advances will lead to change in health care processes as patients can be treated more efficient and the duration of stay in the hospital can be reduced. In addition, new technologies allow for patients to be treated at home or in their general practitioner’s office. Potentially, these developments can lead to less required hospital space and/or the adaption of space to accommodate new techniques.

The patient as partner

Technological progress allows patients to be more in control and organize their health care in a way and on a time that it suits them best. While historically the doctor was leading in the way patients were treated, patients are getting more knowledgeable and are starting to take more control over their health and medical processes (NVZ, 2016).

Smart Building technology

Technology is also influencing facilities and real estate management. It is becoming more common to incorporate various technologies that allow for building management based on data. Through innovations in sensor- technology there are increasingly more possibilities to be in control over aspects like, occupancy, climate and energy. Intelligent buildings that provide data are slowly evolving into smart buildings that are capable of using the collected data to alter elements of the built environment (actively) without, or with very little, human interference (Buckman et al., 2014).

In addition to the concept of smart-buildings, building information modelling (BIM)

technology is defined as an important infrastructural system for providing interconnectivity between various technologies. BIM can provide perpetual information on operation and maintenance, life-cycle costs and energy performance and therefore is an important source of information for FREM-management (Mallik & Irving, 2012).

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2.2. Internal factors influencing demand in hospital real estate

The “raison d’ être” of any organisations’ real estate and therefore that of hospitals is to provide adequate space in order for the primary process to take place. The primary process of hospitals and the organisational structure, in which it takes place, are of a complex nature. Changes in technology, work processes and visions on delivering health care are always present, causing potential change in demand for real estate and space. In this chapter, the internal factors that influence hospital real estate will be explored.

2.2.1. Organisation of hospital processes

In the last two decades, four basic models of organizing the care processes in hospitals have been prominent: Themes, patient flows, care processes and clinical pathways.

Themes

This model is based on the clustering of activities around the treatment process of the patient. A theme consists of a combination of different hospital disciplines that are working together in order to provide a more or less closed off eco-system of care for patients with similar illnesses. In some hospitals the different departments involved in a theme are spatially clustered while in others there is a division between clinical, out-patient and diagnostic departments. In the last case the care-process isn’t physically recognisable but is based on multidisciplinary cooperation between different departments (CBZ, 2002).

Patient-flows

This model is based on the differentiation of four patient-flows; acute, urgent, elective and chronical care. The differentiation is made based on the assumption that every flow is

different to the other in terms of organisation, plannability, the position of professionals, the relation with general practitioners, follow-up care and real estate.

Care-process

This model is mainly based on the steps that a patient has to take from the moment that he is entering the hospital until he leaves. In this journey, five main-processes are distinguished.

• Screening and diagnostics

• Consultation with physician, discussing outcomes of diagnostics and treatment possibilities.

• Various forms of treatment • Various forms of care • Various forms of aftercare

Around these six main processes, ICT, the organisation and facilities are grouped; resulting in six definable centers:

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9 • Center for screening, diagnostics and research

• Out-patient center for consultation

• Treatment center where treatments are provided • Nursing center, nursing wards

• Center for Logistics from which support for all other centers takes place • Centre for knowledge and expertise where professionals work and meet.

Within this model, modern ict-applications are used to accomplish an integral planning of the care-process, not only in the hospital but also outside of it, providing professionals in the entire care-chain with all necessary information about the care-process in a time and place independent fashion. This development brings us to more recent developments in the organisation of care as is described in the next paragraph; Clinical pathways

Clinical pathways

More recently, one of the most prominent changes in organizing hospital/care processes has been the introduction of clinical pathways. By creating pathways that intent to optimize communication between multiple care-processes and organisations, it is expected that efficiency and quality will increase. There is a large diversity in definitions and

interpretations of the phenomenon of clinical pathways. That being said, there are also many similarities in the way that these pathways take shape. Common characteristics are:

- A multi-disciplinary character

- As strong focus on improving quality and efficiency of health care

- An effort to reach the goals that are appointed to the pathway in a structurized and systematic manner.

- A strong focus on aligning all the elements of the care-system to the needs of a homogenous group of patients (Van Hoeve et al. 2010)

2.2.2. Organisational structure

In order for a hospital organisation to function, a solid organisational structure is of utmost importance, especially due to the special relationship between hospitals and their

physicians. Governance within the organisational structure is a complex matter and a good understanding of it is necessary to analyse the influence it has on decision-making.

The relation between hospital organisations and their physicians

Before the 20th century there was no form of business management present in hospital organisations, physicians and/or the church solely managed them. When hospitals started getting much larger and more complex, the need for managers to control the business-processes of the organisation, started to arise. Since then, managers formally took control over the hospital organisations; however, a large part of decision-making still lies with the medical professionals. Where physicians decide over the treatment of individual patients, this is positive. However, the same isn’t necessarily true in the case of business-decisions in which the interests of the physicians and hospital organisations are not the same (NZA, 2009).

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10 The need for reduction of health care costs and the introduction of market regulation in the Dutch health care landscape has resulted in negotiations between boards of directors and physicians in order to determine budgets. The new role of health care insurance companies has further changed relations because of annual negotiations about volume and quality of care that determine the size of the contracts. This results in the need for hospital

organisations and physicians to make agreements that limit the freedom of medical

specialist to make decisions about the allocation of the hospitals’ resources. Physicians are benefitting from good access to hospital facilities and resources but are not paying for the use of these facilities. Therefore, in most cases they do not consider the effects of their specific decisions or wishes on the financial position of the hospital organisation as a whole. In addition, independent physicians working for the hospital, benefit from trying to

persuading the hospital to take responsibility for as much costs as possible. In order for the physicians to see as much patients as possible, create revenue and therefore financial gain, they benefit from extra investments in capacity and equipment by the hospital (Standaart, 2010).

A professional bureaucracy

In order for a hospital organisation to function, a solid organisational structure is of utmost importance, especially due to the relationship between hospitals and their physicians. Governance within the organisational structure is a complex matter and a good

understanding of it is necessary to analyse the influence it has on decision-making.

According to Mintzberg (1980), hospitals are a mixture between a professional bureaucracy and a machine bureaucracy. The primary process of curing patients should be seen as a professional bureaucracy as the organisation is dependent on highly trained health care professionals. These professionals (doctors) have a large degree of autonomy when it comes to decision-making. The decisions they make are often complex and very specific and benefit from decentralized decision-making. When trying to manage the hospital as a whole, this could be problematic as the cure professionals are functioning within a professional chimney structure. Meaning they tend to focus on their specific part of the organisation (e.g.

cardiology) without taking into account the vision of the hospital at large (Mintzberg, 1980. Lunenburg, 2012).

The supporting departments within the organisation ( e.g. Facilities, HRM, ICT) are organised in a machine structure. In contrast to the “professionals”, decision-making is centralized.. These departments are structured as a conventional administration and the management is ostensibly responsible for the entire institution but also removed from direct involvement in the cure operations (Glouberman and Mintzberg,1996).

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11 Glouberman and Mintzberg (1996) give a

very detailed insight in the structure of hospitals. They argue there are actually four worlds within the hospital where

management is not one homogenous process but several, usually quite distinct from each other.

The system tends to rupture itself along two lines as shown in figure 2. The hospital ends up being not one organisation but four, as each part structures itself in an independent way.

The differentiation within the organisation of the hospital into these 4 worlds, leads to inefficiency and lack of control over the hospital as a whole. The four worlds see past each other due to their different

perspectives.

In the cure quadrant, doctors tend to focus their professional career around on specific organ, disease or patient type. They move in their own specialized hierarchy, separated from the rest of the organisation and therefore tend to focus on their specific “professional chimney”.

The nurses-organisation in the care quadrant is responsible for co-ordinating all processes around the patients and supporting the doctors. From an organisational perspective, they are in between the doctors who claim responsibility for the patients and management that claims responsibility for control.

Formally, responsibility for managing the hospital organisation as a whole lies with the managers in the control quadrant. This formal hierarchy is contested by the most influential group within the organisation; the doctors. Management controls the resources, like real estate, and needs to ensure to allocate them in the most efficient way. Doctors ask for resources to treat their patients the best way possible from the perspective of their professional chimney. True control over the hospital organisation is very hard to establish due to this dynamic.

The last quadrant is composed out of several trustees or community representatives like the supervisory board, volunteers, press representatives and patients. All groups have some influence over the hospital organisation but are not directly involved in its operation (Glouberman & Mintzberg, 1996).

Figure 2.Glouberman and Mintzberg, key characteristics of the four worlds. Based on Glouberman, S.,and Mintzberg, H.(1996).

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2.2.3. The Position of FM

In the last decade, FM has made a transition from a traditional cost focus to a more strategic focus on supporting the core business of the organisation (Jensen et al.,2012). Pathirage et al., (2008) describe a development of four generations of FM ranging from; FM merely considered as overhead costs, to FM on a strategic level ensuring alignment between structure, work processes and the enabling of the physical environment according to the organisation’s strategic intent. Fitting FM into an organisation is dependent on multiple internal factors and local contexts, which makes it hard to adopt a standard or best practice for the position of FM (Chotipanich, 2004). In other words, the position of FM within an organisation should be tailor-made in order to be able to provide a maximum of added-value.

Although the position of FM differs per organisation, four general relations between the core business and

facilities management can be identified and are illustrated in figure 1. Passive FM encompasses everyday operations support but a relative unimportance to the strategic level of the

organisations. Reactive FM

has a one-way linkage to the core business (CB). It merely reacts to demand from the CB. Proactive FM has a two-way linkage to the CB as both are interdependent on each other and decisions are made on the basis of an equal dialogue. In Integrated FM, facilities

management has become an integrated part of corporate decision making (Jensen, 2011). Jensen et al. (2012) in their search for clarification of the concept of added-value of FM, have determined 9 main lessons to inspire those who want to incorporate added-value thinking in their FM strategy. Amongst others, one of the most important of these lessons is that the concept of added-value puts focus on strategic aspects by determining the business impacts and effects of FM. Thereby, it aims to address corporate management in their language and perspective to be able to properly address FM-strategies on a corporate level. In addition to convincing corporate management, the concept of added-value is in the eye of the beholder or stakeholder; What value is added for who? Who benefits? (Jensen et al., 2012)

Figure 3. Linkages between strategic planning for core business (CB) and FM (Jensen,2011)

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2.2.4. Stakeholder management

Jensen and Katchamart (2012) argue that relationships with stakeholders should be

managed differently at each level. This calls for a pro-active management of stakeholders by the FM organisation on each of the levels and actively determine and adapt their position in the various relations.

Figure 5 on page 14 is an overview of all stakeholders of a hospital organisation and their interest, power and perspective regarding real estate decisions. This summary was made by van der Zwart (2014) through research of several reports on the hospital sector over

multiple years. The stakeholders are divided into two major groups; internal and external, and in relation to real estate, into 4 different categories, each with their own view on real estate decisions:

• Strategic / Policy makers:

Contributing to the primary goals and competitive advantage of the

organisations. A focus on the improvement of the quality and effectiveness of the primary process. • Financial / controller: The financial

perspective may include reduction of costs, reducing floor area, or

controlling financial risks by ensuring flexibility of real estate.

• Functional / users: A focus on

functional decisions that support user activities by changing quality and quantity of space. Decisions are based on costs vs benefits

• Physical / technical management:A focus on technical aspects like maintaining acceptable quality levels and controlling technical risks that could hinder the primary process (Den Heijer, 2011).

The different perspectives on FM/CREM can be plotted in a quadrant where a distinction is made between operational and strategic interest in relation to a focus on real estate or a focus on the institution. Figure 5 shows all relevant stakeholders of a hospital organisation and their position, interest and power in relation to the 4 categories that determine their view on real estate decisions.

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2.2.5. The position of CREM

Within the CREM profession, it is common knowledge that the more proficient an organisation is in making real estate decisions, the more real estate is adding value to the

organisation. Similar to the transition of maturity in the facility management domain described by Jensen (2011), the Joroff (1993) transformational model is frequently used to determine the level of adulthood/proficiency of real estate organisations. It defines five levels that range from a

(traditional) technical and operational level to a strategic level

(Matousch,2010).

Taskmaster – Providing and maintaining adequate housing for the primary organisation - Technical and reactive – No budget responsibility – neutral added value.

Controller – Similar to the taskmaster - cost minimization in mind - cost minimization is adding value.

Dealmaker – focused on delivering optimal housing and connecting supply and demand - demand-oriented and pro-active - Added value by minimizing costs and establishing financial gain.

Intrapreneurs – Real estate portfolio management - A department within the organisation responsible for its own costs and revenue - competitive with external parties and charges rent to the end-users of the real estate - Demand-oriented, and pro-active - Added value by financial gain.

Business strategists – Real estate strategy in line with corporate strategy - Responsible for its costs and revenues, pro-active, and leading - Decisions of a strategic nature contributing to corporate strategy.

Figure 6.The roles of Joroff (Joroff, Louargand, Lambert, & Becker, 1993)

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2.3. Managing hospital real estate

One of the most elaborate models for managing hospital real estate is presented by Johan van der Zwart (2014) in his PhD. Thesis; Building for a better Hospital. Van der Zwart

introduces an integrated framework for managing hospital real estate that combines insights and models found in health care and corporate real estate management theory. Amongst other theory the PDCA-cycle by Demming is clearly recognizable. At the basis of the

framework is a Meta model for aligning CREM with the organisational strategy based on the EQFM-INK model. The model is depicting 4 steps to ensure alignment:

• Context: Determine common objectives and perspectives from both an organisational- and a real estate point of view. Include the needs and wishes of all stakeholders and do so with a changing context in mind.

• Value: Determine success factors from an organisational point of view and how the organisations real estate can support these success factors and add value.

• Managing: Determine what organisational and real estate changes are necessary to realise current and future objectives. Ensure an ongoing dialogue and reach an agreement on how to implement the organisation and real estate strategies. • Design: Implement the changes in the primary process and building design.

By enriching the model with organisational and real estate models, an integrated framework for the management of real estate in relation to the organisation is created. Amongst a multitude of added theory, CREM-stakeholder management and the DAS-model for analysis of real estate are added, both will be further elaborated on (van der Zwart, 2014)

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2.3.1. Designing an Accommodation Strategy (DAS)- model

The DAS-model was developed by the Department of Real Estate & Housing at the Delft University of Technology. It can be used as a checklist in order to structure the process of designing an accommodation strategy and long-term housing plan

The model consists of four main questions:

• What do we need and what do we have? – Determine the mismatch between current demand and supply.

• What do we need in the future and what do we have now? – Determine the mismatch between current supply and future demand.

• What alternatives are there? – Design solutions for the mismatch.

• What do we want to have in the future? – Step by step plan to transform the current supply into the selected future supply. (van der Zwart et al., 2009)

2.3.2. Long term housing plan

from 1996 until 2006 hospital organisations were obligated to develop a long-term housing plan (LTHP) every 4 years. The government department “college bouw zorginstellingen” (CBZ) that existed until 2008 was tasked with analysing the documents. Since the

government was financing hospital real estate until 2008, hospital organisations had to justify their real estate strategy by means of the LTHP’s.

When market regulation was introduced in Dutch health care, the CBZ was dismantled and the obligation for hospital organisations to make a LTHP was no longer present. However, the risk of real estate financing is now the responsibility of the hospital organisations. Therefore, the need for a good LTHP is more relevant than ever in order to be able to make well informed decisions concerning real estate (Huisman,2008).

In order to develop a strategic vision on hospital real estate, it is necessary to think in scenarios and prepare plans to adapt the organisations’ real estate to possible changes in future demand. Developing these scenarios isn’t an easy task but mandatory in order to change former LTHP’s into a strategic real estate document

A strategic real estate document should be dynamic and subject to change when insights change. By regularly analysing developments that influence the current and future demand, scenarios can change accordingly resulting in a pro-active management of real estate (Huisman et al. 2009).

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2.3.3. (Integral) Capacity Management

Traditionally, hospital capacity planning had a focus on bed numbers, without taking into consideration many other resources that are required to deliver efficient health care. By applying principals from industrial environments, such as Lean-thinking, into hospital

planning and design, patient flows can be improved. Especially when designing new ways to organize the delivery of health care, like clinical pathways, an integral approach to capacity planning is mandatory to ensure the best results (Rechel et al., 2010)

Integral capacity management is the consistent design of planning,

managing and assessing all capacities that are required to deliver health care and add value for the patient, in concurrence with pre-defined quality, service and efficacy levels.

Integral capacity management (ICM) anticipates on existing (plannable) and expected (Emergency), patient flows. Processes within each department have to be in-sync in order to assure that sufficient capacity is available at

the right time. CM should make possible that the hospital can facilitate patients at the right time considering; medical necessity, the patients preference or a logistically determined moment in case a combination of appointments has to take place. This requires an efficient use of hospital capacities such as the outpatient clinic, the availability of physicians and other medical professionals and research-, operating room-, and bed capacity. (Brilleman, 2018)

Figure 9. Based on integral capacity management circle ((Rechel et al., 2010)

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2.4. Dutch hospital architecture

The Dutch hospitals that were built after the second world war had standardized floorplans at the base of their design. The bed wards and treatment facilities of these buildings were separated from each other. Until the mid-nineteen sixties, two basic designs were used; the T-Type building and the H-type building. (Wijdeveld, 2006)

T-type

In a t-type hospital design the

treatment department is situated in a ninety-degree angle opposed the ward blocks.

H-type

The h-type hospital design consists of two rectangular building shapes, connected by a transverse. The ward block was divided in two equal parts, one for men and one for woman. In th treatment block, internal medicine was situated on ground level, surgery on the first floor. The second-floor housed obstetrics, gynaecology and children’s departments. The positioning of the departments in the treatment block corresponded with the

positioning of the wards in the ward block.

K-type

By perfecting the T an H type designs, eventually the K shaped hospital design came into existence. In this design the h-type hospital was taken as a base but the ward blocks were kinked.

Tower on podium

In the second half of the 1960’s, a new type of building was introduced to the Dutch hospital range. This type was already commonly used in the united states and consisted of 1 or multiple layer of low rise building parts with on top of those, a high-rise building that

Picture 1. T-type hospital, (Wijdeveld, 2006)

Picture 2. H-type hospital, (Wijdeveld,2006)

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20 accommodated the wards. This building type was known as a “Tower on Podium” or in Dutch “Breedvoetziekenhuis”.

After the second half of the nineteen sixties the need for larger hospital buildings arose due to mergers of smaller hospital organisations. In some cases, existing real estate was adapted but oftentimes new buildings were created. Since this period, the Dutch hospital landscape has seen new designs with more flexibility in mind.

The structure of Dutch hospitals has seen a transition to a less dominant presence of the nursing wards in the design. Treatment wards and the outpatient clinic as well as flexibility and the design of main traffic areas have had an increasing influence on the design of hospital buildings since the eighties. In recent years hospital building design has seen a transition into a more profound presence although lack of available ground regularly leads to a design that is fitting in an urban environment. (CBZ, 2002)

Overview of recent hospital designs

Double Comb-structure

The double comb-structure is recognizable by a central hallway that connects the different “teeth” of the comb. The building structure is an even grid that allows expansion on the ends of each “tooth”. Hospital departments that require the same housing properties are bundled in the same building section.

Passage-structure

The passage structure originates in the 1980’s and is characterised by two or more building parts that are connected by a glass covered atrium or passage. On both sides and on

multiple levels there are connections to the passage. On ground level shops and restaurants are located in the passage. Similar to the comb-structure, the ands of the building parts can easily be expanded.

Traffic zone

Passage Main entrance

Passage

Picture 4. Comb-structure, (CBZ,2002)

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21 Cross-structure This structure is realized by positioning two or more cross-shaped building parts in such a way a central hall-area is created. This glass-covered

central-hall contains all central facilities of the building. The building can be expanded on the ends of the cross-shaped building parts.

Linear-structure

The linear structure consists of a single “strand” building that accommodates to all hospital disciplines in relation to their connectivity. The “strand” consists

of a double corridor that allows the situation of staircases and technical spaces in the middle

Branched-structure

The branched structure building is designed with a central hall that

branches out to the different building parts of the hospital.

Pavilion-structure

Before the second world war, hospital buildings were frequently situated in a pavilion structure. Multiple categorical buildings were situated on one plot of land. Until recently this design was abandoned but with the

introduction of health care based on patient categories, was re-instated with the design of the Isala hospital in Zwolle as prime example. (CBZ, 2002)

hall hall Main entrance Main entrance hall Main entrance Glass-covered hall hall Main entrance Main entrance hall

Picture 6. Cross structure, (CBZ,2002)

Picture 7. Linear structure, (CBZ,2002)

Picture 8.. Branched structure, (CBZ,2002)

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2.5. Functional zoning

Since 2007 a concept called the “schillenmethode” or

functional-zoning model, has been introduced in the Dutch hospital real estate landscape by “College Bouw

Ziekenhuisvoorzieningen” (CBZ). The model divides the hospital organisation in 4 different zones, each with their own real estate needs. The model was developed to separate parts of the building with different value levels. Figure 10 depicts the

segmentation of departments per zone as developed by “College Bouw Ziekenhuizen” • The Hot Floor: This is the part of the building where all high-tech and high-capital functions

of the building are centralized. E.g. operating-rooms.

• The Hotel: The part of the building where all nursing wards are situated.

• The Office: Administrative and controlling functions, consultation hours by physicians and simple examination and treatment activities. E.g. the outpatient clinic.

• The Factory: Supporting functions to the primary cure process. E.g. Finance & control, Facilities, Human resources.

The different parts vary in their need for flexibility. The Hot Floor, for instance, is continually subject to technological innovations that require change of processes and therefore transformation of space. The office and factory parts are far less influenced by technological developments, therefore, from a real estate perspective, the different parts of a hospital building should each have their own strategic planning.

The overall zoning strategy is that of grouping functions together that have similar accommodation requirements. A major advantage of this strategy is that the zones have a common design and can be build using models that allow for e certain degree of standardization and therefore cost-effectiveness. Each of the four zones has certain characteristics in comparison to each-other, as shown in figure 11.

Functions General Hospital

General ward

Day-care ward

Child care ward

Maternity care ward

Hotel Hot floor

Emergency department Operating rooms Radiology – nuclear medicine Obstetrics Intensive care Coronary care Office Consulting hours Out-patient treatment Organ function examination Physiotherapy Office-like facilities General patient facilities General staff facilities Factory Pharmacy Laboratories Facility services Sterilisation department

Figure 10. Functional zoning, (Paworiredjo, 2013)

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23 Specificity indicates how generic the design of the zone can be. Highly standardized building parts like office zones have a low specificity and can be built relatively cheap. A hot-zone has a very high specificity and is very expensive to build. In general, highly specific building parts aren’t easily adaptable to changing circumstances and therefore lack elasticity/flexibility. Marketability relates to the level of attractiveness of the zone if it would be rejected by the organisation and put on the market. (Taverne, 2010)

2.6. Standardization

An important reason to implement standardization in hospital processes is the reduction of variability and the improvement of patient safety. Although in the WHO-context,

standardization is largely about process-design, the design and standardization of the physical surroundings have a mayor influence (Leotsakos et al.,2014). In addition, standardization of hospital spaces can also contribute to a more efficient patient flow, decrease of waiting time and improvement of occupancy rate, since multiple hospital departments can make use of the same spaces (IHI, 2018). Standardization of hospital space is most profoundly present in the design of out-patient and ward settings, both of which will be further elaborated on.

2.6.1. Out-patient clinic

The out-patient clinic department within hospitals encompasses all (spatial) facilities that are required to perform consulting and basic examination of (mostly) out-patients by physicians and specialized nurses. The out-patient department consist of spaces that are accessible to patients; waiting areas and consultation- and examination rooms and of spaces that are only accessible to staff; workplaces and facilities. In hospital design, there is an increasing trend to clearly separate these two into a front-office and a back-office. Where the former is reserved for direct contact between patient and the health care professional, and the latter is designed as an office environment where staff can work without patient contact. This demarcation in combination with the standardization of spaces potentially provides advantages opposed to tailor made spaces per medical specialism. A higher occupancy rate is possible because standardized front-office rooms can be used by multiple specialisms. When designing a hospital this makes it possible to create fewer consulting and examination rooms resulting in lower construction costs (Gmelig Meijling, 2011).

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2.6.2. Nursing Wards

Of all the functional zones of the modern hospital, the hotel or ward section takes up the most space (approximately 50% of the total hospital space). The hotel section is the part of the hospital where in-patients spend the most time, waiting on and recovering from treatment. The hotel-section is in most cases divided into wards for different specialities and made out of single and multi-bed rooms. The specific type of ward determines which patients it serves. By standardizing wards and patient-rooms as much as possible, it

becomes possible to allow change of use when needed. The wards

generally accommodate three different space types:

Patient space – Single or multi-bed rooms with toilet and shower facilities

Nurse’s base – A centralized hub that allows staff to monitor all patients on the ward

Staff space – Nurses room, doctors room, storage and medicine rooms, etc. Figure 13 gives an oversight of the most common ward-layouts (Alalouch, 2009).

In recent years a trend is visible where hospital organisations that develop new real estate or perform renovations to their existing wards, chose to incorporate more single-patient

rooms. Benefits for both the patient and medical staff can be found in more privacy, a reduction of infections and better conditions for staff to perform their tasks (Klaasen, 2011)

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2.7. Flexibility and adaptability

By introducing flexibility options into the design of the hospital building, “switches” are created that can be “off” or “on”. Building these switches into the design costs money and utilizing the flexibility options often also does. Hospital real estate, in general, has several of these switches that can be used. In some futures the flexibility switches may not be used but, nevertheless, remain valuable as they provide security for the organisation to be able to adapt to different circumstances. The value of the switches is determined by the probability of usage and the value extracted when switched on (de Neufville, 2008). Creating insight in the way uncertainties may evolve and develop real estate scenarios to match them, will add value to the organisation as a whole. This strategy can provide a tool to determine what switches need to be incorporated in the real estate design and when they will need to be turned on or off. (van Reedt-Dortland, 2013)

During the cause of its lifespan, hospital real estate is subject to, largely, unforeseeable changes. Hospital real estate is generally built to last for at least 30 years therefore, it should be able to adapt to these changing circumstances in order to keep accommodating the hospital organisation in a way that contributes to realizing the organisations goals during that period. (De Neuville et al. 2008). Facilities and real estate management are playing a large role when it comes to designing, maintaining and adapting the hospital buildings. By making effective use of the possibilities in flexibility provided by the real estate, the FREM departments can add value by making sure the organisation’s real estate is in line with the organisation’s strategies.

Great efforts have been made in realizing state of the art flexible hospital real estate all over the world. However, there are still many examples of health care facilities that become obsolete and need to be replaced or upgraded before the end of their expected lifespan. (Carthy et al. 2010)

2.7.1. Types of flexibility

The adaptive capacity of a building includes all characteristics that enable it to keep its functionality during its technical life cycle in a sustainable and economic profitable way, withstanding changing requirements and circumstances. (Hermans et al. 2014)

Flexibility is considered to be a set of possible measures that could be taken to create the value adaptability. According to Geraerdts et al. (2014), flexibility of existing real estate can be translated into three characteristics: Rearrange flexibility; The degree to which the location, the building or the unit can be rearranged or redesigned. Extension flexibility; The degree to which the location, the building or the unit can be extended. Rejection flexibility; The degree to which (part of) the location, the building or the unit can be rejected.

According to Jensen and van der Voordt (2017) The adaptive capacity of organisations can be divided into three different categories; Organisational -, process - and product flexibility.

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26 Organisational flexibility

Organisational flexibility encompasses the adaptive capacity of an organisation. To what extent is an organisation capable of changing its strategy to cope with changing

circumstances. Changing circumstances don’t always lead to changes in real estate. A new match between organisation and building can also be found in adapting the organisation instead of the building.

Process flexibility

Proces flexibility relates to the whole life-span of buildings: development, construction, operation and use, from the first initiative and briefing phase until the final use. Decision-making processes need to be structured in such a way that the freedom for changes is maximized (Geraerdts,1998).

Product flexibility

Product flexibility or object flexibility concerns the changeability of the product. If the product is a building, then the product flexibility concerns the changeability of that building, not only during the development phase, but also in particular during the exploitation or use phase. Product flexibility is categorized in three types: Adaptability ; The buildings ability to accommodate changing demands without physical changes, Convertibility; The possibility for construction and technical changes with minimum cost and disturbance and Expandability; The ability to add or reduce the size of a building. This research will focus mainly on product flexibility. In trying to answer the main research question, the flexibility of existing hospital real estate and its capabilities to adapt to changing circumstances is analysed. Product flexibility encompasses the spatial and technical properties of buildings that make adaptations possible. Product flexibility can greatly enhance a buildings life-span as it

enables relatively simple cost-efficient modifications. A high level of product flexibility in the case of hospital buildings can prevent them from becoming obsolete prematurely while they still represent a considerable value. (CBZ, 2005)

Strategic, tactical and operational flexibility In order to prevent confusion in regards of the definition of flexibility, this research will focus on the three levels of flexibility determined by de Neufville (2008). These levels are largely similar to the definitions by Jensen, van der Voordt and Geraerdts. Richard de Neufville ,(2008) categorises hospital building design flexibility on three levels, operational, tactical and strategic. Similarities can be found with the

above-mentioned categorization by Geraerdts. Figure 14. Figure 4: Levels of flexibility, (de Neufville,2008)

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27 Operational flexibility

Operational flexibility could be used on a daily or weekly basis and can quickly adapt the infrastructure usage to deal with short term volatility. This type of flexibility is comparable and in the same domain as “adaptability” as it encompasses small adaptations to

accommodate changes in demand on a short-term basis. Tactical flexibility

Tactical flexibility is more extensive and costlier than operational flexibility. An example would the re-arranging of departments within the existing (flexible) hospital building or the installment and removal of flexible wall systems. The adaptions are made with mid/long term change of demand in mind as they would not easily be reverted. Tactical flexibility is in the same domain as “convertibility” as it seeks to make changes within the existing building within the realm of provided real estate flexibility.

Strategic flexibility

Strategic flexibility involves the increase or decrease of hospital buildings to increase the life-span of the real estate. To accommodate strategic flexibility, decisions should be made in the early stages of designing and building a hospital. Possible scenarios that will influence future change in circumstances should be considered. Strategic flexibility is in the same domain as “Expandability”. It deals with the creation of (expensive) options in real estate acquisition and design, that may never be used and can therefore be seen as an insurance for possible future scenarios.

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3. Questions and objectives

3.1. Objective

Hospital FREM departments are expected to manage valuable real estate assets in a

professional way by being in control and adding value. The flexibility options provided by the real estate are an important tool for FREM to accomplish this. As insights in terms of

flexibility change through time, each hospital building has its particular flexibility options. The introduction of market regulation and the shutdown of the “Bouwcollege”, gave the sector more freedom in developing real estate but also mean increased financial risk. This research aims to contribute to a better understanding of the role FREM plays in utilizing flexibility options of hospital real estate and the influence of hospital building design after the introduction of market regulation in 2008.

3.2. Research questions

3.2.1. Main Research question

Are Dutch hospital buildings that are designed and built since the introduction of market regulation, better equipped to utilize the flexibility of their real estate than their older

counterparts?

3.2.2. Sub questions

SQ1 : Which factors influence hospital real estate?

SQ1.1 : Which internal factors influence hospital real estate? SQ1.2 : Which external factors influence hospital real estate?

SQ2 : How does the design and structure of hospital buildings contribute to flexibility? SQ3 : How is the flexibility of hospital real estate utilized?

SQ3.1 : How are decisions concerning the adaptation of hospital real estate made? SQ3.2 : What factors contribute to the utilization of hospital real estate flexibility?

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3.3. Research framework

In order to present a clear insight in the research process, a framework has been developed. In addition to insight it also provides guidance during the research process. The research is divided into four pillars:

Changing demand explores the reasons why the need for changes in hospital real estate arises. It is expected these reasons are fairly similar for all cases, still, document research and interviews may expose differences per case.

Flexibility options of the existing real estate of the hospital organisations has been analysed. Literature review provided general theory on flexibility, document research and interviews researched the specific options provided to the selected cases and how they fit in to existing theory.

Utilization of flexibility is an under explored aspect of hospital real estate flexibility. Existing theory about flexibility of hospital real estate is widely available. However, if and how it is utilized remains under explored. In other words; Are the flexibility options of the real estate actually used?

The comparison involves the outcomes of the multiple case study and a comparison to each other in order to determine whether hospital buildings that were designed and built after the introduction of market regulation are better equipped to deal with changing demand with flexible real estate options.

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4. Research methods

4.1. Research Purpose

Evaluative research allows for assessment of performance and comparison and is at the base of this research. The purpose of evaluative research is to find out how well something works. The purpose of this research is to find out how hospital organisations make use of the

flexibility provided by the buildings they use. In addition, a comparison is made between the different organisations and buildings to evaluate how well they perform considering

different real estate designs. Questions that were asked during data-collection contain “What”, “How” and “Why” in order to find answers. (Saunders et al.,2009)

4.2. Research strategy

The research uses a qualitative approach conducting a multiple / collective case study. A case study is a research approach that is used to generate an in-depth, multi-faceted understanding of a complex issue in its real-life context. (Crowe et. al, 2011) A multiple or collective case study allows comparison between its cases and provides a deep

understanding of the context of the research. The aim is to research flexibility of hospital real estate in a real-life context and use the findings to enrich the theory already available. Stake, (2003) identifies 3 types of case studies.

An intrinsic case study in which the research focuses on one case and one case only. The purpose is to come to an understanding of that particular case without the aim to develop theory.

An instrumental case study when a particular case is examined to gain insight into an issue or make a generalization. In this type of study, the case itself is of secondary interest as it serves as an instrument to gain understanding of something else.

The third type is a collective case study and will serve as the basis of this research. The collective case study is instrumental study extended to several cases. In this research the cases will be 4 Dutch hospitals. They are chosen with the expectation that understanding them will lead to better understanding, perhaps better theorizing, about a larger collection of cases. (Stake, 2003)

Yin, (2003) defines a similar approach to case studies as Stake does, but uses the term multiple case study instead of collective case study. These two approaches are basically the same. Yin describes the multiple case study as an approach to explore differences and similarities between the selected cases.

Hospitals are complex organisations with large scale real estate resources. Although a lot of research has been performed and great effort has been made to incorporate flexibility in the design of hospital buildings, little is known about the way this flexibility is used in real-every-day life. By conducting a collective/multiple case study, a comparison of the cases can be made to gain insight in similarities and differences between the 4 selected hospitals. By

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31 selecting 2 hospitals that were built before the introduction of performance-based funding and 2 that were built after, a second differentiation in comparison is possible. In order to gain in-depth insights in the way hospitals utilize the flexibility of their real estate and a better understanding of the effects of performance-based funding on Dutch hospital real estate as a whole, the collective/multiple case study is most suited to perform this research. Other research

Amongst many other sources, two have been of great influence and inspiration on this research:

• Van der Zwart’s (2014) Phd. Thesis; “Building for a better hospital”, uses multiple research techniques in order to test CREM concepts in empirical research. Van der Zwart uses the conclusions to improve the applicability of the CREM concepts in the domain of hospital real estate. Throughout the research, case studies are used to contribute to answer specific research questions.

• Jane Paworiredjo (2010) conducted a multiple case study that researches the relation between building structure, building and installation technology and functional zoning. The research leads to the creation of a “Flex Guide” tool that aims to give management more insight in the utilization of hospital real estate flexibility.

4.2.1. Integrating deductive and inductive approach

Making use of existing theory to guide the research and gathering data on an inductive basis, created the need for making use of a combination of deductive and inductive approaches. Existing research methods seem to suggest that driving an investigation to develop theory based on existing theory is not possible. A choice needs to be made for either deductive or inductive approaches. Where the deductive approach starts with theory in the form of hypothesis, qualitative research avoids this in order to prevent prematurely closing off possible areas of inquiry.

This research combines the two approaches. Existing theory has been used to develop a theoretical framework and accompanying constructs. These served as input for the

interviews. Specifying constructs “a priori” that deal with general themes serves as a guide to categorize different variables that have been discussed during the interviews.

Furthermore, it helps to explain the relationship between different constructs or subjects. Constructs provide a focus for the research but, unlike variables, leave open the possibility to find unexpected information. Thus, creating the need for an inductive analysis of the transcripts of the interviews using open and axial coding techniques. (Ali & Birli, 1998) See appendix 7: The integrated approach compared to purist versions of the deductive and inductive approaches.

Managing the flexibility of hospital real estate

Managing the flexibility of hospital real estate

A multiple case study

Master thesis

Summary

Foreword

Table of contents

1. Introduction

2. Literature review

3. Questions and objectives

4. Research methods