New archetypes in Dutch healthcare
A qualitative comparative analysis of methods used by key players in Dutch healthcare to transform their organisation to a more sustainable and patient centered archetype
Floating Piers Christo 2016 Italy
Name: dr. C.L. van der Wijden, MPH Number: 11154977
University of Amsterdam/Amsterdam Business School Master Program: EPMS Strategy
2
Table of contents
Statement of Originality 2
Abstract 3
Introduction 4
Scientific background Patient centered care 6
Value creation 7
Urgency for change 10
Disruptive change 10
Dynamic capabilities 12
Archetypes 13
Research design 15
Results Consultants 17
Visionaries and innovators 19
Board members 23
Table 1 34
Discussion and conclusions 36
References 41
Appendices Appendix 1 Questionnaire 47
Appendix 2 List of interviewees 49
Personal note 50
Statement of Originality
This document is written by student Carla van der Wijden, 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.
3 Abstract
Introduction: The world around us is changing rapidly. Technologies are the drivers of many of the disruptive innovations and customization is a given. Escalating costs in healthcare, due to demographic changes, increasing demand and comorbidity, will make healthcare in its current format unaffordable so healthcare is in need of a change. To transform healthcare to a patient centered model at lower costs, is the challenge for the future.
Research question: What are new archetypes in Dutch healthcare and how do key players transform their organisation to a more sustainable and patient centered model, fit for the future?
Scientific background: patient centered care and value creation in healthcare are discussed using Porter’s traditional value chain. Due to new entrants, technology and the different role of the patient, the traditional value chain will become part of a value creating network. Dynamic capabilities to create this network are analysed. The features of new archetypes in Dutch healthcare and their position in the value creating network are outlined.
Research design: 22 key persons of healthcare organisations were interviewed about patient centered healthcare and board members were interviewed about how they transform their current business. A set questionnaire was used. Organisations were rated for patient centered care using the results of the interviews, enablers of disruptive innovation and a Dutch healthcare rating source, based on patients feedback.
Results: All interviewees consider technological innovations as the enabler of disruption. They share the view that the role of the professional will change significantly and they expect the patient to have a central role. Most hospitals however, still operate in or around the traditional value chain. From the perspective of patient centered care, focus clinics, networking/ecosystem and co-creating are the most successful archetypes.
Discussion: The most successful archetypes are characterized by effective leadership, a corporate focus, clear shared vision at all levels and acting upon it with all stakeholders. The network/ecosystem and co-creating archetypes discuss the underlying orientation. To reconfigure their resources to a patient centered and sustainable archetype, the successful organisations have the developed capabilities of networking, co-creation and continuous agility. How these organisations manage the uncertainties of this development is another dimension of their capabilities and challenges the role of governance.
4 Introduction
The world around us is changing. Mobile internet, automation of knowledge work, big data, the internet of things and cloud technology are the drivers of many of the disruptive innovations in business. But apart from these technologies there are other drivers: society has changed and globalisation and international exchange of people and services are a given. In society traditional anchors are disappearing and people become more self-steering and demanding. In politics comprehensive ideologies do not exist anymore and policies are predominantly focused on pragmatism and the short term.
These disruptive innovations have facilitated new industries. Companies such as Amazon, Apple, Facebook, Uber (Driving good service, 2016) and Airbnb (Stay with me, 2016) have billions of customers and have become omnipresent. These organisations offer new services and use completely different business models (Osterwalder & Pigneur, 2010). They all share a common theme: consistent, year-after-year accommodation of the needs, pain points, and wants of their customers worldwide and innovating their services accordingly (Prahalad & Ramaswamy, 2000; Kolker et al, 2016). In healthcare Uber-like initiatives like ZocDoc, Doctors On Demand, Heal, Pager and Knok Health care do already exist (Detsky & Garber, 2016; Konrad, 2015; Hawkes, 2016), but new initiatives are few.
In 2040 healthcare costs might escalate to some 25 to 30 % of GNP (CBS 2014; Ministry of Health, Welfare and Sport, 2012). More than 25% (€26 billion) was spent on hospital care in 2014. Increasing demand, lack of effectiveness of care (Kuenen et al, 2015), lack of transparency, and difference in quality of care provided (Mulder, 2015) are the issues illustrating why healthcare is in need of a change.
New technologies and eHealth improve health literacy and access to healthcare and will increase self-care management leading to empowerment of patients and enabling personalized medicine (Gilpin, 2014). Windruma & Goni (2008) even speak about a neo-Schumpeterian model of health services. Self-quantification systems are being used to improve health outcomes (Almaki et al, 2015) and enhancing healthcare self-management. In this way further democratization in healthcare will take place (Topol, 2015).
A transition in healthcare, following other industries such as publishing, services and finance, will integrate technological innovations, customization and globalisation (Hwang & Christensen, 2007). So how do healthcare organisations transform themselves and what resources do they need? Do hospitals have the required dynamic capabilities to develop new and sustainable business models at lower costs? Dynamic capabilities are “the capacity of an organization to purposefully create, extend or modify its resource base” (Helfat & Peteraf, 2007) and are unique to each company and rooted in the company’s history. These capabilities are captured in business models that go back decades and that are difficult to imitate (Teece et al, 1997). The key question is, if these dynamic capabilities of an
5
organisation on its own, are sufficient to face the disruptive innovations and to transform to a more sustainable and patient centred model, fit for the future.
In the accelerating, exponentially changing world around us, collaboration and being part of a network sharing resources and capabilities, might be a more successful strategy for an organisation than solely depending on its own capabilities. Are healthcare organisations capable of rebuilding its core, collaborating and networking while reinventing new business models (Dyer & Singh 1998; Gilbert et al, 2012) or are many doomed to fail (Van Poucke, 2016)?
Some healthcare organisations are capable of renewing their business model, shifting from competition to coopetition and co-creating dynamic networks, with consumers and other stakeholders. Good examples of these networks and innovations are in the Netherlands ParkinsonNet (Parkinsonnet; Bloem & Munneke, 2014) and in the United States PatientslikeMe (website); business models co-created by patients, healthcare workers, scientists and sometimes pharmaceutical organisations (Radboudumc REshape Center; Bartl 2015; Kemperman et al., 2015; Co-creation Philips 2015).
Healthcare is changing and the patient will have a more prominent role. Therefore as stated, it begins with understanding what is important to the patient and how the patient defines value in healthcare (Lee, 2004; Lee, 2010; Robinson et al, 2008; Ramaswamy, 2009). To transform healthcare towards a more patient centered system, the value proposition in patient centered care should be analysed (Porter & Teisberg 2006; Kollen 2010). What can we learn from the experiences of organisations in transition to a more patient centered healthcare (Johnson et al, 2008; Magretta 2002)?
Taking all these changes into consideration, in this paper I will explore new archetypes in Dutch healthcare. My research question will therefore be: ‘What are new archetypes in Dutch healthcare and how do key players transform their organisation to a more sustainable and patient centered model, fit for the future?’.
6 Scientific Background
To transform healthcare towards a more patient centered system, it is essential to know the scientific background of patient centered care and value creation in healthcare. As stated in the introduction there is an urgency for change and this will be based on facts and figures. Features of disruptive change in healthcare are discussed. For the transition in healthcare, dynamic capabilities to create a value network and to create synergy are discussed and features of five current archetypes in healthcare are outlined. We start with patient centered care.
a) Patient centered care
The concept of patient centered care has gained increasing prominence in recent years. Yet despite growing recognition of the importance of patient centered care, as well as evidence of its effectiveness in contributing to other system goals such as efficiency and effectiveness, it appears difficult to achieve (Porter et al, 2013). To define patient centered care is a challenge because clear definitions of patient centered care do not exist (Robinson et al, 2008) and patient centered care is a dynamic concept and might be different for different patients, different cultures, different times. Pubmed, the US National Library of Medicine, returns 20505 hits on June 17th 2016 on patient centered care, but no hits on the definition of patient centered care.
The pioneer in Patient Centered Care (PCC) is Harvey Picker. He and his wife defined eight principles of PCC and they are the founder of the Picker Institute (Picker, 2015).
Figure 1 Picker's principles
According to the International Alliance of Patients' Organizations, a global alliance representing patients of all nations across and promoting patient centered healthcare across the world, “the essence of patient centered healthcare is that the healthcare system is designed and delivered to address the healthcare needs and preferences of patients so that healthcare is appropriate and cost-effective” (International Alliance, 2012). This alliance sets out five principles of patient centered healthcare: respect; choice and empowerment; patient involvement in health policy; access and
7
support and information. This means that the patient has to define value and has an active role in defining value in healthcare.
Currently the healthcare system is designed and delivered in a functional way and budgeting by government and Health Insurance Companies is leading. A holistic (patient centered) view on healthcare based on the values, needs and preferences of the well informed patient is not mainstream yet (Through the Patient's Eyes, 1993). Interesting is to examine the value creation or the value proposition in patient centered care (Epstein & Street, 2011).
b) Value creation
Based on American economies of scale, Porter was the first economist who developed a value chain as a basic tool for examining all the activities a firm performs and how they interact (Porter, 1979a; Porter, 1979b). In the value chain value is created.
Value creation, is a set of activities that a firm, operating in a specific industry, performs in order to deliver a valuable product or service for the market. A value proposition is an explicit promise made by a company to its customers that it will deliver a particular bundle of value creating benefits (Buttle, 2009). Osterwalder and Pigneur (2003) stated that ‘Modelling and mapping value propositions helps better understanding of the value a company wants to offer its customers and makes it communicable between various stakeholders’. According to Prahalad & Ramaswamy ‘the meaning of value and the process of value creation are rapidly shifting from a product- and firm-centric view to personalized consumer experiences. Informed, networked, empowered, and active consumers are increasingly co-creating value with the firm’ (Prahalad & Ramaswamy, 2000).
To create this value both the firm and its customers need capabilities. With the resources you own as a firm you create value. Different stakeholders however, working together as teams - including consumers - can create more value and even synergy.
Porter is one of the main drivers in the USA in changing healthcare towards a value based system (Porter & Teisberg, 2006; Porter, 2010). According to Porter value is created by the chain of players as a whole (Porter & Teisberg, 2006). Porter uses three concepts in his concept of value driven healthcare: choice & competition; value in terms of patient health outcomes in money spent and positive-sum competition on value for patients (Porter, 2010). As illustrated in figure 2 (Porter & Teisberg, 2006 page 409) the value chain becomes more detailed and in this thesis, especially the lower part of the value chain of monitoring/preventing, diagnosing, preparing, intervening, recovering/rehabilitating and monitoring/managing will be of interest.
8
Figure 2 Value chain in breast cancer care (Porter Teisberg, 2006 page 409)
Porter’s view focuses on the assumed perspective of the patient and Porter’s most important outcome is an economic, more value for money. His model is a closed system and does not address important issues such as continuity of care, comorbidity, evidence based treatments, the process of care and the moral judgements about healthcare and how to define the quality of care. After all consumers determine the value, based on their individual experiences as end users of healthcare (Gill et al, 2011).
Capabilities are the underlying drivers of value creation. Capabilities are being realized by cooperation between stakeholders to create value from resources as knowledge, skilled personnel, infrastructure, supporting staff, technology etc. Working as a team can create more value from the same resources and synergy. Reconfiguring your resources aligned with the requirements of the world outside, will result in competitive advantage.
Today the capabilities of hospitals are to provide quality healthcare services for patients. Due to a changing political, legal, economical and social climate and facilitated by IT including big data, transparency about quality, costs and added value, has made differences between hospitals visible. This transparency creates a competitive advantage because information about differences in quality between hospitals motivates the customer to go for the best quality available.
9
The stakeholder field is changing dramatically. The usual stakeholders were boards, medical staff and employees, healthcare insurance companies, supervisory and control authorities and the Ministry of Health, Welfare and Sport. New entrants in the stakeholder field are technology companies such as Philips, IBM, Apple, Google and healthcare entrepreneurs. These new entrants bring in different capabilities, such as entrepreneurship, executive power and the capability to co-create. Knowledge based on big data and algorithms is a new and very powerful new “disruptive” capability.
The role of the patient as a prominent stakeholder, being an informed, networking, empowered and active co-creator is a new one (Prahalad & Ramaswamy 2000). This new role of the patient is enabled by information about services, health literacy and experiences in customization in other industries.
All these changes in the stakeholder field including the new role of the patient and in combination with the limited budget, will result in another value chain or even value creating system or framework. The transition from Porter’s value chain, a closed economic model with the traditional stakeholders, to a value creating framework, will have an impact on the competitive advantage. In this new value creating system competitive advantage will be realized involving all old ànd new stakeholders.
As all stakeholders try to safeguard their interests it is very important to find a common concept, supported and shared by all old and new stakeholders. All stakeholders want to improve outcomes and doing so as efficiently as possible. The value framework of healthcare might be that common concept and unite stakeholders in the long term.
In Figure 3a the value chain is part of a value creating system due to new entrants and technology
10 c) Urgency for change
According to the Euro Health Consumer Index (Björnberg, 2016) the quality of healthcare in the Netherlands is very good, but at high costs. The total expenditure in 2014 for the Dutch healthcare system was €94,2 billion; 15,6 % of the Dutch GDP. More than 25% (€26 billion) was spent on hospital care (CBS, 2014; Ministry of Health, Welfare and Sport, 2012). Since 2009 the number of general hospitals however decreased from 116 to 86 in 2016 (KPMG, 2016). This might be caused by merging and upscaling.
In 2040 healthcare costs might escalate to some 25 to 30 % of GNP (CBS 2014). According to the World Economic Forum the main reasons for this cost increase are: “an aging population; an increase in chronic diseases and diseases related to Western lifestyle, mobilization of latent demands through the introduction of individual budgets; expensive new technologies and treatments; volume incentives for healthcare and sluggish growth in productivity” (World Economic Forum, 2013). These data show the urgency for innovation and change. The World Economic Forum expects government and institutes to be the leading change agent, but what is the role of the patient?
d) Disruptive change
There are different ways of innovations: sustaining and disruptive. In sustaining innovations the problem is well understood, markets are existing and predictable and sustaining innovations improves performance, lowers costs and is incremental. In disruptive innovations however the problem is not well understood, markets are new and unpredictable and innovation is dramatic and game changing. In healthcare both innovations will take place: quality management for example and merging are examples of sustaining innovations.
In healthcare, with new entrants and new technologies in combination with the urgency for change, some stakeholders will take up new roles. Technology will be the most important driver of disruption, but it is also one of the most important resources, generating data and knowledge. Allowing new entrants will result in a new role for the patient. In the accelerating world with tough competition in business, stakeholders need to find new ways of cooperation, using new resources (technology) to create value. New business models and value networks can be frameworks that help to find the new/optimal way to orchestrate these new resources to deliver value and create competitive advantage.
Christensen sketches a new landscape of disruptive innovations in healthcare. According to Christensen there are three enablers for this disruptive innovation: technological, business model and a value network (Christensen, 2009).
11 Figure 4 Elements of disruptive innovation.
d)1 Technology
Information technology will play several crucial roles in disruptive innovation at different levels; sharing information among professionals; shifting responsibilities and tasks to lower levels transforming traditional professions and decentralizing care.
The capability to diagnose diseases and develop rules based therapies using the information and interpretation of big data is leading to disruption, enabling primary care doctors to disrupt specialists and nurse practitioners to disrupt doctors and patients to disrupt doctors and so on.
Technology and the diagnostic use of devices at home will decentralize care; personalized medicine based on research and genomics will become more common. Personal Electronic Health Records (HER) reduce paperwork and will enable coordination among providers and enhance involvement of patients in their own care.
The disruptive effect for incumbents and the shared savings effect of technology and digitization are illustrated by a 12% decrease of consultations by general practitioners shortly after the introduction of eHealth, app’s and a website (Thuisarts.nl) and this is just the beginning.
d)2 Business model
The second enabler is the business model of the hospital. The current hospital is a mix of several business models: a solution-shop model, value adding-process business model and facilitated networks with high overhead costs. Solution shops perform diagnostics in general hospitals, for example diagnosing a hernia or breast cancer and specialist practices offer solutions. Payment is fee for service. Value-adding processes are medical procedures for example hip replacement and cataract extraction. Payment is based on the outcome. Focus clinics (only delivering one kind of product and service e.g. cataract extraction) deliver the same care for less costs compared to the hospital. Facilitated networks are meant to enable people to exchange things via a platform, patient networks, dealing with chronic diseases and aiming at exchanging information between patients and keeping them healthy. Examples are ParkinsonNet and Patients Like Me (Dockser Marcus, 2011).
Vested interests by solitary working specialists and hospitals make it difficult to disentangle these different business models. To innovate solution-shops, to deliver care by less skilled staff that is
12
cheaper is threatening their position. Hospitals are paid for the diseases diagnosed and treated, and not for the prevention of diseases. The more services a hospital provides the more it is paid for. This is not infinite because budgets are set by the health insurance companies and the Ministry of Health.
The example of Bernhoven hospital, illustrates how fee for service increases costs. In Bernhoven one of the healthcare insurers started with a new care concept: all medical specialists worked for a fixed fee and shared decision making (with the patient) was introduced (Bertakis & Azari, 201; Lee & Emanuel, 2013). This model resulted in a reduction of 20% production (Klink, 2016). d)3 Value network
The third enabler according to Christensen is an economically coherent value network, the context in which new methods coalesce to govern interaction and coordination. This is a rather new element because most hospitals are used to work solitary and only sharing products and services for cost sharing or quality if required. This third enabler is one that promotes health, not just care or cure. It means that an important company with sufficient scale and scope (insurance company, healthcare entrepreneur) can create a new value network in which new disruptive entities can be combined into a new system. This thesis is limited to the entities and not to this specific value network according Christensen.
In this dynamic world with many changes, how do we orchestrate those enablers; what capabilities do we need?
e) Dynamic capabilities
The concept of dynamic capabilities (Eisenhardt & Martin, 2000; Teece et al., 1997) has evolved from the resource-based view of the firm (Barney, 1986, 1991). Resources that are valuable, rare, inimitable and non-substitutable (VRIN) give a competitive advantage (Barney, 1991). But to create a sustainable competitive advantage VRIN resources alone are not enough. The core competencies or identifying capabilities of an organisation might give a sustainable competitive advantage (Prahalad & Hamel 1990; Leonard-Barton 1992).
Core competences are defined as the collective learning in the organization, especially the capacity to coordinate diverse production skills and integrate streams of technologies. These core competencies differentiate the company strategically and these core competencies are deeply rooted in the values of a company being path-dependent. They are very much alike Teece’s dynamic capabilities. However, in contrast to Teece, core competences are static and internally orientated and Teece’s dynamic capabilities are dynamic and externally orientated (Teece et al, 1997).
Dynamic capabilities are defined as "the firm’s ability to integrate, build, and reconfigure internal and external competences to address rapidly changing environments" (Teece et al, 2007). In the accelerating, exponentially changing world around us these dynamic competences might be essential to survive. Teece et al, propose “three dynamic capabilities as necessary for an organization to meet new challenges: the ability of employees to learn quickly and to build new strategic assets; the integration of these new strategic assets, including capability, technology and customer feedback, into company processes; and lastly the transformation or reuse of existing assets which have depreciated”
13
(Teece et al, 1997; Teece, 2007). Teece refers to successful implementation of these three stages as developing "corporate agility" (Teece, 2007). This corporate agility is “the capacity to sense and shape opportunities and threats; to seize opportunities and to maintain competitiveness through enhancing, combining, protecting, and, when necessary, reconfiguring the business enterprise’s intangible and tangible assets.” Dynamic capabilities also shape and not just adapt to the environment. Specific knowledge, understanding customer needs and decision making, creative activity and entrepreneurial spirit are features of dynamic capabilities. But teamwork and shared values to create a synergy are irrefutable.
It looks like a dynamic world needs dynamic capabilities, or is that too easy? The question is if organisations have the dynamic capabilities to reconfigure their business model or archetype to come to a better fit with the world around them. Let’s explore the archetypes.
f) Archetypes
In line with new ways of orchestrating the enablers of disruptive change and creating more value, different archetypes and how they contribute to patient centered and sustainable healthcare need to be assessed. Archetypes are defined as reconfigurations of the organisation’s business model building blocks1 to have a better fit with the needs of the business environment/market reflecting the capabilities of the organisation (Osterwalder & Pigneur, 2010).
In this paper we discuss five of the most current archetypes: merging, focussing, the patient's journey, networking/ecosystem, co-creation and their features. Categorization takes place based on Porter’s traditional value chain: the traditional value chain (merging); focussing on parts of the value chain (focussing), to open the closed value chain (patient’s journey), to integrate the value chain in a value network and to co-create different value chains being part of a network. Reconfiguration of business model building blocks is also described.
● Merging: this is an old but still widely used model dealing with the whole value chain as described by Porter. It involves all business model building blocks (scale). Merging is believed to make products and services less costly because necessary investments in technology and infrastructure are shared (economies of scale). It strengthens the position and increases possibilities to look at cost effective ways of managing care. Merging can strengthen a facility’s relations with the community; helping with community health needs as well as the possibility of new service lines. These advantages are not unambiguously supported by evidence (Treat, 1976; Radach Spang et al, 2001; Guerin-Calvert & Maki, 2014; Mercer, 2013; Propper et al, 2012).
1The business model building blocks are the CANVAS building blocks: the Customers; Value Proposition; Channels; Customer Relationships; Revenue Streams; Key Resources; Key Activities; Key Partnerships and Cost Structure (Osterwalder & Pigneur 2010).
14
● Focussing on customer segments or parts of the value chain involves all business model building blocks and separates the solution-shop model (diagnostics) and value adding processes as described by Christensen (Christensen, 2009).
● Reconfiguring your business model building blocks in line with the patient's journey is another archetype. The patient’s journey is process mapping of the patient’s journey from the patient's perspective, in order to improve quality of care and release resources (Osterwalder & Pigneur, 2010; Lapsley, 2013)
● Networking/ecosystem is a dynamic reconfiguration of all business model building blocks. Networking/ecosystem integrates different value chains in a value network. Features of networking/ecosystem are holistic thinking and having no complete overview. Connections between the different partners in the system might be volatile, loose or tight. Understanding each others needs in the network, is a prerequisite and learning by doing is a key feature (Williamson & de Meyer, 2012).
● Co-creation assumes a shared value and communication, reflecting honesty and transparency. “The joint creation of value by the company and the customer; allowing the customer to co-construct the service experience to suit their context” (Prahalad & Ramaswamy, 2004, p. 8). Shareholders, patients, suppliers, employees, stakeholders and society co-create. Deep trust and social norms are the features (Ramaswamy, 2009). Reconfiguration of all business model building blocks, but also co-creating the building blocks is another feature.
I examined the scientific background of patient centered care and value creation. The urgency for change is evident. Dynamic capabilities are essential to reconfigure business model building blocks to new archetypes. The results of the interviews with key players in healthcare to test if dynamic capabilities on their own are sufficient for successful transition, are presented in the next chapter.
15 Research design
The empirical research question is ‘What are new archetypes in Dutch healthcare and how do key players transform their organisation to a more sustainable and patient centred model, fit for the future?’
As a medical professional I chose those organisations I’m most familiar with: hospitals, healthcare organisations and healthcare entrepreneurs. Based on several sources (literature, the news, medical information, management literature and personal information from key individuals) a selection of the most innovative players in healthcare was made. Between June 2016 and January 2017 these people were invited to participate. Selection criteria were: important healthcare players, representatives of important healthcare organisations, visionaries, experience in one or more of the mentioned five archetypes: merging, focus, patient's journey, networking/ecosystem and co-creation. The interviewed opinion leaders were invited to suggest further relevant research questions and other healthcare players (snowball effect). Most interviews with healthcare players were recorded. Written summaries of the other interviews were made. A division in 4 groups was made: patient centered care experts; consultants; visionaries and Board Members.
Interviews were prepared by reading annual reports, publications, internet searches and the news about these healthcare players. Because the research question deals with idea’s, visions, and views the most informative, most productive and less time consuming method of a personal interview was taken. A cost analysis of the innovations was outside the scope of this thesis.
Patient’s perspective
Information about the patient's perspective and the transition to patient centered care was gathered by interviewing (alphabetical order) dr. D. de Boer, program leader “Care from the patient’s perspective” at NIVEL; drs. W.F.H. de Boer, Managing Director MC Groep; dr. H.A. Cense, PhD vice chair Federation of Medical Specialists, drs. T. Coenen, Executive Director Rutgers, former Chair to the Executive Board Aids Fonds; drs. O. Gerrits, Director healthcare procurement, Achmea Zorg & Gezondheid; drs. R.J. Knaap, senior staff member at the Ministry of Health, Welfare and Sport; dr. G.J.C. Schulpen, Medical Director ZIO Maastricht Area; prof. dr. J. Strikwerda, professor organization and change (internal governance) at the Amsterdam Business School of the University of Amsterdam; drs. D. Veldman, CEO Dutch Patients Federation. General questions centered around the challenges posed by disruptive innovations and its associated benefits; the definition and prerequisites to develop patient centered care and required capabilities.
Consultancies
Important consultancies in Dutch healthcare are KPMG and Boston Consultancy Group. Dr. A. van Poucke PhD, Chair KPMG Health NL at KPMG, dr. J.W. Kuenen, Senior Partner & Managing Director, Amsterdam Boston Consulting Group and drs. W. van Leeuwen, 1st Principal at The Boston
16
Consulting Group, were interviewed. General questions centered around the challenges posed by disruptive innovations and its associated benefits; their experience in patient centered care and the required capabilities how to develop patient centered care.
Visionaries and innovators in healthcare
Prof. dr. J.A.M. Kremer (professor patient centered innovation Radboudumc) and Lucien Engelen, director Radboud REshape & Innovation Center and drs. J. Tas are visionaries and innovators in healthcare. General questions centered around the challenges posed by disruptive innovations and its associated benefits; their visions and what is needed to transform to patient centered care. Drs. J. Tas (Philips) could not be interviewed but on September 15th 2016 at a conference about innovation of healthcare driven by technology he was the key speaker (NRC Conference Zorgtechnologie, 2016).
Healthcare players with experience in one or more of the five relevant business models were interviewed:
● Merging: dr. J.Th.M. van der Schoot, CEO OLVG; drs. P.E. van der Meer, Chairman Board of Directors Albert Schweitzer Ziekenhuis Dordrecht.
● Focussing: dr. I. Tulevski, fourneer Cardiologie Centra Nederland; drs. J. Moors, former CEO Ziekenhuis Amstelland.
● Patient's journey: drs. Ir. F. de Reij, CEO at Meander Medisch Centrum.
● Networking/ecosystem: prof. dr. drs. L.H.L. Winter, entrepreneur, owner, MC Groep B.V., DC Klinieken, Thomashuizen and Herbergier; prof. dr. C.G.J.M. Hilders, Managing Director at Reinier de Graaf Hospital, professor Medical Management & Leadership at iBMG Erasmus. ● Co-creation: drs. C. van Beek, Member Executive Board Radboud University Medical.
A set questionnaire was used (see appendix 1). The interviewees (see appendix 2) were invited to choose their own patient centered care example. This example was assessed, using indicators of patient centered care (information about costs, quality and added value; continuity of care, patient’s journey, choice, sustainability, prevention/care and cure, and how to stay healthy incentives). The history of “their” example of patient centered care (vision, experience), stakeholders, leadership, culture, bottlenecks and KPI’s were discussed.
A comparative qualitative analysis was performed using the information of the interviews and reports/publications. The organisations were assessed using the results of the interviews for PCC; Christensen’s three enablers (technological (T), business model (BM) and a value network (VN)); and a rating of ≥ 8 at Zorgkaart2. The maximum score was +++++ (Table 1). The organisations were
plotted in the new value creating system in Figure 3b. The results of the interviews including personal comments and the rating of the organisations will be given in the next chapter.
2 Zorgkaart is a Dutch healthcare reviews and ratings source, based on patients feedback
17 Results
The invitation to 24 persons resulted in 22 full interviews. In this chapter we summarize the results of the interviews of consultants, visionaries/ innovators and Board Members and comment on that. The results will be visualized in a Table (Table 1). Further analysing will take place in the discussion part. Consultants
Drs. van Poucke, chair of KPMG Health, identifies 3 driving forces of innovation: increasing age; customization and patient centered care, and digital technology. These forces will reshape the landscape of healthcare. Physicians have to transform themselves to “health coaches ” (patients will be better informed, more empowered and share experiences and information on platforms). More care will be delivered at home and self-monitoring with eHealth and wearables renders visiting hospitals in these cases superfluous and costly. R&D in the hospitals need to develop remote monitoring together with providers of technological innovations (Philips, Microsoft, Apple) (Van Poucke, 2016). Innovative partnerships, leadership, new ways of sharing (of responsibilities, tasks, risks, costs, revenues), intelligent insourcing are important issues. Merging in the traditional way is not the answer to the challenges of today according to Van Poucke (Van Poucke, 2016)
According to dr. Kuenen, PhD Senior Partner & Managing Director and drs. van Leeuwen, Amsterdam Boston Consulting Group, healthcare is organised as an output and budget driven industry and it should be transformed to a patient driven industry and a clear vision for the future is sometimes blurred. In the service bundle Prevention→ Diagnostics→ Treatment Decision Making→ Treatment → Care (comparable with Porter's value chain) innovation takes place in the different compartments. Not every hospital has to offer all services on its own but can provide services using the store in store concept or the alliance/networking model. There are three major challenges: financing in the long term and upscaling new innovative business models (Kuenen et al, 2011); transparency in the differences in quality, and coordination at a national level. Merging might be successful because of the advantages of economies of scale and merging is not threatening the position of incumbent medical staff. Different levers as illustrated in Figure 5 can improve treatment decisions, address practice variation and decrease differences in quality.
18
Figure 5 Differences in quality in care BCG (Kuenen et al, 2015)
Comment: The consultants try to innovate and to reconfigure the value network. If we look at the value creating framework in Figure 3a, consultants focus on the value of the traditional value chain. Their way of innovation is not disruptive in the meaning of new entrants ànd new shared values and complete new configurations. They are neither focussing on capabilities nor on the underlying orientation. The patient or patient centered care is not their value framework but they assume that customization and new technologies will enable patient centered care.
BCG is more traditional and expects that transparency itself will be the lever for a change. This change is incremental and will take a long time. KPMG is paying more attention to new entrants and innovative partnerships, leadership and new ways of sharing but still around the traditional value chain.
19 Visionaries and innovators
Compared to consultants visionaries and innovators go a step further. The two most important issues addressed by innovators are a holistic view of healthcare with all its consequences and the empowerment of patients facilitated by technological innovations.
Visionary
Prof. dr. Kremer, professor patient centred innovation, expects that disruptive innovation will force healthcare to change to a more holistic concept. He expects a shift from a population based to a patient centred concept considering the patient as a unique person in its own context, and a shift from the providers’ to a patient’s point of view. These changes will have consequences for current practice of group based medicine that is based on group based evidence to a more personalized research design (N=1).
Even more important is the question who defines quality in this holistic view. Quality is a dynamic and pluralistic concept in the eye of the beholder. But what is quality? Is it a measurable standardized concept we all agree upon or is it a moral issue? According to Kremer a moral discourse, analogue to the philosopher and sociologist Jürgen Habermas and his “Herrschaftsfreie Kommunikation” (Habermas, 1929), this should take place with all stakeholders about what quality of healthcare means and if it should be measured, and in what way. This is a never ending moral discussion leading to a continuous renewal, innovation and reshaping healthcare as a learning organisation.
Comment: the innovation prof. Kremer advocates, is influencing the complete value creating network as illustrated in figure 3. In his holistic approach the underlying orientation, the (dynamic) capabilities, the value chain and the role of the patient will change. The patient is considered as a source of knowledge and co-creator.
The shared value applied in the whole value creating network is patient centeredness leading to different value chains and patient centered care. Prof Kremer’s vision on capabilities is even more challenging and disruptive. Other stakeholders, other ways of learning, new quality management and co-creating are just a few examples of the disruptiveness. This approach goes far beyond the dynamic capabilities of Teece (Teece et al 2007), because the co-creation and continuous agility but not at least the unpredictability where this will bring us, are new dimensions of capabilities.
Visionary and innovator
Lucien Engelen, Director Radboud REshape & Innovation Center, and one of the most public innovators, states there is an urgent need for innovation. There is an urgency for change, though not all stakeholders are aware of this. Healthcare is not affordable anymore in the long term, old fashioned models are used, unnecessary rituals are carried out, redistribution of tasks and digitization are main issues. He observes healthcare professionals behave like believers and nonbelievers parallel to the climate change debate. The way healthcare is provided is old fashioned: most services in society are offered 24/7 at the convenience of the consumer, but healthcare still works with an outdated model.
20
Professionals do not think patients want to use methods such as Skype which has become a commodity in social life.
To innovate, a holistic or comprehensive model should be used integrated in the training of healthcare professionals. Another important feature of new business models is that you are transparent and co-creating care with patients and family and friends. You have to monitor what you do. Governance and the Ministry of Health, Welfare and Sport are not considered bottlenecks but support the innovations though they lack the instruments to govern those innovations.
Engelen illustrates disruptive innovation with the following example. In case Apple starts a health insurance company and develops an app as a first consultation it will help people to use less of the “old fashioned” healthcare so decreasing costs, empowering people and redistributing care to those who are really in need for a professional. Working together with IBM, Apple and Google does not endanger privacy as such. The recent Netherlands Public-Private Partnership to Launch Comprehensive, Observational Study of Parkinson’s Disease (Verily, 2016) with Verily/Google was carried out meticulously. He is more afraid of start-ups and Chinese internet initiatives threatening patients privacy.
Comment: REshape Center for Health(care) Innovation is a part of Radboud University Medical focusing on patient centered care (see interview with drs. C. van Beek, Board Member Radboud University Medical Center). Engelen’s vision is quite disruptive in a way it will influence the whole value creating network as illustrated in figure 3. The most important feature is patient centeredness and this will influence the traditional value chain, eroding or changing in a disruptive way existing hospitals and healthcare institutions and challenging existing capabilities. The innovation is taking place in and outside the hospitals. If the underlying orientation is touched is not so apparent. Professionals will be trained in a different way so healthcare will transform. In his blog “The digital patient: the double edged sword?” he realizes the pitfalls of digital tools, digitalized patients and quotes Castle-Clarke if “these digital tools could compromise the quality of care and disrupt the way care is provided” (Engelen, 2016; Castle-Clarke & Imison 2016).
Innovator
In Philips the business groups Patient Care & Monitoring Solutions, Population Health Management, Healthcare Informatics and Emerging Businesses “support healthcare providers with clinical programs and technology to implement new models of patient-centric, networked care”. The development of digital health solutions and services that provide integrated patient-centric care and support providers and health systems will achieve better outcomes across the full health continuum: from healthy living and prevention to diagnosis, treatment and home care”. By collecting data and ‘through analytics and algorithms this data can deliver predictive, personalized insights, for example to help motivate healthy behaviour through digital coaching, and to support healthcare professionals in making clinical decisions or alert medical teams to potential problems’ (Thiel et al, 2013).
But according to drs. Tas, visionary and innovator, not much has changed in the healthcare industry when it comes to applying digital and telehealth technologies at scale to improve care for the
21
hundreds of millions of people suffering from chronic disease. He quotes 4 reasons in his blog why innovation is so slow: inertia; scalability; awareness and reimbursement problems. In spite of the fact that there is an abundance of evidence that eHealth can have a huge positive impact, only small steps have been taken (Royal Philips, 2016). The need for organizational and cultural change slowed down plans to deploy eHealth. Patients do not realize exactly what is possible nowadays so they will not ask for it and current business models are not set up to make telehealth a requirement for hospitals or medical practices.
Philips operates in an agile and disruptive way in and especially outside the hospitals. Supporting chronic patients at home with wearables and telemedicine makes it possible living their own life at home and if there is a problem, a quick way of solving it by teleconsulting. Encounteri ng medical problems, Philips initiates meetings or hackathons with groups of experts and based on big data and supported by technology, problems are solved within 2 months and Philips goes on to the next problem to be solved (Philips hackathons)
Philips collects data (HealthSuite device Cloud, 2016), analyses the data, building their resources especially their knowledge in different and volatile configurations and with different stakeholders. They also apply the medical equipment or apps but especially the data collection and the knowledge acquisition will be the most important part of their archetype; this is an exponential growing model.
Comment: Philips is an innovation company aimed at finding solutions through technology and not governed by limited funds or conventional management/governance models. Philips operates in an agile and disruptive way especially outside the hospitals. Their way of problem solving, creating new volatile configurations and different groups of experts is very dynamic and inspiring. Telemedicine, connecting people and creating platforms are patient-centric.
Philips’ innovation does not discuss the underlying orientation or capabilities, but through ‘empowering’ patients it will also influence the value chain. Apart from developing advanced technological solutions or instruments in the hospitals they focus on the (chronic) patient outside the hospital, in the field of mainly prevention and care. The patient is a source of data, empowered by eHealth and telemedicine and connected to others so the patient co-creates value.
The innovation Philips realizes, will not only influence the value chain but more importantly, the complete value creating network as illustrated in figure 3a. The shared value applied in the whole value creating network is patient centeredness but in a different way compared to Kremer. Kremer considers the patient as a source of knowledge; Philips considers the patient as a source of data, building Philips’ resource of knowledge.
Philips’ model turns conventional governance models on its head because for example in a hackathon, everybody is equal, there is no rank and the outcome is unpredictable and beyond conventional control mechanisms (Philips Hackathon). Because of finding a solution for a problem felt by all participants the teams (of different players in different configurations) create more value and synergy. The capabilities Philips shows are very very dynamic.
22 Summarizing comment on visionaries and innovators
All visionaries agree upon an urgency for change and patient centeredness and a holistic view is mentioned several times. If we consider a holistic view as emphasizing the importance of the whole and the interdependence of its parts and apply it on the value creating network of Figure 3a prof. Kremer’s vision is really a holistic vision. His vision, covering the complete value creating network involves all stakeholders to define value and quality and to enhance continuous learning and improvement of services accordingly. In his view the teams of players/stakeholders create value over space over time without interruption. They learn by doing and rearrange their models/archetypes because they have developed their capabilities to adjust to the needs of the environment.
In Engelen’s view patient centeredness is the main issue and he pays less attention to the effects this patient centeredness might have on the value created by the complete value creating network. To integrate his view in existing services is a challenge and apart for the disruptive effects there is no consideration on how to deal with sustainability of services and healthcare.
Philips, as a technology provider, comes and goes and with the data collected it is building up its own resource, knowledge. Philip is offering technological solutions in existing value chains (care and cure) but is focusing on patient-centric care solutions outside the hospital and mainly in the field of prevention and care. Integration is left to the stakeholders.
23 Board members
Compared to consultants and visionaries this group of interviewees has to innovate and implement the changes in their own organisation, so they might be a bit conservative. In hospitals it is very important for CEO’s and Board members to find a common concept supported and shared by all stakeholders, which makes it more likely they compromise to ensure that the innovation will take place without threatening their position. Entrepreneurs are more willing to take “a risk”. Being an entrepreneur you are familiar with the dynamics of the market and used to exercise executive power.
Merging Onze Lieve Vrouwe Gasthuis (OLVG) and Sint Lucas Andreas ( 2015) to OLVG East & West The first plans for a merger were made in 2008. Quality and transparency of care became more and more important. For a top clinical hospital it was a challenge to keep all the medical specializations and specialists on board at reasonable costs on a 24/7 base. With 6000 employees, revenues for the merged OLVG were € 557,4 million (2.4 million profits) (Annual report OLVG 2015). Dr. J.Th.M. van der Schoot, chair of the Board was interviewed.
Vision: The merged entity is believed to increase the quality of complex care, to increase the quality of the medical infrastructure and to lower the costs (Visiedocument 2011). Specialists become more experienced in, and can focus on a special type of highly specialized care, without layoffs. Both hospitals could use the same infrastructural investments, logistics and innovations. It also meant to shift low complex care to outpatient clinics and to move certain specializations from one to the other location. The patient experience is important: offering care nearby and in both hospitals due to shared ICT, all the information of the individual patient is available.
Staff is supportive keeping all the specializations on board. Leadership in transition.
Culture: the support of medical staff and common roots of the merging hospitals (Sint Lucas Andreas was a ‘daughter’ of OLVG) made it easier to merge.
Capabilities: providing high quality care in an efficient way.
Bottlenecks are the provision of all services at 24/7 availability of all staff.
As KPI’s the number of patients and the quality of care are mentioned. The number of patients do increase. The expected increase of quality is not visible yet.
Success factors: according dr. van der Schoot the political climate of required transparency and the relation between volume and quality are success factors. The need for change felt by the board and the professionals is another success factor.
Comment: the question if OLVG offers patient centered care is not easy to answer. The criteria of patient centered care are partly met by information, the sustainability as an organisation and the personal electronic health record (EHR). After applying Christensen’s enablers (technological, business model and a value network), OLVG scores on information technology. Merging dos not influence the complete value creating network as illustrated in figure 3a. Only the value created in the
24
traditional value chain is influenced. Neither on the capabilities, nor on the underlying orientation merging will have an effect.
Merging makes the organisation more powerful, but if the results of the merger are poor, you can’t turn back. Merging makes the OLVG less agile. Merger is an old model and assumed benefits about decreasing costs or increasing quality are debatable (Treat 1976; Radach Spang et al 2001; Guerin-Calvert & Maki 2014; Mercer, 2013; Propper et al, 2012). The latest publication of the Authority Consumer and Market in 2016 did not show a significant improvement of the quality of care after merger (FD, 2016, ACM, 2016).
OLVG ‘innovated’ in the hospitals using an old model and this archetype of merger is based on production and not on shared values (apart from quality of care). No KPI is mentioned for the assumed lowering costs and the increase of quality of care is not visible yet. OLVG is building its capabilities based on scale and the results over the coming years need to be reviewed in detail to assess the success of the merger.
Merging Albert Schweitzer Hospital and RIVAS
The former chair of the Board of the OLVG drs. P.E. van der Meer moved to the Albert Schweitzer Hospital (ASH) in 2015 to merge the ASH with the RIVAS Zorggroep in Gorinchem (a joint project involving local hospitals, home care services and GPs). In 2015 with 3315 employees, revenues were € 358,5 million (6.1 million profits) (Annual report ASH, 2015). ASH and RIVAS worked closely together for 15 years. The intention to merge was communicated already in 2013 and seen as necessary to increase quality of care and sub-specialisation but also to remove financial partitions and bureaucracy.
Healthcare workers, social workers, prevention, child and youth health, general practitioners and medical specialists formed the RIVAS Zorggroep in 1999, providing a continuous vertical chain of care and cure, at home, at other health organisations and at the Beatrix hospital (Annual report RIVAS 2015). With 3174 employees, RIVAS’ revenues in 2015 are € 269,3 million (0.5 million profits). According to their website RIVAS has a holistic concept of care and follows the Planetree model of humanistic healthcare. “It understands the holistic healing process and prescribes each of us with a critical role in creating and supporting health in their model of care. With the spread of their belief and adoption of their philosophies, we enter into an exciting era in modern healthcare, where care is preventative, holistic, and patient-centered as a benefit to caregivers, patients and families alike” (Planetree). Drs. van der Meer is chair of the Board of ASH.
Vision: the merger of ASH and RIVAS was believed to increase the quality and continuity of care and decrease costs. ASH wants to deliver value based healthcare. In general the infrastructure of the hospital is believed to transform itself, focussing on the patient and using big data and algorithms (predicting cardiac failure, genomics). The role of professionals will change. Personally drs. van der Meer wants to connect prevention, care and cure, making healthcare better at lower costs. He wants to offer a better product at lower cost by focussing for example on diabetes, offering patient centered
25
care of excellent quality in the hospital and to a larger geographical area using telemedicine and eHealth for the daily routine.
Bottlenecks: will the merger be approved; the current financial infrastructure in the different hospitals (silo’s in healthcare) and the culture. ASH and RIVAS have completely different healthcare models and creating a shared vision of the merged entity is a critical success factor.
KPI’s are the production and sick leave (4.4%) as a reflection of the working environment, leadership and culture.
Culture: transform to a willingness to change, connectedness and shared responsibility. Staff: feeling more (financially) responsible.
Capabilities: RIVAS has a history of networking, partnerships and vertical integration. ASH has just started to transform itself and the experience of RIVAS is indispensable.
Comment: The criteria for patient centered care (information about costs, quality and added value; continuity of care, patient’s journey, choice, sustainability, prevention/care and cure, and how to stay healthy) for RIVAS are met but not for ASH. Application of Christensen’s enablers, technological, business model and a value network scores in 2017 only on information technology. KPI’s for increased quality of care and cost reduction are not given.
The Planetree concept is real patient centered care and RIVAS has a history of innovation in and between organisations, creating a well functioning network, based on the shared Planetree value. From the perspective of the patient the merger would have created an advantage for ASH. But The Netherlands Authority for Consumers and Markets denied the merger because of their antitrust policy, fearing a monopolistic position after the merger (ASH, 2016).
ASH still wants to offer all services and is not focussing on a limited set of products. Close collaboration with RIVAS and its networks will be essential for ASH, sharing their network and innovate towards a Planetree model. ASH planned to innovate according using an old model, based on scale but in this case also based on a shared value, the patient centered Planetree vision. It would have been a major challenge to merge those two different organisations and to change the culture in ASH.
But now ASH has to reconfigure and build new capabilities, hopefully in close collaboration with RIVAS. In the value creating network as illustrated in figure 3a, at the most the value created in the traditional value chain might be influenced. The patient, capabilities and the underlying orientation remain untouched.
Focus: Cardiology Centers the Netherlands
This organisation started in 2006. In those days in hospitals, it took a long time before a patient, consulting a cardiologist had completed the tests required, due to logistic shortcomings. Patients had to wait and their referrers, the general practitioners had to wait a long time before they were informed about the results and further treatment and so on. So dr. I.I. Tulevski, together with his fellow
26
with the first Cardiology Centre in Amsterdam in 2006. the CCN provides a one stop model, offering excellent care within 24 hours after the referral and reporting back to the referrers on the same day. They focused on Diagnostics and occasionally the Treatment Decision parts of the traditional value chain of Prevention→ Diagnostics→ Treatment Decision Making→ Treatment → Aftercare. In most cases they refer the patients back to the general practitioner or they refer the patient to a neighbouring hospital to undergo cardiac surgery. In this business model the patient, the general practitioner, CCN and the hospital providing cardiac surgery all gain (Annual report CCN 2015).
In 2016 there were 14 locations of CCN in the Netherlands, including CCN in hospitals. CCN (together with Focus Cura) was awarded the Innovation Prize for their initiative “Heartwatch”, a telemedicine Heart Monitoring system using an App so patients can consult their tele-cardiologist, offering appropriate care and preventing unnecessary visits to the hospital and decreasing the number of admissions (Heartwatch, 2016).
According to dr. Tulevski the success of CCN can be explained by the following: they had a vision and acted accordingly by starting a niche providing excellent care on short notice. Staff shares this vision.
The bottlenecks are the budgets of the insurers limiting the amount of care provided by CCN even if that care is less expensive and better compared to neighbouring hospitals. Sometimes other cardiologists in neighbouring hospitals feel threatened.
The KPI’s are growth, revenues, profit, patient satisfaction.
Stakeholders: staff, insurance companies, general practitioners, international partners, neighbouring professionals and (University) hospitals.
Leadership is essential and decisions are taken by the Board after discussing the topics with the whole crew.
Culture: CCN is interested in and connected to people and society, seeing, seizing and creating new initiatives independently. Medical staff is screened for being innovative and entrepreneurial.
Capabilities: standardisation and upscaling is their mantra. They are building bridges, networking and listen to feedback. Their ICT system is well developed and they use all the data they have including the available evidence to standardize care via validated questionnaires. In this way and using a ECG sensor in an iPhone they are developing telemedicine in Ghana. CCN also wants to be a partner in developing a centre of excellence for cardiological surgery, inviting people from abroad to get their treatment in the Netherlands.
Governance: see bottlenecks.
Comment: CCN offers PCC in which content is still king. The criteria of patient centered care: information about quality and added value, continuity of care, patient’s journey, choice, sustainability, are met. The criteria prevention/care and cure, and how to stay healthy are referred and secured by general practitioners.
Being a small organisation operating on multiple locations it is agile. CCN owns and uses its dynamic capabilities (the ability to integrate, build, and reconfigure internal and external competences
27
to address rapidly changing environments). Quality is high and costs are lower compared to care provided by the hospitals. By eHealth and telemedicine CCN offers personalized patient-centric care. Application of Christensen’s enablers, technological, business model and a value network scores + on technological and + on business model enabler (solution-shop!).
In the value creating network as illustrated in figure 3, the value chain is disrupted and value is created in a solution-shop model outside the hospital. The care offered is patient-centric (Heartwatch) and CCN develops and strengthens its dynamic capabilities. CCN does not discuss the underlying orientation.
If this model is sustainable or easy to copy is not clear, but it is very successful. CCN has a clear shared vision and act upon it with all players. With their dynamic capabilities, CCN can reconfigure its business model blocks to a new configuration or archetype. Using algorithms, based on their own data, using questionnaires and telemedicine makes CCN a model to implement in other countries.
Focus: Ziekenhuis Amstelland
Drs. J. Moors, former CEO of Amstelland Ziekenhuis was interviewed. ZHA is a middle sized general hospital. In 2015 with 800 employees, revenues were € 99,4 million (-3.1 million profits) (Annual report ZHA 2015). The vision of the Board was to offer high quality services and products and ZHA experienced a steady growth below the radar until 2010. Focusing was inevitable because of demographic changes in the area and because of required numbers of and experience with certain procedures to guarantee quality of care. This process of focusing, in collaboration with staff, general practitioners and the Free University of Amsterdam started in 2010. At first staff and Board were aligned, but realizing that collaboration meant that certain specializations and services were to be discontinued or replaced by new specialisations such as geriatrics, staff became less aligned with the Board. This did not result in an exchange of specializations and services and ultimately led to resignation of the Board. This demonstrates that for a properly functioning transition to the focus model, full alignment between all stakeholders and a shared vision are required.
Bottlenecks: lack of executive power; the lack of shared values and shared vision; devolved recruitment process of staff.
KPI’s: increased quality of care, increased number of patients and website visitors, referrals by general practitioners.
Stakeholders: key persons in the staff, the Board, staff, insurance companies, general practitioners, international partners, neighbouring professionals and (University) hospitals.
Staff see above.
Culture: countervailing powers in the staff, culture aimed at stabilising status quo. Capabilities: offering very good and even competitive care in line with their profile.
