TOWARDS A RESEARCH SUPPORT UNIT
AT THE AMSTERDAM RHEUMATOLOGY
AND IMMUNOLOGY CENTER
17 January 2016
Dr. Lilian H.D. van Tuyl, student no 10733620, L.vantuyl@vumc.nl 06-44030925 Master thesis for the UvA MBA special track in Health Care Management.
Supervisors:
Prof. Dr. J Strikwerda, Professor of Organisation (Internal Governance) and Change, Amsterdam Business School, University of Amsterdam; j.strikwerda@uva.nl
Prof. Dr J.W.J. Bijlsma, Director Amsterdam Rheumatology and immunology Center (ARC), Professor of Rheumatology at UMC Utrecht, VUmc and AMC Amsterdam J.W.J.Bijlsma@umcutrecht.nl
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Executive Summary
Amsterdam has six health care facilities with rheumatologists employed. In three of these, scientific research activities take place. These three facilities, the rheumatology
departments of the AMC and VUmc and Reade Institute, have recently formed a contract alliance: the Amsterdam Rheumatology and immunology Center (ARC). As scientific
research is the primary focus of the ARC, thoughts are that a central research support unit could be tasked to organise the research activities of the ARC across three locations in such a way that the ARC has a competitive advantage in acquiring (contract) research and can dominate the scientific literature in specific areas of expertise within the field of
rheumatology.
The aim of this thesis was to develop a competitive strategy of the ARC and subsequently design a research support unit that can execute the defined strategy efficiently, given the required contract alliance.
Interviews with staff members of the three facilities, representatives of pharmaceutical industry, granting institutions and patients were analysed using qualitative methodology for elements to be incorporated into Porters 5 forces framework and Barney’s resource based view towards competitive advantage. Following the ARC’s competitive strategy, an organisational analysis was done, exploring functional needs, requirements, governance and architecture of a future research support unit, to recommend an optimal
organisational form given the choice for a contract alliance.
The analysis of the competitive landscape and internal resources showed that the alliance decreases local competition while complementary resources lead to a new product,
translational research, increasing the bargaining position of the ARC. The scarce resource – patients to include in clinical trials – can be secured by the bundling of supply from the three centers. Four main functional areas were recognised around which the RSU needs to be designed: research logistics, linkage of internal staff to support collaboration and linkage of expertise to market demands; project management with a focus on resources and finance; and quality management.
In conclusion, the alliance between the three rheumatology centers of VUmc, Reade and AMC into the ARC creates both opportunities and threats. However, the opportunities are likely to outweigh the threats as local competition decreases, scarce resources are used more efficiently and valuable resources are complementary, further improving the ARCs bargaining position. However, in order to accomplish these anticipated opportunities, a professional research support unit needs to be created, that facilitates the performance of clinical studies that run in two or more locations of the ARC.
Through strategy implementation of the RSU over the coming years, strategic objectives of the ARC – to become a top research institute- can be realised.
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Content
Executive Summary 2 Content 3 I.Introduction 4 A. The situation 4 VUmc 4 AMC 5 Reade 5 ARC 5 B. R&D alliances 6C. The chosen construction, contract and contract governance 7
D. Research questions 8
II.Methodology 9
A. Phase 1: analyse the competitive strategy of the ARC 9
B. Phase 2: towards a research support unit 10
III. Results 11
A. Competitive strategy 11
The competitive landscape: Porters’ five forces model 11
Resource based view 17
Discussion 19
B. Organisational design 22
Organisational needs 22
Organisational requirements 25
Emerging design of the RSU 26
Governance of the RSU 26
Roadmap RSU 2016-2021 27
IV. Conclusions 29
V. Recommendations 29
VI. Lessons learned 30
VII. References 31
Appendix I: Samenwerkingsovereenkomst 34
Appendix II: Questionnaire guide for staff interviews 41 Appendix III: Indication for market share of the ARC 43
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I.
Introduction
Rheumatic diseases are common, with about 10% of the Dutch population daily suffering from a rheumatic condition (1). Most rheumatic diseases, like rheumatoid arthritis,
psoriatic arthritis or gout are first suspected by the primary care physician, who refers the patient to a rheumatologist in one of the 80 Dutch hospitals where rheumatologists are employed. The rheumatologist diagnoses the patients and initiates treatment. Most rheumatic conditions are chronic, so that patients remain under the frequent care of the rheumatologist for the rest of their life. Basic rheumatology research is aimed at
understanding disease processes, ultimately to prevent or cure patients from the disease. However, prevention or cure is currently not a short-term realistic goal. Therefore,
clinical/epidemiological research, aimed at improving patient health outcomes, preventing disease progression and assessing effectiveness of drugs is needed.
Research activities can be divided into 1. industry sponsored research, where
pharmaceutical industries pay a hospital to run clinical trials in order to get information on pharmacokinetics, effectiveness and safety of their newly developed drugs; and 2.
investigator initiated research for which grants need to be obtained by the researcher in order to perform the work. Competition for acquiring grants is fierce, with researchers from academic hospitals, universities and other health care institutions battling for funding of their innovative ideas.
Amsterdam counts 18 hospitals; rheumatologists are employed in 6 of these hospitals: BovenIJ hospital, Sint Lucas Andreas hospital, Slotervaart hospital, Reade rheumatology & revalidation, the Academic Medical Center (AMC) and the VU University Medical Center (VUmc). The last three have recently formed an alliance and are now called the
Amsterdam Rheumatology and immunology Center (ARC).
A. The situation
Within the ARC, the rheumatology departments of two academic hospitals and one private rheumatology clinic aim to enhance patient care and scientific research through close collaboration within Amsterdam. At the same time, the two academic hospitals are in the process of forming an academic alliance, the University Medical Center Amsterdam (Figure I).
VUmc
The Rheumatology department of the VUmc was founded in 1996 and is a self-contained department within division I of the VUmc (2). Most research activities are clinical / epidemiological in nature, with only a small proportion of the research taking place in
5 laboratories and the majority in the outpatient clinic. The department has close
connections with Reade (formerly Jan van Breemen Institute). This is evident from the close collaboration between the centers
on education of new rheumatologists, patient care and patient-centered research.
AMC
The department of clinical immunology and rheumatology (KIR) is a sub department of the department of internal medicine (3). The research activities of the KIR are mostly basic immunological in nature, in collaboration with Athrogen (spin off of the KIR) and Amsterdam Molecular Therapeutics (AMT). The majority of research activities take place in the laboratory.
Reade
Reade is the new name of the
organisation that was formed in 2010 by a merger between the Revalidation center Amsterdam (RCA) and the Jan van Breemen institute (JBI) (4). The Jan van Breemen Institute has been a well-known rheumatology clinic since 1905, that specifically services patients with joint problems. In addition to clinical
services, scientific research activities take place in close collaboration with the VUmc. The majority of research activities is clinical/epidemiological in nature.
ARC
To work towards one ARC, one director was assigned to all three rheumatology
departments in August 2013. Early 2014, the staff-members of the three departments came together to work towards a shared ambition (Box I (5)).
Box I: The shared ambition of ARC
The Amsterdam Rheumatology and immunology Center (ARC) is a transparent organisation with excellent facilities to improve the treatment and investigation of rheumatic diseases by combining high quality care with scientific research. The organisation is characterised by short structural and management lines, and clear sets of tasks. Besides structured multidisciplinary consultation, there is always space for informal, easy accessible contact.
Through the safe culture within the ARC we create space for new ideas in the fields of research, care, education and training. We actively invest in the development of our employees, take care of each other, and are open to constructive feedback. We trust and respect each other and can therefore achieve more together than as individuals.
Patients, health care insurers and patient
referrers see ARC as a top institute, characterized by expertise and tailored patient treatment. Patients receive personal care and feel engaged in both research and education.
Subsidisers and researchers, both in the Netherlands and abroad, see ARC as a reliable and innovative research partner in the fields of both basic as well as clinical research.
We have (inter-) national appeal to students, researchers, doctors and paramedics and we make our expertise available to everyone. In this way, we as ARC make important contributions to society.
6 There are several differences between the three players involved:
- The organisational structure of the departments differ; the KIR is a subdivision of internal medicine, while rheumatology within VUmc is a self-contained department. Rheumatology Reade however is a specialized institution for joint diseases, where logistic and other facilitating departments are all focused towards this area of health care delivery
- The research focus of especially AMC and VUmc/Reade differ; where AMC is mostly involved in basic/immunological research, VUmc and Reade are mainly involved in clinical/epidemiological research.
- The collaborative network differs; Reade and VUmc have a long history of working together, while collaboration with AMC is new for both parties (in fact, there has always been fierce competition between the two academic departments in Amsterdam)
An analysis of the competitive position of the ARC is needed to determine the focus and subsequent organisation of research activities.
Figure I: Schematic representation of the ARC
B. R&D alliances
There are a multitude of governance models that can be applied to jointly organize the activities of separate firms. These can roughly be divided into the following: 1) alliances (where non-integrated parties coordinate activities without changing firm boundaries or asset ownership), 2) acquisitions (where one firm acquires and controls the joint project of
Academic Rheumatology
- Care
- Education
- Research
Rheumatology
- Care
- Research
Academic Rheumatology
- Care
- Education
- Research
7 cooperation, including the assets involved), 3) mergers (where all the assets of the firms involved are merged into a single firm), 4) mutual divestitures (where a new legal entity is created to pursue the joint project without parental ownership or direct control), and 5) joint ventures (where a new entity is created and jointly owned by the cooperating firms) (6). The choice for one of the above mentioned models or forms has large consequences for the way the work can be organized. In the case of an alliance, agreements need to be made on what will be done together and what not; the financial organisation as well as human resource management will largely remain separate entities that at the most can organize their processes and regulations in a similar manner. In the case of a joint venture, one new legal entity is created, which allows the creation of one project and financial administration and management.
However, also in the case of an alliance, there are several ways to legalize the
collaborative R&D activities; a common choice is a contract alliance, where rights and duties are stated within a contract, agreed upon and signed by all involved parties. However, there is a body of literature available that shows that, besides a contract, relationships are an important aspect of forming an alliance (7,8). Sampson has shown that the choice for an organisational form in R&D telecommunications equipment industry depends on the need to share knowledge, the common knowledge of the partners,
diversity of technological capabilities of the partners and the need to safeguard against leakage (6). When even the most protective organisational form, equity joint venture, does not sufficiently reduce the risk of leakage to ensure the level of knowledge sharing, the scope of the alliance can be limited (9).
Robinson and Stuart argue that when equity is involved in alliance agreements, the position of a firm within the broader contracting alliance becomes important, with better networked firms with a stock of past alliances are less likely to allocate equity in the deals that are made (10).
C. The chosen construction, contract and contract governance
The construction that was chosen to organize the collaboration within the ARC can be regarded a contract alliance (see appendix I for the contract). This construction was chosen because of the reluctance of the two academic hospitals to form a joint venture. The construction has implications for the planning and allocation of projects, resources, operations, budgets etc.
Governance is established by the appointment of a daily board with one rheumatologist from each of the three centers and the ARC director, employed by both AMC, VUmc and Reade.
8 The director of the ARC has appointed a head of a research support unit (RSU) in both AMC, VUmc and Reade, with the task to organise the research activities of the ARC across three locations in such a way that the ARC has a competitive advantage in acquiring (contract) research and can dominate the scientific literature in specific areas of expertise within the field of rheumatology.
But what are the competitive advantages of the ARC? And what is the best way to design a RSU in order to become the “top institute” with “short structural and management lines” and “safe culture” as formulated in the ARCs shared ambition (box 1)?
In order to advice the ARC how to deal with this, I have turned to two related fields of research within the management and business administration scope: strategic
management and strategy execution. This is a logical choice, as a well formulated strategy is useless without an organisation that can guarantee execution of the strategy.
Two different views towards competitive advantage are used to analyse the strengths and chances for the R&D alliance, leading to a competitive strategy of the ARC; and an
organisational analysis is done to recommend an optimal organisational form, given the choice for a contract alliance.
D. Research questions
1) What should be the competitive strategy of the Amsterdam Rheumatology and immunology Center?
2) What organisational design is needed to execute the defined strategy efficiently, given the required contract alliance?
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II.
Methodology
This project is divided into two phases:
A. Phase 1: analyse the competitive strategy of the ARC
In-depth interviews have been performed with stakeholders in order to get a grip on the strengths and weaknesses of research activities in the three different centers, on
possibilities and opportunities for research and support of research activities within the ARC and of the possibilities from the perspective of the external environment.
Stakeholders included:
- players involved in the internal organisation; the staff involved in research activities at each of the three centers (n=20, quotes coded as “Q1”)
- players in the external environment;
Representatives from pharmaceutical industry (n=3, quotes coded as “Q2”) Granting institutions (n=2, quotes coded as “Q3”)
Patients (n=2, quotes coded as “Q4”)
Interviews with staff members of the ARC were performed in the summer of 2014, to get a grip on wishes, threats, opportunities and support for a common research support unit (RSU). The interview guide is available in appendix II. For players in the external environment, interviews were informal and no predefined guide was used.
Interviews were analysed using qualitative methodology for elements to be incorporated into Porters 5 forces framework and Barney’s resource based view (11-14). The Five Forces model of Porter (11,12) provides an outside-in positioning view towards strategy, helps to explore the environment and clarifies what is currently present in the field, who the competitors are, what they are up to and how an organisation should position itself in the field. This framework is used to explore the current position of rheumatology research in the three hospitals in contrast to the position of the ARC.
Following the outside-in perspective of Porter, a second step is to look inside the ARC and explore the available resources and capabilities; to this end, the resource based view towards the value, rareness, imitability and substitutability of resources and capabilities as described by Barney is used (13,14). This perspective is not only useful because of its focus on internal strengths, but also because it allows for a structural evaluation of the three players individually; from there it is a small step to identify complementary
resources and capabilities, in order to get a better understanding of the possibilities and competitive advantage of the ARC.
Conclusions about the competitive position of the ARC and directions for facilitation of research activities are drawn from these models and used as input for the next phase.
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B. Phase 2: towards a research support unit
Following the possibilities and challenges that are analysed in the above mentioned phase, strategy needs to be translated into processes, into a research organisation that facilitates research activities for principal investigators (PI’s) within the ARC. This involves alignment of logistic processes, internal governance (15), organisational architecture and change management (16,17).
Strategy used to be linked to organisational structure, based on Chandler’s dictum ‘structure follows strategy … but the market is the common denominator.’ (18). Strategy execution traditionally used to be defined in terms of organisational structure, which in itself was questionable, because the function in a firm tasked with strategy execution is the field of management control, as defined by Anthony (19) and elaborated in Bower’s bottom-up resource allocation process (20). However due to the nature of the assets in an operation as that of ARC, that is knowledge intensive, the field of strategy execution has dramatically changed, away from Anthony’s and Bower’s budget-driven method for strategy execution, towards a new management control system as defined by Kaplan & Norton (21,22). This new management control system is based on the insight that (operational and development) processes and projects that cross the boundaries of departments and firms or institutions are governance mechanisms to create new
knowledge (23), and therefore need to be defined as planning dimensions in the resource allocation process and thus in the system of internal governance.
In the second part of this thesis, I turn to the academic field of organisational design. The required design is explored based on the available literature and on the above mentioned interviews with internal staff members. Through extracting organisational needs and requirements, I will describe the chosen organisational design and architecture. As this thesis is the result of more than a year of working towards a RSU, the proposed design has already been implemented and steps have been taken to work towards execution of the defined strategy through the formation of working groups. This process and
preliminary outcomes are described.
The purpose of working towards a RSU is to enhance the output of academic research of the ARC as compared to the three separate organisations of VUmc, AMC and Reade, through facilitating research activities. It will take several years of work for the RSU to prove its added value, which is beyond the scope of this project. However, based on the described process and implementation of strategy up to now, a roadmap is provided for the coming 5 years, in which measurements and evaluations play an important role.
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III.
Results
Following the Dutch trial registry (24), the current market share of the ARC for Dutch rheumatology research is approximately 44% (out of 55 hits for “rheum”, 24 where by one of the partners of the ARC, appendix 2).
A. Competitive strategy
The competitive landscape: Porters’ five forces model
The five forces model is conventionally used to determine the attractiveness of a product to a market in terms of profitability (11,12). However, it can also be used to give insight into the competitive landscape of a R&D unit of a hospital. Vertical competitive forces include the threat of substitute products or services, the threat of established rivals, and the threat of new entrants. And horizontal competitive forces include bargaining power of buyers and bargaining power of suppliers. Figure II summarizes the five forces
framework for the ARC. The different forces are further discussed below.
Bargaining power of buyers
Buyers in the field of clinical/epidemiological and basic research are those organisations and companies that provide funding for these kind of research activities. These buyers are active on different levels, from regional, national, European to international. The most important buyers to the ARC are discussed below;
The Dutch arthritis association: the largest independent financer of arthritis research in the
Netherlands has three important calls for research funding each year for which researchers working in a Dutch research institute can apply: 1) a clinical/epidemiological call in
January; 2) a basic science call in June; and 3) a translational research call in August. The average chance of research funding is 5 to 10% and grants are a maximum of €240.000 each; although quality of research proposals is the first selection criteria, the Dutch arthritis foundation takes geographical spread and spread across academic hospitals into account. This means that for example, if VUmc, Reade and AMC would normally all receive one grant a year, the ARC would need to acquire 4 grants to realise a competitive
advantage. In this respect, an alliance of the three centers would weaken the competitive position of the ARC as compared to the three different centers individually.
Zonmw: the Netherlands organisation for health research and development is
commissioned by the Ministry and the Netherlands Organisation for Scientific Research (NWO) to tackle specific health problems, for which they design programs. Well known are the Veni, Vidi Vici competitive programs. But also specific programs for ‘cost-effectiveness’
12 or ‘aging’ are relevant to rheumatology research. As these are all competitive programs, it is hard to estimate whether the chances to acquire these funds will increase for
researchers of the ARC as compared to the three organisations individually. These changes are closely related to changes in resources and capabilities.
Horizon2020: the EU framework program for research and innovation that has 80 billion
euro of funding available for the coming 7 years (the follow up of FP7). Large European or international grants are becoming more and more important, as the money involved in these grants is in no proportion to most national funds and enables the receiver to really make a difference. The EU commission sets the requirements and research groups are given the possibility to compete to get funded. Requirements include formation of a network of business partners, academic partners and governmental partners. To form large collaborative networks, investment in networking and facilities is needed. Moreover, the administrative effort that comes with large EU funding requires well organized
administrative and financial support. In this respect, the ARC will need to organize these supporting facilities. If done successfully, the ARC will be a stronger candidate for large European funding compared to the three individual centers, which are currently not efficiently organized to take on these large projects. A PI that received an EU grant in 2015 indicates that chances for success are greatly enhanced when an external consultant is hired to help with the application. Moreover, he indicates that: Q1: “the EUs rules and
regulations require a solid organisation behind a PI that can take over project
management, legal issues and basically everything that is not subject of
research”.
Pharmaceutical companies: large drug companies like Pfizer, Roche and Abbvie do not only
depend on hospitals to run phase 2 and 3 clinical trials, but also reserve annual research budgets with which they sponsor investigated initiated studies without having a say in the conduct or results of the research. With these grants a network is created and it is
anticipated that medical specialists that receive money for their research activities will be more likely to prescribe the drug of their sponsor. At the moment, connections between medical specialists and pharmaceutical industry are close; merging might even increase the interest of industry partners since the large patient population is a potentially
important market for their drugs. Representatives indicate that Q2: “the plans of AMC,
VUmc and Reade to form a research alliance is seen as impressive and a golden
opportunity to become the largest player in the field of rheumatology research”
and Q2: “To partner with ARC is very interesting for pharmaceutical companies,because of the scope of the collaboration, the number of patients involved, the
powerful position, the key opinion leaders involved, …. it’s a great opportunity”. As
such, these companies want to have a good collaboration with the PIs of the ARC.13 One could argue that patients with a rheumatic condition are in a way ‘buyers’, but as they do not directly pay for research activities, they are not considered as such.
In summary, the power of buyers in research is large; as funds are scarce, competition between researchers or research groups is fierce, especially in the case of investigator initiated research. Researchers will need to adapt to the requirements set by the buyers in order to stand a chance. The ARC stands a better chance than the three centers
individually to acquire large European funds and will be an attractive partner to
pharmaceutical industries; but might receive less national funds if geographical spread is taken into consideration.
Bargaining power of suppliers
Suppliers in the field of rheumatology research are the patients with rheumatic conditions that are referred to a rheumatologist for diagnosis and treatment. Clinical /
epidemiological research depends on large numbers of patients, who are willing to participate in academic research activities. Patients are seen as the ‘scarce resource’, as patients are usually referred to close-by hospitals by primary care physicians or because of their own preference to see a physician close to their home. With the 6 hospitals that have rheumatologists employed in Amsterdam, the concentration of suppliers is dense. Close collaboration of VUmc and AMC with Reade is important to the academic centers, as this guarantees a large supply of mainly RA patients. More complex patients are referred to either the AMC or VUmc.
Although patients are allowed to choose their own hospital, statistics show that proximity is the most important factor to determine this choice, and that relationship will likely be even stronger for chronic diseases (25). Therefore, the referring primary care physician can be considered a powerful buyer. Other likely important factors that determine ‘supply of patients’ to the ARC include reputation, accessibility and quality of the coffee.
A patient that collaborated in a group discussion on ‘quality of care’ recently indicated that Q4: “for me, the attention of the physician for my personal life and wellbeing is
most important”.
The ARC will combine the three ‘supplies’ of patients resulting in a three times higher number of patients available for clinical trials. This will greatly decrease inclusion periods and increase efficiency and is a major advantage of the alliance.
Possible disruptive innovations in the field of rheumatic care, attracting large numbers of patients from the Amsterdam area to new facilities might threaten the position of the ARC; however, there are no signs for such a development.
Although suppliers in the form of patients and primary care physicians are extremely
14 however, in a rapidly changing health care landscape, this might be totally different in a few years. Merging of the three centers will secure the supply of patients to research and will increase efficiency through decreased transaction costs.
Threat of substitute products
As described above, clinical/epidemiological research as performed by VUmc and Reade is focused towards prevention of disease progression and improvement of quality of life through testing new therapies. Basic research, as performed by AMC, is focused at unravelling the cause of disease and thereby finding the pathway towards cure. When basic research is successful in identifying the origins of rheumatic diseases, the volume of epidemiological research needed to help patients will decrease. However, complete
substitution is unrealistic, as findings from the lab will always need to be translated and tested in clinical settings. In the unlikely event that rheumatic diseases can be cured, basic research is no longer a substitute but redundant in itself.
Within the ARC, bundling of the capabilities of researchers and professors from the 3 centers, as well as of laboratory resources and clinical patient cohorts, a new ‘product’ is created: translational research – from bench to bedside. The bundling of
clinical/epidemiological expertise with basic science expertise does not only make the ARC a multifaceted player, but provides a real competitive advantage because of the creation of translational research opportunities. This was confirmed as a major advantage by all stakeholders.
There is no real threat of a complete substitute product for clinical/epidemiological
research, although a shift of focus towards basic/immunological research could pose a threat. The ARC will combine the two research foci thus creating a new product
(translational research) and will therefore have a better competitive position compared to the three centers individually.
Threat of new entrants
At first glance, new entrants do not form much of a threat, as investigator initiated research is not profitable. However, prestige and fame is an important reward for players in the field. Moreover, contract research for pharmaceutical industry can be profitable, and especially peripheral hospitals with large patient supplies must be regarded as threatening. Further investigation of this threat by thinking of barriers to entry lead towards a division in ‘strategic groups’: some clinical research is depending on very costly imaging equipment like MRI and PET scanners, while other research works mainly with relatively cheap
materials like surveys to measure patient reported outcomes (PRO). The imaging research has therefore higher entry barriers compared to the PRO research. Loyalty of patients to
15 their treating physician is generally large, as is the loyalty of professors to their
institutions, further decreasing the threat of new entrants.
Threat of new entrants is small as most activities are not profitable, but a contribution
to society. Therefore, it is unlikely that new entrants will want to buy or educate researchers and professors with a track record. However, for contract research, hospitals with easy access to a large number of patients are a threat. There are differences in entry barriers between strategic groups.
Threat of established rivals
Established rivals of the ARC are available on different levels from regional, national to international. Again, differentiation by strategic groups (different research focuses) is of importance. Within Amsterdam, the AMC, Reade and VUmc are each other’s’ biggest rivals. Forming an alliance will eliminate this rivalry. The bigger and presumable stronger ARC will be even more powerful to battle with the remaining national and international rivals. It will be the largest national rheumatology center and its bundling of resources might create a sustainable competitive advantage. Care must be taken to comply with the rules and regulations of the ‘autoriteit consument en markt’. However, as the individual Dutch citizen is not a consumer of research activities, this subject might not be of their highest priority.
Merging with established rivals eliminates the direct rivalry and makes the ARC
stronger to compete with national and international rivals.
From the description of the five forces of competition above it can be understood that the buyer power is the most important unfavourable force at work, while the threat of a substitute product seems small. While describing the different competitors in the field, it becomes clear that resources and capabilities are a vital component of the competitive position of rheumatology research performed within the ARC. To investigate the added value of the ARC as compared to other players in the field, the resources of the three centers, their overlap and their level of uniqueness will give insight into the competitive advantage of the ARC.
16 Figure II: Porters’ Five Forces Model, applied to research activities of the ARC
Threat of new competitors Bargaining power of suppliers Bargaining power of buyers Threat of substitute product
Threat of new entry
- knowledge and track record is needed - network is needed
- infrastructure of research activities is needed
- no profitability, but gain in prestige > When in possesion of a track record, entry is relatively easy
Research funding agencies - Limited number of buyers - diversity of buyers (private, government / pharma, European) - IIR depends on buyers
- Buyers are able to dictate the terms > High buyer power
Subsitution of clinical / epidemiological research - shift of focus towards translational research - shift of focus towards basic research - a shift of focus is possible, but complete substitution of clinical / epidemiological research activities is not realistic > Low threat of substitute product Patients and primary care physicians
(suppliers) power - Clinical / epidemiological research activities are hughly depending on the ‘supply’ of patients - increased patients awareness (from passive to proactive health care demand) is a threat for academic centers - but referal of patients to a clinic is still
mostly based on proximity > Suppliers have power,
but do not use it (yet)
-o
+
o
Competitive rivaly of the ARC- regional competitors eliminated - largest academic rheumatology
unit of The Netherlands - well established international network > rivalry is present but
manageble
+
+
= favourable = unfavourable = neutralo
-Figure 1: Porter’s five forces model:
17 Resource based view
The resource based view on competitive advantage reasons that organisations’ resources are key to an organisations performance (13,14). In order to achieve a sustained
competitive advantage, a resource must fulfil all four of the following conditions: it must be valuable, rare, in-imitable and non-substitutable (shortly: VRIN). In addition to the 4 features of an organisations’ resources, there should also be an organisation in place that can absorb and apply them (VRIN/O). Resources can be split into tradable resources, non-specific to the organisation and capabilities that are organisation-non-specific, used to engage resources in the organisation (26). Table I provides an overview of the resources of each of the three centers individually, and a fourth column with the subsequent resource of the ARC. In the following paragraph, the resources will be evaluated according to the VRIN of the RBV.
Table I: Resources of the three parties that wish to form an alliance
Resources VUmc AMC Reade ARC
Distinguished, experienced researchers and professors X X X* Disease-specific expertise: RA X X X X SpA X X X X PsA X X X SLE X X* Ssc X X X* Vas X X X* OA X X X Patient ‘supply’ X X X X* PET/MRI X X Own laboratory X X
Medical ethical committee X X X X
Research unit that coordinates logistics X X X
Qualified research nurses X X X
* VRIN resources; abbreviations: RA: rheumatoid arthritis; SpA: spondyl artropaties; PsA: psoriatic arthritis; SLE: systemic lupus erytematosis; Ssc: scleroderma; Vas: vasculitis; OA: osteoarthritis; PET: positon emission tomography
18 VRIN
Valuable: a resource is valuable to an organisation, when it enables them to outperform
their competitors. In this respect, the distinguished, experienced researchers and professors and their capabilities are a vital resource to each of the players, as is the disease-specific expertise of staff-members. Without the capabilities of the human resources to write grants and perform research, the core competence of contributing to innovation and improved health for patients with rheumatic diseases, would be lost. The patient supply is valuable as well, but in itself not enabling the centers to outperform their competitors, except perhaps in the case of the large supply of rheumatoid arthritis patients in Reade. However, this picture changes when seen in the light of the future ARC. Assuming that each of the three locations will remain accessible to patients (as is the current plan), the patient supply available for research activities will triple and will certainly enable the ARC to outperform their competitors. All of the other mentioned resources are in a way valuable as well (otherwise they would not have been identified as value-creating resources – a circle reasoning of the RBV that needs further theorizing (27,28) and will continue to be valuable in the ARC setting.
Rare: a resource must be rare in order to provide an above-average return. In this
respect, again the researchers and professors are rare (or better: unique), as is the expertise of physicians in diagnosing and treating rare diseases like SLE, Ssc and
vasculitis, but not RA, SpA, PsA or OA. In addition, the organisation specific capabilities of the research unit are rare, as you will not easily find another combination of people, skills and background to streamline all clinical research activities.
The other resources are not exactly rare, but a matter of investment (MRI, training of research nurses, own laboratory facilities).
In-imitable: a competitive advantage can be created when valuable and rare resources are
controlled by the organisation and can’t be duplicated by their competitors. This is
certainly the case for the ARC’s human resources (researchers and professors and disease specific expertise of certain physicians). In a way, it also applies to the patient supply of the ARC referred to above, as there is no other Dutch rheumatology center that has bundled its research activities across three large clinics. The other resources that were both valuable and rare are not exactly inimitable: a good research support unit can be established by the competitor as well. However, a large supply of patients, especially those with a rare rheumatic condition is not easily imitable, given that patients usually choose the health care provider they are referred to by their primary care physician, or the one that is in the closest proximity of their residence.
19 Non-substitutable: can our competitors substitute our valuable, rare and in-imitable
resources? Resources that have past the above three requirements include the human resources (researchers, professors and certain disease specific physicians), as well as patient supply. A substitute for patients supply would be animals to be studied in animal models and laboratory models, but patient centred research will always be necessary. Likewise, the knowledge, expertise and fame of distinguished researchers and professors is not substitutable, nor is the expertise of disease-specific physicians easily substitutable, as it takes years of experience to achieve such a status.
This analysis results in 3 VRIN resources that might provide the ARC with a sustainable competitive advantage. The ARC will serve as the fourth requirement, that of
‘Organisation’ that should be in place to be able to use the resources.
Figure III provides a summary of the above analysis. This analysis shows us that our human capital, both in terms of employees as in terms of patient supply, is of the highest importance and needs to be treated with care. This might be translated into a special employee-pampering program to further increase loyalty; and special attention to satisfy patients’ needs.
Discussion
The concepts of Porter and the RBV are rather generic and somewhat out-dated, but they allow for a structured analysis of the inside and outside perspective on the RSU of the ARC in its strategic field.
The result of the analysis by the five forces model highlights the vulnerable financial position and dependence of external funding agencies of the ARC.
This dependence of external funding from governmental or pharmaceutical agencies in order to perform research inspires to search for new markets.
Considering the mission of the ARC – to make important contributions to society - it seems plausible to activate society in order to raise money for excellent research. This is how the Dutch Arthritis Association raises money, so why can the hospital not do this? It might be time for a different research atmosphere, where patients are proud to contribute either as a buyer or as a supplier to the research being done at the own hospital.
Future analysis should explore the possibilities of new markets as propagated by the blue ocean strategy (29,30), to create uncontested market space and make the competition irrelevant by bringing costs down while driving prices up hence creating a leap in value for both the organisation and its buyers. One could think of patients’ financial involvement in research activities, in return for increased transparency of results and involvement in implementation of outcome; another strategy is to increase the profitability margin on the commercially sponsored research activities by establishing a professional research support unit; revenues from these activities could serve as funding for IIR activities.
20 Figure III: VRON/O resources of the ARC
The second important observation that is highlighted by the five forces analysis is that suppliers (patients and primary care physicians) are enormously important, but do not act as the suppliers in the way that Porter means with his model. In fact, patients are more a valuable resource, a scarce one that needs to be treated with care and persuasion to be able to use it. This is one of the great advantages of the alliance: the competition for research patients will end and the supply of patients to be included in research activities will triple.
This is confirmed by the VRIN analysis, which emphasizes that the most important resources are the human resources: not only the supply of patients is of importance, but also the skilled researchers and professors that have built a track record in their field of expertise, as well as the physicians that treat the patients with complex and rare diseases and share their expertise in research activities. These findings ask for a strategic focus towards creating loyalty amongst these employees and patients.
Experienced researchers / professors Experienced physicians Patient ‘supply’ PET/MRI Laboratory Metc Research unit Research nurses
Valuable
Rare
In-imitable
Non-substitutable
Experienced researchers / professors Experienced physicians Patient ‘supply’ Research unit Experienced researchers / professors Experienced physicians Patient ‘supply’ Experienced researchers / professors Experienced physicians Patient ‘supply’
Sustained
competitive
advantage
Figure 2: VRIN/O resources of the Amsterdam rheumatology center
Organisation: ARC
+
21 A third observation is the complementary nature of the resources amongst the three players: Reade with its large patient supply, AMC with its research focus on basic
immunological work and VUmc with its focus on clinical/epidemiological work. Combining these three resources within the ARC potentially creates a translational line of research that stretches from bench to bedside and covers the entire cycle of disease, treatment and monitoring of health. This is a powerful asset that improves the competitive position of the ARC. One could even argue that the ARC with its size, combined resources and subsequent power, is disruptive within the market of Dutch rheumatology research (31).
The sorting of resources as presented in table 1 does not only give insight into the VRIN resources of the three different players, but also highlights the areas where transaction
costs can be reduced, resulting in lower costs of research and hence an improved
competitive position (32,33). Especially resources that are used for multiple research activities like a research support unit with all its consultancy, logistic and administrative tasks and a medical ethical committee as well as those resources that are currently available at more than one site, might be used more efficiently to service all three sites. A stronger research support unit enables the staff to attract larger grants with a high administrative burden. In addition to facilitating resources, the human resources might be used more efficiently amongst the three centers.
In summary, the research alliance between the three rheumatology centers of VUmc, Reade and AMC into the Amsterdam Rheumatology Center creates both opportunities and threats. However, the opportunities are likely to outweigh the threats: local competition is decreased when merging with competitors; bundling of the complementary resources of the three centers creates a new product (translational research), which can be used to increase their bargaining position; and their scarce resource – patients to include in clinical trials – will be secured by the bundling of supply from the three centers.
It is an important task of the RSU that the available competent researchers and resources are facilitated to optimally comply with the needs of funding agencies, resulting into competitive research output; and vice versa, that innovative insights of researchers can smoothly be translated into funding opportunities. This will be studied in more detail in the next results-chapter on organisational design.
22
B. Organisational design
The above analyses shows that with the decrease of regional competitors and the valuable human resources, the ARC can become a powerful and even possible disruptive research organisation. This is further enhanced by the differences in research focus between the three partners (epidemiological/basic research), that results in a new kind of research: translational research. In order to execute this strategy of research excellence and
organise research activities across the three different locations, a solid organisational form is needed, within the scope of the official collaboration-agreement (appendix I).
But are there accepted structures, methods or models for organisation design that can be applied to a given situation and context? Strikwerda defines organisation design as “a set of objectives, intentions, criteria, decisions, coherent, consistent and with a degree of completeness, with respect to the organisation of a firm, that has been formally decided by the executive board, or is formulated in a ready-to-sign decision memorandum, and when decided by the executive board, and ratified by the supervisory board if the by-laws of the corporation or foundation require so, is legally binding for the members of the corporation within the boundaries of existing contracts.” (34). At the same time, he stresses that there is a large, yet unstructured body of knowledge in the scientific literature on organisational design and no comprehensive concept or clear set of criteria that helps to design a new organisation (34). A first step in thinking of organisational design is often the structure of an organisation. Traditional organisations like hospitals are often structured by function (functional organisation), product (divisional organisation) or both (matrix organisation). Most organisations end up with a hybrid structure, combining elements of different structures but with one dominant approach. The ARC is a special center as it is a collaboration of 2 departments of 2 academic hospitals in a divisional structure and 1 department from a functional organisation (Figure I). The ARC is primarily a research collaboration; in that sense, it forms an operational (research) integration across the three centers, with the RSU as the backbone of the collaboration.
Given the multitude of models in organisation design, the dictum of Chandler ‘structure follows function’, the required contract alliance, the nature of the organisation (knowledge based view) and resource configuration of the three participating organisations, a bottom-up approach towards design is chosen, with an initial focus on function and processes. Therefore, organisational needs of the RSU are explored.
Organisational needs
The RSU services primarily PIs and other sponsors of scientific research, with the primary aim to produce good and a lot of scientific output.
Opportunities and threats of a common RSU according to staff members of the three organisations are summarized in Table II.
23 According to staff members that were queried to understand their needs for a RSU, it was stressed that one should understand the differences between clinical research activities and basic research activities, and that both types of research need different support: clinical research needs support in the field of logistics, standardisation, quality- , project- and data management, procedures and finances; support of basic research is limited to quality management, procedures and finances. Staff members indicate the need for a RSU that facilitates research activities across the three locations in those areas mentioned above. It was felt that this should be one unit for the entire ARC, supporting those projects that run in more than 1 ARC location.
Furthering on the RSU, staff members indicate that the scope of the RSU is:
- Support of the researcher across the entire chain of initiating research up to study closure
- Collaboration between all partners that are important for this support, a ‘spider in the web’ function
- Improve quality of research through improved data management - Generate funds / enhance profit from studies
- Better control of financial situation
Outside the scope of the research support unit should be: - The selection of interesting studies (content) - Rules for selection of studies or patients to studies
- Agreements between PIs concerning projects at different locations
In addition to the organisational needs from the perspective of staff members, there are several other functions a RSU should be able to fulfil;
Due to the nature of the organisation, the RSU is conceptually an infrastructure to organise the research activities of the ARC across three locations in such a way that the ARC has a competitive advantage in acquiring (contract) research and can dominate the scientific literature in specific areas of expertise within the field of rheumatology. This requires a RSU that is able to connect demands and opportunities from the market with capabilities and innovations from within the ARC. The RSU serves as a counter for researchers where they can put the observations they obtained from their contacts so they can be used to facilitate research; in addition, it serves as a supporting body for tasks that are currently distracting researchers (administration of large research grants; reports; milestones; audits; and other secondary research activities). And as the ARC is a large player with innovative ideas and considerable power to dominate the market, another function of the RSU is to enact by proactively creating demand for new research products through marketing and communication activities. This can be referred to as the
intelligence function of the RSU, which allows translation of internal capabilities, visions and ambitions into competitive projects and contracts. In that respect, an attractive
24 viewpoint is that of Zuboff & Maxmin, positioning the RSU as an infrastructure to aid and support research activities (35). This matches well with the PIs viewpoint towards a central body across three organisations and provides researchers with the needed autonomy. This in contrast to theaccountability/authority paradigm in organisational design in which the RSU would become a controlling and supervising body (36).
Table II: Opportunities and threats of a RSU according to staff members of the three organisations
# Opportunity
Support researchers By supporting researchers they are able to focus more on innovative research activities
Enhance quality Through a consistent and standardized way of working and good data management, quality can be improved
Decrease administrative problems
Improved administration and reports lead to a decrease of
administrative problems within the organisation and towards sponsors Decrease of financial losses Improved project administration can decrease unnecessary losses
(especially at VUmc)
Synergy Learn from each other and stimulate each other leads to creativity and better research
More studies By combining patient populations it becomes easier to select patients for clinical studies and therefore more studies can be performed More income By combining patient populations the earnings from pharma studies
can be increased
Appeal When three organisations with a good reputation and track record become one large powerful organisation, it is likely to become an appealing place to work, study and be treated.
Threat
Increase of bureaucracy Flexibility is crucial in research; one central organisation can be obstructive
Collaboration as a goal instead of a means
The research group / researcher needs to be autonomous to a large extend, collaboration is not a purpose, but a tool to improve research Alignment at the top Collaboration between three organisations needs to grow; alignment
between PIs is vital in order to succeed
sharing income Clear and acceptable agreements need to be made on how to share income
Prioritizing studies Few patients for multiple studies leads to making choices concerning inclusions. Clear and acceptable guidelines need to be made on prioritizing studies
Absence of a single data platform
Different systems for data collection, processing patient electronic records are used in different ways in the different organisations (Epic at AMC / VUmc and Chipsoft at Reade)
25 Another function of the RSU is to manage the resource allocation process: which projects are running, which projects are about to start; who is available and competent to work on which projects; are there enough patients available to run upcoming projects? (37,38) This resembles the function of a Project Management Office; however, it can be questioned whether it is possible or even desirable for the RSU to have all information to optimally allocate researchers, supporting staff, patients, knowledge and competences, as it is a key competence of researchers to use their creativity and knowledge in those projects that will give the highest reward, either in terms of publications or other triggers of esteem. In addition, it was mentioned by the staff members of the three organisations in the
interviews that one of the threats of a common RSU was the enhancement of bureaucracy and limitation of freedom of researchers to go with their gut-feeling. This is in accordance with the literature on resource mobilization in contrast to allocation, where the RSU enables researchers to make good choices rather than making the choices for them (39).
Finally, the RSU is responsible for some level of financial control. In an interview with a representative from a pharmaceutical company it was mentioned that
‘predictability is
more important to us than the actual price’. In other words, being able as ARC to
predict patient participation in clinical trials adds value for pharmaceutical partners. As the RSU is a new venture and planning can only be done based on assumptions rather than past results, discovery driven planning can be adopted: ‘discovery-driven planningsystematically converts assumptions into knowledge as a strategic venture
unfolds. When new data are uncovered, they are incorporated into the evolving
plan. The real potential of the venture is discovered as it develops—hence the
term discovery-driven planning’
(37).Organisational requirements
The organisational needs according to both the staff members and the literature described in the paragraph above can be captured into 4 main organisational requirements or
functions of the RSU:
1. Support of research logistics; facilitating researchers in the process from project idea, to funding opportunities, to data collection, up to study closure, in such a way that autonomy and creativity of researchers are maintained
2. Link the partners to each other, as well as the researchers to the market:
a. the three partners that collaborate; through facilitating communication and networking opportunities
b. Link market demands to researchers capabilities; through connecting competitive skills of researchers to market demands and opportunities
26 3. Project management; including both finances and resources
a. Financial control; generate funds / enhance profit from studies b. Resource allocation management; through gathering information and
providing these metadata to researchers, which enables them to make good choices rather than making the choices for them
4. Improve quality of research output; through standardisation of processes, data management, monitoring of studies and epidemiological training
Emerging design of the RSU
Following the functional requirements as analysed above, Figure IV emerges as the dominant functional design of the RSU within the ARC.
This content-driven, bottom up approach towards designing a RSU requires functional descriptions and responsibilities of involved subjects (41).
Figure IV: Research Support Unit and its coordinating responsibilities
Governance of the RSU
A director of the ARC has been appointed in 2013 who is the initiator of the RSU and determines its scope and vision. In May 2015, a head of the RSU has been appointed.
Head research
support unit
Supervision and policy
Logistics
Support researchers -Sponsor applications - Contracts - METC applications - Patient identificationLinkage
Internal linkage - Website - scientific meetings Strategic linkage Internal capabilities, visions and ambitions to market demands and opportunitiesProject
management
Financial planning Budget calculations Resource planningQuality
management
Standardisation Education/ training Methodological support Monitoring program Data management support27 While initial tasks consisted of the above described exploration of needs, long-term
functional descriptions and responsibilities have not been determined.
And, up to this moment, the director and head of the RSU are the only dedicated ARC employees, with dedicated time to spend on building a strong research collaboration. In the following paragraphs, the desirable organisational architecture, roles and formal reporting relationships is described; and a roadmap for the coming 5 years of the RSU is presented.
RSU architecture
The director delegates the task of day-to-day management of the RSU functions to the
head of the RSU. The head of the RSU reports directly to the director of the ARC, with
whom policy and practices are tuned. The head is responsible for the (delegated) execution of policy within the 4 functional areas (Figure IV).
The head of the RSU is the supervisor of the research support staff employed on ARC projects (i.e. research nurses, data entry managers) and is part of the team that annually evaluates their functioning.
The head is authorized to spend the annual budget attributed to the RSU, in consultation with the director. The director determines the annual budgetary space for the RSU, influenced by the margins that can be reached on contract research activities. In order to motivate PIs to successfully conduct contract research, a fixed part of the profit from contract research should be attributed to the PI to be allocated for investigator initiated research activities.
The head of the RSU needs to be employed and present in each of the three organisations in order to be able to fulfil the intelligence function.
Functioning of the head of the RSU is based on transparent and relevant metrics (42,43). During the current state of building the ARC and RSU, these metrics aren’t as objectively measurable as they would be in a mature organisation. However, in general, metrics need to be assessed annually by the director of the ARC, based on:
- Progression that is made on the policy items determined in the previous year. These items include targets on financial gains on contract research and the extent to which quality improvement initiatives have been successful
- Quality of provided services by the RSU as evaluated by the PIs
Roadmap RSU 2016-2021
Figure V presents a roadmap for the RSU with the most important milestones to be met within the four functional areas in the coming 5 years. These four functional areas are connected to the strategic advantages and collective ambition (box 1) of the ARC as presented in this thesis.
28 Apart from the functional areas, there are other structural changes that need to be
implemented: an ARC scientific research council with PIs from each center needs to be formed, which ensures that disease specific strategic ambitions (a focus towards rheumatoid arthritis, spondyloarthritis and systemic conditions) are aligned with
organisational ambitions. In addition, this council advices the director on ARC policy and financial plans.
Continuous improvement cycles need to be adopted; by empowering researchers and support staff with LEAN methodology, newly designed processes across the three locations of the ARC can continuously be improved and optimized, creating a flexible, learning organisation. Alignment of strategy and processes needs to be evaluated regularly. Kaplan & Norton warn for the difficulties of strategy implementation: “Many
organisations fail in strategy implementation because the necessary people,
capital, and financial resources are not provided for in the budget. As a
consequence, initiatives get implemented on the cheap, trying to steal time from
already busy people and with funding scraped together from small improvements
in the operating budget”
(Kaplan & Norton 2001, p.293).It is therefore recommended to free qualified people and to acquire the required funding before continuing to execute plans.
Figure V: Roadmap of the Research Support Unit 2016-2021
Logistics
Optimalization through LEAN methodology Implement digital patient recruitment through connecting EPD data with research
needs
A reliable and innovative research partner in the
fields of both basic as well as clinical research
Linkage
Create short lines of communication through website, newsletters, networking activities, scientific gatherings Build strategic long-term relationships with sponsors
Safe culture with proud and happy employees and external appeal
Project
management
Implement a financial planning system Appoint dedicated ARC staff: research
nurses and datamanagers
Transparant organization with short structural and
management lines
Quality
Implement an internal monitoring program Standardise workflow across three locations
Implement training programs
Top institute. We actively invest in the development
29
IV. Conclusions
This thesis aims to develop a competitive strategy of the Amsterdam Rheumatology and immunology Center and subsequently design a research support unit that can execute the defined strategy efficiently, given the required contract alliance.
The alliance between the three rheumatology centers of VUmc, Reade and AMC into the Amsterdam Rheumatology Center creates both opportunities and threats. However, the opportunities are likely to outweigh the threats: local competition is decreased when merging with competitors; bundling of the complementary resources of the three centers creates a new product, translational research, which can be used to increase the
bargaining position of the ARC; and the scarce resource – patients to include in clinical trials – will be secured by the bundling of supply from the three centers.
However, in order to accomplish these anticipated opportunities, a professional research support unit needs to be created, that facilitates the performance of clinical studies that run in two or more locations of the ARC.
Four main functional areas were recognised around which the RSU needs to be designed: research logistics, linkage of internal staff to support collaboration and linkage of expertise to market demands; project management with a focus on resources and finance; and quality management. Through strategy implementation of the RSU over the coming years, strategic objectives of the ARC can be realised.
V. Recommendations
Within this thesis, it was shown that the alliance between research departments of VUmc, AMC and Reade is likely to result in a competitive advantage compared to other players in this field, possible even disruptive. It is therefore recommended to continue to strengthen the collaborative movement in order to form a powerful research support unit.
Another result reported in this thesis is the proposal to organize the research support unit within the ARC, structured into four main functional areas. It is recommended that policy and plans within these four areas as presented in the roadmap are executed and that progress is frequently measured and evaluated.
It is recommended to free qualified people and to acquire the necessary funding before implementation of strategic objectives.
This thesis did not focus on the field of change management, yet there are several important factors to take into account while working towards a common ARC and RSU:
30 Resistance is part of the process of change; management should realize that change brings about diverse and intense emotions; constantly providing accurate information and keeping to once promises generates trust and provides the necessary peace for employees to continue their work and pro-actively participate in the change process (44,45). Listening to negative effects of the change and talking long and frequently about it helps employees to be open to the changes (46,47)
VI. Lessons learned
Writing this thesis has taught me there is much more to organizing a new entity than I had anticipated.
First, the limitations of the contract agreement as required by the 2 academic hospitals became clear to me: as the ARC is not a legal entity, certain ways of organizing resources becomes impossible and other -suboptimal- ways need to be explored. Secondly, I was pleased to learn that there are structured models to evaluate competitive advantages. And lastly, I was surprised to learn / become aware of the intelligence function of the RSU, a function I intend to explore in more detail in the nearby future.
I would like to thank professor Strikwerda for guiding me through the complex and conflicting literature on organisational design and pointing me towards aspects of
organisation I had not thought of myself; and professor Bijlsma for his guidance and trust in me to help create and manage the RSU and make it a successful research unit.
