Infected with Huntington’s Disease
Evaluation of the introduction of the Huntington polyclinic at
Zorggroep Noorderbreedte.
Master thesis, MscBA, specialisation Change Management
University of Groningen, Faculty of Economics and
Business
October 2011
by
Fokke Cornelis (Nico) Zijnstra
Abstract
Change in Dutch healthcare industry is most often driven by incidents. This is however not always the case. There are specialities in Dutch healthcare organisa-tions, which can be a role model for other European countries. One of those po-tential role models is the polyclinic for Huntington’s Disease of a regional healthcare organisation in the Netherlands. The implementation of such a poly-clinic function within an existing healthcare organisation is subject of this qualita-tive research in order to identify decisive factors for implementation. Source credibility and clinical leadership combined with formal leadership have been found crucial for success. This study aims to provide greater insight for praction-ers in the healthcare industry to perform the change management process more adequately. Finally, a six stage roadmap for managing intrapreneurial innovation in healthcare settings is proposed.
Key words: Change management, innovation, healthcare, implementation, and
clinical leadership.
Preface
Heraclitus of Ephesus once said: “Πάντα ῥεῖ καὶ οὐδὲν µένει”. Nothing stands
still, everything flows. This was actually the very reason to start studying Change Management at the University of Groningen. In two internships during my bache-lor programme, I have had the opportunity to watch change practioners at work and I realised that if I wanted to have a job like that, change management would most likely be the best background.
One of the greatest lessons that I’ve learned in the past years is to never stop questioning. According to Einstein “curiosity has its own reason for existence.” University has been a valuable addition to my educational life. Where I was used to put theories into practice from my bachelor programme at Noordelijke Ho-geschool Leeuwarden, I learned to take theories not automatically for granted. Finishing this thesis has been a laborious task. A fulltime consultancy job and thesis writing at the same time has been an unlucky combination. It has been a continuous consideration who not to dissapoint, which resulted in choices that did not contribute to a quick finish of this thesis. Finally, however, this moment has come.
I have to thank my supervisor of the University of Groningen dr. Cees Reezigt for giving me a final opportunity to get things on track. From late February this year until now I had to prove that finishing this thesis was really going to succeed. And it has! Thanks to respondents that cleared their agendas for the interviews, thanks the numerous attempts of family and friends asking how things evolved, but foremost thanks to my love Anna-Petra. She must have had various nervous breakdowns since I started this whole process in 2009. Her encouragements, positive feedback and aboveall her presence have enabled me to finish this thesis the way I did.
Nico Zijnstra
Content
Abstract ...2
Content...4
Anne de Graaf & Klaas Kunst (2008)1. Introduction...5
1. Introduction...6
2. Theoretical framework...10
2.1 Change management...10
2.2 Targets of change ...12
2.3 Relevant factors...17
3. Methods ...23
3.1 Data collection...23
3.2 Instrument...24
3.3 Data analysis...26
4. Results...27
4.1 The multidisciplinary concept...27
4.2 Actual implementation ...28
4.3 Communication...30
4.4 Leadership ...32
4.5 Pride ...33
4.6 Quality targets...34
4.7 Reflecting on the implementation ...35
5. Discussion and conclusion...36
5.1 Interpretation of the results...36
5.2 Theoretical implications...41
5.3 Practical implications ...45
5.4 Limitations ...49
There are no such things as
organisations; there are only
people who behave.
1. INTRODUCTION
Most often when healthcare organisations are in the headlines of today’s media it is caused by incidents. Recently, the Rotterdam Maasstad Hospital has been headlinenews for weeks due to the infection of 98 patients with a multiple antibi-otic-resistant bacterium named Klebsiella pneumoniae Oxa-48 (Zorgvisie, 2011). Another example of such negative news was the announcement of former Dutch Minister of Health, Welfare and Sport, Ab Klink, that general practioners who de-viate from the ministry’s directions on vaccination for swine flu will be prosecuted (Ministry of HWS, 2009). This negative imaging easily induces one to think Dutch healthcare is underperforming.
The National Institute for Public Health and the Environment (RIVM) concluded that Dutch healthcare is accessible and cost increase is average (Wester, Burgers and Verkleij, 2009). While for many aspects of care the quality is high, the Neth-erlands does not excel at an international level. Wester et al. (2009) found that the overall level of quality was good, but the Netherlands is outperformed by some countries on clinical outcomes. There are however, specialities in Dutch healthcare organisations which can be a role model for other European countries (ibid.).
Zorggroep Noorderbreedte
Healthcare organisation Zorggroep Noorderbreedte (ZNB from here) delivers hos-pital care and care for the elderly mainly in the province of Friesland in the Neth-erlands. ZNB decided in 2008 to implement a Huntington polyclinic (also known as ‘outpatient clinic’ or ‘outpatient department’). This specialist polyclinic can be such a role model for Europe, according to ZNB’s CEO Wander Blaauw (ZNB, 2009).
The organisation of ZNB consists of two business units: MCL for acute care (i.e. hospital) and Noorderbreedte for elderly care. The Huntington polyclinic has been implemented within the latter business unit and is situated at their care center ‘Nij Friesmahiem’ in Grou. This polyclinic has a regional function for the three northern provinces of the Netherlands (Friesland, Groningen and Drenthe). The polyclinic supports the network (e.g. general practioner, physiotherapist) around a single patient in order to cope with the difficulties that follow with diagnosis HD. The HD polyclinic exists of a team of experts who are able to accompany the pa-tient and its relative(s) during the whole disease process. This team involves a range of disciplines needed: physicians, speech therapists, occupational thera-pists, psychotherapists and social workers. These professionals coherently work together in order to:
- provide the opportunity for the patient and its relative(s) to live at their home as long as desirable and workable;
- prepare the patient and its relative(s) for the problems that might occur during the disease process;
- support home care and nursing home staff which treat HD patients;
- develop and maintain a network for sharing knowledge and skills between medical and paramedical professionals in primary care in the northern re-gion of the Netherlands (ZNB, 2010).
Several actors have participated in the implementation of this polyclinic at ZNB: the project team (consisting of a project leader and a geriatrician1), a case man-ager, the manager of the expertise centre of ZNB, and external parties such as the Huntington Patient’s Association, the regional healthcare office and health in-surance.
Healthcare system in the Netherlands
In 2006 the Dutch Ministry of Health, Welfare and Sport introduced a new healthcare cost system in the Netherlands, based on the principles of durability, solidarity, choice, quality and efficiency. The government announced a new Health Insurance Act (HIA or Zorgverzekeringswet), with an obligatory insurance for every Dutch citizen, which covers short-term healthcare. HIA completes the trinity that configures the Dutch Healthcare system together. It further consists of the Exceptional Medical Expenses Act (EMEA or Algemene Wet Bijzondere
kosten) for long-term care and the Social Support Act (SSA or Wet Maatschappe-lijke Ondersteuning), which made municipalities responsible for setting up social support. Despite the fact that SSA, EMEA and HIA complement each other, the individual manner of defraying is established in law.
Funding for Huntington’s disease
Formerly State Secretary of Health, Welfare and Sports, dr. Jet Bussemaker, pub-lished her vision of long-term care and social support (Bussemaker, 2009). Par-ticipation is a key driver in organising long-term care in today’s healthcare. Peo-ple with a disability need to be able to participate in the society to the fullest ex-tent possible. Bussemakers’ successor, Marlies Veldhuijzen van Zanten-Hyllner, continued this policy. The national insurance scheme for long-term care is EMEA. According to the Ministry’s website “[the] scheme is intended to provide the in-sured with chronic and continuous care which involves considerable financial con-sequences, such as care for disabled people with congenital physical or mental disorders”. The client’s right to care arises directly from EMEA. It is this scheme that bears the cost for treatment of HD based on individual-trailing budgets. The HD polyclinic however does not provide direct treatment, but diagnostic and sup-port services to patients, relatives, home care staff and nursing home staff. Cur-rent legislation does not allow that these costs are defrayed by EMEA. Therefore, the HD polyclinic current budget is partly based on the innovation policy of the Dutch Healthcare Authority. This allows regional healthcare offices and insurers to fund these activities temporarily (NZa, 2011). For another part the polyclinic is funded by the province of Friesland and by ZNB itself.
Implementation of a new department
An innovation is an idea, practice, or object that is perceived as new by an indi-vidual or other unit of adoption (Rogers, 2003), which applies to the implementa-tion of the HD polyclinic. The introducimplementa-tion of innovaimplementa-tion and change in healthcare is difficult and many current programs are, at best, only partly successful (Grol et
al., 2007; Walburg et al, 2006). The success or failure depends on an
This study aims to provide insights for practioners in the healthcare industry to perform the change management process more adequately. Moreover, the find-ings of this research may contribute to the understanding of implementing new departments within healthcare organisations at a more general level. The main objective of this study is to evaluate the implementation of the Huntington poly-clinic within ZNB. Accordingly the following research question has to be an-swered:
‘What are the practical implications following from the evaluation of the imple-mentation of the Huntington polyclinic within Zorggroep Noorderbreedte?’
In order to be able to answer the research question properly, the following sub-questions have been derived:
1. What factors of implementing a new department within a healthcare or-ganisation can be influenced according to academic literature?
2. Which factors of implementing a new department within a healthcare or-ganisation are decisive according to academic literature?
3. Which factors are relevant for implementing the Huntington polyclinic at Zorggroep Noorderbreedte?
4. How has the Huntington polyclinic been implemented?
5. Which factors of implementing the Huntington polyclinic have been deci-sive?
6. How do the findings of this research contribute to improving the imple-mentation of change in healthcare settings?
In this research a factor is defined according the definition of the Cambridge Ad-vanced Learner’s Dictionary. A factor is “a fact or situation which influences the result of something”. A factor is decisive if it is “strongly affecting how a situation will progress or end”. This should be interpreted as being the antonym for ob-structive factors.
2. THEORETICAL FRAMEWORK
To study the decisive factors of implementing a new department in healthcare organisations, it is inevitable to describe a theoretical basis for further analysis. This study will draw further upon the assumption that implementation is a proc-ess of change. First will be discussed what change management is about. This will serve as the starting point for distinguishing factors that influence change. Before these factors can be distinguished, it is necessary to narrow down the wide vari-ety of theories on influencing change.
2.1 Change management
It is no longer an avant-garde theory that change is at the heart of every organi-sation at present. The world is changing constantly, at a faster rate, and more complex than ever before. Managing change is therefore being one of the most important and difficult issues facing organisations today (Burnes, in Buchanan, Fitzgerald and Ketley, 2007). It is a trending topic amongst practioners and aca-demics to explore upon further in order to provide understanding of organisa-tional change. In the following, there will be looked at different approaches to change, in order to come to a definition of what managing change is about.
2.1.1 Approaches to change
dichot-omy is build further upon in the book Breaking the Code of Change (Beer and No-hria, 2000). Beer and Nohria identify significant differences in the way an organi-zation might manage change and how to approach aspects of the change process (Leppit, 2006). Organisations plan and establish change programmes in order to strive for value maximisation or these organisations just experiment and evolve. However, public sector change, rather than change in the private sector, is in many occasions driven by government policy. Therefore, one might question if Beer and Nohria’s theory holds in public sector settings. It is however useful in defining what change management is about.
Both the planned approach and the emergent approach to change are at the end of the continuum for approaches to change in Figure 1 (Buchanan et al, 2007; Burnes, 2004; Kotter and Schlesinger, 2008). Buchanan et al. (2007) state that change along this continuum can be seen from a static point of view or a more dynamic perspective.
While planning change, managers should consider the (complex) setting in which it is used (Grol et al., 2007). It is implicit within the arguments for the planned and emergent approach that the state of environment determines whether the planned (static) or emergent (dynamic) change approach would be better suitable (Buchanan et al., 2007; Burnes, 2004). Burnes (2004, p. 453) however argues that “managers can and do exercise a considerable degree of choice”. Kotter and Schlesinger (2008, p. 139) are more conservative in acknowledging that manag-ers have “some choice of where to operate on the continuum”. They argue, how-ever, that it would be best to opt for a position on the continuum as far right as possible (ibid.).
Buchanan et al. (2007, p. 252) stated, “there is often no such thing as one best way”. The view that approaches to change can be placed on the continuum in Figure 1 supports this view. However, the assumptions that managers have a considerable degree of choice or little choice, lead to different views on ap-proaches to change. It depends on the degree of freedom of choice that authors
Stable ENVIRONMENT
Planned
Turbulent Emergent
acknowledge whether they argue for a best way for each organisation or a best way for each situation.
Buchanan et al. (2007) for example use the concept of path dependency to de-cide which change approach to adopt, therewith pleading for one best way for each organisation. It can be argued however, that managers should be allowed to select the most appropriate approach for each situation (Burnes, 2004). The dif-ference between both perspectives is that Burnes (2004) argues that managers actually do have a choice, rather than merely build further upon (successful) pre-ceding initiatives.
This research will draw further upon the view that managing change is about “the exercise of choice: choice in terms of what to change, choice in terms of circum-stances under which the change takes place, and choice of the approach adopted” (Burnes, 1996, p. 17). A disregard for the presence or absence of choice means taking decisions by default, and thus possibly disregarding major opportunities for increasing performance (ibid.). For this research, this implies a perspective that aims at the most appropriate approach for each situation.
At this point different approaches to change have been elaborated and the impor-tance of choice has been emphasised. Before change practioners will be able to exercise choice effectively, it is necessary to gain more understanding of factors that influence change. These factors can be found from a wide range of available theories and their applicability on healthcare (Grol et al., 2007; Grol and Wens-ing, 2006; Plas and WensWens-ing, 2006; ZonMW, 2007). In the following part, this wide range of theories will be further delineated.
2.2 Targets of change
In general, theories on change can be divided into two broad categories: theories that explain how an intervention will facilitate a desired change and theories that focus on the process of change (Rossi et al. 2004). Grol et al. (2007) argue that an ideal model for change would incorporate elements of both theories.
thus has to have insight in how specific interventions influence the desired change. Therefore, this research will mainly focus on theories that explain how interventions facilitate a desired change. This does not imply that process theo-ries will be neglected entirely. Many of both types of theotheo-ries “describe overlap-ping factors related to strategies for change” (Grol et al., 2007).
Despite a degree of choice, there are constraints that appear beyond the scope of the individual organisation (Buchanan et al., 2007; Burnes, 2004). This implies that there are different levels at which constraints appear. Before relevant factors for this research can be distinguished, it is useful to continue on these different levels. Hence, further discussion on these levels can guide as a method for nar-rowing down the wide variety of theories available.
Theories on change that explain effects in healthcare environments can be di-vided into theories that aim at four different targets: theories focused on indi-viduals, theories related to social interaction, theories related to the organisa-tional context, and theories related to the political and economic context (Grol et
al, 2007). These four categories can be further subdivided into seventeen
sub-categories of theories. This is a useful structure for this research, because it pro-vides a holistic framework that allows one to filter out those (subcategories of) theories that are particularly useful for this research (i.e. for the implementation of a new department within a healthcare organisation). In the following, therefore each target level will be discussed in order to select only those subcategories of theories that are useful for this research. These remaining categories will than be analysed in order to distinguish relevant factors.
2.2.1 Individual level
Theories on change management in healthcare that relate to the individual pro-fessional have their roots in cognitive, educational, and motivational theories (Grol et al., 2007). It can be argued whether these theories are useful for analys-ing the implementation of new department within a healthcare organisation.
Cognitive theories refer to decision-making by healthcare professionals.
Decision-making in healthcare settings will be elaborated further on in paragraph 2.3.1.
Educational theories as defined by Grol et al. (2007) focus on motivation to
learn (and change). In terms of change, educational and motivational
theo-ries concentrate on task behaviour, for example hand-washing behaviour in a
situation of poor hand hygiene (Grol et al., 2007). This research focuses on the implementation of an organisational entity (i.e. the HD polyclinic), which does not involve specific changes in task behaviour (Veenhuizen and Tibben, 2009). Thefore, educational theories and motivational theories are less useful for this re-search.
2.2.2 Social context
Another ecological level is the social context, which comprises of theories of communication, social learning theories, social network and influence theories, theories related to teamwork, theories of professional development, and leader-ship theories (Grol et al., 2007). Many theories in this category however focus on taskbehaviour in relation to medical outcomes, which is not the focus of this re-search. Therefore, only theories on communication and leadership will be treated in the next part.
Literature on change and communication has broadly treated the importance of creating urgency for change (Cummings and Worley, 2005; Kotter, 1996; Grol et
al., 2007). Communicating that message of urgency is a method to influence
people. Frequent and effective communication contributes to a decline of uncer-tainty. This in turn helps to gain support for change, since uncertainty is one of the major “obstacles to people’s willingness to get involved in the change proc-ess” (Cummings and Worley, 2005). Earlier was already found that frequent communication actually contributes to successful implementation of change (Da-manpour, 1991). This demands for further insight in how the persuasiveness of such a message can be influenced. This is in line with the findings of Fitzgerald et
al. (2002), who argue that the acceptance and adoption of change in healthcare
According to theories of leadership, effective leadership may encourage, guar-antee or obstruct change (Grol et al., 2007). Literature on change management has always emphasised the relation between leadership and organisational change (for example Beer and Nohria, 2000; Burnes, 2004; Grol et al., 2007; Stoker, 2005). Only for that reason, it seems justified to explore theories of lead-ership in order to distinguish relevant factors for this research.
Basically, leadership is about changing and influencing others (Stoker, 2005). From a change perspective this can be translated as shaping the behaviour of (groups of) individual employees in order to achieve goals. Logically, conventional management would practice this influencing. However, this does not necessarily has to occur. For example, it can be argued that effective implementation re-quires understanding formal and informal leadership in a team or an organisation (Grol et al., 2007). Therefore, one has to have insight in who the (in-)formal leaders are and how they use their power to influence. In paragraph 2.3.3 this topic will be discussed further.
2.2.3 Organisational context
In the organisational context theories can be divided into five categories: theory of innovative organisations, theories of integrated care, complexity theory, organ-isational learning theory, and theories of organorgan-isational culture (ibid.). Not all of these theories are applicable to this research, either because the focus of this re-search is on implementation or because theories focus on organisations or even networks as a whole. Therefore, only theories on organisational culture will be treated in the following part.
2.2.4 Political and economic context
Theories on reimbursement and theory of contracting constitute the fourth cate-gory of theories on change in healthcare: the political and economic context. In general, changing factors related to this context are out of reach of those within the organisation who are involved in improving healthcare (Grol et al, 2007).
Reimbursement theories suggest that changes in the reimbursement of
healthcare providers can be used to influence individual and organisational per-formance (Barnum, Kutzin and Saxenian, 1995). Therefore, three methods can be applied: profit sharing, pay-for-performance and the venture returns method (Burnes, 2004). Only pay-for-performance is allowed in Dutch healthcare indus-try, especially for EMEA. The Ministry of Health, Welfare and Sport works on two bills that will enable the application of both the profit sharing method as well as the venture returns method in healthcare organisations (Van de Poel, 2011; Van den Elsen, 2010).
Pay-for-performance is a method that adds (individual) bonuses on top of a basic salary and is related to a predetermined performance target (Burnes, 2004). The collective agreement for long-term care professionals allows providing such bo-nuses once or on a temporary basis (SOVVT, 2010). However, there is no clear academic evidence for the relation between pay-for-performance and the quality of care (Grol et al., 2007). The main weakness of this method is that performance targets do not specifically aim at the implementation process. Therefore, it will not be subject of this research.
Proponents of contracting theory assume that purchasers of healthcare can in-fluence healthcare services by determining the needs of populations and setting the priorities of groups and services (ibid.). Applying contracting theory implies that contracts between purchasers and providers of healthcare should at least in-clude quality targets for care for specific groups such as HD patients. Again, qual-ity targets in this perspective should be aimed at the implementation. The Dutch Healthcare Authority (NZa) funded the HD polyclinic on a temporary basis. This might allow purchaser and provider to formulate specific quality targets. In para-graph 2.3.5 this will be looked upon further.
Ta-ble 1, which shows which subcategories are applicaTa-ble and which are not. The last column highlights those subjects found in the previous, which will be elaborated on further in the following part.
Table 1 Applicability of theories found (summary)
Theory A N/A Subject of research
Individual level
Cognitive theories X Decision-making Educational theories X
Motivational theories X
Social context
Theories on communication X Persuasiveness of communication Leadership theories X Formal/informal leadership Social learning theories X
Social network and influence theories X Theories on team effectiveness X
Organisational level
Innovative organisations X Theories of integrated care X
Complexity theory X
Organisational learning theory X
Theories of organisational culture X Features of supportive culture
Political and economic level
Reimbursement theories X
Contract theories X Quality targets for implementation A = applicable; N/A= not applicable
2.3 Relevant factors
This paragraph will elaborate further upon the factors found in the previous part, in order to discuss whether these factors are relevant or not. Each part will be summarized with a conclusion on whether the factor is found to be decisive or not. Therefore, the factors will be discussed in the light of the definition of deci-sive: strongly affecting how a situation will progress or end.
2.3.1 Decision-making
decision-making by healthcare managers (Kovner and Rundall, 2006). There is however no sufficient evidence to adopt such an approach (Reay et al., 2009).
The paradox here is that although such a contingency approach for (healthcare) managers can be criticized because of the arguments mentioned earlier, the mechanism of EBP is important to take into account when performing change in a healthcare setting nevertheless. After all, this is how decision-making by healthcare professionals occurs in general. These healthcare professionals “have a large reservoir of specific experiences that they can use as a source for learning and changing” (Grol et al., 2007, p. 108). Healthcare professionals use their res-ervoir of experiences and the scientific evidence to assess the relative advantage of change in comparison to the current state (Buchanan et al., 2007). It is this balance between advantages and disadvantages of different alternatives that is the main assumption in rational decision-making models (Grol et al., 2007). Rational decision-making theories explain poor results in terms of lack of relevant (scientific) information and incorrect expectations about the consequences (Grol
et al., 2007). In reverse, it does not explain high quality by the availability of
relevant information and correct expectations. The problem here is that one can-not unpretenciously copy these models of decision-making in daily routine into situations of change. It would be to simplistic to argue that change practioners in healthcare only have to emphasise relative advantage of the proposed change. This relative advantage is a result of experience and scientific evidence (i.e. in-formation). What can be derived from this is that change practioners in healthcare do have to take into account this information need in order to facilitate the decision-making process of the individual professional. Recognising this as a process implies that success is not a direct result of providing the appropriate in-formation. It can be argued whether this factor is not more obstructive than it is a success factor. This implies that ‘information need’ only will be decisive (i.e. strongly affecting the outcome) when change initiatives fail.
2.3.2 Persuasiveness of communication
communication. Persuasion from this perspective involves repetition of the mes-sage at a continuous basis (Burnes, 2004; Grol et al., 2007; Kotter, 1996). Organisations consciously have to use both formal and informal communication channels (Burnes, 2004). Two routes of communication can be marked: a sys-tematic process and a peripheral process. In the first process a message is con-sciously considered and benchmarked against other messages and beliefs. In a peripheral process the recipients of the message are more responsive to periph-eral cues, such as source credibility (Grol et al., 2007). Introducing new ideas (e.g. a HD polyclinic) can be effectively transmitted using a credible source (Du-rantini et al., 2006; Kumkale, Albarracín and Seignourei, 2010; Van Dijk, 2006). The assumption underneath this thought is that the effect will most likely be the greatest if a credible person (i.e. source credibility) presents the message. This implies that source credibility affects the perceived validity of the message. Credibility here can thus be defined as the degree of trustworthiness of the source (Hovland and Weis, 1951).
In the previous paragraph the information need for decision-making has been emphasised. From that point of view, source credibility can also contribute to in-fluence healthcare professionals. Especially when a message is less intensively considered (Grol et al, 2007). Source credibility has been concluded to be one of the important elements that affect the persuasiveness of communication. Several authors found a positive relation between source credibility and the effectiveness of transmission (Durantini et al., 2006; Kumkale, Albarracín and Seignourei, 2010; Van Dijk, 2006). In contrary to information need, source credibility there-fore can indeed be defined as a decisive factor.
2.3.3 Leadership
Closely related to the previous topic is the subject of leadership. Strong leaders’ ambition and enthusiasm will most likely contribute to successful change, but it does not engage everyone (Buchanan et al., 2007). What is commonly believed is that effective leadership promotes and guarantees innovation and change (Grol et
al., 2007). This does not necessarily (only) have to occur by those leaders that
(Downey, Parslow and Smart, 2011), therefore this phenomenon that cannot be ignored.
Staff and peers are attracted to informal leaders as non-management, because they are knowledgeable, exude confidence and are trustworthy (Grabowski and Logan in Downey et al, 2011). Informal leaders typically are those individuals that use their influence to set team norms and values and coordinate group ef-forts. What advocates for informal leaders is that they generally are involved with substantive knowledge (Van Dijk, 2006). This contributes to the trustworthiness of the informal leader. Crucial for change in healthcare organisations is a form of informal leadership, termed clinical leadership: “clinicians have to be involved in leading the process” (Wilderspin and Bevan, 2006, p. 48). This form of informal leadership combined with formal leadership (i.e. professional managers) may very well be the optimal blend for creating a mutual support network for change. This is also because of the non-clinical aspects that have to be managed particu-larly well, in order to facilitate the healthcare professionals in the primary process (ibid.). The strength of the leadership combination depends on the personal char-acteristics of the clinician and the professional manager and the chemistry be-tween those individuals. There is however no single correct approach (Buchanan
et al., 2007; Burnes, 2004; Downey et al, 2011; Grol et al., 2007). Clinical leadership
Besides its relation with decision-making it also relates to leadership issues within the organisation. In the previous was highlighted that informal leaders are attrac-tive to staff and peers, because they are perceived to be trustworthy. This in turn argues for informal leaders to act as credible sources for information. In this light clinical leadership has been explored. The involvement of clinicians has been found to be important for successful change initiatives in healthcare settings (Wilderspin and Bevan, 2006). As with source credibility it can be stated that clinical leadership contributes to successful managing change, rather than its ab-sence will be obstructive.
Leadership combination
whereas existence of such a combination contributes to successful change. There-fore, the existence of the formal-informal leadership combination can be seen as a decisive factor.
2.3.4 Supportive culture
Two elements that contribute to a supportive culture have been treated in the previous paragraphs: the formal/informal leadership combination and persuasive communication. A third element that constitutes a supportive culture is pride (Bu-chanan et al., 2007). The relative success of a healthcare organisation compared to its peers contributes to the degree healthcare professionals take pride in their work (Wilderspin and Bevan, 2006). The assumption underneath is that profes-sionals who take pride in their work are more receptive to change than others. Therewith, competition can have great impact on people’s attitude for change. The factors source credibility, clinical leadership, and the leadership combination contribute to a supportive culture. Each of these factors also contributes to (suc-cessful) change directly. The third element for a supportive culture, pride, influ-ences change only indirectly. If healthcare professionals do not take pride in their work, there might be a less supportive culture to change. However, it cannot be stated that (the absence of) pride directly leads to success nor failure. Therefore, pride cannot be defined as a decisive factor.
2.3.5. Quality targets on implementation
2007) it cannot necessarily be stated that quality targets are decisive. However, based on its popularity one can argue that quality targets at least contribute to success. Following the line of reasoning from the previous paragraphs it can be defined as decisive, because the absence will not directly lead to failure, whereas its existence contributes to successful change.
3. METHODS
This study aims to explore the decisive factors for implementing a new polyclinic within a healthcare organisation. The focus of this research is on understanding and interpreting these factors. Therefore, qualitative research is a suitable ap-proach for this subject (Cooper and Schindler, 2003). Qualitative research allows one to collect data systematic and structured, enabling the researcher to make statements about phenomena. The collected data will be used to outline of the implementation of the Huntington polyclinic.
3.1 Data collection
Before the implementation of the Huntington polyclinic at ZNB can be evaluated, the decisive factors have to be defined. Therefore, this study can be divided into two sections. The first will focus on establishing the decisive factors by carrying out a literature research on this topic. Literature on change management will be the most significant source for information. The literature used in this thesis is found in the university journal databases. Therefore, Business Source Premier, Econlit, Elsevier Science Direct and Pubmed have been used. Moreover, articles where found by using literature references of the articles found. The key search terms for using the journal databases were: ‘change’, ‘change management’, ‘managing change’. These search results have been narrowed further by the use of ‘healthcare’ or ‘health care’ as additional search term. Besides articles and books, the Internet is used for investigation. Internet is one of the most impor-tant channels for organisations to communicate with their constituents (Buono, 2004). For analysis of company information the focus is on their web presenta-tions, and available plans and reports of the polyclinic.
telephone and personal contact, but the interviews did take place in a face-to-face setting.
3.2 Instrument
The interviews with the different parties involved in the implementation of the polyclinic served to gain insight in the different perspectives on how this imple-mentation has been performed. The decisive factors mentioned in the previous chapter formed the guiding principles of the interviews. The interviews have been introduced by explaining the intention and background of the research. Followed by open questions, which allows the researcher to gain insight in how the poly-clinic has been implemented, such as: “Why and how has the polypoly-clinic been im-plemented?” and “What has been your role within the implementation?” This type of questions (starting with which, why, what or how) is essential for this approach in order to find out why and how people think. Another example question is: “To what degree do you consider the implementation of the HD polyclinic as a suc-cess?” The subsequent interview questions have been based on the literature study in the previous chapter.
Marleen Milder Project leader
Ruth Veenhuizen Geriatrician Gea van Dijk Manager Expertise Centre Jaco-Derk v/d Tang Financial advisor Klaas Visser Controller Han Morshuis Care advisor Dirk v/d Wedden ChairmanHuntington Patient’s Association Jelleke Dokter Regional agentHuntington
Patient’s Association
Project team ZNB
Huntington Patient’s Association De Friesland
Wilma Vink Ergotherapist
Hans Smorenburg Nursing home manager
Cathy Trousset Social worker Tineke Veenstra Speech therapist Huntington polyclinic Branda Kootstra Case manager polyclinic
3.2.1 Source credibility and information need
Interview questions concerning source credibility where derived from the work of Durantini et al. (2006). The first question aims at exploring how different stakeholders have been informed before and during the implementation of the polyclinic. ‘Qualified nature of the source’ and ‘trustworthiness’ have been identi-fied as important indicators for source credibility (Durantini et al., 2006). There-fore the following questions have been asked: “To what degree do you consider the source as qualified to do so?” and “To what degree do you consider the source of information as trustworthy?” After that two questions arise: “How did this degree of qualified nature and trustworthiness of the source influence the implementation of the HD polyclinic?” and “To what degree did this communica-tion source influence your perceived sense of urgency for a HD polyclinic?” The last question has been added because the sense of urgency perceived by the stakeholders involved is an indicator for the impact of the message of communi-cation (Burnes, 2004; Kotter, 1996).
3.2.2 Leadership
The work of Downey et al. (2006) and Wilderspan and Bevan (2006) has been the foundation for interview questions on the leadership combination. “Who in the initial team set team norms and values and coordinated group efforts?” and “Does that person have formal title or authority?” are two questions that aim at identifying informal leadership. Than the partnership between formal and informal leader can be explored (Wilderspan and Bevan, 2006). Therefore the following question has been formulated: “How would you describe the chemistry between the project leader and the informal leader of the former question?” After that has been explored it is important to relate the degree of chemistry to the actual im-plementation: “How did this influence the implementation of the HD polyclinic?” 3.2.3 Quality targets
3.2.4 Pride
The interview questions on pride have been based on the work of Wilderspin and Bevan (2006). “To what degree do you feel proud of what you have achieved with the implementation of the polyclinic?” and “What caused this feeling if pride?” are two questions that aim at identifying whether the respondents feel proud about the achievements of the project and which reasons cause this feeling. Further-more it was asked how this feeling of pride developed from the start of the pro-ject and how this may have influenced the implementation.
Finally, the interviewees have been asked what they should have done differently or if according to them important elements have been missing in the interview. 3.3 Data analysis
The objective of this research is to perform an evaluation of the implementation of the HD polyclinic within ZNB. Therefore, the respondents have been asked to give their opinion on how the polyclinic was implemented. For this approach in-terviewer errors have to be avoided. Interview error is a major source of sam-pling error and response bias (Cooper and Schindler, 2001). The interviews have been recorded by using a digital voice recorder with permission of the respondent in advance. Afterwards, the interviews were transcribed to provide the rich detail that the method is used for. The transcribed version of the interview have been send to the interviewees. This so-called member check allows the respondents to review the data, which will contribute to the validity of this research (Burnard, 1991).
4. RESULTS
So far factors have been derived from academic literature. In this chapter the re-sults of the empirical research will be reported. The actual implementation will be compared to the factors found in theory. The results have been derived from 13 in-depth interviews and document analysis and will be used in order to answer the third and fourth research question: How has the Huntington polyclinic been implemented? And: Which factors of implementing the Huntington polyclinic have been decisive? First, the multidisciplinary concept of a HD polyclinic will be de-scribed briefly in order to provide understanding in what has been implemented. 4.1 The multidisciplinary concept
The concept is designed as a carousel of different disciplines that assess the pa-tient and its companion in approximately 4 hours time. Both papa-tient and compan-ion joinly start visiting the occupatcompan-ional therapist. Afterwards a geriatrician, a speech therapist, a psychologist, a medical social worker and frequently a re-gional manager of the Patient’s Association will visit them individually. Before the assesment is concluded with a final visit with the geriatrician and the caseman-ager, the patient and companion will have lunch dinner together with the occupa-tional and speech therapists. At the end of these sessions, this approach leads to a multidisciplinary care plan and a home implementation plan.
Once clients (both patiënt as well as carer) have been at the polyclinic, they will repeatedly visit the polyclinic every six months in order to monitor the patient’s development. The financial advisor of the insurer stated: “This is more or less like candy floss: every time a thin layer is added.” This implies that the client base of the HD polyclinic increases gradually. However, the healthcare professionals of the HD polyclinic do not deliver care at home in the intervening period. In their role as experts in the field of HD, these healthcare professionals support (local) primary care.
Initial motive
therapist, social worker, psychiatric nurse and an occupational therapist) in order to treat the ambulatory patient at home until the patient died. This multidiscipli-nary approach lead to the idea that treating HD at such an early stage could help HD patients to life at home all the time it is possible and desirable. The geriatri-cian stated it as follows: “We truly want to get to know people from the moment they are being diagnosed with HD. We want to give them a voice before HD liter-ally deprives them of their words and deeds.”
4.2 Actual implementation
The previously mentioned case, combined with a lack of adequate care for this category of patients in the region, lead to the development of a project plan. This is the moment in time where the implementation started. The results on how the implementation was performed can be found in table 2.
Table 2 Initiation
Component Results
Initiative - The geriatrician and a care coordinator jointly wrote the projectplan; - The first concept was discussed with the team of different disciplines; - The first concept included inpatient facilities.
Objective - “To instigate proper guidance for HD patients that allows these patients to life at home as long as this is possible and desirable” (projectplan).
Request for interest
- The geriatrician send out a request for interest to all general practioners, neu-rologists and psychiatrists in the province of Friesland that might be confronted with HD patients anytime in the future;
- The number of response to the request for interest was negligible, but the geriatrician continued the plan for creating a polyclinic function.
Involvement of other stakeholders
- The geriatrician invited the chairman of the Huntington’s Patient Association to share her ideas on a polyclinic function for HD patients in the province of Friesland;
- The main reason to discuss this idea was to gain support from the Patient’s Asso-ciation, which had to be ‘partnering in word and deed’ to gain trust of internal stakeholders at ZNB as well as external (financial) stakeholders;
- The chairman of the Patient’s Association directly promised his support; - Regional agent of the Patient’s Association did research on the potential for new
clients in the northern region;
The initiation of the project has been described previously. The following step is to describe the results on how the project was organised in terms of project structure and funding. These results are presented in Table 3.
Table 3 Project organisation
Component Results
Project structure
- A project leader was appointed to work out the plan financially and to make a project description;
- The nursing home manager of Nij Friesmahiem was asked to contribute to the project in terms of accommodation capacity;
- The manager of the expertise center was hierarchical responsible for staffing the polyclinic and for gaining commitment of the board of ZNB;
- The geriatrician and the project manager have actually gained the commitment of the board;
- The nursing home manager, the manager of the expertise centre and a financial advisor were appointed as steering committee, who were responsible for rolling out the project;
Funding - After board approval the projectplan was submitted to the Dutch Healthcare Authority (NZa);
- Submission was necessary to become eligible for NZa’s innovation policy. This policy allows regional healthcare offices and insurers to fund these activities temporarily;
- The terms and conditions include a clause that an application requires a dually signed contract between healthcare supplier and the regional healthcare office (and/or insurer).
- The geriatrician and the project leader discussed the initial concept with a care advisor and a financial advisor of De Friesland.
- These discussions primariy focused on care contant first, requirements and defi-nitions;
- Subsequently discussions focused on how facts and figures have been under-pinned and which assumptions have been used to realise the plan;
- Legislation determined that the insurer had to submit the plan, because this type of (HD) care typically falls under general insurance. This is a formal process. - NZa approves almost all application due to a lack of knowledge, which is needed
for testing the application content.
- The geratrician acknowledges the important role of the insurer in this stage, however she is convinced that she “has been providing the right amount of am-munition [for the insurer] in order to succeed.”
Table 4 Developing the concept
Component Results
Developing the concept
- The regional agent of the Patient’s Association joined the project team (although not formally);
- The developing process evolved several project team meetings, focusing on care content;
- Decision-making has been a gradual process. Every choice has been made in consultation, which was much appreciated by all respondents;
- Support of an internal business consultant was expected by the project team for the organisational part of the project;
Stakeholder influence
- The geriatrician and the project leader jointly discussed the concept periodically with the care advisor and the financial advisor of De Friesland;
- ZNB reported on financial figures, content development, collaborations, the multidisciplinary nature of the project, and the image the project developed troughout the country.
- ZNB initiated progress and evaluation meetings, which were also important for De Friesland. Care advisor: “This project can also contribute to a positive attitude towards De Friesland, if an insurer shows compassion for such a patient group in this region. Such positive publicity will undoubtly have spinoff at other levels.” - These meetings were important in another way: De Friesland had to be
per-suaded to pave the road for other insurers’ clients.
- The financial advisor approached other insurers to induce them to join the initia-tive.
Marketing - The project team started up the marketing function;
- Brochures have been produced for specific target groups: hospitals, nursing homes and other care organisations;
- The geriatrician published articles in scientific journals;
- Network conferences have been organised to map other parties’ requirements for a polyclinic function, which mostly focused on content of care.
The previous part has treated results on the question how the HD polyclinic has been implemented. The focus in the following paragraphs is on the factors that have been derived for the theoretical framework: source credibility, qualified na-ture of the source, trustworthiness, clinical leadership, leadership combination, quality targets and pride.
4.3 Communication
Table 5 Communication
Component Results
Formal com-munication
- The geriatriican informed internal stakeholders in formal meetings, by email and in informal talks;
- The information was mostly content-related, but also financial or regulatory information.
- The geriatrician did take the lead in both informing internal and external stakeholders. The geriatrician on the progress meetings with De Friesland: “Strikingly, progress meetings with De Friesland have been our initiative. From the start they were not eager on that, but I insisted on those meetings every six months. I reap the benefits now, because they exactly know how we progress. Every six months we reported our progress, a financial section included”; Informal
communica-tion
- Although formal meetings existed, there have been frequent informal contacts with De Friesland. The financial advisor: “It is a difference if you have to wait for the next formal meeting, deliberately treating all subjects on the agenda, or just call to discuss the situation and what to do the forthcoming week”;
- The communication between the geriatrician and the chairman of the Patient’s Association has been informal most of the time. They meet randomly, not neces-sarily direct related to the HD polyclinic;
- These occassions include international conferences (e.g. Canada, Czech Republic) and travelling together to meetings with Dutch professionals on HD;
- The geriatrician and the chairman of the Patient’s Association knew eachother as former colleagues (i.e. geriatricians).
The previous part aimed at exploring how different stakeholders have been in-formed before and during the implementation of the polyclinic. From theory po-tential decisive factors have been derived, which have been tested empirically. The results will be reported in Table 6.
Table 6 Communication factors
Component Results
Source credibility
- The level of involvement of the geriatrician has been important for all respon-dents;
- The chairman of the Patient’s Association: “A professional who displays such a level of involvement has to be appreciated. She deserves all of our support. We did provide the geriatrician of support to the degree to which we are able to.” - All respondents have made similar comments.
- According to the regional agent of the Patient’s Association it is “due to the in-volvement of the geriatrician that the HD polyclinic became such a success.” - Sense of urgency occurred by all respondents due to contentrelated arguments.
Qualified nature of the source
- The geriatrician was knowledgeable about all developments (content, financial and regulatory);
- This allowed the geriatrician to inform all stakeholders on all topics;
- Respondents did not perceive this as problematic. The speech therapist on this: “The geriatrician informed us on all topics. Due to her involvement with the pro-ject, she attended all meetings related to the polyclinic, which allowed her to in-form us about those meetings. The projectleader, for example, did send emails on how to cope with rules of registration, but not on the developments of the project.”
- Content-related information on HD is scarce and there has been relatively little research on HD that is relevant for professionals of the polyclinic;
- The geriatrician used cases to inform both internal and external stakeholders; - The geriatrician is named prominently a qualified source for informing about
con-tent-related issues, since she is a medical specialist on the subject;
- All stakeholders enormously appreciate that the geriatrician participates in inter-national conferences and scientific publications;
- The role of the organisation as a whole is emphasised by De Friesland. ZNB is described as a large, reliable organisation, who stands for the idea;
Trustworthi-ness
- The determination and compassion of the geriatrician was an important reason for the respondents to judge her a trustworthy. The chairman of the Patients As-sociation: “Than you go for it, driven by compassion. The geriatrician was the right person at the right position. Hence, when you are metalworker and your neighbour is diagnosed with HD, the only thing you can do is to be nice to the patient.” The financial advisor: “Because the geriatrician was so determined, al-most made us instantly believe the concept. Trust is very important in this pro-ject. It will be hard to generate a businesss case, because there are no yields to earn. This is mostly about wellbeing and one cannot easily express the value of such a project in money.”
- The geriatician maintains good relationships with University Medical Center Groningen (UMCG) and Leiden University Medical Center (LUMC). The Center for Human and Clinical Genetics (LUMC) and the Department of Genetics (UMCG) both emphasised the need for a polyclinic function for HD patients and therewith confirmed the view of the geriatrician.
- If the project leader had informed the internal stakeholders about content-related topics, this would not have been trustworthy. Providing financial and regulatory information by the geriatrician is however not seen as problematic; - As a results of the determination of the geriatrician, the manager of the expertise
center accepted that the geriatrician would be a key figure in this project, despite the hierarchical positions both have.
4.4 Leadership
Table 7Leadership
Component Results
Informal leadership
- The geriatrician has been the initiator from the very first start;
- The project leader had been involved for the formal side of the implementation, which focused on the conditions needed for such a polyclinic function;
- The geriatrician is described as a ‘perfect networker’ and succinctly pitching her vision and view on recent developments.
- The geriatrician is unanimously named as the person who sets standards of the polyclinic;
- The geriatrician is unanimously named as the figurehead of the polyclinic. - The project leader: “The geriatrician has been pioneering. She was the initiator
and internal protector of the project.” Leadership
combination
- The hierchical leader (manager of expertise center) empower both the geriatri-cian and the project leader to fulfil their role as they did;
- The geriatrician and the project leader acted autonomous. The manager of the expertise centre: “I do not have to worry neither care-related issues nor condi-tions, because the geriatrician and the project leader do.”
- This is also recognised by external stakeholders: “There are massive healthcare organisations with multistage decision-making, which because of that never will have innovational projects. Despite the size of the organisation, the geriatrician is given a great amount of freedom and the employees do cope with that very well.”
- The chemistry between the geriatrician and the project leader is described as very well and their relationship as complementary.
- The geriatrician and the project leader have been sociable towards eachother, which is observed mainly by the members of the multidisciplinary team; - There has not always been clarity about the tasks and responsibilities of the
pro-jectleader.
- The leadership combination is seen as one of the success factors of the imple-mentation. The manager of the expertise center: “the fact that this is a bottom up initiative with great involvement of the geriatrician and the project leader, is why the initiative was received very well by all participants.” This enthused both the multidisciplinary team and external stakeholders.
4.5 Pride
Table 8 Organisational culture
Component Results
Pride - All respondents talk with pride about the realisation of the HD polyclinic; - Not all respondents were involved with the single patient case that was the
mo-tive for initiating the polyclinic;
- The feeling of pride emerged during the project and differs from respondent to respondents;
- Different stakeholders influenced eachother’s feeling of pride positively; - Positive articles of the Patient’s Association lead to a feeling of pride at the
healthcare professionals of the polyclinic;
- The feeling of pride at the healthcare professionals increased dramatically be-cause they experience what it meant to patients.
- The geriatrician visiting (international) conferences was named by all respon-dents of one of the elements that they were proud of. The medical social worker: “I am very proud. This is a unique project. Not only in the Netherlands, but also worldwide. Our geriatrician visited a conference in Canada and others enthusias-tically responded that they were very interested in the concept. That is very spe-cial, especially because it is unique project in the little town of Grou.”
- The fact that the concept became renowned caused pride at the external stakeholders.
4.6 Quality targets
The last component of this research that has been subject of the interviews is quality targets. In Table 9 the results on this topic are shown.
Table 9Quality targets
Component Results
Use of targets - In the terms and conditions of the innovation policy of the Dutch Healthcare Authority (NZa) two conditions are included on measurable quality targets and performance indicators to measure these targets.
- These requirements are “fague and multi-interpretative” according to the finan-cial advisor;
- It has been a quest for the project team how to evaluate temporarily. The geriat-rician: “NZa demands an evaluation, but it was all good. The message was more or less like ‘keep up the good work’. NZa nor the ministry of Health, Welfare and Sports have insight in how projects like these should progress.”
- The set of targets for evaluation has been discussed with De Friesland before ZNB reported on these targets;
- These targets did not include targets on implementation of the polyclinic; - There are no stringent guidelines that guarantee success of such projects. The
care advisor: “Therefore, we agreed upon targets on production figures, patient flow, but also on soft subjects like the occupation of the team, client satisfaction and following the latest developments on HD.”
tar-gets. These targets were perusal in order to focus on treatment rather than other issues;
- Defining content-related targets was hard due to a lack of information on HD. The case manager: “Every organisation has its own protocols on care delivery. There are no standard protocols for HD, because it is such a rare disease that is relatively unknown. Every discipline acts according to the protocols that they are used to.”
- The multidisciplinary team members did not miss quality targets on implementa-tion. For example, the occupational therapist: “It is to others to monitor those targets. My job is delivering treatment and I try to perform that job as good as I possibly can.”
4.7 Reflecting on the implementation
5. DISCUSSION AND CONCLUSION
In this chapter the main research question will be answered. Therefore the results of the previous chapter will be interpreted to come to an overall conclusion and both theoretical and practical implications will be outlined. The final part concerns a reflection of this research, including reliability, validity, and the lessons learned from the research process.
5.1 Interpretation of the results
Considering the main research question of this study, which factors have been
decisive for successfully implementing the Huntington polyclinic within Zorggroep Noorderbreedte, it can be concluded that clinical leadership and the leadership
combination have been decisive factors for successfully implementing the HD polyclinic. All respondents praised the role of the clinical leader in this project and identified this as highly influencing the success of this particular project. In order to gain more in-depth understanding of the results, the subquestions will be an-swered in the following part.
5.1.1. Applicable factors according to theory
The first subquestion concerned factors that can be influenced when implement-ing a new department within a healthcare organisation. Primary focus has been on theories that explain the how an intervention will facilitate a desired change. Research on a wide variety of these theories applicable to change initiatives in healthcare produced five subjects of research. These subjects originate from change theories that aim on four different targets (individual level, social context, organisational level and policital/economic level). This search in turn delivered seven factors as summarised in Table 2.
Table 2Applicable factors
Theory Subject of research Factors
Cognitive theories Decision-making - Information need Theories on communication Persuasiveness of
commu-nication
- Qualified nature of the source - Trustworthiness
Leadership theories Formal/informal leadership - Informal leadership (clinical leadership) - Leadership combination
Theories of organisational culture
Features of supportive cul-ture
- Pride
Contract theories Quality targets for imple-mentation
5.2.2 Decisive factors according to academic literature
A credible source for communicating the (change) message has been concluded to be highly important to affect the persuasiveness of communication. Especially, when it comes to introducing new ideas and concepts, such as the HD polyclinic, source credibility is important. It can be concluded that source credibility is a de-cisive factor due to the positive relation between source credibility and effective tranmission.
Besides source credibility another decisive factor is (informal) clinical leadership. The involvement of clinicians has been found important for successful change ini-tiatives in healthcare settings and is interrelated with source credibility. Trustwor-thiness is one of the most valuable characterics of an informal leader, which in turn is essential for source credibility. In addition, theory suggests that a leader-ship combination of formal and informal leaders is decisive for successful change initiatives.
Finally, it has been suggested that the existence of quality targets might very well be decisive for success. This is however based on its popularity in practice, be-cause there is a lack of scientific evidence.
5.1.3 Implementation of the HD polyclinic
The initiative for the polyclinic has been a single action by the geriatrician. She has been determined to realise care for HD patients from the very beginning, even though potential partners in the region did not show their interest. The neg-ligible number of response to the request for interest can be explained by the relative low amount of HD patients. A significant proportion of the general prac-tioners will most likely never come across an HD patient.
stimu-lates distrust between stakeholders, it is this type of entrepreneurship that is needed to create innovation in healthcare (Putters, Breejen and Frissen; 2009). What is striking in this case is the determination at the start to become a full service provider for HD patients, including inpatient facilities. This in fact has never been part of the project. This can be explained by the fact that the patient that has been the initial motive for the initiative passed away. Therefore, there was no urgency to create inpatient facilities anytime soon.
Decisive factors for implementing the HD polyclinic
The factors as found in the theoretical framework have been tested empirically. In the following part these factors will be discussed individually: source credibility, clinical leadership, leadership combination, pride and quality targets.
Source credibility – It depends of the nature of the content whether source credi-bility actually was descriped as important during the implementation. In general, the respondents described that the geriatrician is the most credible source when it comes to care-related content. However, when it comes to organisational issues it is not necessarily someone else. The geriatrician had a major role on communi-cating both care-related as well as organisational issues. The high degree of credibility on both topics is not only related to tangible evidence (e.g. writing sci-entific articles or a presumed lack of knowledge on organisational issues). The respondents describe other arguments as well: enthusiasm, commitment, main-taining a network (e.g. UMCG and LUMC), and determination of the geriatrician that allow her to have the adequate knowledge on both care-related and organ-isational issues. This might be explained by the state of basic knowledge on or-ganisational issues at most of the stakeholders (i.e. trained as healthcare profes-sionals). Another explanation might be a lack of interest on these topics, which also can be related to the former explanation. However, the data does not allow drawing conclusions on these explanations.
