Fostering environmental innovation in hospitals
A case study on University Medical Centers in the Netherlands
By
Caroline Boerema
University of Groningen
Faculty of Economics and Business
MSc Business Administration - Strategy & Innovation
Abstract
While environmental innovation is of increasing importance to organizations in their attempts to become more sustainable firms, hospitals have not kept pace with this development though from an environmental perspective having ample reason to do so. As such, this paper examines how hospitals, specifically University Medical Centers (UMC’s) in the Netherlands, can foster environmental innovation in their organization, thereby focusing on the fuzzy front-end of the innovation process. In doing so, this paper conducted a case study, thereby considering the organizational factors of support and encouragement, resource availability and structure, often suggested to be of influence to creativity. Analyses shows that communication and interaction patterns in particular are important aspects to be organized by UMC’s when desiring to stimulate creativity in the environmental area, motivating employees to engage in creative thinking by signaling its importance and enabling creativity by
Index
1. Introduction ...4
2. Environmental innovation in hospitals...6
2.1 The hospital as high-reliability organization ...6
2.2 Environmental sustainability and innovation ...8
2.3 Environmental innovation in hospitals...9
3. Fostering creativity in (high-reliability) organizations ...12
3.1 The fuzzy front end of innovation ...12
3.2 Organizational encouragement and support ...13
3.3 Availability of resources ...15
3.4 Organizational structure ...18
3.4.1 Multidisciplinary teams/work groups ...20
3.4.2 Boundary spanning activities ...23
4. Research methodology ...25
4.1 Methodology ...25
4.2 Case selection ...25
4.2.1 Case: University Medical Center ...26
4.2.2 Additional sources of information: remaining UMC’s and the NFU ...27
4.3 Data collection and analysis ...28
5. Results and analysis ...31
5.1 Organizational encouragement and support ...31
5.2 Availability of resources ...34
5.3 Organizational structure: teams/work groups and boundary spanning activities...37
5.3.1 Teams/work groups in the University Medical Center...38
5.3.2. Creativity at the tactical/operational level...42
6. Conclusion ...51
1. Introduction
As a global awareness regarding environmental issues is emerging, organizations are increasingly
facing a growing concern about the impact of business on the environment. This has translated in a
rising demand for environmentally friendly practices, being introduced more and more within organizations in response to internal and external forces (Gadenne et al., 2009). Concepts like corporate social responsibility, corporate and environmental sustainability and eco-efficiency and -effectiveness are gaining substantial momentum, broadly referring to the implementation of business practices that meet present needs while simultaneously allowing for future needs to be met (van Marrewijk and Werre, 2003; Dyllick and Hockerts, 2002). Reasons for committing to environmentally sound operations range from compliance to legislative demands, the expectation of economic benefits, to an ethical consideration that this is the right way to behave (Gadenne et al., 2009). Adopted by both commercial and non-profit organizations, companies from disparate industries are now developing and introducing environmentally sustainable business practices to the point that entire eco-industries have emerged (Ekins, 2010).
Nevertheless, this sustainability movement has not progressed equally rapid throughout all industries or market segments, the hospital sector in the healthcare industry being a prime example (Johnson, 2010). Concerned that environmentally friendly strategies restrain possibilities to meet stringent regulatory requirements on such matters as quality care, infection control and building standards, hospitals have often been detached from integrating sustainability in their business practices and the development of their facilities (Johnson, 2010). Moreover, green policies are usually forced to compete with a number of other issues pressuring hospitals, including problems obtaining capital, rising costs and preserving operating margins, an aging population, staff retention, and outdated
facilities (Andrews, 2009).
From an environmental perspective this is an unfortunate development, as hospitals have a substantial negative impact on the environment. In continuously operating, hospitals perpetually require light, heat, and extensive energy for ventilation, equipment, sterilization, and laundry and food preparation, making hospitals highly energy-intensive facilities (Johnson, 2010). Furthermore, hospitals generate significant amounts of waste, require huge quantities of water and squander energy, for example having to pump in fresh air rather than recirculate it to reduce infection (Martin, 2009). This also implies that hospitals could have much to gain from initiating environmentally sustainable practices within their organization (Phillips, 2009). Possible benefits to be obtained do not merely include an improvement of the bottom line, but also enhanced patient health and well-being, increased staff
In that, though not having kept pace with other businesses, some hospitals have moved forward to address green issues in order to reduce their environmental impact. And the possible cost, satisfaction and health benefits might also increasingly pressure otherwise cautious hospitals to take environmental sustainability into account (Johnson, 2010). An interesting concept to consider here is that of environmental innovation as a contributor towards achieving environmental sustainability objectives. The concept of environmental innovation has been referred to as new or modified products/services, processes, techniques, practices and systems that avoid or significantly reduce negative environmental impacts (Ekins, 2010). As innovations allows for more radical improvements, environmental innovation could result in benefits otherwise not obtained (Andrews, 2009). On the other hand, innovative activities might be necessary for hospitals to be both environmentally sustainable and
assure regulatory compliance.
Yet, while relatively simple initiatives as purchasing clean energy might be fairly easy to introduce, the inherent complexity of innovation could make environmental innovation difficult to accomplish for hospitals (Machiba, 2010). The purpose of this paper will therefore be to examine how hospitals can shape their organization in order to foster environmental innovativeness. Considering the relative inexperience hospitals have with environmental innovation, the paper will specifically look at the process of generating creative ideas as one of the initial stages in the innovation process. The study will be further focused by specifically examining how patterns of communication and interaction could be organized in a manner that fosters the creation of new and valuable ideas. In that, the practical relevance of the study could be to provide hospitals with a better apprehension of the strategies and initiatives to be taken in order to enhance environmental innovation within the organization. To that end, the research question to be answered in this study is: How can hospitals
organize their patterns of communication and interaction in order to stimulate the generation of creative ideas that contribute to environmental sustainability?
2. Environmental innovation in hospitals
In examining hospitals’ ability and opportunities to be environmentally innovative, this section of the paper will describe some hospital-specific aspects which are deemed relevant to take into consideration when determining a hospital’s innovative capacity. In doing so, this paper characterizes hospitals as high-reliability organizations. Furthermore, the meaning and consequences of environmental innovation as an initiative towards greater sustainability are discussed in order to obtain a better understanding of this concept and its contribution to reducing a firm’s negative environmental impact. Finally, several implications that being a high-reliability healthcare organization could have on a hospital’s environmental innovativeness will be discussed.
2.1 The hospital as high-reliability organization
Research has suggested that the delivery of health care, by its nature, requires that organizations providing such services act as high-reliability organizations (Baker et al., 2006). High-reliability organizations are characterized by their high potential for causing failures that lead to catastrophic consequences, yet the actual number of failures is low due to highly predictable and effective operations. These high-reliability organizations function in hazardous, fast-paced, and highly complex technological systems essentially error-free for long periods of time (Roberts, 1990). The same can be said for many hospitals, where thousands of opportunities for major accidents are possible everyday, but the actual occurrence of medical errors resulting in deaths is found to be extremely low (Baker et al., 2006). Many hospitals are challenged by variability of individual patients, incomplete evidence bases, rapidly evolving technologies, and shifting financial and regulatory climates (Carroll and Rudolph, 2006). Yet, in being a high-reliability organization hospitals seek to minimize the likelihood of system errors or medical accidents in such a highly complex system by ensuring high levels of quality and safety for patients, employees and the public (Knox et al., 2000). In that, reliability principles include methods of evaluating, calculating and improving the overall operating performance of a complex system, which could be applied to improve the rate at which a system consistently produces appropriate outcomes (Gauthier et al., 2006). As such, applying reliability principles to health care has the potential to reduce defects in care processes by helping to understand errors, increase the consistency with which appropriate care is delivered and improve patient outcomes (Gauthier et al., 2006), though high-reliability also allows for other organizational goals to be pursued, like low waiting times and fast and accurate laboratory results (Carroll and Rudolph, 2006).
accountability, frequent and immediate feedback regarding decisions, compressed time factors, and synchronized outcomes (Roberts and Rousseau, 1989). Perrow (1984) explicated complexity and tight coupling in particular as key properties of high-reliability organizations, defining complexity as interactions ‘of unfamiliar sequences, or unplanned and unexpected sequences, and either not visible or not immediately comprehensible’. These complex interactions often found in high-reliability organizations commonly result from an extreme variety of organizational components, systems, and levels, each having their own standard procedures, training routines, and command hierarchy (Roberts and Rousseau, 1989). Similarly, the delivery of health care occurs in a complex environment that is dependent on multi-team systems (Baker et al., 2006; Plsek and Greenhalgh, 2001), where decentralization of authority and decision making is usually found in hospitals, needed to permit prompt and flexible field-level responses to unforeseen circumstances and rapidly evolving incidents (Gaba, 2000). Characteristic of decentralized hospitals is that employees frequently operate in distinct silos, have been trained in separate professions and possess distinct expertise (Baker et al., 2006). The traditional model of the hospital is that of a ‘guild workshop’ at which physicians are admitted to conduct their independent work. The workshop provides basic support services, most importantly nursing staff, capital equipment, and specialized shared technologies such as laboratory and radiology, but the work conducted and its quality are strictly the purview of the physician. Despite the advent of managed care and developments in legislation, in most settings the individual physicians, acting independently, are still the primary arbiters of what care is rendered and how it will be accomplished (Gaba, 2000). A culture of reliability is often deemed important in such settings, so that employees are socialized to use similar decision premises and assumptions when they operate their own units. Then, those decentralized operations are equivalent and coordinated, and reliability is enhanced by the encouragement of uniform and appropriate responses by field-level operators (Weick, 1987).
Yet, while healthcare often occurs in a variety of decentralized units, reciprocal interdependencies commonly exist across the many units and levels of a high-reliability organization, referred to as tight coupling (Baker et al., 2006). Tight coupling does not pertain to the number of connections between two units in an organization, but relates to the brittleness of those connections. Tightly coupled systems have more time dependent processes, more invariant sequences, overall designs that usually allow only one way to reach a goal and little slack. Where loosely coupled systems offer more opportunity for immediate, spur of the minute, redundancies and buffers, tight coupling means that there is no slack or buffer between two components of a process, so that ‘what happens in one directly affects what happens in the other’ (Perrow, 1984). In other words, the tasks performed by one organizational member are influenced by the tasks performed by other members of the firm, where these tasks must be coordinated for effective performance and delivery of safe care (Baker et al., 2006; Plsek and Greenhalgh, 2001). This subsequently implies that in tightly coupled systems the buffers
2.2 Environmental sustainability and innovation
Although providing reliable and high-quality care continuously remains the primary concern of hospitals, these organizations have, as previously mentioned, moved forward towards addressing sustainability issues as well. Responding to society’s increasing focus on sustainability, companies have become aware of their own responsibility in this matter, subsequently implementing corporate sustainability as a business activity (Aras and Crowther, 2009). While subject to varying definitions, the concept of corporate sustainability can be defined as ‘meeting the needs of a firm’s direct and indirect stakeholders (including shareholders, employees, customers, pressure groups and communities), without compromising its ability to meet the needs of future stakeholders as well’ (Dyllick and Hockerts, 2002). In that, corporate sustainability usually describes the planned and strategic management processes of working towards a balance of economic, social, and environmental goals and values (Signitzer and Prexl, 2008). Corporate sustainability is thus considered to comprise three dimensions, where the environmental dimension is specifically concerned with the maintenance of natural capital (Goodland, 1995). Environmentally sustainable companies are thereby said to ‘use only natural resources that are consumed at a rate below the natural reproduction, or at a rate below the development of substitutes. They do not cause emissions that accumulate in the environment at a rate beyond the capacity of the natural system to absorb and assimilate these emissions. Finally they do not engage in activity that degrades eco-system services’ (Dyllick and Hockerts, 2002).
product quality, environmental innovation essentially pertains to those innovations which result in a reduction of the environmental impact whether such an effect is intended or not (Machiba, 2010).
2.3 Environmental innovation in hospitals
In examining environmental innovation in hospitals, this paper will focus specifically on University
Medical Centers (UMC’s) vested in the Netherlands. These hospitals might have much to gain by
taking environmental sustainability issues into consideration. From the information that is currently available in this respect it can be deduced that the negative impact of the UMC’s on the environment in terms of energy and water consumption, waste generation etc., will presumably increase in the years to come (Preliminary Study MJA-3 UMC’s, 2010). For example, the absolute amount of energy consumption shows a growing tendency, particularly due to an increase in the usage of electricity, as depicted in figure 1. This increase in absolute consumption is caused on the one hand by volume growth, meaning that more physicians and students will need to be educated and an increasing number of patients and diseases have to be researched and treated. On the other hand, the usage of more energy consuming medical equipment additionally accounts for the rise in energy consumption by UMC’s. Though developments like a concentration of basic functions, the more efficient use of buildings and its surface, and remote training and learning should slow down absolute energy growth, a decrease in consumption cannot be established that way. If the actual energy consumption keeps developing as it has the past years, consumption will increase with approximately two percent each year assuming that energy savings remain at a level similar to that of previous years. If no further measures towards energy conservation would be taken, the total amount of energy consumed would rise even more each year, where volume growth in combination with rising energy prices will possibly
double the energy costs by 2030(Preliminary Study MJA-3 UMC’s, 2010).
As such, these findings on the increasingly negative impact that UMC’s appear to have on the environment suggest that benefits are to be obtained from aiming to be more environmentally sustainable. This is especially true of more rigorous energy-efficiency goals; as the more easily attainable sustainability objectives will become scarcer, the firm will need to increase its efforts to secure acceptable levels of energy/water consumption, waste generation etc., often demanding considerable innovative activities (Preliminary Study MJA-3 UMC’s, 2010). Yet, while many UMC’s have stated their intention towards becoming a more sustainable company, environmental innovations are currently scarce. This could be due to a lack of external forces and trends driving environmental sustainability within the UMC’s. In being high-reliability healthcare organizations, the main external stakeholders of UMC’s, which aside from patients include healthcare providers, insurers and patient associations, are primarily concerned with error-free, quality patient care (Baker et al., 2006), as well as with issues like financial performance and market functioning (Consultation Report, 2010).
Numerous other organizational and environmental issues seem to constrain environmental innovation within UMC’s even further. When looking back a number of years, it becomes apparent that the healthcare industry has been a rather conservative sector. Not many substantial changes have occurred in patient care during this period; the scale has increased and the treatment methods are more
profound, but significant changes have not come about(Consultation Report, 2010). The existence of
a ‘guild structure’, with own specialties, training and associations (Gaba, 2000), has not been beneficial to innovative practices either, as physicians for example tend to stick to more traditional and familiar treatment methods even when less invasive treatment methods exist. This, as traditional working methods are ingrained in the culture and interpretation of the physician, who often consider alternative methods as an existential threat for their individual autonomy and reputation or their entire profession, except perhaps when alternatives are complementary to current practices (Omachonu and Einspruch, 2010; Consultation Report, 2010). Another trend evident from considering past years, is that patients mainly desire the traditional treatment methods, which could stifle innovativeness. Furthermore, the control and financing systems currently present within University Medical Centers might additionally constrain innovation; for example, financial compensation on the basis of the number of nights that patients stayed in the hospital makes investing in alternative treatment techniques with shorter recovery times less attractive (Consultation Report, 2010).
operational processes of firms, particularly in the absence of centralization (Gaba, 2000). As such, current laws and regulations may represent significant barriers which hinder innovative activities in hospitals (Herzlinger, 2006). Furthermore, regulation is generally not up-to-date, thereby stifling innovation as new opportunities and developments are often not yet acknowledged and accepted. Lobbying for a more rapid adjustment of regulation is extremely difficult for UMC’s, particularly because regulation is often established at the European level (Consultation Report, 2010).
Thus, while sustainability might be of increasing significance to UMC’s, environmental innovation has not been a common occurrence due to numerous innovative constrains. The purpose of this paper will therefore be to examine how environmental innovation can be stimulated within UMC’s, taking the characteristics of high-reliability organizations into consideration. It is important at this point to acknowledge that the formation of innovations is often assumed to be a multiple stage, non-linear process (West, 2002). Though numerous stages of innovation could be distinguished, this paper draws on West (2002) in considering innovation to be a two-component process, encompassing both creativity and innovation implementation. Thus, to be innovative, organizations will have to be creative, yet also demonstrate high levels of initiative to bring these creative ideas to the implementation stage (Amabile, et al., 1996). Creativity involves the production of novel and useful ideas in any domain (Woodman et al., 1993). In that, creativity can be conceptualized as a necessary first step or precondition required for innovation, where the creative outcomes can range from minor adaptations in workflow or products, to major breakthroughs and the development of entirely new products or processes (Shalley and Gilson, 2004). Innovation implementation on the other hand, is the process of gaining the appropriate and committed use of an innovation by target employees (Klein and Sorra, 1996). So, where creativity concerns thinking about new things and developing ideas, innovation implementation is about the application of these ideas, i.e., the introduction of new and improved products, services, and ways of doing things at work. Ultimately innovation can then be
defined as comprising both stages (West, 2002).
As the following section discusses dimensions of work environments that are related to innovation, distinguishing between the different stages in the innovation process is deemed relevant since particular variables may influence creativity differently than innovation implementation due to their conceptual differences (West, 2002). As separately discussing organizational environments for both creativity and innovation implementation would be beyond the scope of this paper, the remainder of this paper will specifically focus on the context of creativity. This in the expectation that, as environmental sustainability has not played a significant role within hospitals as of yet, the number of existing environmental innovations to be implemented is limited. This would imply that currently the challenge for hospitals would be to create environmentally sustainable innovations, before
3. Fostering creativity in (high-reliability) organizations
Focusing on the fuzzy front end of innovation, this section of the paper discusses the organizational factors predominantly identified in prior research as fostering creative behaviors within firms. In that, several propositions are composed concerning the possible ways to effectively organize a high-reliability organization such as a hospital towards establishing these organizational factors and
stimulating creativity towards environmental sustainability objectives.
3.1 The fuzzy front end of innovation
One significant aspect of creativity involves stimulating and/or facilitating the generation of new ideas. In new product development (NPD) research, idea generation is often referred to as the fuzzy front end of the NPD process, as depicted in figure 2. Considered to be the earliest stage of the NPD process, the fuzzy front end covers the period from the generation of an idea to its approval for development or termination (Verworn, 2009). Research has suggested that of all the actions that organizations can take to improve their NPD processes, those taken at the fuzzy front end provide the greatest time savings for the least expense, due to the relatively low cost of generating several potential ideas compared to the cost of actually implementing any one idea (Reid and de Brentani, 2004). Research has provided evidence for a link between new product performance and time spent on up-front activities, suggesting that a search for better processes in support of the fuzzy front end appears to be called for in order to help firms achieve greater success in their efforts to develop new products, services, processes etc. (Cooper and Kleinschmidt, 1995). Thus, as activities and decisions concerning the fuzzy front end can be considered the starting point of innovation processes, assessing ways to organize this stage is deemed particularly relevant in examining how to enhance creativity in high-reliability organizations. As creativity and innovation initially demands novel and valuable ideas, considering this early stage of the creative process is regarded an appropriate way of further focusing
the scope of this study.
Figure 2: The fuzzy frond end of innovation (Koen et al., 2001)
idea generation and creativity. A substantial body of research has accumulated on a wide range of factors at the individual, group and organizational levels of analysis found to be associated with creativity in the workplace (Shalley and Gilson, 2004; Anderson et al., 2004), yet this study will focus specifically on fostering creativity at the organizational level. In that, this section will provide a brief description of several organizational and situational factors found to determine the creative capacity of organizations, examples of which are depicted in figure 3. The organizational factors predominantly considered to facilitate or inhibit creativity and innovation within firms include organizational encouragement and support, the availability of resources and the organizational structure (e.g. Amabile et al., 1996; Woodman et al., 1993; Shalley and Gilson, 2004).
Figure 3: Organizational and situational factors influencing innovation (adaptation of Glynn, 1996)
3.2 Organizational encouragement and support
creativity has thus demonstrated that employees are more likely to produce unusual, useful ideas if
they are given license to do so by the situation or by explicit instructions (Amabile et al., 1996).
Behavioral attributes said to be conducive to creativity within organizations include challenging the status quo, idea generation, risk taking behavior, open exchange of information etc. (Woodman et al., 1993, Amabile et al., 1996). Encouraging such behaviors should enhance creativity levels within a firm as they stimulate employees to experiment with new ideas and be more open to communicating and seeking input from other sources (Shalley and Gilson, 2004). For example, as pursuing creativity usually involves risky courses of action, an organization’s disposition towards risk and the level of uncertainty avoidance affects employees’ propensity to be creative (Ford, 1996). Additionally, the higher levels of challenge often associated with risk taking could incite interest and excitement amongst employees about their work activities, focus attention and effort towards completing these activities and demand creative achievements by, for example, encouraging individuals to focus simultaneously on multiple dimensions of their work (Oldham and Cummings, 1996). In that, employee trust of management is central to dealing with the uncertainty and complexity inherent in creativity, as trust enables individuals to take risks without fear or undue penalty for failure (Chandler et al., 2000). On the other hand, the absence of external controls or constraints is also assumed to be a prerequisite as it allows individuals the flexibility to explore new ways of doing things, consider different alternatives, take risks and experiment with ideas and materials, thus calling for a supportive,
non-controlling organization (Shalley and Gilson, 2004).
significantly lower than those expecting an external evaluation that would provide constructive information on how to improve their performance, which is beneficial for both the intrinsic motivation and the creativity of employees (Shalley and Perry-Smith, 2001).
The open interaction with members of the organization has additionally been considered an effective way towards enhancing employees’ perceptions of encouragement and support for creativity (Scott and Bruce, 1994; Tierney et al., 1999). By openly interacting with employees, firms can communicate their expectations concerning creative behaviors, which could for example be manifested in creativity goals and objectives. Having goals can play a significant role in the motivation that individuals display towards attempting creative actions, as goals are desired outcomes that are an essential part in organizing intentional behavior, attention and action (Ford, 1996). The establishment of goals increases individual attention and effort by providing clear targets towards which employees can direct their energies. Indirectly, goals might also motivate employees to discover and use task strategies that will facilitate goal achievement (Shalley and Gilson, 2004). Creativity goals might be a stated standard that an employee’s output should be creative or that individuals should attempt to engage in activities that could lead to creative outcomes, like environmental scanning, data gathering etc. On the other hand, the occurrence of creativity has been found to be less likely when goals for creativity are not established, yet goals for other aspects of performance, such as production quantity or possibly the reliability criteria as maintained by high-reliability organizations, are formulated. A related way in which leaders can foster the creative performance of individuals is by making it a requirement of the job, thereby explicitly or implicitly making it known that creativity is required to perform the job effectively (Shalley and Gilson, 2004). By clearly communicating the desired goals and requirements, organizations can signal their disposition towards creativity. Open interaction could furthermore decrease the likelihood that individuals experience the fear of negative criticism that can undermine the intrinsic motivation necessary for creativity (Amabile et al., 1996).
Proposition 1: Hospitals desiring to foster creativity towards environmental sustainability will do so by showing organizational encouragement and support through such initiatives as open communication and goal setting.
3.3 Availability of resources
supportive of creativity (Woodman et al., 1993). On the other hand, a lack of such significant resources might reduce the commitment to creative goals (Chandler et al., 2000). Additionally, the distribution of resources towards the establishment of a reward system that promotes creative and innovative behavior should further enhance creativity levels within the organization. In that, it is contended that creative efforts requires individuals to believe that creative work and performance accomplishments will result in rewards, providing the encouragement and motivation for employees to engage in such activities (Woodman et al., 1993). Rewards should be given in recognition of individuals’ competence, attempts to engage in creative activity, and their actual creative accomplishments. As such, rewards could convey important information to employees on the value of creative behavior, where this informational component of rewards has been linked to both intrinsic motivation and ultimately creativity (Shalley and Gilson, 2004). Not adopting an appropriate reward system, for example one that is characterized by ill considered evaluation, could even suppress creativity, especially when non-creative behaviors are rewarded (Chandler et al., 2000). However, the relationship between resource availability and the perceived organizational support for creativity might be confined by a threshold effect, where the allocation of resources above some point have no further effect in facilitating creative behavior (Scott and Bruce, 1994).
However, this paper expects tangible slack resources like materials, equipment and machinery as well as financial resources in particular to be scarcely available to most hospitals, especially for such peripheral issues as environmental sustainability. Hospitals are for example increasingly experiencing strong pressures to contain the growth in health expenditures, where many hospitals are amongst others affected by budgeting cuts and the financial impact of new technologies and drugs. Yet, even in the face of diminishing resources, public expectations of high quality health care continue (Lega and DePietro, 2005). As such, a significant amount of resources will be needed to produce a level of organizational output which meets reliability and quality demands, where sustainability concerns are subsequently forced to compete with numerous other and possibly more pressing issues for any remaining (slack) resources (Andrews, 2009). The possibilities for employees to try out new ideas or take risks may subsequently be restricted by such a lack of tangible and financial resources, while a failure to allocate sufficient resources towards innovation initiatives could additionally be interpreted by employees as a lack of organizational support and encouragement. As such, the absence of resources needed for the development and implementation of ideas could dampen the motivation to behave creatively or might result in employees refraining from creative thinking altogether, even more so as there are little prospects for rewards to be had (Amabile et al., 1996). Therefore, the lack of sufficient tangible and financial resources could decrease the creative capacity of the organization.
Proposition 2: The limited availability of tangible and financial slack resources will constrain the creative capacity of hospitals.
organizations, influence can be exerted on these components. Task motivation is affected by the presence or absence of salient extrinsic constraints (Amabile, 1983), where as previously mentioned such factors as autonomy, fair evaluation and rewards, and open interaction are found to enhance intrinsic motivation (Amabile et al., 1996; Shalley and Gilson, 2004). Creativity-, and domain-relevant skills could amongst others be improved through training and education (Amabile, 1983). Training can provide guidance on how to generate novel ideas, whereas education might result in exposure to a variety of experiences, viewpoints, and knowledge bases, reinforce the use of experimentation and divergent problem solving skills, and lead to the cognitive development of individuals so that they are more likely to use multiple and diverse perspectives and more complicated schemas. Additionally, employees should be more comfortable in trying new things and be aware of different alternatives and opportunities when a more extensive skill set is developed (Shalley and Gilson, 2004).
Collectively, these individual skills could accumulate or convert into what Glynn (1996) describes as organizational intelligence, defined as ‘an organization’s capability to process, interpret, encode, manipulate, and access information in a purposeful, goal-directed manner, so it can increase its adaptive potential in the environment in which it operates’ (Glynn, 1996). In that, organizational intelligence does not merely encompass domain-relevant knowledge, but also pertains to context-specific knowledge related to problem perception and information gathering, making unfamiliar events understandable in terms of how they relate specifically to the organization (Damanpour, 1991; Glynn, 1996). As such, the generation and development of creative ideas demands the availability of sufficient information, knowledge and skills throughout the organization (Monge et al., 1992; Woodman et al., 1993), often substantially present within hospitals which are human capital and knowledge intensive organizations. Health services are provided by a large multiplicity of different and often highly educated people or occupational groups, such as medical, maintenance, and administrative staff, each holding a specific set of skills, expertise and knowledge (Zigan et al, 2009).
Proposition 3: The complex nature of hospitals implies access to a large amount of skills, knowledge and information fostering idea generation.
3.4 Organizational structure
encourage employees to make decisions of their own, making it less likely for these individuals to explore new ways of working (Shalley and Gilson, 2004). The concentration of decision-making authority further prevents innovative solutions, while the increase in communication links makes communication between levels more difficult and inhibits the flow of information and innovative ideas (Damanpour, 1991). Internal strife, conservatism and rigid, formal management structures could further impede creativity as individuals could perceive these factors as controlling, thereby decreasing the intrinsic motivation essential for creativity (Amabile et al., 1996). Also, the bureaucracy within organizations could stifle creativity when subsequently a significant amount of time and effort needs to be taken to get new ideas considered to such an extent that employees are less likely to try new approaches to work (Shalley and Gilson, 2004).
Organic organizational designs on the other hand, represent adaptive and flexible organizational structures like a matrix, network designs and parallel or collateral group structures, which should enhance creativity within firms (Woodman et al., 1993). This, as organic structures promote open, ongoing interaction with the external environment as well as information seeking from different or multiple sources (Shalley and Gilson, 2004). Important aspects characteristic of organic structures said to enhance creativity involves those pertaining to organizational complexity, which entails the level of specialization, functional differentiation and professionalism present within the firm (Damanpour, 1991). When considering the different specialties found in an organization, a greater variety of specialists would provide a broader knowledge base and increase the cross-fertilization of ideas (Kimberly and Evanisko, 1981). Functional differentiation represents the extent to which an organization is divided into different units. Once coalitions of professionals are formed within differentiated units, they can both elaborate on and introduce changes in the units’ technical system and influence changes in their administrative systems (Damanpour, 1991). Diversity and specialization can also have a positive effect on the generation of creative ideas by promoting conflict (Hurley and Hult, 1998). Finally, professionalism reflects the professional knowledge base of firm members requiring both education and experience, which should increase boundary-spanning activity, self-confidence and a commitment to move beyond the status quo (Pierce and Delbecq, 1977).
skills and expertise can be found (Baker et al., 2006). The availability of such assets as information, knowledge and expertise are of significance for improving the creative performance of organizations, though optimally benefitting from these attributes demands effective communication and interaction flows (Monge et al., 1992). Such communication and interaction systems should also allow for information exchange with the firm’s environment, where environmental scanning and extra-organizational professional activities of individuals has been suggested to bring innovative ideas, as this provides opportunities to act proactively (Hurley and Hult, 1998). Creative structures and processes should furthermore allow continuous decision-making, follow through on problems and the
postulation of new issues that arise within the firm (Dougherty and Hardy, 1996).
Proposition 4: From a structural perspective, fostering creativity in hospitals necessitates the establishment of effective communication and interaction flows to optimally utilize the available knowledge, information and capabilities.
As such, research has pointed towards the establishment of social capital, referring to the sum of resources accumulated in the organization by a stable network of intra-organizational relationships. Social capital is assumed to deal with social aspects existing between individuals in an organization, where it is argued that social capital increases the capacities for the creation, sharing and management of knowledge, as well as aid organizations in speeding up the learning process and integrating tacit knowledge (Bueno et al., 2004). Creating social capital requires the hospital to organize the overall patterns of interaction and connection between the members of the organization (Vainio, 2005). On the other hand, relational capital could also be obtained, referring to all resources that are related to the creation, maintenance and extension of external relationships, which could expose the organization to new knowledge, information etc. (Zigan et al., 2009). As hospitals are characterized by the presence of various occupational groups and numerous external stakeholders, organizing effective communication and interaction flows should allow the hospital to access a greater array of skills, expertise, knowledge, information etc. (Zigan et al., 2009). In that, two frequently discussed strategies concern
the establishment of multidisciplinary teams and boundary spanning activities.
3.4.1 Multidisciplinary teams/work groups
with respect to job- or task-related attributes, such as organizational position, profession, education, tenure, knowledge, skills, or expertise, has been associated with enhanced creative performance (Hülsheger et al., 2009). This cross-functionality provides opportunities for the timely integration of critical information in creative processes due to an increased access to new knowledge and information and heightened, high-quality learning experiences (Edmondson and Nembhard, 2009). In that, cognitive diversity should also bring differing perspectives on issues to the group and potentially constructive conflict, thereby increasing the potential number of novel combinations that can be developed, though some degree of overlap in knowledge and skills is said to be necessary for effective group work to occur in this respect (West, 2002). More functionally diverse groups furthermore tend to engage in more external communication, resulting in the group becoming informed by multiple, non-redundant sources of knowledge that expand the creative possibilities (Ancona and Caldwell, 1992). The ability of cross-functional groups to capitalize on this external knowledge sharing could be related to the ability to absorb new knowledge, where having a broad extant knowledge base reflective of the combined experiences and backgrounds of diverse members gives these groups a higher absorptive capacity and thereby increases their potential to see the value of new information (Cohen
and Levinthal, 1990; Edmondson and Nembhard, 2009).
more team members are enabled to perform well, the more they can contribute to the attainment of shared goals. Thus, group members will help each other and discuss different viewpoints to optimize performance for their mutual benefit (Hülsheger et al., 2009). However, task and goal interdependence
must be strongly perceived by individuals to affect their creative attitudes (Glynn et al., 2010).
Group size and longevity have also been contended to influence the creative accomplishments of teams or work groups. Research suggests that work groups are most effective when they have sufficient, but not greater than a sufficient number of members to perform the group task. Creative teams should be large enough for a wide array of diverse viewpoints, skills, knowledge, expertise, resources and perspectives to be found, necessary to complete the complex task of producing creative ideas. Yet, work groups that are too large could become too unwieldy to enable effective interaction, exchange and participation (West and Anderson, 1996; Hülsheger et al., 2009). Furthermore, groups could become less creative over time as communication with key information sources and environmental scanning often decreases. Group longevity is also associated with a tendency to ignore and become increasingly isolated from sources that provide the most critical kinds of feedback, evaluation and information (Katz, 1982). Additionally, long tenured groups often become less creative as they are more susceptible to groupthink, become more homogeneous, and are less inclined to be critical and to challenge the status quo. These groups also tend to develop routine work patterns and stable structures they are unwilling to change as they give them a sense of security (Katz, 1982; West and Anderson, 1996).
high-reliability organizations as this allows health care workers to effectively and efficiently coordinate their activities to deliver safe patient care (Baker et al., 2006).
Proposition 5: Improving the creative performance of hospitals requires the establishment of multidisciplinary teams/work groups, thereby allowing the desired level of reliability to be maintained as well.
3.4.2 Boundary spanning activities
In effect, an innovative team could be regarded as somewhat of a cohesive network in which most individuals have direct ties to each other, enabling team members to act collectively and share information and knowledge as well as non-information resources (Fleming et al., 2007), especially as such closed social structures should engender greater trust among individuals (Coleman, 1988). However, another critical aspect of the innovation process is the ability of the innovating unit, whether this is an innovative team or an individual, to gather information from and transmit information to several external domains (Tushman, 1977). Cohen and Levinthal (1990) for example contend that the ability of an organization to recognize the value of new, external information, assimilate it, and apply it to commercial ends is of significance to the innovative capabilities of the firm. This ability, which was labeled a firm’s absorptive capacity, depends on the individuals who stand at the interface of either the firm and the external environment or at the interface between subunits within the organization (Cohen and Levinthal, 1990). Yet, communication across boundaries has been said to be inefficient and prone to bias and distortion (Tushman, 1977). As such, the development of capabilities enabling the effective transfer of information and integration of multiple sources of expertise is demanded, even more so as organizations are becoming increasingly fragmented by multiple functional, geographical, hierarchical and professional boundaries (Santos and Eisenhardt, 2005), which as previously mentioned also pertains to hospitals.
contrasting coding schemes and play a contact role between the work unit and external information areas (Tushman, 1977). Essentially, these boundary spanners scan the environment for new information, thereby attempting to determine its relevance in relation to the information already available in the organization (Cohen and Levinthal, 1990). The capability to leverage boundary-spanning practices within and across organizations, and as such acquiring and assimilating new information, has also been recognized as central to competitive advantage (Lindgren et al., 2008).
Research has argued that such cross boundary communication often involves several special boundary spanning roles over different phases in the innovation process (Tushman, 1977). At the early stage of idea generation, Fleming et al. (2007) for example claim that when boundary spanners collaborate as brokers, they would invent more new ideas, while also being in a better position to identify opportunities for creative arbitrage, referring to the exportation of ideas from a context in which the idea is already known to a context in which it is not. In case of brokered collaboration, one individual links two or more others who have no direct ties to each other (Fleming et al., 2007). Proponents of brokerage for example argue that individuals whose networks bridge the structural holes between disconnected parties have earlier access to a broader diversity of information and knowledge, have experience in translating information, and have an advantage in detecting and developing rewarding opportunities. Brokerage thereby provides a vision of options otherwise unseen (Burt, 2004). Brokerage has furthermore been correlated with weaker ties (Fleming et al., 2007), where research has contended that weak ties are for instance more likely to connect people with diverse perspectives, different outlooks, varying interests, and diverse approaches to problems while also providing access to a wider array of people and more non-redundant information (Perry-Smith and Shalley, 2003). In that, brokers maintain an advantage as they are ideally positioned to receive new and previously uncombined ideas. In this position, brokers have the best opportunity to generate new combinations,
and exploit and manipulate the information flow for their own benefit (Fleming et al., 2007).
4. Research methodology
The research methodology constitutes the plan of investigation used for obtaining evidence to answer the proposed research question, thereby representing the blueprint for the collection and analysis of the data employed within this paper. In that, the type of methodology applied in this study will be discussed as well as the data sources used.
4.1 Methodology
In examining the aforementioned propositions and aiming to answer the research question posed, this paper adopts a more formalized approach to research. The study conducted can be characterized as descriptive research, defined as the description of phenomena or characteristics associated with a subject population through the collection of data and the classification of the frequency of or interaction amongst research variables (Cooper and Schindler, 2006). This study too will be descriptive in nature as the creative capacity of hospitals will be described, as well as feasible ways to foster creativity further in such high-reliability organizations. In trying to obtain a more in-depth understanding of creative behaviors in hospital settings, this study can be construed as qualitative research, primarily relying on qualitative techniques to gather information on the research topic. Where quantitative research attempts the precise measurement of some behavior, knowledge, opinion or attitude, qualitative research represents interpretive techniques that seek to describe, decode, translate and otherwise come to terms with the meaning of certain phenomena (Cooper and Schindler, 2006). Qualitative or interpretive research thus seeks to develop understanding through detailed
description and is thereby considered the more appropriate form of research for this paper.
Qualitative research thus involves non-quantitative data collection used to increase understanding of a topic. Though several approaches for qualitative research can be identified, this paper will specifically consist of a case study, combining individual interviews with record analysis and observation to understand events and their ramifications and processes (Cooper and Schindler, 2006). Case studies encompass those studies in which one or a small number of cases (respectively single case and comparative case study) in their real life context are selected and where scores obtained from these cases are analyzed in a qualitative manner (Dul and Hak, 2007). Case studies are preferred in examining contemporary events, though only when the relevant behaviors can’t be manipulated. The strength of the case study is its ability to deal with a full variety of evidence, documents, artifacts,
interviews, and observations (Yin, 2003).
4.2 Case selection
question. In that, case information will be presented concerning those organizational attributes deemed relevant for comprehending and analyzing the research findings. Additional sources of information, expected to increase the reliability and generalizability of results, will be described as well.
4.2.1 Case: University Medical Center
The opportunity presented itself to do an in-depth case study within a University Medial Center in the Netherlands desiring further insight into ways to foster environmental innovation within hospital settings. As will be explained further in the subsequent paragraph, it is this one UMC in particular that is used as the case to be examined in order to answer the research question. The significance of this specific case for the study conducted is in the opportunity to both interview key individuals within the organization as well as obtain information through participant observation, referring to the assumption of a role within the social situation in order to gain an inside view of the events (Yin, 2003). Participant observation in particular is considered an important source of evidence in examining patterns of communication and interaction, presumably allowing even more informal patterns to be ascertained. While a general description of the case is provided in Appendix A, the characteristics of the UMC deemed relevant to outline at this point for the examination of communication and interaction patterns specifically pertain to the structure of the organization.
personnel, beds, and OR-time and has its own budget (Selfevaluationreport NIAZ Accreditation 2007). Finally, the advisory and consultative body of the University Medical Center (Staff Assembly, Employee Council and the National Client Council CRAZ) have advisory powers and powers of
consent in divisions (Factsheet, 2009).
In this University Medical Center, environmental issues are mainly the concern of the sector Arbo & Milieu, a unit within the directorship Personnel & Organization which is responsible for health and safety services as well as environmental considerations and policies. The latter is particularly dealt with by the environmental team, part of the sector Arbo & Milieu which consists of environmental advisors (Annual Environmental Report, 2009-2010). In aiming for environmental performance to continuously remain an integral part of business operations, the organization furthermore utilizes decentralized Arbo & Milieu contact persons at the different departments and supporting services (Selfevaluationreport NIAZ Accreditation, 2007). One of the more significant initiatives taken towards enhancing the environmental sustainability of the UMC includes the development of an environmental management system, used to develop and implement the firm’s environmental policy and manage its environmental aspects, thereby striving for a continuous improvement of the firm’s environmental performance. In collaboration with the other University Medical Centers in the Netherlands, the UMC also entered into an environmental agreement with the government (Meerjarenafspraak-3 or MJA-3), which focuses on such issues as the development of an energy management system, sustainable
purchasing and transportation policies (Annual Environmental Report, 2009-2010).
Another relevant aspect of the University Medical Center’s organizational profile when assessing communication and information flows, concerns the hospital’s continuous involvement in numerous partnerships and collaborations with important stakeholders. The more prominent collaborations occur with local general medical practitioners, regional hospitals, and with the other UMC’s in the Netherlands. Other crucial stakeholders in this respect are the National Client Council (CRAZ) and the local and regional patient associations (Social Report, 2009-2010).
4.2.2 Additional sources of information: remaining UMC’s and the NFU
individuals contacted, many failed to respond or expressed an unwillingness to participate assuming they had nothing to contribute to this particular research. Those prepared to take part in this study represented three different UMC’s in the Netherlands, yet the information provided is deemed insufficient in order for these UMC’s to serve as additional cases. Instead, in using the information obtained from these University Medical Centers this paper aims to validate some of the results from the single case study, possibly increasing the reliability or external generalizability of the research findings (Yin, 2003). By focusing specifically on UMC’s in the Netherlands, this paper adopts an approach which resembles the most-similar-case technique, a strategy for conducting comparative case studies which analyzes findings and characteristics across similar or comparable cases in the expectation that this will provide the strongest basis for generalization (Schultz and Kerr, 1986).
Another source of information are the publications by the Dutch Federation of University Medical Centers (NFU), a partnership between all the UMC’s in the Netherlands aimed at maintaining the mutual interests of these hospitals. Particularly the assessments of the NFU in collaboration with consultancy companies exploring the possibilities towards obtaining the energy efficiency goals set out in the environmental agreement MJA-3 are deemed relevant for this paper. As of yet, a preliminary study has been conducted by the independent research organization TNO and the consultancy firm KplusV towards determining the organizational developments and trends which the UMC’s will likely face in the subsequent years, estimating future energy consumption and environmental performance by these organizations, and identifying the most important energy conservation and innovation possibilities (Preliminary Study MJA-3 UMC’s, 2010).
4.3 Data collection and analysis
production processes, particularly concerning the machinery and equipment used. As such, an interview was executed with the head of the directorship Property Management, as this directorship develops and manages the building in which the University Medical Center is vested. Finally, as departments have a certain degree of autonomy in for example their acquisition decisions, the head of one of the departments was interviewed in order to obtain information concerning the fostering of innovativeness at this tactical level. The department concerns a research facility, chosen in particular because aside from an interview, information on events and their ramifications and processes was obtained through participant observation.
Additionally, four interviews were conducted at some of the remaining University Medical Centers in the Netherlands (Appendix B), whereby attempts were made to find participants with functions similar to the interviewees of the case study to increase the comparability of results. As such, interviews were organized with the sector Arbo & Milieu of two different UMC’s, at one hospital interviewing an environmental advisor while at the other a staff member of the unit Corporate Social Responsibility (CSR). At a third University Medical Center, interviews were conducted with the head of a research facility similar to that of the case study, and a purchasing manager responsible for large purchases for scientific medical research. Despite attempts to the contrary, an interview could not be organized with the purchasing department of the case study, yet the interview with the purchasing manager is used as it provides information deemed relevant for the issue of boundary spanning. Finally, an interview was conducted with a consultant of the consultancy KplusV (Appendix B), which as previously indicated was one of the companies approached by the NFU to examine the possibilities to improve the environmental performance of the University Medical Centers in the Netherlands, where the interview focused on discussing the preliminary study MJA-3 UMC’s (2010).
5. Results and analysis
Having introduced this paper’s study on stimulating environmental innovation in hospital settings, describing prior research on fostering creativity within organizations as well as the case of University Medical Centers in the Netherlands, this section will present the results of the case study. These results will subsequently be analyzed, reflecting upon the aforementioned propositions on the basis of the information obtained from the interviews conducted and secondary data sources. The results are
organized based on the structure maintained in the aforementioned literature review.
5.1 Organizational encouragement and support
The previously described environmental management system as established by the sector Arbo & Milieu represents one of the more significant initiatives taken within the UMC towards improving the firm’s sustainability. One of the environmental advisors, who along with a project group was responsible for developing the environmental management system, explained that this measure was taken after the Board of Directors signed an environmental policy statement. In that, the Board of Directors declared their commitment to expanding their social responsibility and contribute to improving their environmental performance by adding an active environmental policy to their business operations (Environmental Policy Statement, 2008). According to the environmental advisor ‘…the
environmental policy statement meant an important starting-point for us, indicating where the Board of Directors stand and what they think.’ As explained by one of the members of the Board of
Directors, the environmental policy and the subsequent environmental management system are established to more cohesively organize the until then rather disintegrated efforts towards tackling environmental issues made by various clusters and directorships. This environmental policy thereby represents an important step towards realizing one of the pillars of the firm’s strategic direction. In this multiannual plan the UMC amongst others expressed a commitment to enhance their sustainability and social involvement, for example stating the desire to make ‘a contribution to improving environmental
conditions and sustainability by e.g. taking measures to help reduce CO2 emissions in new premises’
(Strategic Direction, 2009-2013). In the environmental policy statement the Board of Directors declare their intention to ultimately make the UMC the most sustainable center for care, knowledge development and knowledge transfer in the Netherlands (Environmental Policy Statement, 2008). The environmental advisor pointed out that ‘This objective is easily uttered, but I put it in there [the
environmental policy statement] to see how far the Board of Directors was willing to go. They share the same opinion, so the steps we are making now imply on many fronts that we really want to move ahead in the field of sustainability.’
like purchasing and housing, though the extent to which the environment is an issue of concern appears to differ per University Medical Center. Many of these UMC’s have established somewhat of an environmental policy though or are in the process of developing such, allowing for environmental objectives to be laid down and reported throughout the organization. An environmental advisor at one of these other UMC’s for example described their multiannual policy which ‘…consists of five topics,
being energy consumption, housing, purchasing, transportation and awareness.’ Communication on
the initiatives taken was thereby said to be of importance for implementing policies and gaining employee support and cooperation, where the staff member of one hospital’s CSR unit additionally argued that ‘It is extremely important to inform everybody because before you know it people are
working on similar projects without knowing it from one another. This should be prevented.’
The energy covenant MJA-3 drafted by the UMC’s and the government in the Netherlands signifies another important environmental agreement, designed primarily to attend to issues concerning energy consumption (Annual Environmental Report, 2009-2010). In this covenant the UMC’s have agreed to strive for an energy-efficiency of approximately 30 percent in the period 2005-2020, expanding to an energy-efficiency of 50 percent by 2030 (Preliminary Study MJA-3 UMC’s, 2010). Such energy conservation efforts are made as in recent years the energy consumption has been found to annually increase with an average of three percent, particularly with respect to electricity. This has, amongst others, resulted in an energy conservation project by the principal UMC under consideration, with the purpose of realizing measurable energy and cost savings by increasing the energy conservation behavior of employees and by establishing (technological) energy saving procedures (Social Report, 2009-2010). Executed by a project group consisting of representatives of the directorships Property Management, Personnel & Organization, and General & Technical Services, this project set out to increase employee awareness by informing departments by means of such media as the intranet and by giving presentations, while also distributing energy checklists to be filled in by departments, and performing or supporting energy scans and pilots (Social Report, 2009-2010). The environmental advisor further explained that ‘The project is an awareness trajectory, to which a target was
eventually attached by the Supervisory Board, though this was not the initial motivation of the project. It complicates things when you learn halfway through the project that instead of an average increase in electricity or energy usage of three percent…this increase can only be one percent in 2010…Yet it certainly demonstrates that the Board of Directors stand behind such a project…’
Aside from the previously mentioned energy-efficiency goals, little concrete sustainability goals have been formulated by the University Medical Center. The environmental advisor for example pointed out that ‘… the environmental policy statement is a qualitative summary of issues we want to work
on.’ The main objectives set out in the environmental policy statement are the management and
