The patient of the future : what does the Zuyderland Medical Centre need to understand about its patients in order to serve them in an optimal way?

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The Patient of the Future

What does the Zuyderland Medical Centre need to understand

about its patients in order to serve them in an optimal way?

By Kim Hurkens

Supervisor: Dr. M. Rademakers

Date of submission: 19-1-2017 Confidentiality restrictions: none Written by:

Dr. Kim Hurkens Laan van Westfalen 39 6162 KJ Geleen Tel.: +31644987907

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The patient of the future by Kim Hurkens

Abstract

Customer centricity is a well-known concept in business organizations. It can be a valid strategy in order to maintain a sustainable business by retaining and attracting customers. In healthcare however, little is known on what factors are important for patients when in need of healthcare. In order to serve patients the best way possible, insight in this is important.

The Zuyderland Medical Centre is a large recently merged hospital in Limburg. Important competitors are the other hospitals in Limburg, Belgium and Germany and the private clinics. After the merger, the hospital became internally oriented and lost sight of its real purpose: providing optimal care for the patient. With this thesis we try to give insight in what this optimal care should comprise according to the patient.

The research in this thesis comprises of four parts: a literature review,

qualitative analysis, quantitative analysis and the development of personas. For this, three frameworks are applied. The organizational design research process is applied for a systematic approach of the qualitative research. The data of the qualitative analysis is analysed by a thematic analysis framework of Braun and Clarke. Finally, the creation of personas is performed by means of the persona creation process.

Based on the qualitative and quantitative data, four clusters of patients are formed: active-cognitive, active-affective, passive-cognitive and passive-affective. These clusters were further formed into personas. The active patient actively chooses his/her healthcare whereas the passive patient does not. The cognitive patient bases his/her decision on cognitive attributes such as location and travel distance, whereas the affective patient values attributes as human approach or experiences. Also, the general practitioner is important for all four groups.

This research is relevant because it gives insight in which factors are

important for patients when choosing a hospital. This information can be used in a corporate strategy in order to become more patient-centric. The personas can also be used as a tool to create awareness and engagement throughout the organization. To the best of our knowledge, this research is one of the most extensive patient centricity studies in a hospital setting. Despite the demographic differences, the key characteristics found in this study could be used to analyse other hospital

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VI. Patient centricity and organizational strategy page 39 VII. Conclusion, limitations and recommendations page 42

VII.A. Conclusion page 42

VII.B. Limitations page 44

VII.C. Recommendations page 45

VII. References page 46

Appendix I Abbreviations page 48

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5 Chapter I. Introduction

The internal and external environment of healthcare is changing rapidly. These changes occur regionally, nationally and globally. The change in demographics is very important. Globally, people are getting older, and people are in need of

healthcare for a larger proportion of their life. Also, there is a global rise in the aging population so that the prevalence of elderly is rising rapidly.

Secondly, the Dutch healthcare system is still successful but unstable. In 2006, a healthcare reform has been established in order to contain costs. The social health insurance (ZFW) and private health insurance (PHI) were combined to form the private social health insurance (ZVW). For the population it has become obligated to have basic health insurance. Also, with the introduction of the health insurance act (zorgverzekeringswet), ‘regulated competition’ was created in order to improve quality. It was thought that through competition and market forces, healthcare providers would be incentivized to provide high quality and efficient care.

Subsequently, two new acts have been implemented in 2015, the long-term care act (wet langdurige zorg) and the social support act (wet maatschappelijke

ondersteuning). The long-term care act is applicable for patients who require home-care and aimed to create more freedom of choice for the patient by switching to another contracted healthcare provider. With the social support act, healthcare delivery for patients with disabilities have become the responsibility of local authorities who directly pay healthcare providers.

Thirdly, with ground breaking innovations in healthcare, we have more diagnostics and treatments at our disposal. Technology and IT are becoming increasingly important in the hospital setting. Due to these better diagnostic- and treatment options, patients are admitted to the hospital for a shorter duration of time. On the other hand, these involving technologies bring about higher costs of

healthcare.

Fourthly, patients nowadays have higher demands with regard to excellent healthcare than patients several decades ago. Patients become accustomed to customer centricity and will also increasingly demand a patient-focused service. Patients start to shop around in order to get excellent care, just as they would for convenience products. Also, through the rise of the internet, people want to use different communication channels to interact with their environment, including their

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caregivers. In addition, the interaction between the patient and physician is changing with patients increasingly wanting to be included in the decision making process. They are becoming more informed and educated and demand more time for discussion and information.

These changes make it necessary to evaluate the way healthcare is delivered. After all, the way we think we have to deliver healthcare may differ from what the patient expects from healthcare providers. ‘Eighty percent of CEOs believe that they deliver a superior customer experience, only 8% of customers agree’ is what Bain and Company report in ‘Closing the Delivering Gap’ after surveying 362 firms on customer service (Allen, Reichheld, Hamilton, & Markey, 2005). In business

organizations, the shift from product focus to customer focus has set in roughly two decades ago. In healthcare however, customer centricity and focus on customer service is a rather unknown concept. However, because of the trends mentioned above, it is essential for hospitals to truly understand their patients in order to serve them in the best possible way. Also, patient centricity could be a clear strategy in order to maintain a successful and sustainable business (hospital) by retaining and attracting patients and to gain competitive advantage.

This thesis addresses the issue of customer/patient centricity and the patient’s decision making process. For this, an extensive literature review is performed.

Secondly, four patient categories are developed by means of a qualitative analysis through interviews. Thirdly, the qualitative analysis is validated by a quantitative analysis through an electronic survey. Finally, a proposal on how to incorporate this knowledge into a change strategy is made.

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7 Chapter II. Case description

II.A. Organizational structure.

The Zuyderland Medical Centre is a recently merged organization consisting of two large hospitals: the Orbis Medical Centre Sittard and the Atrium Medical Centre Heerlen. The current hospital belongs to the largest STZ ('samenwerkende

topklinische ziekenhuizen') hospitals of the Netherlands with over 5000 employees and 1400 beds. The hospital consists of different departments which have their own daily management. The departments are clustered in RVEs ('resultaat

verantwoordelijke eenheden'). These RVEs are managed by RVE managers

(medical and non-medical managers). These RVEs report to the board of directors of the hospital. Medical specialists are either self-employed and part of the MSB

('medisch specialistisch bedrijf'), or are in the employment of the MSB.

II.B. Context and competitors

The Zuyderland Hospital is situated on two main locations, Sittard and Heerlen, and has a number of small locations only providing ambulatory care such as Brunssum, Kerkrade and Echt. It has a service area of 475.000 inhabitants. Furthermore, the Zuyderland group also consists of a ‘care-part’, with nursing homes, elderly care centres, hospices and a home care organization.

The patients of the Zuyderland generally have a worse health status compared to inhabitants in other parts of the Netherlands. Until forty years ago, the mining industry flourished in Limburg. As a result, inhabitants are generally low educated with lower incomes compared to the rest of the Netherlands. Also, they are exposed to more risk factors. Due to the mining industry but also as a result of the chemical company DSM, proximity to the Ruhr area and the industry of Liège. Finally, the Zuyderland is situated in an area with an increasingly aging and diminishing population.

In the province of Limburg, there are four hospitals next to the Zuyderland: The VieCuri Medical Centre in Venlo, the Sint Jans Gasthuis in Weert, Laurentius in Roermond and the academic hospital of Maastricht. There is some overlap in the service areas of the different hospitals (figure 1).

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Figure 1. Hospitals in the province of Limburg

Other important competitors in Limburg are the Belgian and German hospitals, such as the hospital of Oost-Limburg in Genk and the University Medical Centre in

Aachen. Annually, more than 80.000 Dutch patients travel to Belgium or Germany to receive medical care. Main reasons to go abroad are a high quality of care at low costs and the absence of waiting lists (ANP, 2016). It is currently unknown how many inhabitants of Limburg go abroad to receive medical care.

A last group of competitors that is gaining popularity are the private clinics, the so-called ‘zelfstandige behandelcentra’ (ZBC’s). The number of ZBC’s is increasing rapidly. For plastic surgery, anesthesiology, orthopedic surgery, dermatology, allergology and ophthalmology, the market share of ZBC’s is higher than 2%.

According to health insurance companies, ZBC’s can have added value compared to hospitals. The main reasons for this are a high service standard, excellent logistics and their low price rate, which is approximately 10 to 15% lower than that of

hospitals. Attracting patients to the ZBC’s usually works by worth-of mouth

advertisement. General practitioners generally do not refer patients to ZBC’s. The presence of ZBC’s in the service area of hospitals could stimulate hospitals to be more competitive (Homan, 2012). In Limburg, the Reinaert clinic is a large ZBC with practices in Maastricht, Sittard and Amstenrade. They focus on low complex and high volume surgery, oral/dental surgery, cardiology, ear-nose-throat diseases,

orthopedics, pain control and plastic surgery. It claims to be cheaper than the local hospitals and services are said to be excellent with no waiting lists.

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II.C. The burning platform

After the merger, the Zuyderland hospital struggled financially. Several causes can be identified. Before the merger was finalized, the Heerlen hospital was thought to have sufficient liquid assets. But a significant portion of the budget turned out to be already allocated to existing projects with regards to new-build, therefore not really contributing to the liquid assets of the hospital. Furthermore, in Heerlen there was a decline in the number of DOTs (‘DBC op weg naar transparantie’, the Dutch

reimbursement system for medical treatments). Before the merger the hospital in Sittard showed growth in production, however, had scarce liquid assets and was less solvent. The hospital had to let go approximately 380 fte (fulltime-equivalent) to balance the budget.

These two hospitals merged to try to create synergy and therefore profit. This merger proceeded in steps. For example, in the first step the internal medicine departments, surgical departments, laboratories and gynecology departments would merge. The intended benefits of the merger in terms of finances came later than expected due to delays in the merger process, delays in new builds, and so on. Another challenge was the initial restriction of production growth by the government and at the same time the intention to create a free-market based healthcare system, which makes treatments cheaper.

All these factors contributed to an initial loss of 14 million. Due to increased production on certain areas (elderly care, gastroenterology, abdominal surgery, prostheseology) and increase of efficiency this initial loss decreased to a loss of eight to nine million.

With the merger and after the disappointing financial results, management realized that the organization had become highly internally oriented. All focus was on internal management processes and stabilizing the current situation. They lost sight of the real purpose of the hospital, namely providing optimal care for the patient. In order to connect to the (potential) patients of the Zuyderland again, a project called ‘patient of the future’ was created. In this thesis, the results of this project will be explained.

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II.D. Problem statement and research questions

This thesis aims to answer the following problem statements:

1. What does a hospital need to understand about its future patients?

2. How to incorporate this information into a strategy aimed to serve patients in the best possible way?

The following research questions are formulated to answer the problem statement: 1. What are the key characteristics of patients choosing for the Zuyderland? 2. What are the reasons for patients (not) to choose Zuyderland?

3. What are the key elements of the patient’s hospital selection process? 4. Based on key characteristics, can patients be categorized in representative

clusters?

5. How should the Zuyderland align its corporate strategy with these key elements in order to achieve a higher patient preference over its competitors? 

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11 Chapter III. Literature review

III.A. Customer loyalty and centricity in business organizations

For a product, or service, there are two perspectives, that of the designer/supplier and that of the user. Although often thought, these perspectives do not share similar motives (Norman & Ortony, 2003). Bain and company mention in their report ‘closing the delivery gap’ that 80% of companies believe that they serve the customer in the best way possible, while only eight percent of their customers agree with this (Allen et al., 2005). They describe two possible explanations. The first is the paradox between growth of the company and the ability to maintain a long-term relationship with the customer. Apparently growth of the business goes along with (financial) decisions that are less attractive for the customer. Secondly, it is extremely difficult to gain profound understanding of what customers really want and even more to deliver exactly this all the time in an era where requirements and needs change and

increase constantly (Allen et al., 2005).

For the past decades, businesses considered internal cost-efficiency as the main source of value creation. For a long time, businesses controlled the way products were developed, produced and sold. It was the business-centric view of value that was prevailing and customers were not considered as part of the value chain (Pralahad & Ramaswamy, 2002). In recent years, however, due to advances in technology and communication and increased information (internet) and education, customers are becoming significantly more influential and demanding in determining value (Makarem & Al-Amin, 2014). This increased the influence of customers and the increasing market competition forces businesses to consider value creation in a different way. Orientation of businesses therefore is slowly shifting from a supply driven to a demand driven model; from appeasing the customer to customer satisfaction to customer delight (Johnston, 2004).

Studies show that, especially in service oriented business, such as hospitals, customer loyalty greatly depends on customer service. Interestingly, for these

businesses, delivering basic services in a trustworthy way that meet the needs of the customer seems to be more important than providing for a unique service experience (Dixon, Freeman, & Toman, 2010; Hollander, Hertz, & Klein Wassink, 2013). Service excellence has little positive impact on increasing loyalty but suboptimal service does have a large negative impact on customer loyalty. Therefore, improving service

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quality should focus on helping the customers to perform their task as easy and convenient as possible (Dixon et al., 2010; Johnston, 2004).

III.B. Customer loyalty and centricity in healthcare

Healthcare is one of the largest service industries and still for the most part supply driven (inc., 2014). For healthcare, customer or patient- centricity is still a fairly new and unknown concept. Consequently, data on patient centricity is scarce and focusses on the interaction between physician and patient and the clinical decision making process. Furthermore, in literature, adding value for the patient is focused on the healthcare-professional’s perspective and therefore on the technical aspects of the service (Makarem & Al-Amin, 2014). Porter describes that the main goal of providing healthcare should be to achieve the highest value for the patients, centred around the patient. He states however that value solely depends on results and that in healthcare, this is measured by the outcomes achieved and not the quality of services delivered (Porter, 2010).

With the Dutch healthcare system being one of the most agile (and legislated) in the world, top quality healthcare is being delivered throughout the country with relatively low variability in the technical aspect of care between hospitals. Thus, the technical side of healthcare may not be the most promising factor to distinguish oneself from competitors. Also, from a patient perspective, it is difficult to judge this particular aspect of healthcare due to the lack of knowledge about this aspect (Berry & Bendapudi, 2007).

III.C. The decision making process

The decision making process is a complex set of actions. Every decision is

influenced by intuitive and conscious processes. No decision is completely rational (Slovic, Finucane, Peters, & MacGregor, 2007). Damasio stated in 1994 that

‘rationality is not only a product of the analytical mind, but of the experimental mind as well’ (Damasio, 1994). For product design, three different levels of cognitive and emotional processing are thought to be of importance: visceral, behavioural and reflective (Norman & Ortony, 2003). Visceral processing is an immediate reaction to the product or service. It helps to make a fast assessment of a certain situation and is intuitive by nature. Behavioural processing manages the everyday and simple

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Empirical research on the decision making process is still scarce and is not often a topic of academic research. Research on the decision making process is part of user experience research and originates from the human-computer interaction design research. The user-centred analysis was mainly cognitive- or task oriented and focused mainly on usability testing. Later on, it became apparent that other (non-task related) factors are also important for a good user experience, such as

aesthetics, surprise, intimacy and the ability to fit behavioural goals. This concept was called emotional usability and linked products with needs and values

(Hassenzahl & Tractinsky, 2006). Research in the field of tourism and hospitality increasingly focusses on experiential marketing. In experiential marketing it is

recognised that cognitive as well as affective components determine the preferences of tourists for certain destinations (Kim & Perdue, 2013; Lin, Morais, Kerstetter, & Hou, 2007).

Other recent research further stresses the importance of emotions and affects and focuses more on subjects such as the decision making process or subjective well-being (Slovic et al., 2007). The user experience perspective assumes that experiences are unique interactions between aspects of the product or service

(form), the internal state (expectations, needs, motivations, mood) of the user and the context (Hassenzahl & Tractinsky, 2006). This conclusion is in line with the

interactionist-perspective model of Stewart and Punj. The interactionist perspective model states that, in customer decision making, you have to take into account the task (context), the individual and the interaction between the two (Slovic et al., 2007). In clear and structured situations, task effects prevail whereas individual differences are important in unclear and unstructured situations (Stewart & Punj, 1983). Feelings are becoming predominantly important when the customer experiences emotions, there is time pressure, reduced cognitive resources, when a decision is complex and is involving uncertain trade-offs (Avnet, Tuan Pham, & Stephen, 2012).

III.D. Decision making in healthcare

When applying the theories of cognitive and emotional behaviour as stated above, the hospital is an environment that is highly emotional, unfamiliar and frightening for the customer. Decisions often have to be made without profound knowledge, under time pressure and sometimes with uncertain trade-offs. Therefore, it would be logical

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if decisions are for a large part made based on feelings and emotions, by visceral and behavioural processing.

Another factor that has to be taken into account is the willingness and

capability of patients to make adequate decisions. Patients are increasingly expected to be autonomous, active and well informed customers. According to the

government, their conscious choices would ultimately lead to increased competition between healthcare providers and consequently higher standards of quality and efficiency. Therefore, policy makers stimulate the development of different sets of tools to ‘help’ the patients in their decision processes, such as hospital rankings and other quality indicators. However, it is largely unknown how capable and willing patients actual are to make these choices for themselves and how they make their decision. Available literature shows that patients still are passive customers and make their choice unconsciously (Harris, 2003). Different studies show that patient experience is the predominant factor for patients to choose for a certain hospital (Leister & Stausberg, 2007).

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15 Chapter IV. Frameworks and methods

IV.A. Frameworks

In this section, a number of frameworks are proposed which are derived from the literature review and are considered to be a profound basis for following research.

a. Goal-directed design research process framework

For the qualitative data collection, the framework of goal-directed design research process developed by Cooper et al. is used (Cooper, Reimann, Cronin, & Noessel, 2014). The goal-directed design research process is a frequently used framework in literature with respect to qualitative research in interaction design. The model

provides a clear structure and takes into account all the established decision making factors (mental models, tasks, context, product) as found in the literature review. In this way, this model currently is the only research technique available that provides information about the product in general and information at functional or detail-level. As explained in the literature review, interaction design finds its roots in human-computer interaction design. As such, this approach is mainly used in research on products rather than on services, which is the main focus of this research project. However, since the underlying research questions are the same (how and why) this method is considered applicable for this thesis. The goal-directed design research process comprises of six elements (Cooper et al., 2014):

• Kick-off meeting • Literature review • Competitive audits • Stakeholder interviews

• Subject matter expert interviews • User and customer interviews

Kick-off meeting.

A kick-off meeting is not strictly part of the research process. However, it is important for all professional participants to contemplate and discuss key questions in order to establish a clear focus for the project. This discussion could also provide clues about how to structure the interviews.

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Literature review.

For the literature review, scientific research on the subjects of customer centricity and the customer decision process was included. Where available, literature on these subjects specifically concerning healthcare (patient centricity and the decision making process of patients) was also included. Furthermore, internal documents on marketing strategy, patient satisfaction, complaints and other patient centricity

projects were analysed. Also, social media websites and news items were included.

Competitive audits.

The hospitals Maastricht University Medical Centre and the Laurentius Roermond were evaluated, based on online information and personal experiences of the project team.

Stakeholder interviews.

The project was started on behalf of the board of directors of the Zuyderland hospital. The Chief Financial Officer (CFO) and the alliance director of the Zuyderland were actively involved in the project and participated frequently in the project meetings. As such, insight was gained regarding their view on the product, budget and schedule, technical constraints, business drivers and their opinion of the patients.

Subject matter expert interviews.

SME interviews were not considered relevant because the content of the subject was not considered highly technical, complex or legal. Also, the aim is not to investigate the use of a product but to gain insight in which patients choose the Zuyderland and why and to evaluate their decision making process.

Customer Interviews.

For the interviews, employees of the Zuyderland were trained on how to perform the interviews to guarantee a standardized acquisition. The interview questions were partly based on existing literature to assure standardization. Interviews lasted

approximately 45 to 75 minutes. Interviews were performed in the hospital as well as on the street of nearby villages. The street interviews were generally shorter than the interviews performed in the hospital for the sake of practicality and took

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b. Thematic analysis framework

For the analysis of the qualitative data, the framework described by Braun and Clarke was adopted (Braun & Clarke, 2006). Thematic analysis is a widely used and

accepted analytic method for analysing qualitative data. With thematic analysis it is possible to identify, examine and record themes, patterns and relationships within data that are thought to be important for the investigation.

For thematic analysis, a number of considerations have to be taken into account. Themes can be identified in two ways: bottom up (inductive) or top down (deductive) (Braun & Clarke, 2006; Hayes, 1997). In the bottom up approach, the identified themes have a strong relationship with the original data. The data does not have to fit a pre-developed framework nor is the data analysis hindered by

assumptions of the researcher. In the top down approach, data analysis is influenced by the assumptions and expertise of the researcher. Therefore, overall data

description is less rich and focus is more on one or more parts of the data (Braun & Clarke, 2006).

Another consideration is the level of identification of the themes. Braun and Clarke (2006) mention the explicit level or interpretative level approach. The explicit level approach does not search for meanings behind the words. Data are clustered to present patterns of semantic data, which are then related to previous literature to put these patterns into perspective. The interpretative level approach searches for the meaning behind the words to identify underlying insinuations, concepts and ideas. A last consideration Braun and Clarke mention in their research is the division into realist and constructionist analysis. In the realist analysis method, analysing

experience, thoughts and motivations is straightforward because of the assumption that there is a simple relationship between language and experience. The

constructionist analysis method presumes that experiences are linked with social behaviour rather than with individual behaviour and therefore aims to evaluate the social context of the individual. For this study, the bottom-up, explicit level approach and realist analysis was applied.

The process of thematic analysis comprises of six phases. The first phase is to become familiar with the dataset. For this phase, since the amount of data was

extensive, the data was first transcribed, formatted and cleared. After this, the data was scanned several times to get a thorough feeling and understanding of the content of the interviews. The second phase of the thematic analysis is to generate

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initial codes. For this, important text elements were labelled to reduce and organise the amount of information. The third phase involves searching for themes. The codes were divided into possible themes and sub-themes. In the fourth phase, the

suggested themes were refined based on internal homogeneity and external heterogeneity (Braun & Clarke, 2006; Patton, 1990). Themes were evaluated on possible patterns and then related to the total dataset. The dataset was reread to determine if the themes make sense and to check whether data was missed during the process. In phase five the final refinements were made and themes were defined and named. The last phase comprises of the writing of the report.

c. Creation of personas

Personas have proven to be successful in many different organizations. In business organizations, the concept of personas is widely adapted. Microsoft’s chief

experience architect in the customer and partner experience, Sasha Frljanic, describes at the Microsoft blog: ‘Web design, how you nurture your clients, your go-to-market strategies- all of these can be based on personas, with happier customers and a much greater chance of success for you’ (Tomlinson, 2016). But also, in

healthcare, best practice cases with respect to personas exist. The Mayo clinic has a very successful Mayo Clinic Persona Project Team focusing on employee personas (awards, 2014). The National Cancer Institute (NCI) successfully created personas in order to better serve their Spanish-speaking population (Wichman, 2015).

The data of the qualitative and quantitative research were used to develop a clear subset of patients. For this, a modified version of Coopers’ framework of the persona creation process was used (Cooper et al., 2014). A model is often used to understand and conceptualize the customer, the relationship between them, the hospital and their social and physical environment. There are different kinds of

models, including user roles, profiles, market segments and personas. Although user roles, market segments and profiles also try to describe the relationship between user and product. They are thought to be inferior to the use of personas. Personas are based on in-context research, convey broader human motivations and focusses not only on the task or demographics and purchasing behaviour but also on the individual, his/her user behaviour and goals.

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a. Group interview subjects by role b. Identify behavioural variables

c. Map interview subjects to behavioural variables d. Identify significant behaviour patterns

e. Synthesise characteristics and define goals f. Check for redundancy and completeness g. Designate persona types

h. Expand description of attributes and behaviour

Participants were identified as either patient or non-patient of the Zuyderland.

Behavioural variables and patterns were established through the thematic analysis of the qualitative data. The interactionist-perspective model as discussed in the

literature review was also used as a framework to adequately address both task and individual factors that are important for the decision making process. First results were then validated by the quantitative data. After establishing behavioural patterns, additional details were investigated, such as demographics, emotions, motivations and relevant factors for interaction with these participants. Personas were checked for completeness. Since the objective was to create primary and secondary

personas, the designation of persona types is not applicable. The expansion of the description is preliminary, since the goal of this thesis is to create preliminary personas which can be expended further by the different departments.

IV.B. Methods

a. Overview of methods

The research in this thesis consist of four main parts (figure 2). The first part comprises of an extensive literature review in order to establish a theoretical basis and to determine which frameworks and methods are best applicable for this research. For the literature review we kindly refer to chapter III of this thesis.

Secondly, data is collected by means of qualitative research. This method is chosen because it best answers the how and why behind certain choices and behaviours (Ritchie & Lewis, 2003). For the qualitative research, the goal-directed design research approach is chosen as a framework as described above. The data is then analysed through thematic analysis to determine important themes with regard to the decision making process. Subsequently, to support the data from the qualitative

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research, quantitative research was performed on data gathered by means of an electronic survey. Finally, the information of the qualitative and quantitative research is used to create personas.

Figure 2. Overview of methods

b. Qualitative research: Field research and hospital interviews

The qualitative research was done according to the goal-directed design research process framework described in detail above. The sixth step of this process comprised of interviews with users of customers. In this section we further explain how the interviews were performed.

The interviews started with an introduction, followed by a section on characteristics and demographics of the interviewed person. The next section

Literature review

•Customer centricity and loyalty

•Customer's perspective and decision making

Qualitative research

•Goal-directed design research process •Kick-off meeting

•Literature review •Competitive audits •Stakeholder interviews

•Subject matter expert interviews •User and customer interviews •Thematic analysis

Quantitative research

•Data collection by means of electronic survey

Persona creation

•Clustering of data •Persona creation process

•Group interview subjects by role •Identify behavioural variables

•Map interview subjects to behavioral variables •Identify significant behaviour patterns

•Synthesise characteristics and define goals •Check for redundancy and completeness •Designate persona types

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contained questions on which factors were important for the decision making

process. In the third section, questions about hospital experiences gave insight in the development of the relationship between the interviewee and the hospital as well as how this person makes his/her choices. Finally, questions about the perception of the Zuyderland gave insight in how people perceive the hospital and her environment. Permission for audio-recording was obtained so that interviewers could engage with the participants and the interviews could be thoroughly analysed in a later phase. Participants were selected based on purposive sampling in order to get a

representative population. We aimed to interview (future) patients of the Zuyderland and participants who do not go to the Zuyderland. Participants were recruited in the hospital and in the municipalities surrounding the hospital. In the hospital, patients of the emergency department, wards and clinic were asked to participate in order to obtain a diverse set of patients. The cities surrounding the hospital were part of the service area of the hospital as well as a number of cities that were not. Also, due to the location of the hospital and because we know that a significant number of Dutch inhabitants visit foreign hospitals, interviews were also performed in Belgium. The service area of the Zuyderland comprises of the ‘Oostelijke and Westelijke

Mijnstreek’ and lies between the Belgian border in the West and the German border in the East, the town Echt-Susteren in the North and the region East-South Limburg in the south. It comprises the following municipalities: Heerlen, Kerkrade, Landgraaf, Brunssum, Nuth, Voerendaal, Simpelveld, Onderbanken, Beek, Schinnen, Stein, Sittard and Geleen. Interviews were performed in Stein, Elsloo, Echt, Valkenburg, Heerlen, Maastricht, Meerssen, Sittard and Hasselt (Belgium).

c. Quantitative research: survey

To support the data from the qualitative research, quantitative research was conducted by means of an electronic survey. A questionnaire was sent out to inhabitants of Limburg by © Flycatcher Internet Research B.V. Closing date of the questionnaire was the 21st of September 2016 and on the 19th of September panel members were sent a reminder. Flycatcher is ISO 26362 certified for their access panels and has access to a panel of more than 10,000 people of 12 years and older who voluntarily agreed to participate in research. Selected panel members were contacted by email with a personal link. The following rules applied in order to minimize the possibility to skip questions or give impossible answers: all questions

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had to be answered in order to send in the questionnaire, altering the answer was possible, questions that were not applicable were automatically skipped, minimum and maximum values were determined and the reproduction was variable. The questionnaire was pre-tested with regard to content and technical aspects.

IV.C. Statistical analysis

The statistical analysis was performed with IBM Statistical Products and Service Solutions (SPSS) Statistics 23. Were applicable, data was presented as absolute numbers and percentages. Continuous variables were given as means +/- standard error (SE) Spearman correlation coefficient was determined to assess correlations between outcome parameters.

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23 Chapter V. Results

V.A. Kick-off meeting

The kick-off meeting of the project was in Maastricht on June 24th. During this meeting several issues were discussed: the burning platform, which patients will come to Zuyderland and which do not, needs of our patients, biggest challenges and our biggest competitors. This provided clues for how to structure the literature review and interviews.

V.B. Literature review

According to the goal-directed design research process, after the kick off meeting, the second step was to perform a thorough literature review. However, in order to gain a thorough understanding of the topic as well as to determine which frameworks were suited for this research, the literature review was performed first. For the

literature review we therefore kindly refer to chapter III of this thesis.

V.C. Competitive audits

For the competitive audits, an informal investigation was performed on the website, customer satisfaction data and location for the Dutch largest competitors with geographical overlapping service areas. In this way, strengths and limitations of the services offered by the competitors were determined.

Maastricht University Medical Centre

Maastricht UMC received a 7.0 on ‘www.zorgkaartnederland.nl’. 43% of patients recommended this hospital. The website looked nice and was user friendly with up to date information regarding changed traffic situations. Also, news on latest research activities and even healthy recipes were given. Basic information with respect to diseases and certain treatments was missing.

The signposting of the hospital was suboptimal. It was difficult to find the main entrance of the hospital. The route from the parking to the entrance was easy to find due to clear explanation boards. Orientation signs, however, presented an overload of information which made it difficult to find the way to the department. Service at the reception desk was friendly and fast and helped to find the department.

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The atmosphere of the hospital was good. There was a lot of natural light and the central hall offers many facilities and shops. There were golf caddies for the elderly and disabled. The waiting rooms looked spacious and friendly with enough privacy and plants. The reception ladies were friendly and had a nice interaction with the doctors. There was a feedback-terminal present.

Laurentius Hospital Roermond

The Laurentius Hospital received an 8.2 on ‘www.zorgkaartnederland.nl’. 92% of patients recommended this hospital. The website looked nice and was user friendly with up-to-date reports on changed routes but also general news items. Information about diseases and treatments was found easily.

Finding the route to the hospital was easy. At the train station, directions to the hospital were clearly given and it was only a 10-minute walk. The entrance was very small and not nice. The receptionist was not hospitable and rather impersonal. The signposting was very clear and finding the way was easy.

The atmosphere felt rather clinical and hospital-like. Overall experience was not negative but also not welcoming. It felt like a standard hospital and not like a place of excellence or top-clinical treatments.

V.D. Key characteristics of participants and their opinion about the Zuyderland a. Key characteristics of the total research population

In table I and II, the baseline characteristics of the investigated populations are presented.

Table I. Baseline characteristics of interviewed populations

Interviews Questionnaire

Hospital Extern

Number (percentage) Number

(percentage) Number (percentage) Sex Male 15 (53.6) 28 (36.4) 473 (49.8) Female 12 (42.9) 48 (62.3) 477 (50.2) Age in years < 30 4 (14.3) 22 (28.6) 161 (16.9) 30-39 8 (10.4) 124 (13.0) 40-54 5 (17.9) 12 (15.6) 201 (21.1) 55-65 12 (42.9) 21 (27.3) 240 (25.3) > 65 6 (21.4) 13 (16.9) 224 (23.6)

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Secondary school 4 (14.3) 20 (26.0) 289 (30.5) Intermediate Vocational Education (MBO) 7 (25.0) 18 (23.4) 195 (20.5) Higher Professional Education (HBO) 6 (21.4) 15 (19.5) 249 (26.2)

University and higher 2 (7.1) 10 (13.0) 203 (21.4)

Table II. Service area

Interviews Extern Questionnaire

Number (percentage) Number (percentage)

Inside service area 40 (47.4) 427 (44.9)

Outside service area 36 (52.6) 523 (55.1)

The overall mean age of the participants was 50.5 years (+/- SE 0.54). Outside the service area, participants younger than 30 years were overrepresented. These younger participants mainly lived in Maastricht and were most likely students (figure 3). Also, for similar reasons participants having followed secondary school were overrepresented (figure 4).

Figure 3. Age with respect to service area

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b. Qualitative analysis: Field research and hospital interviews

In total, 76 street interviews were performed. The general opinion of the Zuyderland in the service area was fairly positive. The merger of both hospitals was not well understood and especially the inhabitants of Sittard and Heerlen seemed to be very loyal to their nearest hospital location and were most reluctant to travel to the other location when necessary. Main complaints included suboptimal contact and service and lack of transparency about procedures for the Sittard location. The main

complaint about Heerlen was that people did not feel understood by their doctor and felt that medical staff did not have enough time to explain clearly.

In total, 27 hospital interviews were performed at the outpatient and inpatient clinic (internal medicine, oncology, geriatrics) as well as the intensive care. On a scale from zero to ten, patients scored the Zuyderland a 7.7 (SE +/- 0.41) and a Net Promotor Score of 7.8 (SE +/- 0.44). Positive and negative experiences could be divided into three themes: communication, the care-process and facilities (table III). Communication, attention and approach were perceived as both a positive and negative experience. The fact that patients were seen by many different physicians and a lack of a clear contact person were the main negative points, as well as long waiting times and the fact that investigations were not coordinated so that patients had to visit the hospital several times. The merger had a negative influence on patient experience because patients had to travel further to undergo certain

treatments. The new hospital building of Sittard was often perceived as to impressive and a waste of money.

Table III. Experiences of inpatients

Positive experiences Negative experiences Overall Theme

Treatment Communication Communication

Attention Make own treatment plan

Not treated as a number Patient in charge

Personal approach Impersonal approach

Comforting Lack of interest

No explanation Blind spots

Bad communication between physicians

Transfer between departments Different physicians Care process

Lack of clear contact person Long waiting times

Investigations not coordinated Medication not in stock

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Close by Two locations Facility

Becoming out of date Too impressive Cost too much money Bad hygiene

Not well reachable by phone

c. Quantitative analysis: Survey

On 15 September 2016, a questionnaire was sent out to 1,635 inhabitants of Limburg. Of the 1,635 questionnaires sent, three were discarded due to error messages (incorrect email address, full mailbox). Ultimately, of the 1,632 questionnaires sent, 950 questionnaires were returned and considered

representative (58% response rate). Data was reported in an SPSS-data file.

On a scale from zero to ten, participants within the service area of Zuyderland scored Heerlen a mean of 6.80 (SE +/- 0.09), whereas participants outside the service area scored Heerlen a mean of 6.66 (SE +/- 0.12). The Sittard location received a mean score of 7.32 (SE +/- 0.06) from participants inside the service area and a mean of 7.05 (SE +/- 0.1) from participants outside the service area.

Overall, participants did not feel great loyalty for the hospital (40% did not feel loyal, 24% were indifferent and 37% felt loyal to a certain extent) (figure 5). Also 48% of participants reported no real connection to the Zuyderland, 21% was indifferent and 31% felt a certain connection (figure 5).

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The majority of participants considered the Zuyderland as reasonable honest, sincere and reliable. Also, with respect to dedication, friendliness, compassion, hospitality and sensibility the hospital scored positively. For aspects as prestige, top-clinical function and reputation, scores tended to focus more around indifferent. Remarkably, overall, Heerlen scored lower than Sittard. Answers of participants within and outside the service area did not differ significantly (appendix II).

V.E. The key elements of the patient’s hospital selection process

a. Qualitative analysis: Field research and hospital interviews

Based on thematic analysis as explained above, we were able to develop a data structure consisting of initial codes, candidate themes and final themes.

The initial codes consisted of semantic content that appeared to have some similarities and were organised into coherent groups. After this, codes were combined to form first order themes, which represent a more abstract and

overarching level of data representation. The last step was to review and refine the candidate themes to form the final themes (figure 6 and 7).

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Figure 7. Decision making process: hospital patients.

Analysing the interviews with respect to how and why people choose a hospital, a number of factors arose.

The level of involvement: active versus passive

The first factor was the level of involvement in the decision making when in need of healthcare. When having an emergency, participants did not feel to have a choice. Another group of participants were very active in searching for the best care

themselves and were confident in making the right decision by themselves. This group consisted of more individualistic people while the more collective participants found opinions of others important to make a decision. Another group was referred by their general practitioner without an active conversation about which hospital to go to. Lastly, one group did not seem to have an opinion about the matter or did not feel the need to think over which hospital they should go to.

Two indicative quotes:

‘The hospital admission was an emergency, there was no time to think about an admission to another hospital. I would have preferred Maastricht. In the end, I was glad to be in Heerlen because the travel distance is shorter for my husband, who is disabled’.

‘Healthcare is the same everywhere, so it does not matter whether I go to Roermond or Sittard’.

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Cognitive versus affective attributes

When making an active choice, there were attributes that participants found important when choosing a hospital. The first group based their opinion mainly on

cognitive attributes. Distance, location, reachability were very important reasons for

considering a hospital. Other considerations were, for example the waiting list, internet, whether it is an academic hospital or not, being employed by the hospital, the ability for family to come and visit easily.

‘I was able to get an appointment on short notice. My general practitioner arranged this for me’.

‘I work at the hospital so for me it is easy to visit this hospital. This way, I am able to go to the appointment when I am at work’.

The second group of participants who actively chose seemed to value more affective attributes. These participants reported factors such as trust, good service, expertise, previous experience, human approach, good feeling, atmosphere and a human approach.

‘In Sittard there is too much space and the space is used inadequately. The hospital is too clinical, fake and over the top. The merger means centralization and therefore becomes less personal and there is less attention for the customer. It is based on pursuit of profit and efficiency. The hospital sells ice-cream. This is wrong, they should sell healthy food only’.

‘My choice depends on the physician, trust and personal experience’.

b. Quantitative analysis: survey

The level of involvement: active versus passive

A number of questions regarding the involvement in decision making were asked. With regard to the question whether the participant would consider another hospital when in need of healthcare, about half of participants (53.9%) did not (table IV). 64.4% did not consider foreign hospitals such as hospitals in Belgium or Germany a viable option.

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Table IV. Level of involvement in the decision making

Questions Answers expressed as a percentage

Never (2,3) Neutral (4) Always (5,6)

Consideration of alternative hospital 53.9 18.8 27.3

Consideration of foreign hospital 64.4 11.5 24.1

Highly active (2,3) Neutral (4) Inactive (5,6)

Involvement in the decision 61.7 19.4 18.9

Totally disagree (2,3)

Neutral (4) Totally agree

(5,6)

Don’t know

Make adequate decisions without help 13.9 14.3 69.7 2.1

Involvement of others in choosing a hospital 32.4 14.2 50.5 2.8

I don’t find it difficult to let others decide 37.1 17.1 44.2 1.6

Choosing the right care is interesting 26.2 14.8 55.3 3.7

I decide in consultation with my physician 10.0 13.3 71.6 5.1

The GP knows best which hospital to choose 13.2 13.8 68.8 4.0

The GP knows what is important to me 13.4 12.4 64.2 10.0

The GP always gives me multiple options 39.9 11.7 23.0 25.4

I never ask the GP about alternatives 36.7 12.6 37.6 13.1

Every hospital is adequately equipped to help me

19.9 14.0 59.5 6.6

I don’t have confidence in the Dutch healthcare system

52.8 16.2 29.8 1.2

GP= general practitioner

61.7% of participants said to be active in making a healthcare decision. Also, 69.7% of participants felt that they could make an adequate decision without help. 71.6% made a decision in consultation with his/her physician. Regarding the question whether the participant found it difficult to let others decide which care he/she should receive, answers were mixed, 37.1% indicated to have no problem with this versus 44.2% who did find this difficult. Only 55.3% of participants thought making choices regarding healthcare is interesting (table IV).

The GP played a crucial role in the decision making process. The majority of participants thought that the GP knows what is important for them (64.2%). Also, participants thought that the GP knows best which hospital to select (68.8%). Less unanimous were the opinions regarding the presentation of multiple options by the GP (39.9% responded that this did not occur, 23.0% responded that it did) and whether they actively asked the GP about alternatives (36.7% always asked for

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alternatives, 25.7% sometimes asked for alternatives and 37.6% never asked for alternatives).

Interestingly, the majority of interviewees thought that every hospital was able to meet their healthcare demand (59.5%). Only a small majority (52.8%) had faith in the Dutch healthcare system. There were no significant correlations between these items and gender, age, education or service area (correlation coefficients below 0.4).

Cognitive versus affective attributes

A number of context- associated factors associated with the hospital itself could be important when choosing for a hospital. These task factors could be related to cognitive attributes and affective attributes. Most important factors were available expertise (87.3% of participants found this most influential), quality of care (87.2% of participants found this most influential) and friendliness of staff (79.7% of participants reported this as most influential), followed by transparency, travel distance and

quality of the facilities. Less important were language (21.2% of participants reported this as most influential) and website (22.5% of participants reported this as most influential) (table V).

Quality of care was labelled as evaluation at affective level because patients generally judge quality of care based on experienced quality rather than on hard end points. Interestingly, experiences of acquaintances and strangers were not

considered very important (55.5% and 21.8% respectively reported this to be of influence). Also, familiarity with the hospital did not seem a major influential factor (65.4%). Reputation of the physician and reputation of the hospital were fairly important (78.7% and 79.6% respectively).

Table V. External factors associated with the hospital

Factors Answers expressed as a percentage Cognitive versus

affective factors

No influence Neutral Significant influence Cognitive Affective

Travel distance 22.0 11.0 67.0 Quality of facilities 12.7 20.4 66.9 Website hospital 56.3 21.3 22.4 Friendliness of staff 6.7 13.6 79.7 Language (dialect) 55.1 23.7 21.2 Quality of care 4.3 8.5 87.2 Available expertise 2.5 10.2 87.3

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Transparency 6.8 16.1 77.1

Experiences acquaintances 24.0 20.4 55.5

Experiences strangers (online)

54.5 23.7 21.8

Familiarity with the hospital 17.5 17.2 65.4

Positive experience with this hospital

6.6 10.1 83.3

Reputation physician 7.3 14.0 78.7

Reputation of the hospital 6.0 14.5 79.6

With respect to service, overall percentage scores were lower. These service factors were more cognitive by nature. Perceived as important by participants was support by personnel (85.9%) and privacy in their rooms (80.0%). Less important were quality of the food (68.1%), visiting hours (62.8%), parking (61.2%), extra’s (56.0%) and spacious rooms (53.2%) (table VI).

Table VI. External factors associated with service of the hospital

affective factors Service

Not important Neutral Very important Cognitive Affective

Spacious rooms 24.6 22.2 53.2

Privacy in rooms 8.7 11.3 80.0

Visiting hours 17.7 19.5 62.8

Parking (availability and costs)

20.5 18.3 61.2

Support by personnel 3.7 10.4 85.9

Quality of the food 14.0 17.9 68.1

Extra’s (Wi-Fi, television, multimedia)

20.3 23.7 56.0

Communication was another context factor associated with patient satisfaction. Overall, these questions had high percentage scores and were partly cognitive and partly affective. Except for the amount (87.8%) and readability (88.8%), all items scored above 90.0% (table VII).

Table VII. External factors associated with communication of the hospital

affective factors Communication

Not important Neutral Very important Cognitive Affective

Friendliness of staff 2.5 7.2 90.3

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Readability of information 3.1 8.1 88.8

Amount of information and communication

3.7 8.5 87.8

Understanding personnel personal situation

2.8 6.7 90.5

Time to reassure the patient 3.3 6.2 90.5

Efficiency in receiving information and communication

2.4 5.8 91.8

No significant correlation was found between these factors and age, education, gender or service area (spearman correlation coefficient below -r- <0.262).

With regard to health status most participants thought of themselves as being fairly transparent and conscious about their health (72.7% and 79.7%). A small majority indicated being too busy to think about their health status all the time (55.2%) (table VIII).

Table VIII. Questions associated with individual context, health status

Questions Answers expressed as a percentage

Does not reflect me Neutral Does reflect me

I am transparent about my health 14.2 13.1 72.7

I am very conscious about my health 6.7 13.6 79.7

I am too busy to think of my health on a daily basis 55.2 22.4 22.4

I am athletic 48.0 19.5 32.5

I don’t take risks when health concerns 26.5 25.4 48.1

I like healthy food 19.7 24.4 55.9

Most of the participants perceived themselves as confident decision makers (59.9%). They preferably made decisions themselves and were not comfortable in letting others make decisions for them (table IX).

Table IX. Questions associated with individual context, decision making

Questions Answers expressed as a percentage

Does not reflect me

Neutral Does reflect

me

I am a confident decision maker 17.8 22.3 59.9

Does not apply Apply

sometimes

Apply often

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I try to have clear goals before I make a decision

1.6 31.8 66.6

I’ll try to investigate all pros and cons of the alternatives

6.8 38.6 54.5

I leave decisions preferably to others 66.2 30.7 3.1

I often postpone decisions 34.5 56.0 9.5

When I have to make a difficult decision, I am often pessimistic in finding a good solution

42.5 45.4 12.1

There was a moderate correlation between transparency about health status and consciousness (r =0.551, p <0.05) and interest in healthy food and avoiding risks (r =0.521, p <0.05). No correlation was found with demographic characteristics.

c. The clustering of patients

Based on the results of the qualitative research, two main themes were developed, namely active versus passive decision making and the importance of cognitive versus affective attributes in decision making. To support these themes, key survey questions from the quantitative dataset were selected. Next, all participants were clustered according to their responses. The cluster-analysis resulted in four clusters with almost equal sizes that differed significantly in variables that were selected (table X).

Table X. Clustering of participants

Number of participants (percentage)

Passive Active

Cognitive 237 (25.0) 206 (21.7)

Affective 294 (30.9) 213 (22.4)

The active patient

With respect to healthcare, the active patient thought that the quality of care is the same in every hospital. He/she reported to be capable of choosing the right care themselves. They did not actively ask the GP for alternative options. Quality of life for them was to be healthy. They loved healthy food. Personal development was less important. The active-affective patient was very transparent about his/her health status and was a confident decision maker. The active-cognitive patient took fewer risks with regard to his/her health. The active-cognitive patient was very loyal to the Zuyderland and felt very connected in contrast to the active-affective patient who felt

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the least loyal and connected. The active-cognitive patient thought that the

Zuyderland was trustworthy the most, in contrast to the active-affective patient. Also, the active-affective patient was less convinced the Zuyderland was compassionate and caring. Services of the hospital that were considered to be important by the active patient included facilities, spacious rooms, privacy and visiting hours. Also, friendliness of staff, assurance and understanding by hospital staff was thought to be important, especially for the active-affective patient. Previous experiences and

transparency were especially important for the active-cognitive patient.

The passive patient

The passive patient was not interested in finding out how to receive the best healthcare, in contrast to the active patient. He/she searched less for additional information and was a less confident decision maker. They asked the GP for their opinion and alternative options, but interestingly, they did not take opinions of family, friends and others into account. Personal development was important for the

passive-cognitive patient. They were least transparent about their health status. They were willing to accept a larger risk with regard to their health status, compared to the active (cognitive) patients. They were not particularly interested in healthy food. The passive-cognitive patient found familiarity with the hospital important. They did not let bad experiences in other hospitals influence their choice for a hospital. The passive patient, and especially the passive-affective patient tended to be less extreme in his/her statements compared to the others (figure 8).

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Figure 8. Characteristics according to cluster

d. Personas

The active-cognitive patient

Dave Ubaghs is 35 years old and currently working as a salesman. His cognitive way of approaching problems helps him in his work. He aims to live a healthy lifestyle and likes to play soccer every Saturday. He is keen on cooking healthy for himself and his family. He finds his health very important and therefore is not prepared to take any risks. Dave is open to suggestions of his family with regard to healthcare and feels pretty confident in choosing the right care for himself. Last month, he visited the hospital after injuring his knee with soccer. The doctor was very open and honest, which he appreciated very much. He would go to this doctor again when necessary and recommend her to others.

The active-affective patient

Saar Limbeek is 60 years old and has 30 years of experience as a nurse. She values a healthy lifestyle but does not particularly want to put much effort in this.

She finds her health important and openly discusses her health issues. Saar is convinced that she can make the right decisions when it comes to her health and choosing a hospital. When visiting the hospital, she is always very glad to see a friendly face. Mainly when she is anxious, this is comforting.

She is a bit sceptical about hospitals in general and sometimes feels that they do not care enough. This is why she visits different hospitals when previous experiences have not been positive.

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The passive-cognitive patient

Sieb van Rij is 66 years old and is enjoying his retirement. After retiring he is an enthusiastic member of the local orchestra, playing the saxophone and participates in the carnival club. He enjoys his cigar and nice evenings with rich food and good company. His health is not his primary concern and he does not talk much about it. When in need of healthcare Sieb will visit his local hospital. He has no particular wishes with regard to services, as long as his needs are met it is ok.

The passive-affective patient

Bregje Lammerts is 25 years old and is currently working as a hairdresser. After work, she likes to go out with friends. She does not like to go to the doctor but thankfully she has not been in touch with healthcare often. When having a health problem, she will first try to fix the problem herself by taking pain killers. Bregje does not really have an opinion about her general practitioner, hospital or healthcare in general.

The patient of the future : what does the Zuyderland Medical Centre need to understand about its patients in order to serve them in an optimal way?