VBHC: What changes in the organization of care delivery in a hospital setting? An evaluation of VBHC projects in a Dutch Hospital setting
Master thesis MSc Change Management
University of Groningen, Faculty of Economics and Business
Preface
This thesis is written in a turbulent time of Covid-19, which required adjustments in the process of my thesis, due to the case site of a hospital. I would like to express my gratitude to everybody who has helped and supported me to adjust and finish this master thesis. Therefore, I would like to pay special regards to Oskar Roemeling who has been a great supervisor with his flexibility and support to find new ways to successfully complete the thesis in this turbulent time. Besides that, I would like to express my gratitude to Gera Welker and Vera Hanewinkel who helped to find respondents and assisted where possible, even though they worked under high pressure and had to change to
Abstract
Purpose: Value-based healthcare (VBHC) has been an interest in the healthcare sector, by increasing patient value via outcomes with equal or lower costs. However, the actual outcomes in terms of the change in organizational care delivery have not been researched thoroughly in the Dutch healthcare sector. Therefore, this research aims to investigate the change in organizational care delivery after the implementation of VBHC initiatives.
Methods: a multiple embedded case study is conducted in a hospital setting, with twelve semi-structured interviews with respondents who are all connected to a VBHC program and VBHC experts. Moreover, a Dutch VBHC framework containing four quadrants (patient value, organization of care, costs and steering) has been used to compare the findings and to identify enablers and barriers about the implementation and organization of care delivery.
Findings: the research found that the four quadrants of the framework are partially evident in the hospital setting. Motivation, cooperation, communication, the connection of a business analyst, and patients as co-authors increase the success of the VBHC project. However, the crucial role of data is underestimated, because of the legislative issues of sharing (cost) data and the lack of an universal documentation style in the care network. Moreover, clinicians possibly resist the new working style and innovation that accompanies VBHC.
Table of contents
1.
Introduction……….………P.51. Introduction
Over the last years, governments have been pressuring national healthcare institutions to improve high-quality care with more patient-centered services (Pencheon, 2012). Considering the social, demographic and epidemiological context, hospitals and healthcare systems must respond to these new care needs. This encourages scholars and healthcare managers to redesign the healthcare services in an innovative manner (Carlo et al., 2018). According to Schut (2009), the current free market system in healthcare makes room for new opportunities based on greater accessible and efficient programs. One of these new opportunities is Value Based Healthcare (VBHC) introduced by Michael Porter and Elizabeth Teisberg in 2006 (Porter and Teisberg, 2006).
VBHC shifts the focus from profitability and volume of care, to the value of care. Value is defined as: “health outcomes achieved per dollar spent”. Moreover, practitioners should aim for the highest value possible, which should be the overarching goal of the whole healthcare delivery system. Therefore, the VBHC equation exists; patient value is the health outcomes divided by the costs. The greater the health outcomes divided by equal or lower costs, the greater the patient value(Porter, 2010, p.2477). So, with VBHC patient outcomes increase in value, with lower or equal costs.
Porter (2010) stresses that in order for a value based system to be successful, a reform of the care delivery system is required. To accomplish this value-based delivery system, six strategic principles are designed. These principles stress that health outcomes should be measured along the full cycle of care, integrated practice units (IPUs) need to provide care around medical conditions along the full cycle, bundled payments should to be introduced and electronic medical records need to support integrated care and outcome measurements. Moreover, an universal insurance coverage system is needed. (Porter, 2010).
autonomy and the nurses have less autonomy. All these factors are important to consider when a VBHC project is implemented and has to be successful (Fiorio et al., 2018).
The literature describes the obstacles of implementing a VBHC program in practice. It is claimed that clinicians are not qualified to be managing the VBHC process (Abdallah, 2014). Besides that, clinicians are reluctant to involve patients in the decision making process (Legare and Witteman., 2013). Also, the cultural aspect of the organization is not considered thoroughly (Ahaus, 2018). Furthermore, it is difficult to define and measure value as little research is available on how to make use of standard outcome sets (Damman et al., 2020). In short, VBHC encounters challenges because of the complexity of multiple stakeholders in healthcare and also the acceptance and change in working style of clinicians. Besides that, defining and measuring value is still difficult, and the cultural aspect of the organization is not considered thoroughly in VBHC. Lastly, a fully successful implementation case site of Porters’ VBHC has not been described in the literature yet.
Furthermore, Porters’ VBHC is based on the American healthcare system, so it is questionable if it is fully suitable to apply and copy in different nations, because national healthcare systems differ globally. The Dutch healthcare system is different from the American healthcare system, because Dutch citizens are obliged to obtain basic healthcare insurance. Besides that, the Dutch government keeps a close eye on the insurers and coordinates the basic insurance. Moreover, the electronic health record (EHR) contains all health documentation of patients and enables care providers, for example different hospitals, to electronically communicate. Lastly, the Dutch healthcare sector becomes more centralized with more integrated networks that cooperate. Therefore, Ahaus (2018) designed a VBHC framework based on the Dutch healthcare system. The framework contains four VBHC quadrants of patient value, steering, organization of care and costs.
Even though Ahaus (2018) designed the Dutch VBHC framework, no research is available about what changed in the organization of care delivery in the Netherlands. Besides that, it is unclear what actually has changed in a hospital after a VBHC program is implemented, because little
methodological frameworks for patient centered evaluations are available, because of
To answer the research question, retrospective research is conducted in a Dutch hospital setting. The hospital (hereinafter referred to as the Academic Hospital) started implementing VBHC programs in the form of living-labs in 2017. Currently six different living-labs are implanting VBHC programs. The data is collected via company documents and semi-structured interviews. The results of the data collection are compared to the Dutch VBHC model of Ahaus (2018).
The results from this study contribute to the literature by giving insight on what actually changes in care delivery in a hospital setting when a VBHC program is implemented. To illustrate this, enablers and barriers are designed in the quadrants in the framework of Ahaus (2018), that are considered to be important for the implementation of a VBHC program in a hospital setting (Ahaus, 2018).
Moreover, this research contains a wide scope and identifies different areas for further research to solve the identified barriers in the findings. Besides that, the managerial implications provide a framework with enablers and barriers to consider for managers and clinicians when a VBHC program is implemented.
2. Literature review
In this section the theoretical background on the literature of VBHC will be discussed. In section 2.1 the concept of VBHC is discussed with its different principles. The second section (2.2) dives into the literature on the impact of VBHC in hospital settings focused on clinicians, patients, data gathering and costs. Afterwards, section (2.3) discusses important perspectives about implementing
innovations in a hospital settings. The final section (2.4) contains a reflection of the research.
2.1 Value Based Health Care (VBHC)
Michael Porter together with Elisabeth Teisberg introduced the concept of Value Based Healthcare with their book Redefining Healthcare, which has been the basis for the VBHC research in the world (Porter and Teisberg, 2004). Here, Porter and Teisberg (2004) argue that the focus of the healthcare system should be on value for patients and not profitability and volume. The purpose is to maximize value for patients by achieving the best outcomes at the lowest costs possible (Porter and Lee, 2013). It was argued that the healthcare industry was fragmented (Porter, 2010). Fragmentation is the focus on individual parts of care and not the whole care delivery process. This leads to inefficient
healthcare systems, increased costs and poor quality (Stange, 2009). However, this fragmentation can be solved by implementing VBHC that changes the whole infrastructure of the healthcare system. (Porter, 2010).
The main purpose of VBHC is to deliver the highest value possible for patients in relation to the costs of providing care (Andersson et al., 2015). Porter designed three tiers on which VBHC is based, which guide the shift of the total healthcare reform (Porter, 2008). The three tiers consider if the health status is achieved or retained, the results during the experience of care, and the sustainability of health. Later on, Porter designed a strategy to implement VBHC based on six principles. All principles need to be integrated and complement each other (Porter and Lee, 2013). The principles are briefly discussed below, but appendix A contains a more detailed description of the principles.
The third principle is to move to bundled payments for the care cycle. This means that every patient should pay once for the full cycle of care(Porter and Lee, 2013).. These bundled payments enhance principle four, which is to integrate care delivery systems. It will also enhance teamwork and high value care for everyone involved in the care cycle. This makes cooperation between governments, health systems and insurers necessary. Principle five, expand geographical reach, will result from the former principles and requires a focus on value and not volume. Lastly, all principles are not able to integrate and complement each other without principle six; a supporting information technology (IT) platform(Porter and Lee, 2013).
Since Porter introduced the concept of VBHC, different authors conceptualized these principles into frameworks. As the Dutch healthcare system is different from the American healthcare system, Ahaus (2018) designed a framework of VBHC based on the Dutch healthcare system. The framework consists of four quadrants. The quadrants are: patient value, costs, organization of care and steering. Please see Figure 1 below for the framework of Ahaus (Ahaus, 2018).
Figure 1: Dutch VBHC Framework Ahaus (2018)
Abbreviations framework Ahaus (2018): PROM- Patient Reported Outcome Measures, PREM- Patient Reported Experience Measures, BI support- Business Intelligence support, PDCA- Plan Do Check Act.
clinician. The second quadrant costs aims to reduce costs with equal or improved outcomes for the patient. The third quadrant organization of care aims for multidisciplinary cooperation in teams similar to the IPU’s of Porter (2013), to provide the right care at the right place (Porter and Lee, 2013). Both patients and clinicians need to be included in the new organization of care. Lastly, the fourth quadrant steering aims to constantly improve and learn by visualizing outcomes in a dashboard(Ahaus, 2018).
The difference between Porter(2004;2008,2010;2013) and Ahaus (2018), is that Ahaus focuses more on the use of Patient Reported Outcome Measures (PROMS) in the consultation room with patients to enhance shared decision-making between the clinician and the patient. Also, Ahaus advocates the use of Patient Reported Experience Measures (PREMS) to evaluate the care process by using the perspective of the patient. Besides that, the design of a dashboard to visualize the performance of the care path of a patient is also new (Ahaus, 2018).
Several VBHC initiatives have been successfully implemented. Examples are the UCLA Integrated Performance Improvement Model, the University of Pittsburgh with its Patient Centered Medical Home model, Project Sonar and the Randomized Evaluation Algorithm for Chron’s Treatment (REACT). All these VBHC approaches have been successful in resulting in positive care outcomes by using evidence-based multidisciplinary care. Moreover, these case sites were positive to lower disease complications, lower time to surgery and lower re-hospitalization (Van Deen et al., 2017; Essary et al., 2009; Singh et al., 2018; Khanna et al., 2015). However, as acknowledged by these VBHC case sites, the reproducibility and thus scalability of these VBHC projects is the biggest challenge (Regueiro et al., 2018). Long-term systematic changes are desired to smoothen the transition to VBHC models (Ahmed et al., 2019). This means that currently, projects and models based on VBHC principles do exist, but the whole healthcare reform as stated by Porter et al. (2006) is not practiced yet (Porter et al., 2006). VBHC is considered a system reform, but no complete VBHC system is fully implemented and working accordingly.
Whilst the framework of VBHC has been thoroughly described by Porter et al.
In addition, the dynamics of employees and leaders play a crucial role in VBHC, which seems difficult as they require a different working style. Firstly, clinicians are reluctant to include patients more in the decision making process of VBHC, because they find it time consuming and every patient has different characteristics, so they cannot be generalized (Legare and Witteman., 2013). Secondly, physicians are not educated and trained to be managers, but they have power in healthcare
organizations. Therefore, do they need to be involved in VBHC programs, but also coached to acquire management skills (Abdallah, 2014).
Moreover, it is difficult to define and measure value, because currently only evidence-based guidelines are available (Ahaus, 2018). Also, Mannion and Davies (2002) note that little research is available on how care organizations are able to learn and adopt from analyzing cost and outcomes. It is important to note that just analyzing and displaying the data is not enough (Mannion and Davies, 2002). Finally, it is argued that the healthcare sector is complex and a hospital cannot just implement a new measurement structure for VBHC and expect real improvement in the end (Batalden and Davidoff, 2007).
2.2 VBHC in a hospital setting
The implementation of VBHC is difficult for hospitals, because hospitals require adaptation to a patient-centered clinical pathway that is based on innovative patient evaluations (Pennestri and Banfi, 2019). These innovative patient evaluations can be measured via PROMS, PREMS and the ICHOM set (Ahaus, 2018). Moreover, Porter (2010) stresses that a feedback loop needs to be implemented with a focus on the daily practices that will increase the value of care in the end (Porter, 2010). Also, measuring and processing patient-oriented outcomes and performing the correct economic analysis are keys to achieve better value of care (Gabriel et al., 2019). However, this seems difficult as healthcare is complex, because stakeholders have different interests. For example, the board of directors of a hospital and its doctors who have different strategic goals, or the insurer who wants to keep the costs as low as possible. In VBHC health is seen as an objective parameter, a collective goal and a subjective experience of the patient (Pennestri and Banfi, 2019). Below, the impact of VBHC on clinicians, patients, data gathering and costs are discussed.
2.2.1 VBHC impact on clinicians
When a VBHC program is implemented, clinicians are affected on their daily working practices (Porter and Lee, 2013). Clinicians are required to work in Integrated Practice Units (IPUs) and to use an overall supporting IT platform (Cormier et al., 2012). Moreover, they do not know what types of questions they should ask to include patients in their care process (Schwartz, 1992) Therefore, the VBHC approach requires multidisciplinary involvement and commitment along the full cycle of care under strong leadership (Bozic and Ward, 2014).
Also, because of internal redesign in the hospital, new roles emerge and existing roles require modification. Cross-training and multitasking of personnel becomes more important with patient-centered care (Lega and De Pietro, 2005). Moreover, laboratory professionals are increasingly more important, because they are key to interpret data correctly and thus, increase value (Pennestri and Banfi, 2019).
2015). Clinicians still prioritize clinical outcomes over using, for example PROMS, and base their clinical treatment advise and decisions accordingly (Damman et al., 2019).
In short, VBHC requires clinicians to change to an IT-driven IPU-network and to shift to more patient-centered care. This seems difficult, as clinicians are not trained to this new working style, and are resistant to it. Clinicians opinionate that the patient is centered enough and value their own clinical treatment advise the most.
2.2.2 VBHC impact on patients
The inclusion of patient expectations to organizational and clinical measurement indicators, is argued to enhance the success of incorporating the patients in the VBHC initiative (Pessaux and Cherkaoui,2018). Patients should be routinely questioned on what they find important concerning trade-offs and values, but no specific approach is available on how to construct their preferences (Damman, 2020). If patient values are not explored and they are not assisted in determining their preferences, this might lead to overtreatment and misdiagnoses (Mulley; Trimble; Elwyn, 2012).
Moreover, Patients are finding it difficult to assign values and make decisions based solely on numbers provided by the clinician (Peters et al., 2009; Fagerlin, Zikmund-Fisher & Ubel, 2011). Therefore, risk communication guidelines based on the shared decision making principles can help patients to make valued decisions (Sheridan et al., 2013; Trevena et al., 2013; Tolbert et al., 2018). By successfully using Shared Decision Making Models (SDM) patients’ awareness is increased, the understanding of the available options is more clear and the quality of decisions made is higher in the end (Stacey et al.,2017). Moreover, person-centered learning health systems (PC-LHS) enables to enhance the value for patients. Those systems contain contextual factors of the well-being of
patients, social determinants of health and experiences, values and priorities of patients and their clinicians (Kuluski and Guilcher, 2019).
To sum up, the importance of incorporating patients in their own caretaking process is highlighted, but how to realize that contains to be challenging. Moreover, patients are finding it difficult to base decisions on (numbered) data provided by the clinicians. However, SDM models help to enhance the successful inclusion of patients on their own care process.
2.2.3 VBHC impact on Data gathering
caretaking process (Alonso et al., 2013; Øvretveit et al., 2017; McNamara et al., 2015; Nijagal et al., 2018 ; Verberne et al., 2019).
The International Consortium for Health Outcomes Measurement (ICHOM) is an example of a successfully designed cooperation network, that incorporates patient data, physicians and registry leaders. The ICHOM sets enables clinicians to measure, analyze and improve performance by making the patient the center of the care delivery process in a coordinated and effective process (ICHOM, 2020). Another example are Patient Related Outcome Measurements (PROMS). PROMS can
successfully be used to optimize the care delivery for a preferred technique based on the perspective of patients (Black, 2013). Using PROMS has been proven to increase awareness of patients’ concerns (Marshall , Haywood, Fitzpatrick, 2006). Also, it enhances the communication between the patient and the care provider (Yang et al., 2018).
However, the use of standard outcome sets encounters problems. Currently, no PROMS are available to analyze care delivery processes where patients encountered complications during the treatment. Also, the amount of PROMS analyzed is little. Therefore, it is difficult to base decisions on limited respondents (Phan et al., 2019). Besides that, PROMS often neglect the inclusion of clinicians and surgeons (D’Ambrosi et al., 2018).
Moreover, it has been shown that technological problems and lack of time of supportive personnel make it difficult to successfully integrate PROMS in the consultation of patients (Damman et al., 2020). Also, a lack of knowledge on how to support patients in using PROMS prevents it from being successfully implemented (Damman et al., 2020). Finally, definitions that are used to compare outcome data vary between countries or institutions, which hinder comparisons. Therefore, it is important to develop and use universally standard outcome sets (Black, 2013)
In short, VBHC requires standardized data sets, and a strict adherence to reporting procedures, in order to facilitate decision making and determine overall care value. The ICHOM set and PROMS are valuable to use, but also confront problems. The systems are not innovated completely to include all parties involved and to communicate effectively in the whole care cycle and between nations.
2.2.4 Impact on Costs
stay of patients in the hospital. The efficacy results in a reduction of re-hospitalization. These increases in efficacy and efficiency are beneficial, because they lower overall costs for the hospital (Fiorio, Gorli, Verzillo, 2018). Finally, evidence suggests that activating patients in their own healthcare process is associated with lowering costs (Hibbard, Greene, Overton, 2013).
To successfully implement VBHC principles, an one-time investment is required that trains staff on the new procedures and processes. The return on investment will probably yield, once the principles are fully integrated in the daily practices and the organizational culture (Damman, 2020). However, value calculation is difficult for health organizations, because it requires both PROMS and cost information, which are not always easily available. Besides that, gathering that amount of information is very time consuming and thus, costly. Moreover, it requires good cooperation between the employees that manage the costing systems and the clinicians delivering care (Gabriel et al., 2019).
To conclude, implementing VBHC leads to more efficiency and efficacy, which result in lower overall costs, due to lower re-hospitalization. However, according to VBHC, patients pay once for their full care process, and this is difficult because it requires successful cooperation of all actors involved in the care delivery. Moreover, value calculation is challenging, because it requires varied information, which is not always available.
2.3 Implementing Innovations in a hospital setting
Academic medical centers are constantly innovating and developing new treatment options and working styles. These new innovations need to be evaluated on their success, but this encounters obstacles and points of attention. The following paragraphs highlight these obstacles and points of attention to consider, when a (patient-centered) innovation is implemented and evaluated in a hospital setting.
Fiorio et al. claimed that patient centered innovations are difficult to evaluate, because the required data might be sensitive and not available for research. Also, the diversity in types of patients and all their required characteristics make it difficult to design a patient centered evaluation methodological framework for evaluation. (Fiorio et al., 2018). Moreover, Grimshaw et al. (2005) showed that implementing new knowledge and interventions in care, does not necessarily lead to greater effects (Grimshaw et al., 2005).
institutions in and outside of the organization (Kampstra et al., 2018). However, evaluating the different options of treatment processes is known to be a subjective process for clinicians, patients and researchers (Ubel & Silbergleit, 2011; Veatch, 2007). This might be, because patients allocate the evidence differently from clinicians. For example, non-clinical outcomes might patients find more important than clinicians (Damman, 2020).
Also, when an implementation process is analyzed, the meaning-making process of the innovation differs between policy makers and clinicians (Timmermans and Berg, 2003). The cultural shifts, long-term goals and underlying assumptions are often not clear to doctors and nurses when they are initiated by policy makers. This is due to the identification of clinicians to their specialization within the hospital. This problem can be solved by developing organizational sensitivity in clinical education in the specialization (Liberati et al., 2015). Next to this, managers and policy makers in hospitals should first take the natural networks of hospitals into account before trying to change them. Therefore, it is very important to first understand the organizational culture before implementing a change (Braithwaite et al., 2009).
Altogether, it is important to note that clinicians, patients and policy makers all have different perceptions about the patient-centered innovation, when evaluated. Moreover, it is highlighted hat clinicians do not always understand the purpose and need of the innovation, because of lack of communication.
2.4 Reflection
Reflecting upon the literature review, it can be concluded that more empirical research is required about the actual outcomes in the organization off care delivery in VBHC programs. It is still not clear what actually changes in the care delivery after a VBHC program is implemented. Also, no full VBHC healthcare reforms according to the principles of Porter (2004;2008,2010;2013) have been described in the literature. Moreover, little research is available about what enables the implementation of a VBHC program and what experienced barriers are. Therefore, this research fills that empirical gap by researching a VBHC program in a Dutch hospital setting in a retrospective nature. This study
evaluates the process of the VBHC program and identifies enablers and barriers. Afterwards, the findings are compared to the Dutch VBHC framework of Ahaus (2018) to consider the Dutch context and to provide insights about overlapping enablers and barriers and to identify new ones.
3. Methodology
In this section the nature of the research is explained. First, the choice of a case study is discussed, Second, the research setting and the case selection is explained. Third, the data collection methods are defined. Lastly, the methods of the data analysis are clarified.
3.1 Research approach
A case study was chosen, because the aim of this research was to gather new insights on the actual effects of implementing VBHC programs. Currently, little information and research is available on the effects of implementing a VBHC program in a hospital setting, so this research is considered
explorative. Due to its explorative nature, and a ‘how’ research question, the case study seems to be most appropriate (Yin, 1994; Meredith, 1998).
Accordingly, a multiple embedded case study is chosen, because it allows to analyze the data within the cases and to compare the cases of different departments. By taking the multiple case study approach, patterns emerge between the cases and differences occur. Besides that, in-depth analysis of the single cases is possible and can be benchmarked against the other cases (Yin, 2003). This makes the research strong and reliable (Baxter and Jack, 2008). Moreover, a multiple case study allows for a wide exploration of the research question and different departments of the Academic Hospital participate in this research. Also, a multiple case study guards against the observer bias and increases external validity. (Eisenhardt and Graebner, 2007). Finally, two different types of data collecting are used. Namely secondary-data documents and semi-structured interviews. Because of this combination, triangulation is ensured where different types of methods increase the reliability and validity of the research (Karlsson, 2016).
3.2 Case description
The case site of this research is a large Academic Hospital In the Netherlands, also referred to as the Academic Hospital. The hospital is a considerable big player in the healthcare system as the biggest hospital in the north of the Netherlands. The hospital founded its medical center in 2005, has around 14000 hospital beds and around 13000 employees, which makes it the largest employer in the northern Netherlands. Moreover, the three core aspects of the hospital are patient care, medical education and scientific research. Finally, the hospital has a managing role to all the other hospitals in the region, due to its expertise in treatment of complex cases.
launched the Project VBHC in 2018 where different academic hospitals work together on VBHC. The project VBHC started in the Academic Hospital, because of quality agreements made with the Insurer and the board of directors of the Academic Hospital. The insurer wanted the Academic Hospital to include VBHC in several high priority departments. Together with the board of directors and established Managing Project Team, four living-labs were initiated and started with a kick-off event in December 2017. The living-labs are project groups that try to incorporate a VBHC initiative in their department.
The board of directors established the Managing Project Team which takes the lead in the Program VBHC and have a consultation role towards the living-labs. All living-labs contain a project leader and a medical leader. Besides that, the Managing Project Team chose a free approach on how the living-labs wanted to implement VBHC. These approaches vary in scope, timing, policy and engagement of professionals and patients. Since 2017, new living-labs are introduced and other living-labs are at a final stage. Currently, six living-labs are implementing VBHC programs, which are the Heart-network, Oncology-network, Stroke follow-up care, Nephrology 1, Neprhology2, Appropriate treatment plan older oncology patients.
3.3 Data collection
This research is retrospective in nature, and combines different types of information from each case site. This varied from analyzing secondary data e.g. action plans and memo’s, to primary data consisting of interviews with stakeholders. Additionally, extra data was gathered, when something was unclear, or required more elaboration via e-mail.
First, secondary data was gathered and analyzed as input for the semi-structured interviews and to obtain more insight on the case site. Second, 12 semi-structured interviews were conducted, because they are appropriate to explore sensitive and complex issues. Moreover, the
To complement these semi-structured interviews with project leaders of the six living-labs, different actors who were all connected to the program VBHC have been interviewed. First, the two
coordinators of the program have been interviewed and a business analyst has participated in an interview. Also, two current and one former member of the managing project team have been interviewed. To sum up, all respondents have been or still are connected to the Program VBHC in the hospital. Respondent Ruben is a professor in healthcare management and is considered to be one of the experts in the field of VBHC in the Netherlands. Respondent Rick is also an expert in VBHC with a background as a researcher at the Academic Hospital and several management roles. Also, some respondents have been interviews multiple times, because of their different roles in the program VBHC. For example, Anne is one of the coordinators of the program, but also the project leader of two living-labs. The names of the respondents are replaced with fictive names to ensure anonymity.
All interviews are recorded and transcribed thoroughly. After the transcript was finished, the transcript was send to the respondent for approval. By doing this, the internal and external validity increased and the researchers bias was reduced (Voss et al., 2002). Table 1 shows an overview of the respondents and the characteristics of the semi-structured interview.
Interview protocols were designed and send beforehand to the employees. Please see appendix B for the different interview protocols. The interview protocol with the project managers of the living labs has been sent to the research supervisor and to the supervisor of the Academic Hospital. Afterwards the protocol was optimized according to their feedback. Also, the interview protocols with the two experts on VBHC and the business annalist, were corrected after feedback was given by one of the project managers of the managing project team of the Program VBHC. By conducting these steps, the multiple-case research was strengthened by increasing the validity and reliability (Karlsson, 2016; Yin, 1994). Lastly, a test interview was conducted with the thesis supervisor from the Academic Hospital to find weaknesses and to ensure the interpretation of the questions are correct. This improves the quality of the data collection (Chenail, 2011; Kvale, 2007). `
INTERVIEW NAME PROFESSION DATE LENGTH MEANS
1 Anne Project Manager Managing Project team 24-02-2020 94 minutes Face-to-face interview 2 Julia Implementation expert Managing
Project team 03-04-2020 45 minutes Videocall
4 Anne Project manager living-lab Nephrology 1 15-04-2020 56 minutes Videocall
5 Anne Project manager living-lab Appropriate treatment plan older oncology
17-04-2020
61
minutes Videocall
6 Ruben Lector VBHC expert
20-04-2020
38 minutes
Videocall
7 Lisa Business analyst Academic Hospital 20-04-2020
38 minutes
Videocall
8 Sophie Project manager living-lab Heart-network 22-04-2020 63 minutes Videocall
9 Rick Project manager living-lab Nephrology 2
22-04-2020
57
minutes Videocall
10 Lara Project Manager Managing Project team 22-04-2020 56 minutes Videocall
11 Amy Project Manager living-lab Stroke follow-up care 24-04-2020 64 minutes Phone call
12 Rick Lector VBHC expert
24-04-2020
48 minutes
Videocall
Table 1: Overview characteristics semi-structured interviews
4.1 Data analysis
4.
Findings
The findings section starts with an explanation of the organization of VBHC in the Academic Hospital and highlights the adjustments that have been made. Second, the within-case analysis explains the origin, main objective, progress and preliminary results, and the enablers and barriers of all six living-labs briefly. The within-case analysis is brief, because the cross-case analysis that follows, dives more in the similarities and differences of all living labs. Also, the three experts connected to the VBHC program highlight important aspects to consider when a VBHC initiative is implemented. Lastly, all identified enablers and barriers are categorized in the Dutch VBHC framework of Ahaus (Ahaus, 2018).
4.1 Organizing VBHC
Start and structure of program VBHC
In 2017 the board of directors of the Academic Hospital decided in the quality agreements with the insurer to start with a VBHC program. A Managing Project Team was created containing of people with different expertise to implement the program successfully. The chairman of the managing project team was fully employed to the Project VBHC and the other members were only partially dedicated to the program and have a consultation role. The team consisted of an implementation expert, business analyst, program manager, a doctor and the CEO of policies of the Academic Hospital as the chairman. Since the start in 2017, the positions of the managing project team have been replaced by other people with similar expertise, but the role of a business analyst disappeared. The managing project team has a meeting every two weeks, where the project manager brings questions to the table from the living-labs.
To conclude, the Expertise team and the Central Data expertise team would consult the Managing Project team periodically, but this was never really successful. Here, a main obstacle relates to the data-questions from the living-labs to the Central Data expertise Team, which were lacking specificity. Moreover, the Expertise Team had difficulties with the frequency of the meetings, at times there were too many, at other times too few to participate. It seems that the initial set-up or structure at the start of 2017 was an ill-fit, which led the two teams to quit cooperating with the Program VBHC. Instead, the Managing Project Team requests experts to participate individually when needed. Anne mentions that this approach is more successful: “…., so everyone that we want to connect incidental, we do that on an individual basis. So we sometimes ask people” Can I ask you something about this”, or we just have conversations with people…..yes, that works fine.”. Please see Figure 2 below with an illustration of the structure of the Program VBHC at the start in 2017 and currently in 2020.
Figure 2: Organizational structure of Program VBHC 2017 and 2020
The start of four living-labs
process very well. Because, you actually made few agreements about what you have to deliver. So then you also can’t really say; you are too late. Because too late with what? For what?”.
Evaluation of 2018 and start of phase two of Program VBHC
At the end of 2018 an evaluation of the whole Program VBHC was conducted, which resulted in more directive management. Anne illustrates: “In 2019-2020 we went in a more directive direction….So if we want more directive management, we also need to design focus points.”. This resulted in three focus areas that are emphasized in the Program VBHC in the Academic Hospital. Moreover, selection criteria are defined for the new living-labs in order for the Managing Project Team to have a more directive role. Please see table 2 for the outcomes of the evaluation of the program.
Selection criteria new living-labs Focus areas VBHC Academic Hospital
Connects to (one of) the three focus areas
1. Improve patient outcomes in the consultation room
Involve patients in the living-lab 2. Active patient participation in the improvement of care process Include PROMs/PREMs 3. Integrated care network in the
region Periodic evaluations (internally and
with whole managing project team) Consider the cost aspect
Roles need to be defined with its responsibilities
High motivation Medical leader
Table 2: Results evaluation Program VBHC
It can be concluded that the evaluation of 2018 has helped to improve the structure and guidance of the Program VBHC and the expectations of the labs. However, it is still not clear when a living-lab is finished and leaves the Program VBHC. Right now, when living-living-labs prefer to stay connected to the program it is granted when they have a new viable question. This is questionable, because this might slow the process down to engage with new living-labs in the Academic Hospital and for the living-labs to integrate VBHC individually.
Priority of Program VBHC
As mentioned before, the Managing Project Team is still coaching the living-labs, but the position of the business analyst disappeared. Also, the project manager of the Managing Project Team recently changed from Anne to Lara who has only a 20-hour contract. This means that the Managing Project Team has less hours available to coach the living-labs, even though the program is expanding. Besides that, the Expert Team and the Central Data Expertise Team are not operational anymore, which puts more pressure on the Managing Project Team to facilitate the living-labs. Therefore Rick, Anne, Julia and Lara all stress the importance of the priority of the program, because they find the current priority too low. Julia describes: “I would think, hope and want that the board of directors makes this part of the mission and vision. That you say: “VBHC, that is our working style”. If we all focus on that, I think we could make bigger steps.”. Moreover, the Managing Project Team does not know if the priority of the Program VBHC is high or low in the Academic Hospital, because the board of directors do not provide this information. Rick illustrates; “Yes, they know it, but it could be that other priorities prevail. But I don’t know it and I would have liked to know it.” Therefore, it can be concluded that the Program VBHC has more responsibilities since the start in 2017 with more living-labs, but less manpower and expertise consultation.
4.2 Within-case analysis
The following section describes the six living-labs independently in terms of their origin, main objective, process and preliminary results, and enablers and barriers.
Case A - Heart-network Origin
Main objective
The goal of the Heart-network is twofold. The first goal is to establish an integrated network where protocols are implemented on what care is provided at what location and to communicate
effectively. After this goal has been implemented successfully, the second goal is to implement shared-decision making based on quality of life questionnaires (PROMS).
Process and preliminary results
The living-lab is successful in creating an integrated network where patients can easily shift between hospitals, to get the right care at the right place. An analysis showed that patients were
over-diagnosed in the care process. Therefore, a protocol is designed to manage what type of care is provided in which hospital. These protocols are designed between the third and second-line
hospitals and is currently designed for the GP’s. Also, patients are included in the process by a focus group and mirror-sessions. Moreover, patients are asked on their quality of life based on PROMS. Currently, this living-lab is analyzing what is saved in terms of money and executions on a general level. This is an adaption from the initial plan of analyzing cost-data of individual care paths, because this was not possible due to legislation issues and the openness of sharing the data of several hospitals. Also, not all cost-data is always correctly electronically documented.
Enablers and challenges
This living-lab is mainly successful because of its great cooperation in the integrated network, mostly due to the good transparent communication and regular monthly meetings from the start with all connected hospitals. The GP’s were not involved from the start, which leads to cooperation issues from the doctors in the hospitals. The doctors in the hospitals are finding it difficult to define their questions to the GP’s, which results in low cooperation, because the GP’s do not know what their exact task is.
Moreover, the designed protocols require a change in working style from the doctors, administrative staff and nurses. The administrative staff has to use the checklist in the EHR and document it
Furthermore, the second goal, to implement shared-decision making based on outcome data provided in the EHR is challenging, because the different EHR’s cannot communicate on an universal level yet. Therefore, a collaboration with the IT department is set-up to design this. Sophie mentions: “.. The EHR’s cannot talk with each other, but that is currently in progress. It really depends on how successful that is going to be. So it is currently horrible, and I hope it’s going to be possible in four years” . Lastly, the living-lab is delayed, because of the complexity of sharing data on an aggregate level in the network and the outcomes-analysis was a time-consuming process. Therefore, no results have been achieved on paper about the implementation of the protocol. Sophie illustrates: “So, we are perfectly on schedule, but you don’t know the results. That takes a very long breath”.
Case B – Nephrology 1 Origin
The living-lab Nephrology 1 was one of the first four projects of the program VBHC and was therefore experimental and in a start-up phase. The nephrology department was already collecting quality of life data, but did not include it in the care-path of the patient.
Main objective
This living-lab has two goals with two medical leaders. The first goal is to get insights on how successful the transplantations are in the full cycle of care, so the integrated unit. The living-lab wanted to analyze the quality of life of patients who did not get a transplantation and who only take medicine. The second goal is to use PROM data in the consultation room with patients to enhance shared-decision making. As mentioned before, quality of life data was already asked, but not included in the consultation room yet. Therefore, Nephrology 1 wanted to incorporate that type of data in the consultation room. The PROMS are integrated in the program Roqua and did not fulfill all the needs of the doctors, because it was not generalizable over the whole patient group. Roqua is an electronic program that is mainly used in scientific medical research and therefore not most
appropriate to use in the consultation room. Besides that, Roqua is not integrated with the other system that the department uses, so currently the living-lab is trying to implement the PROMS in the EHR via a dashboard.
Process and preliminary results
The second goal was also adjusted. The PROMS are analyzed in the program Roqua and did not fulfill all the needs of the doctors, because it was not generalizable over the whole patient group. It is possible to analyze results per patient, but not in relation to the whole patient population. Besides that, because the program Roqua is a different system than the EHR, no comparison is possible between the quality of life PROM and clinical outcomes that are documented in the EHR. Therefore, the living-lab is currently trying to implement the PROMS in the EHR via a dashboard. The next step is to find the connection with the integrated network, but this is on-hold, because a subsidy is provided for a new living-lab Nephrology 2, which is the current priority.
Enablers and barriers
The cooperation in the living-lab was good, but it was noticeable that the medical leaders had a preference for one specific goal and differed in motivation. Anne illustrates: “When you notice a difference in ambition, then there can be an uncertain moment when you say; ‘okay we think this part of the data analysis is not feasible’, is there still enough motivation from people to make a case out of it?”. Moreover, the collaboration with the Managing Project Team was good, but the assistance was sometimes difficult because of the optimistic goals. The living-lab had no data-expert in the team, but the Managing Project Team could not assist with that. Another barrier is that Nephrology 1 used the program Roqua instead of the EHR, which resulted in an adjustment of the goal, because the doctors were not satisfied with the use of Roqua.
The analysis of the quality of life of patients after surgery, resulted in a change in mindset of doctors to not only focus on clinical outcomes. However as mentioned, the living-lab is on hold, because of the priority given to living-lab Nephrology 2, which will be discussed below.
Case C- Nephrology 2 Origin
Nephrology 2 is a result from living-lab Nephrology 1 and started in August 2019 with a granted subsidy. The Medical leader of the living-lab applied for a subsidy of the Zorginstituut Nederland that has the program of Shared Decision-making. The Medical leader of this living-lab is also one of the Medical Leaders of living-lab Nephrology 1. One of the goals of the living-lab is to implement shared-decision making and because of the subsidy, a new living-lab is started with a new Project Leader.
Main objective
patient fills in a PROM about quality of life, and based on the algorithm all possible prognosis are designed. These outcomes are used in the decision with the clinician and the patient to decide on how to continue in the care path. This could possibly lead to fewer transplantations, because of a higher quality of life without a transplantation and thus, lower costs. The illiterate patients are also considered, and therefore it needs to be easy to understand. Moreover, the location where this decision could be made best and with what type of clinician is considered.
Process and preliminary results
The living-lab was a bit behind schedule because of all jurisdiction of sharing and analyzing medical data, but is on schedule again, because of extension of the deadline due to Covid-19. Another
challenge was that there was an ambition to include one patient as a co-designer in the project team, but that was not possible. Therefore, a focus group consisting of patients provide feedback on the process on a regular basis. Finally, critique is on the priority of the program VBHC in the Academic Hospital. Rick illustrates; “ …if you see what the other Academic Hospitals can do,….they have a whole team with a lot of people where they can achieve a lot. …. But giving a bit more freedom, so you can do more as a project team, that would be great.”
This living-lab is still at the final stage of all jurisdiction about sharing and using the medical data. However, they have a clear vision on how to continue in the future. The future of the living-lab, highlights the importance of the integrated care cycle. The general practitioner gets a greater role in the shared decision-making. Also, the importance of shared decision making in the whole care path of the patient increases, and requires more integrated participation of the whole network.
Enablers and barriers
Moreover, the cooperation within this living lab is very good with regular meetings every two weeks. Also, the cooperation between the medical leader and the project leader is running smoothly, with the medical leader as the center of attention and the project leader in a supportive role.
to Miss Jansen from a small town.”. Finally, costs are not considered and analyzed actively, but might be lower in the future because of possible fewer transplantations.
Case D- Appropriate treatment plan older oncology patients Origin
This living-lab started with the motivation of the four medical leaders, two surgeons and two geriatricians. They already ran a project about the quality of life of elderly patients undergoing surgery in oncology. The risks of surgery are higher for elderly patients, and therefore they might not benefit from it. This might lead to lower costs, as the patient might choose to not undergo surgery, because it does not necessarily lead to higher quality of life. Still, they wanted assistance from the Program VBHC to start with data analysis and create a theoretical base.
Main objective
The goal is to insert PROMS in the consultation of a patient with a specialist nurse to talk about the goals and quality of life of the patient. However, the Program VBHC provides assistance in data analysis on saved costs in the integrated network. Moreover, a second goal is to formulate a theoretical basis for this new working style to find support for this initiative to expand to other oncology departments.
Process and preliminary results
The living-lab first wanted to collect cost-data in the whole network, but that was not possible due to legislation issues. Therefore, the costs are analyzed internally in the academic hospital successfully. Analysis shows that patient outcomes stay the same with equal or lower costs in the Academic Hospital. The future goal is to collect results of costs in the integrated network in cooperation with the insurer. This is very complex, but with the cooperation of the insurer, the living-lab tries to map it out on a general level.
living-Enablers and barriers
The cooperation and motivation within the living-lab and with the managing project team is good. However, as mentioned before, the Program VBHC connected the living-labs to other departments and gave it more status. Still, some other oncology specialties are divided about the new working style of the project and slow it down in its expansion. The new working style provides a greater role for the specialist nurse that discusses the PROM with the elderly patients. Anne illustrates; “The difference in interests is mainly also to take the next step. That other people say; ‘I think it is ridiculous that you guys are doing this and don’t see the added value’.”. This leads to frustration in the living-lab, because funding gets also more difficult due to fewer support.
Case E- Oncology network Origin
The Oncology Network living-lab was one of the first living-labs of the program VBHC and was already a running project on itself. Hospitals become more centralized and specialized in treating patients with cancer. This means that patients have to move to different hospitals for different parts of their treatment. Therefore, the Oncology Network is initiated to design an evaluation cycle about the processes, outcomes, patient experiences and costs in the network.
Main purpose
The purpose of this living-lab is to help to design a methodology for this evaluation cycle that is applicable for all parties in the network. The methodology has to deliver improvement suggestions about the processes, outcomes, experiences and costs. After the methodology is designed, the cycle is run one time to improve it.
Process and preliminary results
The positive cooperation between all the hospitals resulted from a high level of trust and
transparency of sharing quality and cost data. Together with the outcomes of mirroring sessions with patients, this has led to many concrete improvements that are implemented successfully. For
The analysis of the cost have been based on tariffs and executions, but were challenging. Jane illustrates: “We looked at all the tariffs, well you can’t even share those, there are rules for that.” Still, the living-lab found possibilities to share the data and run the analysis successfully. One analysis showed that for the same Diagnosis Treatment Combination (DTC) was higher at the Regional Hospital than the Academic Hospital for the similar execution. Jane illustrates: “Interestingly, when you take a societal perspective, you would say a patient with lung-cancer can be treated cheaper in the Regional Hospital than the Academic Hospital. The Academic Hospital contains more facilities, more infrastructure, more expertise and so on. That is because the prices aren’t real yet. We saw in the comparison that the tariff, for example for a systematic treatment that had the similar DTC in the Academic Hospital as in the Regional Hospital, was higher in the Regional Hospital….Then you could almost say on a basis of the costs, everybody, also less complex patients, should be treated in the Academic Hospital. Of course, you don’t want that.”
Moreover, this analysis showed that analyzing and comparing costs is quite difficult. Jane: “So it is very difficult to define your policy, because you know that the cost prices and the selling prices are not real tariffs.” Further, Jane participates in the Linean Instituut, a national initiative that investigates how costs can be compared and integrated in a network from the government. She explains that costs cannot be compared in real euro’s, but on a standardized price level, or on a level of
executions. Jane illustrates: “…that is one of the things that is already expressed there, and a paper will be written about it, but if you want to map efficiency effectively, you don’t need euro’s. If you want to use euro’s than you should use standardized prices and not what they currently use.”. Enablers and Barriers
The high level of transparency, trust and discretion between the hospitals has led to sharing high quality and sometimes sensitive data and to successfully run analyses in the network. Initially, another’s’ hospital methodology was copied, but this was not suitable, because it was based on another EHR with different software. This caused problems, because all hospitals document in a different manner and the methodology could not extract the necessary information. Besides that, the EHR does not have sufficient characteristics to function optimally in this network. Therefore, the NKR (Dutch Cancer Register) data is used in combination with the DITA (Darwin Information Typing Architecture) registration, which is a documenting style for technical data. So, no PROMS or PREMS are used in this living-lab. Instead, mirroring sessions are initiated with patients to get the
Further, analyzing actions and comparing it between hospitals is difficult, because patient populations differ in the hospitals and their level of expertise as well. Jane explains: “It was very difficult to collect comparable data from the systems. Subsequently, it was also difficult to correctly interpret the data, because the patient population is very different. So the Academic Hospital is for the complex care.”
Case F - Stroke follow-up care Origin
This living-lab started as one of the four starting living-labs of the program VBHC. Clinicians noted that patients sometimes developed depressive feelings after suffering of a stroke. These outcomes were not included in the follow-up trajectory and were desired to include via a PROM and a consultation with a specialist nurse.
Main objective
The goal is to improve the follow-up care of a patient after a stroke. The program VBHC subsidized a specialist nurse that consults the patients on their well-being in the follow-up care trajectory. The first-goal was to design a validated PROM via file-research. Afterwards, the new intervention of the consultation with the specialist nurse had to be implemented.
Process and preliminary results
First, the living-lab conducted file research to design validated PROMS successfully. Second, the PROMS were implemented in the program Roqua that contains a database on the well-being of patients that suffered from a stroke and their follow-up care. The living-lab was successful in designing a template that incorporates the PROM from the patient compared to the general patient population. The patients can also take the template with their personal results home. Moreover, the template can also be digitalized, with means that the consultation can be conducted via a phone call or videocall.
Enablers and barriers
The cooperation within the living-lab has been very positive, because this got a lot of attention at the start of the process. However, the strategy of the living-lab was contradicting with the opinion of the managing project team which caused some friction. The managing project team stressed the
importance of including the integrated network, but the living-lab wanted to start small only in the Academic Hospital to guarantee its success. Amy illustrates: “…the program VBHC really wanted that, were also really pressuring on it, on that last part that you really have to get that collaboration. We really preferred, that we first got it right ourselves, and afterwards look at that.”. However, now that the implementation if the PROM in the consultation has been successful, the new goal of the living lab is to combine it in the integrated network. Lastly, the final results analysis still needs to be conducted, but the project leader of the living-lab had moved another project, so it is unclear by whom and when this will be done.
4. 3 Cross-case analysis living-labs
In this cross case-analysis the Program VBHC is first analyzed in terms of goals and focus areas. Second, the process of the program and outcomes achieved are evaluated. Third, the structure of the program and the living-labs is analyzed. Lastly, enablers and barriers are presented in relation to the VBHC framework of Ahaus (Ahaus, 2018).
Focus areas and goals of the living-labs
Table 3 illustrates the focus areas of all living-labs compared to the four quadrants of patient value, costs, organization of care and steering from the framework of Ahaus (2018). All living-labs have been questioned about the basics of VBHC principles. Namely, the integrated network in the region, the consideration of costs, the focus of improving the outcomes and values of patients and the inclusion of data to support the these VBHC principles described before.
The quadrant patient value is twofold in the focus areas of the living-labs. First, all living labs aim to improve patient value and outcomes with their projects. Second, the focus area of incorporating data via PROMS and PREMS in the EHR or Roqua, is also connected to the quadrant of patient value of Ahaus (2018).The incorporation of data is present in all living-labs. However, the methods used, vary by half of the living-labs using the EHR and the other half is using Roqua that has a greater focus on scientific research.
Moreover, the quadrant of costs as a focus area is divided in the living-labs. Half of the living-labs focused on analyzing and lowering costs. Living-labs Heart-network and Oncology-network are only successful in analyzing costs in the integrated network. Appropriate treatment plan older oncology patients also analyzed costs, but only ran the analysis internally in the Academic Hospital. The other three living-labs (Nephrology 1, Nephrology 2 and Stroke follow-up care) don’t consider costs actively, but estimate that the costs might lower because of the designed interventions.
The final quadrant of steering is only actively a focus area of the Oncology-network that aims to constantly evaluate the cooperation in the network effectively. The other living-labs also all evaluate their performance regularly, but this is not a focus area. Interestingly, the Heart-Network and Oncology Network are quite similar with its focus areas. Both living-labs focus on the integrated network and its costs, whereas this is a future ambition for the other living-labs. Besides that, both living-labs are high-priority network projects where the Program VBHC is part of a greater whole.
Case E: Oncology network YES YES (Integrated network YES YES (algorithm EHR) YES Case F: Stoke follow-up care NO (Future ambition) NO YES YES (PROM in Roqua) NO
Table 3: focus areas living-labs compared to framework Ahaus (2018)
Appendix D shows Figure 5 with an overview of the goals of the living-labs in relation to the focus areas of the living-labs. The focus area of improving patient-value/outcomes, is supported by the goals; improve patient outcomes/ involve patients in design living-lab, involve patients in their own care process, PROM in consultation patient and Shared decision making. This focus area has the highest frequency of committed goals. This is probably because it corresponds to the two areas of Improve patient outcomes in the consultation room and Active patient participation in the care process of the Academic Hospital.
Thereafter, the focus area of the integrated care cycle/network is second in its frequency of committed goals. The goals of the living-labs are: Provide care at the appropriate location, Design evaluation methodology for the network and Integrated care cycle/network. This also corresponds to the third focus area of the Academic Hospital of Integrated care network in the region. Moreover, the focus area of incorporating data in the living-lab is also mentioned substantially with the goals: PROM in consultation patient, Shared decision-making, Design dashboard and Data-driven decision making. These goals are mentioned substantially, because they facilitate the living-labs in achieving the other goals. Lastly, the focus area of considering costs in not mentioned frequently and only with the goal to obtain lower costs. This is probably because costs do not play a substantial role in the Program VBHC and because of the complexity of analyzing costs.
Enablers in the living-lab
communication led to motivation to finish the project, but not because of the Project VBHC, because the living-lab had different interests than the Managing Project Team.
Also, all living-labs have frequent feedback meetings to discuss the obstacles and successes of the project within the living-lab and with the (partially) the Managing Project Team. This enhances the success of the living-lab, because it remains a priority for all people connected to the living-lab, and it enables to discuss the successes, obstacles and next steps to be taken. Moreover, the Managing Project Team is also positive about the cooperation with the living-labs, but finds it difficult to attract other departments or people with expertise to the program, because most questions are either too vague, time-consuming or complex.
Another enabler is the relation of the medical leader to the work floor. It is enhancing when the Medical Leader is able to motivate the clinicians on the work floor to easily implement and proceed with the process. The medical leader is the key, because he/she knows all staff on the work floor and has to work with the new intervention in the end, as the project leader leaves to a new project. Sophie explains this about medical leader James: “James includes his colleagues from the second-line in the shared decision-making. He is also really an advocate of it. James also really thinks along about what works and doesn’t work for the doctors and specialist nurses. That is really nice.”. Besides the relation of the medical leader with the work floor, an enabler is that the medical leader is motivated himself/herself. All medical leaders were motivated to pursue the project VBHC, except for the Stroke follow-up care, which resulted in a slight delay because of cooperation difficulties with the Managing Project Team and difficulties to conduct the final analysis to finish the project.
Further, living-lab Nephrology 2 has a contract with the NVM (Nierpatiënten Vereniging Nederland) to include patient outcome data as constant feedback on the process of VBHC. The other living-labs do not have a contract with a patient association to continuously involve patients in terms of feedback. However, the Heart-network, Oncology-network and Appropriate treatment plan older oncology patients all use mirror-sessions with patients to gather feedback about the process of the living-lab.
necessarily an enabler, because the start-up phase of a project can be difficult and starting new projects is always good, but these three living-labs have been very successful in achieving their goals.
Expertise/difference in composition living labs
As you can see in Table 4, the structure of the teams of the living-labs differ substantially in terms of their size and connected experts. All living-labs have a project manager and one or two medical leaders. It seems that the success of designing and integrating PROMS enhances when an expert is included in the project. The Heart-network and Appropriate treatment plan elderly oncology patients, both have a business analyst or advisor that is specialized in designing PROMS. The project manager of the Stroke follow-up care is specialized in conducting research in the Academic Hospital and had worked with PROMS before. Moreover, the Heart-network team contains a business analyst, but is using the business analyst for the DITA registration and NKR data, which has also been successful.
Also, both the Stroke follow-up care and the Appropriate treatment plan elderly oncology patients have a specialist nurse in their team to support the new intervention. Additional manpower enhances the success of the new intervention. Moreover, the Appropriate treatment plan older oncology patients was very successful in running several analyses to support the intervention due to a PhD student. Also, the researcher from the nephrology department assisted Nephrology 1 greatly by designing a PROM and to provide insights on the success of the transplantation program.
It can be concluded from this section that the success of the design of the interventions (mainly PROMS) and to run analyses, depends greatly on experts connected to the Program VBHC. Therefore, it is critical that they are included in the living-labs from the start. Initially the Program VBHC
designed the Expertise Team and the Central Data Expert Team to pursue these difficult tasks, but that never successful and the teams were never replaced.
Funding of living-labs
Some living-labs received funding to pursue their project. Stoke follow-up care is the only living-lab directly funded by the Program VBHC. This living-lab was funded to hire a specialist nurse for the consultation to integrate the PROMS. Nephrology 2 is also funded by a national health foundation to develop an algorithm and ultimately to implement shared decision-making. Moreover, both the Heart-network and the Oncology-network are bigger initiatives than only the Program VBHC. They both receive funding from other parties involved from the network. Lastly, the Appropriate
Nephology 1. However, Nephrology 1 currently has a low focus, because the current priority is the greatly subsidized Nephrology 2. Anne explains: “You know the moment money is assigned to it, you know it is a huge external stimulus to start something. Because you have two years with 700.000 euro, that is a huge amount of money. You have money for two years with a project manager to realize what you have initiated. Yes, then a lot of things are moved aside to ensure that it all will be realized.”.
Start date Goals Living-lab team Completed goals Enablers (What went well) Barriers (What went badly) Case A: heart network Start program December 2017, Project not on schedule Integrated care network, increase quality of life patients, lower costs in network Project Manager Sophie, Medical leader Academic Hospital that connected other Medical leaders, Quality advisor (PROMS), IT department for documentation assistance Protocol designed, information on saved costs, Protocol is implemented, lower over-diagnosis Good cooperation 2nd end 3rd- line care, regular (feedback) meetings with network Cooperation with general practitioners, Partially resistance from doctors, cost goal adjusted because of problems sharing data, living-lab is delayed Case B: Nephrolo gy 1 Start program December 2017, Project not on schedule Insights success of transplantatio ns of whole patient population in the network, PROM in consultation room with patients Project Manager Anne, 2 Medical leaders, Researcher Nephrology Change in mindset clinicians to patient values, Insights on patient population, PROMS in Roqua Good communication in small project group, Cooperation Medical Leaders with work floor
