René Louis Kloppenburg
Research to the delivery of intramural care within the
boundaries of the needs assessment
University of Groningen
Faculty of Economics and Business
MSc Business Administration
Business & ICT
October 2008
intramural environment
Research to the delivery of intramural care within the boundaries of
the needs assessment
Master thesis
Author: R.L. (René) Kloppenburg
Student number: s1677853
Date: 09-10-2008
Institute: University of Groningen
Faculty: Economics and Business
Degree program: MSc Business Administration Specialisation: Business & ICT
Version: 1.0
Status: Final
Number of pages: 101
Faculty supervision
Supervisor: Prof. dr. ir. J.C. (Hans) Wortmann Co-assessor: Drs. J.H. (Hans) van Uitert
External supervision
Supervisor: Dr. A. (Ate) Dijkstra
Preface
“The care sector has to innovate in order to provide affordable, accessible, and good healthcare. Innovation is the engine for the necessary improvements in the care sector.”
Ad Scheepbouwer, Chairman of the Board of Directors KPN (Scheepbouwer, 2006) At this moment innovation in the care sector is a hot issue. Many care providers are wondering how they can provide care within the boundaries of the needs assessment. The actual topic and focus on the complex caring process challenged me to conduct this research. During my study I was confronted with a phenomenon that fits my life slogan. We have learned to stay loyal to our position and often confuse this with our identity. During my research I heard several people say: “How can I adapt to the new way of working? I am a caregiver.”
When one asks how the living is made, most people describe their daily tasks and not the purpose of the system they are part of. As a result they tend to interpret their responsibilities within the boundaries of their tasks. Often one has the tendency to blame someone else when their task is not executed as planned (“The enemy is an outsider.”) From both a philosopher’s view as a business view, I believe my life slogan on the bottom of this page is one of the principles to be happy and successful.
Without any pretension of completeness I want to thank the following persons for their contribution to the research. I would like to thank Hans Wortmann and Hans van Uitert - my faculty supervisors of the University of Groningen – for the useful feedback and wise suggestions. Ate Dijkstra – my external supervisor of Noorderbreedte - I would like to thank for his advice, positive discussions, and accompaniment during my master thesis’ research and for making the internship available. Also I would like to thank John van Meurs for his role in acquiring the internship.
Besides, I want to thank everyone I have interviewed and observed for their cooperation. Next to Inge Bergsma, Miks van Schelven, Betty Halma, and Dick Elzenga - the expert interviewees - I also want to thank all other interviewees and observed persons. In order to keep anonymity, I will not mention these persons by name, but they know I mean them. Also I would like to thank my colleagues within Noorderbreedte – staff department – for their contribution to this research and the informative times.
Last but not least I want to thank my family, friends, and girl-friend for their support and enjoyment during my study.
As soon as you hold someone else responsible for your upset, you have given away the key to your happiness - Isaac Shapiro
Abstract
Among developments and changing points of view in society and healthcare, is an increase of elderly people. As a consequence there is an extending need for care. The economic scarcity and the clients’ grown assertive behaviour are the main reasons the government of the Netherlands introduced the needs assessment.
Quality of life, cost awareness, and client centred care are issues addressed by the needs assessment. This assessment is seen as a way to combine cost reductions with better bottom-line impact (pursuing the ‘sweet spot’) and in meanwhile provide client centred care. By means of a needs assessment, the care demand of a client is classified in one of the ten standard weighted care packages. These packages state in general terms which kind of care a client needs and what the costs are.
Caregivers decide how the amount of care, stated in the weighted care package, will be delivered to the client. Since the agreements among caregivers regarding the realisation of care are not at maximum and variation is not at minimum, a certain care demand can lead to different ways of delivering care. The possibility to trace the information upon which the caregivers base their decisions is important in order to provide care within the boundaries of the needs assessment. The needs assessment introduces the economic boundaries, but the care providers are struggling to fulfil the requirements of the government and client within those boundaries. This research provides a possible solution direction to deliver intramural care within these boundaries.
Research question
The research question of this research is:
Can the intramural care be executed within the boundaries of the needs assessment and in which way is it possible to detect care beyond those boundaries within Noorderbreedte?
Research methodology
By means of the theoretical framework insights are acquired regarding several concepts of the intramural caring process. These insights are the basis on which the empirical framework is build. The empirical framework consists of twelve observations and four expert interviews. The observations and interviews provide information regarding the current situation. On basis of an analysis of the theoretical framework and empirical framework, a possible solution direction is provided.
Most important findings
1. Sweet spot - There is little quality control in the intramural caring process.
There are no regular measurements of performance and therefore no appropriate change can be initiated where needed. Besides, the current defrayment mechanism cannot cope with the weighted care packages.
2. Client centred care - The client will be the focal point instead of the
availability of care. This means the care delivery has to address the specific needs of the client irrespective of its interests of the care provider.
3. Coordination - Two coordination mechanisms were determined. The first
mechanism is the care coordinator who is responsible for the caring process. The second one is a heuristic mechanism in absence of any identifiable authority role.
4. Uncertainty - The studied intramural caring process has to deal with
environmental uncertainty and task uncertainty. The current planning horizon and decision-making mechanisms make that the current way of delivering care cannot cope with these uncertainties and the needs assessment.
5. Process architecture - A certain care demand does not lead to a single,
definitive sequence of events. Besides, weighted care can lead to the situation a client is rushed through the caring process.
6. Culture - There is limited readiness on the part of the caregivers to accept
innovation outside the medical domain.
Solution direction
The traceability and management efficiency of the caring process can be increased by first coping with the task and environmental uncertainty and at the same time control the caring process. The care package model is proposed as a possible way for realising this by creating more critical intersubjectivity. This way the agreements among caregivers regarding the realisation of care can be at maximum and variation at minimum. Hence, there is clarity on which information the care delivery is founded and quality of life can be increased.
Recommendations
First, the participation of the client in the caring process has to be increased in order to secure the pathways of care. Second, a project group has to be initiated for managing the caring process and is responsible for reconciling, management of time and people, and leadership. Third, it is recommended to optimise the intramural caring process. This is the starting point and foundation for providing care within the boundaries of the needs assessment. Fourth, a cultural project has to be initiated in order to implicate the employees in the necessary cultural change. Fifth, one has to agree on appropriate data collection methods. This is important in order to acquire insight in the care during the process.
Taking care of the needs assessment in an
intramural environment
Table of contents
1 Introduction _________________________________________________1
1.1 Traceability of the demand-delivery match ____________________________ 2 1.1.1 People’s ageing ________________________________________________ 2 1.1.2 Client empowerment ___________________________________________ 4 1.1.3 Problem ______________________________________________________ 4 1.2 Problem statement ________________________________________________ 5 1.2.1 Research objective _____________________________________________ 5 1.2.2 Research question______________________________________________ 5 1.2.3 Sub questions__________________________________________________ 5 1.3 Research model ___________________________________________________ 8 1.4 Scope and limitations ______________________________________________ 8 1.5 Definitions_______________________________________________________ 10 1.6 Bookmark anchor _________________________________________________ 11
2 Research methodology ________________________________________13
2.1 Method of data collection __________________________________________ 13 2.2 The topical scope _________________________________________________ 14 2.3 The research environment _________________________________________ 15 2.4 Participants’ perceptions __________________________________________ 15 2.5 Research ethics __________________________________________________ 15 2.6 Research quality__________________________________________________ 16
3 Intramural care ______________________________________________18
4 Information and decision-making ________________________________36
4.1 Decision process __________________________________________________ 36 4.2 Data and information______________________________________________ 38 4.3 Value of information ______________________________________________ 39 4.4 Decision behaviour ________________________________________________ 39 4.5 Managing processes _______________________________________________ 39
5 Process architecture __________________________________________41
5.1 Business process architecture_______________________________________ 43 5.2 Framework for cure and care _______________________________________ 45
6 Description of cases __________________________________________47
6.1 Case study plan __________________________________________________ 48 6.2 Observation findings ______________________________________________ 50 6.3 Expert interview findings __________________________________________ 51
7 Data analysis ________________________________________________53
7.1 Sweet spot ______________________________________________________ 53 7.2 Client centred care _______________________________________________ 54 7.3 Coordination _____________________________________________________ 54 7.4 Uncertainty ______________________________________________________ 55 7.5 Process architecture ______________________________________________ 56 7.6 Culture__________________________________________________________ 56 7.7 Nature of the problem_____________________________________________ 57 7.8 F4CC plot________________________________________________________ 57
8 Solution direction ____________________________________________60 9 Conclusion and recommendations _______________________________64
9.1 Conclusion _______________________________________________________ 65 9.2 Recommendations ________________________________________________ 67
10 Reflection __________________________________________________71
10.1 Reflection theoretical framework __________________________________ 71 10.2 Reflection empirical framework____________________________________ 71
11 Bibliography ________________________________________________72 Appendices ____________________________________________________76
Table of figures
Figure 1: Traceability in the Demand-delivery match _________________________ 1 Figure 2: Absolute numbers of elderly in the Netherlands _____________________ 3 Figure 3: Stacked line diagram of elderly and non-elderly in the Netherlands ____ 4 Figure 4: Research overview ______________________________________________ 8 Figure 5: Research scope_________________________________________________ 9 Figure 6: The caring processes in the research’s scope________________________ 9 Figure 7: Research structure_____________________________________________ 12 Figure 8: Intramural care chain __________________________________________ 22 Figure 9: Client participation in the caring process__________________________ 25 Figure 10: Three decision moments _______________________________________ 31 Figure 11: Intake to care planning ________________________________________ 31 Figure 12: Care planning to care delivery __________________________________ 32 Figure 13: Care delivery to care planning __________________________________ 33 Figure 14: Deming's quality cycle _________________________________________ 37 Figure 15: Scope of information __________________________________________ 40 Figure 16: A business entity as a system ___________________________________ 42 Figure 17: Care information process Bornia Herne __________________________ 42 Figure 18: Organisation diagram (after Harmon, 2007) _______________________ 44 Figure 19: Framework for Cure and Care (F4CC) ____________________________ 45 Figure 20: Studied caring process plotted in F4CC level 2 ____________________ 58 Figure 21: Care package model __________________________________________ 60 Figure 22: Organigram Zorggroep Noorderbreedte (Dutch version) _____________ 76 Figure 23: Organigram Bornia Herne ______________________________________ 77
Table of tables
1
Introduction
Combining cost reductions with better bottom-line impact. This is a scenario where every company is looking for. Benson et al. (2004) describe an objective to dramatically improve both cost and bottom-line impact: the ‘sweet spot’. This combines cost reductions with better bottom-line impact.
Although Benson et al. (2004) focus on information technology, the objectives are also applicable to the care sector which is dealing with both care costs and the impact of the needs assessment on the bottom line. Therefore, caregivers have an important role in pursuing the ‘sweet spot’ since they iteratively translate (read: match) the needs assessment (demand) into the delivery of care. In other words, the caregivers decide how the amount of care, stated in the needs assessment, will be realised. This realisation has to be as reliable as possible, so that any caregiver will assign the same variables, among which care dependency and life domains, to clients as any other caregiver (Kerlinger, 1973). However, agreements among caregivers regarding the realisation of care are not at maximum and variation is not at minimum. Therefore, a certain needs assessment can result in different care deliveries with a different quality of life and different costs. Hence, there should be clarity on which information the ‘composed’ realised care (care pathway) is founded. The possibility to trace this information, and the decisions based on it, is therefore important in order to provide care within the needs assessment’s boundaries. Figure 1 depicts the traceability in the demand-delivery match of the caring process.
Figure 1: Traceability in the Demand-delivery match
The blue arrow in Figure 1 illustrates the traceability of the demand-delivery match which exists of the following three sub matches:
1. Match between client’s needs assessment and the care plan (needs – plan match);
1.1 Traceability of the demand-delivery match
The match of the demand and delivery of care has received much attention from the governments (second pillar coalition agreement) as well as client organisations during the last decades (Algera, 2005; Regeerakkoord, 2007). As a result, from January 1, 2009, the level of the budget of a care provider will be fully aligned with the weighted care of its clients in order to enable better individual financing and client centred care. At this moment the budget is aligned with the capacity of the care provider. The new way of allocating scarce resources, called weighted care defrayment (in Dutch: zorgzwaartebekosting), has a major impact on care providers and their way of delivering care. Besides, the weighted care defrayment demands open and transparent decision-making and accountability in health services administration (Maddalena, 2007). Hence, the flow of care has to be traceable - forwards as well as backwards - throughout the caring process in order to cope with the weighted care defrayment.
Algera (2005) states societal developments and changing points of view in healthcare are at the base of the increased interest in this new way of defrayment. These developments and points of view include:
• People’s ageing;
• Client empowerment.
1.1.1 People’s ageing
Ageing is the worldwide phenomenon of becoming older. Stuart-Hamilton (2000) distinguishes two types of ageing. The first is universal ageing; age changes which all older people can expect to experience to some degree (e.g. skin wrinkling). The second is probabilistic ageing; aspects of ageing likely to affect most (but not necessary all) older people (e.g. the onset of type two diabetes).
An estimation of the age of humans in prehistoric times tells us that old age was extremely rare. In the seventeenth century, probably one percent of the population was over 65 (Stuart-Hamilton, 2000). The past 60 years the worldwide ageing increased more than three hundred percent.
Ageing in the Netherlands
Table 1: Ageing comparison Year Age category 1960 1970 1980 1990 2000 2008 0-20 4.331.042 4.657.606 4.431.785 3.822.205 3.873.008 3.938.987 20-40 3.098.779 3.650.362 4.441.579 4.912.128 4.761.504 4.267.449 40-65 2.968.611 3.338.678 3.602.326 4.252.617 5.076.996 5.783.085 65-80 864.423 1.089.232 1.303.447 1.477.909 1.652.103 1.799.411 80+ 154.399 221.743 311.877 427.715 500.339 615.350 Total 11.417.254 12.957.621 14.091.014 14.892.574 15.863.950 16.404.282 Source: www.cbs.nl, 2008
The increasing number of elderly people is illustrated in Figure 2. It shows that the absolute population of elderly people in the Netherlands increased from 1,018,822 in 1960 to 2,414,761 in 2008 in a nearly linear way. This means the population of elderly people has increased with a factor of 1.44 in the past five decades.
Figure 2: Absolute numbers of elderly in the Netherlands
Figure 3: Stacked line diagram of elderly and non-elderly in the Netherlands
Bearing in mind that the care costs of people increase as they grow older, it is a challenge to cope with the costs. Especially in the last year of one’s life, people have high care costs (www.rivm.nl, 2008). With an increasing number of elderly people (ageing), price actions, and new treatments, defrayment is an important issue in the care sector.
1.1.2 Client empowerment
Algera (2005) argues a societal development is the call for client empowerment, on macro-level in health policy, and on the micro-level in the care delivery. As a consequence, the traditional supply orientation of healthcare is being replaced by the client’s demand for care (Ministerie van Volksgezondheid, Welzijn & Sport, 1997, 2005). Not the availability of care, but the client has to be the focal point. The delivery of care should be tailor-made in sense of addressing the specific needs of the client and initially irrespective of the interests of the care provider.
1.1.3 Problem
The traceability of the demand-delivery match is of high importance due demographic developments, despite limited budgets. Therefore, care providers are interested in matching the delivery of care with the client’s needs in an efficient way. The needs assessment introduces the economic boundaries, but the care providers are struggling to fulfil the government’s and client’s requirements within those boundaries.
The next sections will state the research problem and divide it into sub questions.
1.2 Problem statement
This section establishes a persuasive context for the research. First the research object is described, followed by the research question and sub questions.
1.2.1 Research objective
The objective of this research is to provide Noorderbreedte insight in the intake, planning, and delivery phases of the caring process of Bornia Herne, one of the somatic nursing homes. This insight can lead to process improvements and therefore to delivery of care within the boundaries of the needs assessment. Ultimately, a competitive advantage in the care market can be gained.
1.2.2 Research question
The increased importance of traceability of the demand-delivery match, described in the previous sections, has led to the following research question:
Can the intramural care be executed within the boundaries of the needs assessment and in which way is it possible to detect care beyond those boundaries within Noorderbreedte?
1.2.3 Sub questions
In order to give an answer to the research question, sub questions are drawn up. Abbreviations and terms in the following sub questions are explained in section 1.5
Definitions. By answering the questions below the objective of the research will be
General orientation
In order to acquire general insight in the current caring process, the following sub questions are drawn up. The purpose of this part is to acquire a basic understanding of the process under study.
1. What is the intramural AWBZ care chain for the VVT-sector? 2. How does the needs assessment process take place?
3. What does the organisational structure of Noorderbreedte look like? 4. Which activities can be defined within this caring process?
5. Which roles appear to what degree in this caring process?
Decision-making
In order to determine how the caring process is being managed, it is important to acquire insight in the decision-making process since ‘translating’ the care demand from one phase to another involves making decisions. By answering the sub questions below special attention is paid to the phases in the decision process, differences between data and information, value of information, decision behaviour, and the aggregation levels of information.
6. How does the care decision process take place?
7. Which management levels are present in this caring process?
Process architecture
In order to elaborate on the information aspect of the caring process, the architecture has to be illustrated. To depict a complete overview of the factors which influence this process, it is important to provide a high-level overview of the external environment and internal environment of the organisation under study. Subsequently, the possible role of the Framework for Cure and Care for plotting the caring process will be explained.
Care pathways
This is the empirical part of the research and its purpose is to study if the findings support the theoretical framework. The sub questions below explore important steps in the decision-making mechanism of the caring process. Hence, a better understanding of how a client navigates through the caring process is created (care pathways). Insight in the care pathways is important, since the care pathways are derivatives of the intake, planning, and delivery phases of the caring process.
11.How are the agreements between client and caregiver being explicated? 12.How is the care planning being matched with the weighted care package? 13.How is the actual care delivery being matched with the care planning? 14.How is the actual care delivery measured?
15.How does the quality control work, and which quantities are monitored in which way?
16.Which management tasks are executed?
Analysis
This part contains an assessment component regarding the current situation. By answering the sub questions below the problem is stated in detail and the nature of the problem is described. By doing this, a framework can be created for the solution direction.
17.What are the requirements and boundary conditions of a solution direction? 18.To what degree is the F4CC valid for plotting these processes?
19.What is the nature of the problem by arranging the caring process?
Solution direction
Finally, in order to provide a solution direction and answer the research question, the following sub questions elaborate on the solution direction.
20.Which alterations in the caring process provide a solution for the problem? 21.To what degree is an information system able to support a possible solution? 22.Which role can F4CC perform in this solution?
1.3 Research model
In order to realise the formulated research objective, a combination of desk research and a case study is made. The desk research covers the theoretical side of the research and the case study the practical side.
In the theoretical research factors which influence the delivery of intramural care are identified on basis of literature. The acquired insights are processed in a list of questions which is the starting point of the case study. The goal of the case study is to verify and supplement the theoretical findings and provide an answer to the research question.
Phase # Phase description Method
1 Explore the organisation Desk research and orientation interviews
2 Formulate theoretical points of interest
Literature research and interviews
3 Evaluate the central points of interest in practise
Observation of points of interest
4 Solution direction Feedback from practise and
the theoretical framework
Figure 4: Research overview
1.4 Scope and limitations
Intramural care in the VVT-sector
Figure 5: Research scope Sub processes intake, care planning, and care delivery
The research focuses on the three sub processes of the caring process. The sub processes consist of intake, care planning and care delivery. No attention is paid to a client who exits the caring process. However, a brief description is given regarding the needs assessment. Figure 6 depicts these three studied caring processes of Bornia Herne: Intake, care planning, and care delivery. In comparison with Figure 1, the figure below states the phases where the matches take place. Hence, intake encompasses the needs–plan match, care planning encompasses the plan–delivery match, and care delivery encompasses the delivery–plan match.
1.5 Definitions
In this report several terms are being handled. The definitions are described below.
A
ADL Activities of daily living (in Dutch: Algemene Dagelijkse Levensverrichtingen)
AWBZ The General Law on Special Medical Expenses (in Dutch: Algemene Wet Bijzondere Ziektekosten) concerns the insurance of all Dutch citizens for care and support in cases of protracted illness, invalidity, or geriatric diseases.
C
Caring (verzorging) Intentional acts based on the welfare of another.
Client A person who demands services in favour of his/her health, wealth, or safety.
Curing (verpleging) Care (see: caring) a client receives because he/she is physically or mentally ill, or disabled. Curing is always intended to make a person better or at least stabilise the illness or disability.
F
F4CC Framework for Cure and Care.
I
Intramural Care which takes place within the building of the involved care institution.
L
Life care plan Describes the meaning of the care agreements for the ADL of the client.
LCP Life Care Plan (in Dutch: Zorgleefplan, see ‘Life care plan’)
V
VVT-sector Sector for supporting people in their personal care and nursing by means of curing, caring, or caring at home (in Dutch: Verpleging, verzorging of zorg thuis).
Z
1.6 Bookmark anchor
Chapter 1 and chapter 2 encompass the formalising of the research. Chapter 1 introduces the research problem, the problem statement, the research model, and the scope and limitations. Chapter 2 describes the method of data collection used in this study, the topical scope, the research environment, the perceptions of the participants including the research ethics, and the validity and reliability of the research.
Chapter 3 up and including chapter 5 encompass the theoretical framework. Chapter 3 provides general information in order to acquire basic understanding of the process under study. This chapter starts with terminology and continuous with describing the AWBZ, needs assessment process, organisational structure, indicators of the caring process, the life care plan, and the decision moments including important roles. Chapter 4 provides insight in the decision-making process. Attention is paid to the phases in the decision process, differences between data and information, value of information, decision behaviour, and the aggregation levels of information. Chapter 5 encompasses the architecture of the caring process in order to elaborate on the information aspect of the caring process including the introduction of the Framework for Cure and Care.
Chapter 6 encompasses the empirical framework. On basis of twelve observations and four interviews the as-is situation is studied in this chapter. Attention is paid to the case study plan, observational findings and expert interview findings.
Chapter 7 encompasses the data analysis which is based on the theoretical and empirical framework. In this analysis the problem domains are simplified and described. Besides, this chapter depicts an F4CC plot of the caring process.
Finally, chapter 8 up and including 11 encompass the finalising research. Chapter 8 provides a possible solution direction. Chapter 9 concludes the research and provides recommendations including a way how to validate the possible solution direction. Chapter 10 states the reflection on both the theoretical framework as the empirical framework. Chapter 11 provides the list of literature used in this research.
2
Research methodology
The first part of the research, the theoretical framework, explores the intramural environment and the importance of decision-making with relation to the needs assessment. This part is based on professional literature and interviews. The acquired insights of the theoretical research help to identify the issues on which to focus the empirical research.
The second part of the research, the empirical framework, encompasses a case study to acquire insight in the caring process which is in scope of the research. The acquired insights of both parts are the starting point of the formulation of a solution direction.
2.1 Method of data collection
Cooper & Schindler (2006) distinguish two kinds of data collection methods: monitoring and communication. Both classifications are used in this research.
The monitoring classification includes the study in which the researcher inspects the activities of a subject without attempting to elicit responses from anyone. In this research observations are used for monitoring.
In the communication classification, the researcher questions the subjects and collects their responses by personal or impersonal means. In this research,
interviews are used for collecting data by means of the communication
classification.
The observation method is selected because of its strengths (Cooper & Schindler, 2006):
• It is the only method available to gather certain types of information;
• Collect the original data and the time they occur;
• Not depend on reports by others. Every respondent filters information no matter how well intentioned he or she is;
• Secure information that most participants would ignore (too common or it is not seen as relevant);
• Able to capture the whole event as it occurs in its natural environment;
• Participants seem to accept an observational intrusion better than they respond to questioning.
Limited by the time horizon, the majority of the data used in the research is secondary in nature. The following secondary data is used:
• Documentary;
• Multiple source;
These three types of secondary information can be available in various ways such as books, symposium papers, and internet.
Because of the observations, the investigator has no control over the variables in the research and can only report what has happened or what is happening. The research is concerned with findings out who, what, where, when, or how much, and therefore the study is descriptive (Cooper & Schindler, 2006). However, subsequent studies might be causal.
2.2 The topical scope
The initial research objective of this project is to study how Noorderbreedte Bornia Herne can execute intramural care within the boundaries of the needs assessment. This question is a how-question about a contemporary set of events over which the researcher has no control and has open and explorative characteristics. This means that the case-study approach is the most appropriate (Cooper & Schindler, 2006). The case study is a powerful research methodology that combines individual and (sometimes) group interviews with record analysis and observation. It is decided to conduct a multiple case study in order to be able to compare client caring processes and to identify common patterns. This thesis reports on four case studies in order to explore the relevant caring process issues (decision moments). A list of guiding questions has been drawn up in order to obtain a comprehensive view of the caring process and promote internal consistency.
Semi-structured and unstructured interviews were conducted with different persons who were involved in the caring process. By interviewing a care coordinator, general practitioner, client administration employee, and the location director of Bornia Herne, the researcher collected a broad perspective on the specific caring process under study.
Beside it, several other persons were interviewed to collect general information of the caring process. In total, thirteen interviews were conducted of which the duration varied from 45 minutes to 2 hour.
2.3 The research environment
The research takes place at Bornia Herne’s ‘De Schakel’-department and the design occurs under actual environmental conditions. Therefore field conditions relate to this research. The reasons for conducting the research at Bornia Herne’s ‘De Schakel’-department, is because of the time horizon of four months. In order to produce a complete picture of the delivery of intramural care, the focus is on the caring process with a relative short lead time. The lead time of 2 weeks to a maximum of 26 weeks makes Bornia Herne’s ‘De Schakel’-department the most suitable location for conducting the research.
2.4 Participants’ perceptions
Participants’ perceptions might influence the outcomes of the research to a certain degree. When participants believe that something out of the ordinary is happening, they may behave less naturally (Cooper & Schindler, 2006). If a caregiver knows he or she is being observed and has the feeling the observation is an evaluation, it is likely the caregiver changes his or hers performance. Therefore it is important to emphasize the observation is not intended to evaluate the caregiver’s performance, but to map the information flows of the caring process.
2.5 Research ethics
In research all parties should exhibit ethical behaviour. Cooper & Schindler (2006) use the following definition of ethics:
Definition of ‘ethics’:
Ethics are norms or standards of behaviour that guide moral choices about our behaviour and our relationships with others. The goal of ethics in research is to ensure that no one is harmed or suffers adverse consequences from research activities (Cooper & Schindler, 2006)
To safeguard against a participant’s embarrassment, discomfort, or loss of privacy the research is conducted by following three guidelines:
1. Explain study benefits;
Because direct contact is made with a participant, the study’s benefits are discussed. When an interview or observation starts the researcher introduces himself with his name, the name of the research organisation, and a brief description of the purpose and benefit of the research (Cooper & Schindler, 2006). This puts the participant at ease and knowing why one is being interviewed or observed improves cooperation through honest disclosure of purpose.
Also it is important that the participant has a privacy guarantee in order to retain validity of the research as well as to protect the participant. A participant (e.g. client) has the right to refuse cooperation in the observatory study.
Securing informed consent consist of fully disclosing the procedures of the proposed observatory study and interviews before requesting permission to process with the study. Oral consent is believed to be sufficient in this research. In case of the observatory research this consent is given by the care coordinator and the client. In case of the interviews the consent is given by the one who is being interviewed.
Appendix C: Informed-Consent procedure shows how the informed consent
procedure is implemented.
2.6 Research quality
In order to conduct a sound research, attention has to be paid to the validity and reliability by means of the following tests:
• Intern validity – Cooper & Schindler (2006) define this as the degree to
which the conclusions drawn about a demonstrated experimental relationship truly imply cause.
• Extern validity – Cooper & Schindler (2006) define this as the degree to
which an observed causal relationship generalise across persons, settings, and times.
• Reliability - Cooper & Schindler (2006) define this as a characteristic of
measurement concerned with accuracy, precision, and consistency; a necessary but not sufficient condition for validity.
The intern validity is guarded because the research on the cases is conducted by interviews and observation. Both techniques are applied in combination with a list of questions. Therefore, the outcomes can be compared. In the interviews, experts are asked about their opinion. The opinion of experts is compared to the outcomes of the observations. This contributes to the internal validity of the research.
that important scientific propositions have the form of universals, and a universal can be falsified by a single counter-instance. In order to guard the extern validity, interviews with experts in different areas of interest are conducted.
3
Intramural care
In order to answer the research question, this chapter encompasses intramural care (also known as clinical care) which is in scope of the research. This chapter provides general information about the intramural caring process in order to acquire basic understanding of the process under study. The following sub questions will be answered in order to reach the objective of the research.
• (1) What is the intramural AWBZ care chain for the VVT-sector?
• (2) How does the needs assessment process take place?
• (3) What does the organisational structure of Noorderbreedte look like?
• (4) Which activities can be defined within this caring process?
• (5) Which roles appear to what degree in this caring process?
Intramural care is care which is given within the walls of an institute, including:
• Hospital;
• Nursing home;
• Care home;
• Institution for the mentally disabled.
3.1 Terminology
Before proceeding, it is important to describe what is understood by care, the care sector under study, extramural care, intramural care, and the life care plan. This section encompasses the definitions of these terms. Drok (2007) states the following definition of care:
Definition of ‘care’:
The entire spectrum of economical activities which have a direct or indirect relation with care, health, and wealth, by which applies that the organisation delivers care services and a direct contribution to the delivery of care products (Drok, 2007).
In the care several sectors can be identified. The scope of the research encompasses one specific sector: the ‘VVT-sector’. The user guide of the weighted care packages offers the following definition of this sector:
Definition of ‘VVT-sector’:
VVT (in Dutch: Verpleging, Verzorging en zorg Thuis) is the name of the care sector that is used by a lot of elderly people and chronically ill people. They are supported in their personal care and nursing by homecare (extramural) or residential care homes and nursing homes (intramural). Next to elderly people and chronically ill people also adolescents and adults can make use of this care. Therefore, the term ‘care’ is applied instead of elderly care (Gebruikersgids ZZP, 2008).
As stated above, the VVT-sector consists of extramural and intramural care. It is important to describe what is in scope of the research, but also what is out of scope. Therefore, first the definition of the extramural care, which is out of scope, is given.
Definition of ‘extramural care’:
The second part of the VVT-sector is the intramural care. This type of care is in the scope of the research and Krijger (2004) provides the following definition:
Definition of ‘intramural care’:
The care delivery of intramural care always occurs in kind and is offered via residence. The client is refunded the cost for residence, care, and wealth through the General Law on Special Medical Expenses. (Krijger, 2004).
As stated in section 1.1 Traceability of the demand-delivery match, client centred care (and financing) is the fundamental idea of the weighted care packages. A way to register a client’s demand of care and agreements is the life care plan. The following definition of this plan will be used:
Definition ‘life care plan’:
A dynamic document based upon published standards of practice, comprehensive assessment, data analysis and research, which provides an organized, concise plan for current and future needs, for individuals who have a weighted care package (after Med-Legal Services, 2002).
Section 3.6 Life care plan elaborates on this dynamic document.
3.2 General Law on special medical expenses (AWBZ)
The General Law on Special Medical Expenses (in Dutch: Algemene Wet Bijzondere Ziektekosten (AWBZ)) concerns the insurance of all Dutch citizens for care and support in cases of protracted illness, invalidity, or geriatric diseases. In order to control the costs on the medium and long term, the AWBZ is intended for the disabled, older citizens in need of care, and psychiatric patients (Ministerie van Volksgezondheid, Welzijn en Sport, 2008a).
The AWBZ care chain consists of the following four parties:
1. Client. The client has a certain need for care which has to be translated in a demand for care. Subsequently the demand has to be registered at the Regional Indication Institute.
2. Needs assessment institute (in Dutch: Centrum Indicatiestelling Zorg (CIZ)). The CIZ is responsible for making an objective, integral, and independent indication. This needs assessment is an objective determination of the client’s need for care and by extension an assessment for the demand for care. Definite answer regarding the indication decision is given to the client and care insurer.
3. Health insurance agency (in Dutch: zorgkantoor / zorgverzekeraar). This office provides the legality test and defines the care. It looks for the most appropriate care provider in the region.
4. Care provider (in Dutch: zorgaanbieder). The care provider is the last link in the care chain and provides the care.
In brief the characteristics of the general Law on special medical expenses are (Algera, 2005):
• Collective insurance of all citizens of the Netherlands;
• “Expense insurance” long-term care, including home care use;
• Accounting for about 40% of all healthcare expenditures in the Netherlands;
• The needs assessment which is carried out by independent regional assessment agencies (since 1998) is considered to be the entrance ticket to apply for the General Law on special medical expenses.
3.3 Needs assessment process
The function of the CIZ is to provide an objective, independent and integral needs assessment. Goal of the needs assessment is to contribute to the required transparency. The needs assessment assesses and registers the demand of AWBZ-care (see previous section).
Initiator of the needs assessment process is the applicant. This applicant can be the client, but also a representative of the client. The applicant requests a certain degree of care. Next, the CIZ determines which care the client needs and distinguishes six kinds of care (www.ciz.nl, 2008):
• Personal care (in Dutch: persoonlijke verzorging);
• Nursing (in Dutch: verpleging);
• Support accompaniment (in Dutch: ondersteunende begeleiding);
• Activating accompaniment (in Dutch: activerende begeleiding);
• Treatments (in Dutch: behandeling);
Besides the kind of care, the CIZ determines the duration and period of care. Formally, an AWBZ care provider is not involved in the decision-making of a needs assessment. However, the fact that a care provider can have a supporting role in the needs assessment makes that they have influence on this process. The supporting role of the care providers consists of providing information on which the CIZ bases its needs assessment.
The CIZ strives towards a needs assessment’s lead time of maximum six weeks. Subsequently, the CIZ hands over the needs assessment to the applicant and the health insurance agency. The health insurance agency supervises the periods between the needs assessment and the initial delivery of care by the care provider. Figure 8 illustrates this process.
Figure 8: Intramural care chain
3.4 Organisational structure
Organisations are structured in various ways. The way they are structured depends on their culture and objectives. The structure determines, among which, the way an organisation operates and performs. Hence, a well structured organisation will maximize the efficiency and success of the business.
Appendix A: Organigram Zorggroep Noorderbreedte depicts the organigram of
Zorggroep Noorderbreedte. Zorggroep Noorderbreedte consists of Medical Center Leeuwarden (MCL) / MCL Harlingen and Noorderbreedte. The rectangle which is marked red highlights the location of the research (Bornia Herne is a care location). The figure clearly illustrates the research is conducted by order of the Executive Secretary. The location where the actual research is conducted is situated below Noorderbreedte.
Appendix B: Organigram Bornia Herne depicts the organigram of Bornia Herne. It
3.5 Indicators of the caring process
This section encompasses the three indicators of the caring process of Noorderbreedte, respectively:
• Quality – Well delivered care that complies to established standards;
• Defrayment – The costs of care;
• Customer focus - Competing care business demands an enterprising and
active attitude.
3.5.1 Quality in the caring process
The INK-management model (derivative of EFQM Excellence Model) is applied to improve quality by means of conducting self-assessment. The assessments are conducted by auditors in order to acquire an independent view of the organisation. By means of this model the maturity of an organisation is determined and the improvement points are highlighted. In the care process under study, the management model encompasses the quality model of the Foundation of Harmonisation Quality Assessment in the Care Sector (in Dutch: Stichting Harmonisatie Kwaliteitsbeoordeling in de Zorgsector (HKZ)). This model can be used for certification and complies with the ISO 9001 norms. A derivative of this HKZ-model is the Norm Verantwoorde Zorg (NVZ).
The meaning of quality in the VVT-sector is documented in the NVZ. This instrument consists of norms and indicators and is drawn up by Actiz, the
Landelijke Organisatie Cliëntenraden (LOC) and the associations NVVA, AVVV and
Sting. The starting point of those norms is the quality of the client’s life. The norms define which results the support of institutions should have regarding the lives of clients (www.zorgvoorbeter.nl, 2008). On the basis of these norms a quality frame is developed which helps in determining to what extent an institution complies the prescribed norms.
The indicators are an important part of the quality frame. There are two types of indicators which can be distinguished on basis of how they are being measured (www.zorgvoorbeter.nl, 2008):
1. Specific care indicators or professional indicators. On the basis of client
oriented questionnaires the caregiver collects data regarding pressure ulcers, falls, and incontinence. These questionnaires are executed once a year by the care organisation itself.
2. Client experience indicators. These indicators are being measured with
help of an independent client consultation which has to be executed once every two years by an accredited measurement authority. The authority measures client related indicators with the CQ-index (Consumer Quality Index). The CQ-index is established by clients or their representatives through a questionnaire which consist of questions which ask about the client’s experiences with care.
The measurement of the specific care indicators and client experience indicators has three goals.
1. Information for internal control: Make clear on which points the organisation accelerates and where they can improve;
2. Information for the client: Compare caregivers and make a selection on basis of specific criteria;
3. Render account for care and cure towards the inspection and other parties: The indicators depict possible health risks in the caring process.
The self-assessment and the NVZ are identical to the basic principle of the Deming cycle: plan-do-check-act. This cycle is described in section 4.1 Decision process.
3.5.2 Defrayment in the caring process
The defrayment of the caring process will be measured as of January 1, 2009 by means of the weighted care defrayment (in Dutch: zorgzwaartebekostiging). At this moment an organisation in the VVT-sector is funded on basis of their available capacity. In the new ‘weighted care defrayment’-system the organisation will be funded on basis of their delivered performance per client. The total amount of money per client will depend on the weighted care (in Dutch: zorgzwaarte) of the client (Ministerie van Volksgezondheid, Welzijn en Sport, 2008b).
The weighted care is determined by the CIZ. There are two situations in which a needs assessment can be initiated:
• A person needs care for the very first time;
In both cases the CIZ evaluates the request and decides which degree of care is needed. Not every person needs the same care, therefore the CIZ created a classification of the weighted care.
The weighted care consists of ten packages, so-called weighted care packages (in Dutch: zorgzwaartepakketten), which entitles the degree of help or care of a person. Package 1 is for people who can take care of themselves in a reasonable way. Package 8 is for severe ill people who need caring and accompaniment the clear day. The higher the number of the package, the more caring is needed.
Package 9 is for short term caring. For example, when a person broke his leg and has to recover. Usually a person goes to home afterwards.
Package 10 is for people who suffer a terminal disease and find themselves in the final stage of their disease. The kind of people with this package demand care which cannot be given at home.
3.5.3 Customer-focus in the caring process
No clients means no revenues. The competing care business demands an enterprising and active attitude. The goal of Noorderbreedte is to build a customer-focused organisation (Jaardocument Zorggroep Noorderbreedte, 2007). Kadernota 2008 states client participation as an important priority.
Client participation appears in several ways in the caring process of Bornia Herne. Initially the client (and / or the representative) participate the intake conversation. The result of this conversation is the life care plan agreement.
Figure 9 illustrates the client participation as described above.
3.6 Life care plan
As described in section 3.1 Terminology, the life care plan is a dynamic document which provides an organized, concise plan for current and future needs of a client. This information about the client’s care is kept in the client dossier life care plan. Bornia Herne distinguishes three phases in this document:
1. Intake;
2. Life care plan; 3. Other.
Each phase is supported by several documents. Table 2 lists the phases and corresponding documents of Bornia Herne. The corresponding numbers of the documents are used in chapter 6 Description of cases for listing the findings.
Table 2: Client dossier Life care plan Doc.
#
Phase Document name Document name in
Dutch
1 Administration data/ indication Administratieve gegevens/indicatie
2 Nurse anamnesis Verpleegkundig
anamnese
3 Client type Typering cliënt
4
Intake
Life domains Levensdomeinen
5 Care dependency agreements Afspraken t.a.v.
zorgafhankelijkeheid
6 Plan of action: goals-actions/agreements
Actieplan: doelen-acties/afspraken
7 General practitioner order / execution research
(Huis)artsenopdracht / uitvoeringsonderzoek
8 Agenda Agenda
9 Daily report Dagrapportage
10 Discipline report Rapportage disciplines
11 Completion conversation about life care plan
Afrondingsgesprek over ZLP
12 Finalising conversation report Verslag familiegesprek
13 MDO life care plan conversation MDO-ZLP bespreking
14 Registrations Registraties 15 Life care plan (LCP) Optional Optioneel
16 Overview directions and protocols Overzicht richtlijnen en protocollen
17
Other
The next sections will briefly describe the purpose of the documents. This way insight is achieved in the information which officially has to be registered.
3.6.1 Intake
The ‘intake’-phase consists of four documents which should be completed during the intake conversation:
1. Administrative data/ indication
Administrative data form including indication forms. Most of the required data can be acquired through Forum (the current administration system). Missing data has to be filled in together with the client. Indication forms have to be added to the life care plan.
2. Checklist first conversation or nursing anamnesis
Residence, care, and health risks are points of interests. Nursing anamnesis is filled in by means of the hospital anamnesis.
3. Client type
This document provides insight in the values, lifestyle, and preferences of the client’s personal history.
4. Life domains
Consist of a description of the four life domains of a client:
• Housing- and live conditions
• Participation
• Mental consent and autonomy
• Physical consent and health
Each domain consists of a question list and a writing form. The questions list encompasses questions which can be asked during finalising conversations, and observation moments. Goal of the life domains is to register specific situations, preferences, and demands of a client. The results of the finalising conversations can lead to the formulation of goals and actions which can be added to the action plan, care dependency scale and agenda.
3.6.2 Life care plan
5. Care Dependency Scale
A list consisting of fifteen questions about the client. The total score of those questions can be used to identify the client profile and therefore the client’s dependency (Dijkstra, 1998).
6. Action plan: goals-actions/agreements
Consist of goals with corresponding actions and evaluation moments.
7. General practitioner order/ execution request
A form which is filled in by the general practitioner and sometimes by a caregiver. The general practitioner always has to sign the order / execution request.
8. Agenda
Actions and agreements are being ‘converted’ to a weekly schedule of the client.
9. Daily report
Report by the carers on account of the action plan and other details.
10. Discipline report
Report by means of the action plan and other special points per discipline.
11. Completion conversation about life care plan
Document containing the outcomes of the conversation about the care agreements. It contains the feedback on the compliance with the agreements and has to be signed by the client and the carer.
12. Finalising conversation report
Report of a finalising conversation (on location or by phone). The family / contact person can provide feedback regarding the caring process. The feedback is written down in this report.
13. (Multidisciplinary) Life care plan conversation
Preparation and report of the multidisciplinary conversation and finalising conversation (in Dutch: afsluitend gesprek).
14. Registrations
Consists of various registrations regarding a client’s physical condition.
15. Optional
3.6.3 Other
The ‘other’-phase consists of all other documents which are created and updated during the caring process. Some examples of the documents are:
16. Overview guidelines and protocols
Contains the guidelines and protocols which apply to the client.
17. Medication list
The form which contains the medication of a client.
18. Remaining
Various forms which do not fit into the categories mentioned above.
In this section several actors of the caring process are mentioned. The next section describes the different roles in the caring process and illustrates their contribution to the life care plan. Chapter 6 Description of cases will also present the results of the case by means of the document numbers in Table 2.
3.7 Roles
In order to acquire a complete insight in the intramural caring process, this section encompasses the roles and their competences. One has to realise that the living aspect is the central focus and not the care itself. This is accomplished by making different disciplines work together in a professional and correct way.
The following roles can be distinguished in intramural caring process of Bornia Herne which is in scope of the research:
1. Client
The client is the person who demands care.
2. Care coordinator (A)
The care coordinator coordinates and monitors the quality and continuity of care, gives direction to staff the teams, is responsible for the organisation within the teams, is responsible for execution and co-responsible for the development of the location policy.
3. Carer
are four types of carers which can be distinguished based on their education and privileges: • ADL-employee (level 1); • Helper (level 2); • Caretaker (level 3); • Nurse (level 4).
‘De Schakel’-department in Bornia Herne uses helpers (level 2) and caretakers (level 3) for the delivery of care.
4. Personal attendant
The personal attendant is a carer which is assigned to be the contact point for a specific client.
5. Paramedic
This role consists of various disciplines and the composition differs from client to client. Some examples are:
• Occupation therapist; • Speech therapist; • Physiotherapist; • Orthopaedist; • Etcetera. 6. General practitioner
The general practitioner (GP) is a physician whose practice is based on a broad understanding of all illnesses. He does not restrict his practice to any particular field of medicine. This role is co-responsible for the caring process.
Figure 10: Three decision moments
Decision moment 1 and decision moment 2 together have a time horizon of 2 weeks. After these 2 weeks decision moment 3 evaluates the outcomes of the former decision moments and (re)establishes objectives. Finally, another iterative period of 2 weeks (decision moment 2) commences.
The decision process is described in chapter 4 Information and decision-making. The first decision moment in the caring process is the ‘intake to
planning’-phase which is modelled below.
Figure 11: Intake to care planning
result of a needs assessment. The care coordinator receives this weighted care package indication by the health insurance agency. Next, the care coordinator stores this indication, an initial diagnosis, and some advance information in the client dossier.
Subsequently, the caregiver receives the demand of care and conducts the intake conversation. In connection with the intake conversation, the initial demands, preferences, and habits of the client are stored in the client dossier. Finally, the decision moment 1 is closed by means of a square containing the character ‘D’. The ‘D’ is an indication for the décharge of Bornia Herne from conducting decision moment 1.
Organisation Business process
= Zorggroep Noorderbreedte Bornia Herne ‘De Schakel’-department = Decision moment 2: Care planning to care delivery
ACTOR ACTIVITY DIAGRAM
Setting:. . . . . . . . Client Care Coordinator Caregiver Client dossier General practitioner Paramedic Care demand Make / review (initial) action plan Care demandCare demand
Care demand
Care demand
Care demand Deliver care and
observe client
Deliver care and observe client Deliver care and
observe client
Describe observations /
care given
Describe observations / care given
Describe observations / care given
Figure 12 above also depicts the first transaction which is modelled as a square containing the character ‘C’. The ‘C’ stands for transaction à charge which indicates that Bornia Herne is charged with fulfilling the client’s demand for care after decision moment 1. In this phase caregivers, the general practitioner, and paramedics deliver care and observe the client. As a result, the observations conducted and delivered care are described in the client dossier by all disciplines. Subsequently, the caregiver makes or reviews the action plan which is the input of the finalising conversation. Finally, decision moment 2 is closed by means of a square containing the character ‘D’. The ‘D’ is an indication for the décharge of Bornia Herne from conducting decision moment 2.
Figure 13: Care delivery to care planning
(agreed action) are described in the client dossier. Subsequently, the outcomes of the MDO-LCP conversation serve as the input of the finalising conversation. The client should agree prospective care by signing an agreement and a report added to the client dossier. Next, the caregiver, general practitioner, and paramedic decide on modifying the planned care delivery. Subsequently, the care coordinator checks whether the agreed care planning fits the current indication (needs assessment). When the agreed care planning exceeds the boundaries of the needs assessment, a new needs assessment has to be conducted. Finally, decision moment 3 is closed by means of a square containing the character ‘D’. The ‘D’ is an indication for the décharge of Bornia Herne from conducting decision moment 3.
Role two to six are people who deliver care to role one. Therefore, role two to six are the caregivers of Bornia Herne. The shared competences of these caregivers are that they have to focus more on social, cultural and personal welfare instead of care. Rood (2008) states that a caregiver requires the following competences:
• Flexibility and creativity;
• Demand and client driven;
• Adapt to care (in)dependency;
• Networking, communicating, and negotiate within the boundaries of the needs assessment and the law;
• Entrepreneurship, initiative, drive, and more courage;
• Enable client participation;
• Support the client instead of arrange everything;
• Integral approach of the client.
These competences are required in order to cope with the introduction of the weighted care packages. The absence of one or more competences in the current caregiver profile points towards the demand for a cultural change.
3.8 Decision moments
particular point of view with certain kinds of effects (Fay, 1996). These kinds of effects are, among which, expressed in decision moments. In the caring process of Bornia Herne, caregivers are daily faced with these decision moments. The values communicated to them, among which their experiences and interpretations, will determine their actions which makes the decision-making a rather subjective process.
