Integration in acute care: collaboration during triage
University of Groningen Faculty of Business and Economics
MSc Supply Chain Management MSc Technology & Operations Management
Master‘s Thesis
Student: Leon Blokhorst Student number: S2403528 E-mail: l.r.blokhorst@student.rug.nl
First supervisor: D.J. van der Zee Second assessor: C.T.B. Ahaus
Purpose: Currently, large amounts of patients are initially referred to the wrong care
provider, causing troubles for the acute care system. Integration of acute care providers during triage could be a solution to improve the allocation of patients to the right care provider. This thesis aims to contribute to the current literature by providing initial knowledge on integration during triage. The research goal is to identify both enablers and barriers for successful collaboration during triage. Furthermore, the particular role of physical proximity within integration is investigated.
Methodology: This research can be characterized as an explorative case study. The study is
motivated by a pilot investigating the effects of increased collaboration during triage. Within this pilot, multiple parties are co-located in order to collaborate more intensely while performing triage. Expert interviews and participant observation were used to accurately identify the process under investigation. Interviews with both operators in the emergency control room and initiators/managers of the pilot were used to identify the most important factors enabling and inhibiting the success of integration in the given context. Lastly a small performance analysis has been carried out, in order to give an indication of the effects of integration on the accuracy of triage.
Findings: Based on the case study ten enablers and six barriers for achieving successful
integration are identified. Integration of systems and integration of actors are the most important layers for integration in the context of triage. Furthermore, proximity facilitates integration by occupying three main roles, (1) decreased barrier for communication, (2) increased ability for information sharing and (3) increased ability for sharing of expertise. Lastly, all operators perceive increased accuracy of triage due to integration.
Implications: The findings contribute to literature by identifying enablers and barriers for
achieving successful integration in the context of triage. Managers can use these in order to implement integration in the context of triage by means of a co-location. Furthermore, roles of proximity within integration have been identified, including a new role. This understates the importance and added value of physical proximity within integration.
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ACKNOWLEDGEMENTS
LIST OF ABBREVIATIONS
ABCD = Airway, Breathing, Circulation, Disability
ACC = Ambulance Control Center
ANW = Avond, Nacht, Weekend (Evening, Night, Weekend)
ED = Emergency Department
EMS = Emergency Medical Services
GP = General Practitioner
NTS = Nederlandse Triage Standaard
MKA = Meldkamer Ambulance
SCI = Supply Chain Integration
UMCG = University Medical Center Groningen
Table of content
1. INTRODUCTION ... 7
2. THEORETICAL BACKGROUND ... 9
2.1 THE ACUTE CARE SYSTEM... 9
2.2 TRIAGE IN ACUTE CARE ... 10
2.3 SUPPLY CHAIN INTEGRATION ... 12
2.4 THE ROLE OF PHYSICAL PROXIMITY ... 14
2.5 MAIN FINDINGS FROM LITERATURE ... 15
3. METHODOLOGY ... 17
3.1 RESEARCH QUESTIONS ... 17
3.2 RESEARCH DESIGN ... 17
3.3 DATA COLLECTION ... 18
Step 1: Process identification ... 18
Step 2: Identification of barriers and enablers for integration ... 19
Step 3: Identification of the effects on triage accuracy ... 20
3.4 DATA ANALYSIS ... 20
4. CASE DESCRIPTION ... 21
4.1 MOTIVATION FOR THE PILOT ... 21
4.2 PARTICIPANTS OF THE PILOT ... 21
4.3 PROCESSES: OLD SITUATION ... 23
4.3.1 Meldkamer Ambulancezorg ... 23
4.3.2 Medrie huisartsenzorg ... 26
4.3.3 Zorgcentrale Noord ... 28
4.4 PROCESS: NEW SITUATION ... 30
4.4.1 Set-up of the new process ... 30
4.4.2 Contribution: main areas for increased collaboration ... 30
4.4.3 Contribution: example cases better handled due to collaboration ... 33
5. RESULTS ... 34
5.1 ENABLERS FOR SUCCESSFUL INTEGRATION ... 34
5.2 BARRIERS AFFECTING SUCCESSFUL INTEGRATION ... 37
5.3 THE ROLE OF PROXIMITY... 39
5.4 TRIAGE ACCURACY ... 40
5.4.1 Perceived accuracy by operators ... 40
5.4.2 Outcomes based on data ... 41
5.5 SUMMARY OF THE FINDINGS ... 42
6.1 ENABLERS AND BARRIERS ... 44
6.2. PROXIMITY ... 45
6.3 MANAGERIAL IMPLICATIONS ... 45
7. CONCLUSION ... 47
7.1 CONCLUDING REMARKS ... 47
7.2 LIMITATIONS AND FURTHER RESEARCH ... 47
References ... 48
Appendix I: Interviewprotocol ... 52
Appendix II: Coding tree example ... 55
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1. INTRODUCTION
The health burden on emergency services throughout the world is increasing, patient expectations are rising, and all organized care systems are having to cope with the problems of increasing demand, increasing financial pressures and limitations on staff (Robertson-Steel, 2006). Currently, the acute care system is characterized by a lack of care-coordination, which makes it increasingly unable to appropriately respond to the increasing demand placed upon it every day (Cozijnsen and Van der Erf, 2018).
Emergency medical services (EMS), emergency departments (EDs) and general practitioners (GPs) struggle to cope with the increased inflow of patients (IOM, 2007). This increased demand is partially caused by the fact that, large amounts of patients end up at the wrong care provider. For example, many patients are presented at the ED, while they could also be helped by GP, home care or other care providers (e.g. Kiers, 2018). This is caused either by an incorrect assessment of the person in need (i.e. incorrect self-referral) or by an incorrect assessment of the person performing triage. This thesis focuses on the latter. Consequently, additional work is generated as patients have to be again referred, transported and/or treated by the right care provider. Secondly, patients could also lose critical time to treatment, if they are in urgent need of treatment and are initially referred to the wrong care provider. Furthermore, EDs make up a considerable amount of the total costs of hospitals and it is evidently less expensive to treat patients at a GP instead of transporting them with EMS and providing treatment at the ED (Hans et al., 2011). To reduce overloading of care providers, it is of utmost importance that emergencies are accurately assessed, rapidly identifying what is the best available response, in order to use the limited resources most effectively (Robertson-Steel, 2006).
Triage is the screening of patients to determine their relative priority for treatment (Kobusingye, 2006). Different types of triage exist. This thesis focuses on pre-hospital triage, as this research focuses on the allocation of patients to a care provider, indicating that this is the first point of contact and the patient is not at a care provider yet. Based on the outcome of triage, the most appropriate response to an emergency is determined. For a person with an urgent need, several different entries are possible to enter the acute care system — not just calling 112. Patients can also contact their GP, call home care contact their general practitioner, treat themselves, call home care, call social services, or get help from a pharmacist (Alberti, 2004). Currently, these providers are all acting individually, however integration of acute care providers may be beneficial for the accuracy of triage.
inter-~ 8 inter-~
organizational communication and effective sharing of patient information and expertise which might lead to more accurate outcomes of triage.
Although there is a high managerial and social need to improve the coordination within acute care networks and within triage in particular, literature regarding this subject is very scarce. Most of the literature addressing integration within healthcare is focused on integration between hospitals departments, instead of between different care providers (Hans et al., 2011). Secondly, research has paid little attention to the potential role of physical proximity in achieving successful integration. There is however, extensive literature focusing on the concept of supply chain integration (SCI). Findings for this domain might be very well applicable to acute care networks for which there is a high need for organizations to collaborate closely in order to deliver high quality care. Several authors have made an attempt to identify factors influencing the success of SCI. (e.g. Fabbe-Costes et al., 2008; Van der Vaart and Van Donk, 2008). As every context has their own characteristics, enablers and barriers are context-specific and not directly generalizable to the context of triage in acute care. Main dimensions of SCI however, can serve as an overview in order to identify factors within the context of triage in acute care.
This research aims to contribute to the current literature by filling a gap within the domain of acute care networks, namely to identify enablers and barriers for successful integration during triage. Secondly, this research aims to identify the specific role and potential benefits of physical proximity in achieving successful integration of acute care providers during triage. In order to achieve the research aims, an explorative case study is performed initiated by a pilot. The pilot aims to investigate the effects of coordination of acute care providers, by creating a care coordination center in which multiple acute care providers are co-located in order to perform triage. The pilot covers an area of nearly 400.000 inhabitants in the eastern of the Netherlands and the care coordination center is established in Zwolle, Overijssel.
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2. THEORETICAL BACKGROUND
This theoretical background will first characterize the acute care system, and consider needs for its integration. Next, it is zoomed in on the process of pre-hospital triage within an acute care context, thereby identifying problems faced in operating the acute care system. As little research has been conducted on integration and coordination within a healthcare context, the third section will elaborate on the concept of supply chain integration (SCI). It is believed that better integration between acute care providers can possibly increase the accuracy of triage. In this section, main layers of SCI will be identified. These will serve as an overview for identifying SCI enablers and barriers in the context of triage during the case study. Subsequently, there will be zoomed in on the specific role of proximity within integration, which seems to have a facilitating role in ensuring successful integration. The chapter will end by summarizing the key findings from literature and visualization of these findings in a conceptual model.
2.1 THE ACUTE CARE SYSTEM
Acute care is the process of referring and treating patients with emergency conditions. These are patients with an injury or illness that is acute and poses an immediate risk to a person‘s life or long-term health and it is important to attend to these patients immediately (Ramanayake et al., 2014). Acute care providers handle in the concern of these patients in order to enhance survival, control morbidity and prevent disability (Kobusingye et al., 2006). In doing so, providers need to respond both fast and appropriate. This includes rapid assessment, timely provision of appropriate interventions, prompt transportation to the nearest appropriate health facility and effective treatment (Kobusingye et al., 2006).
The acute care process exists out of three main steps – triage (also called diagnostics), transport and treatment (Van der Zee, 2017). When a person has an urgent need for care, the need for care must be prioritized in order to link this person to the most appropriate care provider (Robertson-Steel, 2006). This process is called triage and it will be further explained in the next section. The next step is the transportation of the patient to the right care facility (e.g. the transportation of a patient to the ED by EMS). Lastly, when the care facility is entered, the patient should be given the right treatment as fast as possible.
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Although emergency care must be appreciated as a system with interdependent components (Kobusingye et al., 2006), it is well known that acute care providers cooperate sub-optimally (Cozijnsen and van der Erf, 2018). The acute care system is known for its fragmented nature and the different providers all tend to function independently (Alberti, 2004). Due to the lack of care-coordination, the acute care system is inadequate and inconsistent in the quality of care it provides (e.g. Robertson-Steel, 2006) and increasingly unable to appropriately respond to the demands placed upon it every day (Cozijnsen and Van der Erf, 2018). The pressure on EMS has increased sharply and EDs have become overcrowded (Pines et al., 2007). Furthermore, the lack of coordination also causes problems to the flow of high acuity patients (e.g. stroke patients). In many cases patients pass through multiple urgent healthcare chains before being admitted to the hospital, losing critical time for treatment (Doggen, 2013). There are large concerns regarding the impact of these developments on the quality of care and the outcomes for patients. An important cause of these trends is that large amounts of patients are referred to the wrong care provider, resulting in additional work and the loss of potentially critical time. Integration of acute care providers during triage is necessary to get the right patient at the right care provider within the right time (Cozijnsen and Van der Erf, 2018), in order to relieve the pressure on acute care providers and to avoid unnecessary delay, that may hurt patients‘ health.
2.2 TRIAGE IN ACUTE CARE
A critical activity within the acute care process is triage. Triage refers to the process of determining the clinical need of the patient as a method of managing the possible risk (Mackway-Jones et al., 2013). Different types of triage exist. Robertson (2006) has identified three phases of triage in modern healthcare systems. Pre-hospital triage is the most initial form. It refers to the assessment of the need for care when a patient is calling with an urgent need. Based on the need for care, the most appropriate response should be determined. Second, triage at scene is performed by the first clinician attending the patient (e.g. EMS personnel performing a short triage when an ambulance arrives on scene). Third, there is triage on arrival of the patient at the care provider in order to make a more accurate diagnose (e.g. when a patient arrives at the ED). This thesis focuses solely on the phase of pre-hospital triage. In the remainder of this thesis, triage will refer to pre-hospital triage.
Two main purposes are recognized for triage: ―[1] to ensure that the patient receives the level and quality of care appropriate to the clinical need (clinical justice), and [2] that departmental resources are most usefully applied (efficiency) to this end‖ (Fitzgerald et al., 2010, p. 80). Within triage, patients are prioritized on a certain scale, based on the urgency of their situation (Mackway-Jones et al., 2013). Triage protocols are generally used to assist the person performing triage. The determination of the urgency is generally based on a combination of an indication given by a triage protocol and the own interpretation of the person performing triage (Bukman, 2018). Based on this outcome, the most appropriate response is chosen (Robertson-Steel, 2006).
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they are actually false (Salmon, 2016). Translated to triage this would be a situation of „overtreatment‟, indicating that the urgency of the patient‘s need was overestimated (Cozijnsen and Van der Erf, 2018). A clear example is the amount of people that inadequately end up in the ED. Especially large amounts of elderly people, are incorrectly referred to the hospital, which is unacceptable (Kiers, 2018). Furthermore, there is an increase in the amount of Treat-No-Transport EMS calls (Jansen et al., 2016). These are situations, in which EMS has to respond to an urgent call, but ends up not needing to transport the patient, indicating that the patient may not require EMS and hospital service. False negatives represent the opposite situation, i.e. situations that are concluded false, whereas they are actually true (Salmon, 2016). Translated to triage this would be a situation of ―undertreatment”, indicating that the urgency was underestimated (Costijnzen and Van der Erf, 2018). An example of such wrong decision making, includes the prioritization of patients with chronic heart disease or stroke symptoms to low-priority groups. Incorrect decisions may result in the loss of critical time for treatment and jeopardize the patients‘ health (Salman et al., 2017) There are several causes for patients ending up at the wrong care provider. False positives in many cases represent frail elderly people. These patients have multiple and complex illnesses, often due to internal diseases, creating challenges for triage. In many cases the most secure option is chosen – i.e. sending EMS – while other care providers would have been more appropriate (Kiers, 2018). Furthermore, triage support systems tend to overestimate situations and often advice a higher urgency level as needed (Bukman, 2018). Causes for false negatives generally refer to a lack of knowledge of symptoms in order to accurately assess situations and the lack of awareness of adequate responses when symptoms appear. Lastly, there is large diversity within triage systems used by care providers (Robertson-Steel, 2006), causing
inconsistency to the prioritization of patients.
The challenge within triage is to be able to accurately assess the full spectrum of clinical presentations from critical illness and injury through to minor illness and minor injury (Robertson-Steel, 2006). It is clear that both false positives and false negatives are harmful for the acute care process, as false positives cause troubles for acute care providers in terms of extra work load or a need for rerouting the patient, while false negatives can have disastrous effects for patients. Many of these problems can be led back to the fact that there is too little coordination during triage (e.g. Cozijnsen and Van der Erf, 2018). Integrated triage systems are necessary to respond to the current problems (Robertson-Steel, 2006).
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Response time
Accuracy of the chosen urgency
Accuracy of the chosen action and provider
response is chosen. This can reach from giving advice on the phone to sending an ambulance. Lastly, this includes the deployment of mobile units (e.g. ambulances) or not. In order to effectively manage urgent patients, there must be responded both fast and appropriately. This results in the following performance measures. In order to respond fast, there should be a short response/dispatch time. Furthermore, based on the need for care the right urgency should be chosen. Based on this urgency the most appropriate care provider should be chosen.
Figure 1: Visualization of the process of triage
2.3 SUPPLY CHAIN INTEGRATION
Within the acute care system, multiple organizations collaborate closely in order to deliver high quality care. Patients are often helped by a supply chain consisting of multiple parties before ending up at a treatment facility (these services can include home care, GP, emergency control room and EMS). Clearly, integration of parties‘ activities is paramount to safeguard an adequate and timely response to a patient‘s call for help. In order to identify how successful integration within triage should be realized, the most important barriers and enablers for successful integration between multiple supply chain partners will be identified.
Although the field of SCI is relatively new, many authors have stressed the importance of SCI. SCI is considered to be core to successful supply chain management and a higher level of integration is generally desirable for organizations (Sabet et al., 2017), because it embeds capabilities in organizational processes and creates conditions conducive to improving SC performance (Koufteros et al., 2010). Many benefits of SCI have been named in literature, including better production plans and improved delivery due to mutual exchange of information and capabilities (Zhu et al., 2018), facilitation of responsiveness to customer needs and providing supply chain partners with on-line and on-time access to information (Flynn et al., 2010).
Many authors have made an attempt to define supply chain integration (SCI), which has resulted in many definitions. Within this thesis, SCI will be defined based on the definition of Flynn et al. (2010). They define SCI as the degree to which the focal firm strategically
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collaborates with its key supply chain partners and collaboratively manages inter-organizational processes with the goal to achieve effective and efficient flows of products and services, information, money and decisions, to provide maximum value to the customer at low cost and high speed. This definition is comprehensive in the aspect that it includes all supply chain partners (oppositely of solely focusing on upstream or downstream integration) and a clear explanation of the purpose of SCI.
The basis to realize SCI is by better cooperation and collaboration, shifting away from managing individual functional processes, to managing integrated chains of processes (Flynn et al., 2010). Because every context has its own characteristics, enablers and barriers are not directly generalizable, but are context-specific. This is especially the case for acute care due to the distinct characteristics of this context. However, main dimensions or categories of integration can be used as an overview in order to identify more specific enablers and barriers. Fabbe-Costes and Jahre (2008) have identified four layers that have to be integrated in order for SCI to be successful. These layers are integration of flows, integration of processes and activities, integration of technologies and systems and lastly integration of actors. The four layers are especially useful, because they seem well applicable to the context of triage in acute care and are focused on external integration, which is also the case in this thesis. They will be shortly described within the context of triage.
Integration of flows
Within the integration of flows, a distinction can be made between the flow of physical resources, information flow and financial flow (Fabbe-Costes and Jahre, 2008). Within the acute care context the main focus will be on the integration of information flows. Although information is key in order to accurately determine the best response to a call (Davies, 2016), currently acute care providers have very little information regarding patients‘ medical background (Cozijnsen and Van der Erf, 2018). Increased access to patient information is key in order to improve the accuracy of triage (Davies, 2016). Furthermore, all acute care providers use their own mobile units. Currently all units belonging to EMS can be monitored, however this is not the case for resources from home care. Monitoring and potentially also the interchange of all vehicles might be beneficial for the process within acute care (Cozijnsen and Van der Erf, 2018).
Integration of processes and activities
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Integration of technologies and systems
The integration of technologies and information systems is seen as key within a healthcare context. Because there are many different organizations involved within the care of patients, there is a need for integrated IT systems, making it possible that all parties have quick access to patient information (e.g. Pouloudi et al., 2016). This is especially important within triage, because a patient‘s medical background might have a big influence on the care needed and the access to this kind of information might increase the accuracy of the chosen response. This is however a very difficult issue due to the effects on the privacy of patients. Furthermore, all acute care providers have their own triage systems and protocols. This diversity of healthcare triage systems is creating difficulties in developing integrated care services (Robertson-Steel, 2006).
Integration of actors
Integration of actors refers to the organization structure and the way of working together. As mentioned before, large amounts of patients initially contact the wrong care provider. Therefore, acute care providers can largely benefit from each other by referring a patient to the right care provider. In order to do this, organizations should be well aware of the capabilities and qualities of other disciplines, which is currently not the case (Cozijnsen and Van der Erf, 2018). Subsequently, organizations have to be aware of the benefit of effectively collaborating during triage, in order to transfer patients when appropriate. Integrating these providers is key in improving this process (Robertson-Steel, 2006). By putting providers together, they are constantly able to communicate, share information and expertise and help each other (Davies, 2016).
2.4 THE ROLE OF PHYSICAL PROXIMITY
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Scarce examples of proximity of resources can be found within the field of healthcare. These are mainly linked to the focus concept. A focused healthcare unit can be described as the aggregation of patients in one unit, while the resources to serve these patients are co-located (Hyer et al., 2009). Shortell et al (1994) mention that the concept of focus makes it easier to coordinate activities, communicate relevant information, and deal with problems and complex situations. These are benefits that might be essential in the process of triage, as patient information is essential for accurate triage and operators have to deal with complex and divergent requests.
2.5 MAIN FINDINGS FROM LITERATURE
Acute care providers are cooperating sub-optimally, causing them to struggle with the demands put on them. EMS struggle to cope with an increased demand, EDs are overcrowded, and large amounts of patients end up at the wrong care provider, making that patients with an urgent need cannot always count on appropriate care. More accurate allocation of the patient to the right care provider is necessary, which demands the integration of different acute care providers during triage. Integration of acute care providers might increase the ability to share information and expertise, to increase knowledge about other disciplines and increase the access to a patient‘s medical information, resulting in more accurate outcomes of triage. In order for integration to be acquired successfully, integration must be applied on multiple layers. Four main layers for integration have been identified based on the work of Fabbe-Costes and Jahre (2008). Proximity might play an important role in the success of integration, as the different providers can more easily collaborate and communicate.
Acute care network integration - Integration of flows
- Integration of processes - Integration of systems - Integration of actors
Triage accuracy
- Accurate assessment of the need for care
- Accuracy of chosen urgency - Accuracy of chosen provider Physical proximity of actors
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Figure 2: Conceptual model
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3. METHODOLOGY
The first section of this chapter will elaborate on the choice for the research question and the data required to answer these questions. Next, the choice for an explorative case study will be motivated. The third section will focus on the methods used for data collection. The methodology will end by discussing how the data will be analyzed, in order to provide an answer to the research questions.
3.1 RESEARCH QUESTIONS
Based on the literature analysis, it can be concluded that the pressure on acute care providers has grown and providers struggle to cope with the increased demands put on them. An important cause is the large amount of patients that are initially referred to the wrong care provider. Several authors have stated that integration of acute care providers during triage is necessary, in order to more accurately allocate patients to the right care provider. There is however no literature stating how successful integration during triage should be achieved. Secondly, physical proximity might play an important role in order to achieve successful integration during triage. This research aims to identify how successful integration within triage should be achieved and secondly aims to identify the specific role that physical proximity plays within this process, based on the following two questions:
1. What are enablers and barriers for successful integration of acute care providers during triage?
2. What is the role of physical proximity within the integration of acute care providers during triage?
3.2 RESEARCH DESIGN
In order to form an answer to the research questions, an explorative case study will be performed, based on a pilot. This thesis aims to create new knowledge, by identifying enablers and barriers for integration between acute care providers and to specify the specific role of physical proximity within this process. The research can therefore be characterized as explorative. A case study is very well applicable (1) when situations are studied in its natural setting, (2) to answer why, what and how questions and (3) to early, exploratory investigations (Karlsson et al., 2016). The method therefore fits perfectly with the aim of this research and its research questions.
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3.3 DATA COLLECTION
To form an answer to the research questions, data is collected in multiple steps. The first step is to identify the process under investigation. Because this research is initiated by a pilot, it is important to accurately identify and visualize the process before the pilot with the situation during the pilot, in order to make meaningful comparisons. The second step is formed by the identification of enablers and barriers for successful integration during triage. The literature review and process identification serve as input for the interviews. Interviews with operators of the pilot serve as a way to identify enablers and barriers and subsequently expert interviews with managers and initiators of the pilot serve as a way to validate and complete the findings found previously. Lastly, a small performance analysis is performed to compare the outcomes of triage during the pilot with outcomes before the pilot. This step is performed to create an indication of the results of integration during triage.
Step 1: Process identification
The starting point for this research, is the identification of the process under investigation. Because this research is linked to a pilot, both the old processes (all parties have their own procedures for performing triage) and the process during the pilot, must be accurately identified. Two data sources are used for realizing this – interviews and participant observation.
The initial step is formed by expert interviews with initiators of the pilot. These are unstructured interviews, because at this point the researcher does not have much knowledge regarding the process and the interviews are meant to create initial knowledge on the process. The interviews serve as a way to acquire managerial information regarding the context of acute care and triage in particular. Furthermore, the initial process is compared with the process during the pilot in order to identify the most important differences. Lastly, the set-up of the pilot and the stakeholders involved are discussed.
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In order to ensure the correctness and completeness of the process maps, these are validated. This is done during interviews with both operators and initiators of the pilot.
Step 2: Identification of barriers and enablers for integration
Semi-structured interviews are used as the main source of data for identifying enablers and barriers for integration as well as for identifying the role of physical proximity. Semi-structured interviews are very well applicable for this part, because they are very useful in identifying stakeholder views: ―the goal of any qualitative research interview is to see the research topic from the perspective of the interviewee, and to understand how and why he or she comes to have this particular perspective‖ (King 1994, p. 14, our emphasis). Secondly there is flexibility in how questions are asked and what follow-up questions to use (Van Teijlingen, 2014). This is particularly important in this case, because there are also potential other enablers and barriers that are not yet identified. Interviews are recorded and transcribed in order to analyze the data accurately.
Based on the analysis of existing literature and the identification of the process an interview protocol was developed. A well-designed research protocol enhances the reliability and validity of case research data (Karlsson, 2016). The interview protocol can be found in Appendix I. The first step in developing the interview protocol, is to identify the main dimensions for integration based on the performed literature analysis. Because no specific enablers and barriers are identified yet within the context of triage, the identified SCI layers (Fabbe-Costes and Jahre, 2008) serve as main categories for the interview questions. Subsequently, based on the identification of the process, questions are identified in a more precise way. Based on the process steps identified questions arise. Furthermore, the observations and informal talks with operators also create initial thoughts on enablers and barriers resulting in questions. Based on the acquired knowledge, an interview protocol was developed including potential enablers and barriers. Questions are categorized based on the four SCI layers. The interviews were also used to identify the role of proximity and to identify if interviewees have perceived an improved accuracy of triage.
Multiple disciplines participate in the pilot, each with their own perceptions on the pilot and its outcomes. Interviews will be conducted with people from all relevant disciplines, in order to accurately identify the effects of integration and the role of physical proximity. First, operators from the pilot will be interviewed. Because these are the day-to-day operators of the pilot, it is assumed that they have identified and/or encountered the most important enablers and barriers for integration. Operators that will be interviewed include:
2 Coordinating doctor‘s assistants (GP care)
2 ZCN centralists (Home care)
2 MKA centralists (EMS care)
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and problems occurring during the pilot. Therefore, it is assumed that they are also well able to identify the most important enablers and barriers for successful integration.
Step 3: Identification of the effects on triage accuracy
The last step in the process is to identify the effects of integration on the accuracy of triage. Initially, the goal was to compare outcomes during the pilot with outcomes before the pilot, in order to compare the performance and create an indication of the effects of a co-location for triage on the accuracy of triage. However, eventually the right data could not be collected. Therefore, it was chosen to measure performance based on the perceptions of operators at the care-coordination center and a small performance analysis based on other data.
3.4 DATA ANALYSIS
In order to analyze the data from the interviews, the recorded interviews first will be transcribed. Transcribed interviews result in very large amounts of data, and it is therefore of high importance to try to reduce data into categories (Miles and Huberman, 1994). Therefore, in order to analyze the data, a coding technique has to be applied. Coding of interviews is central to effective case research, because this allows a chain of evidence to be established, which further increases the construct validity (Karlsson et al., 2016). Within this research, an inductive coding approach described by Gioia et al. (2013) is used. Inductive coding seeks to analyze the data fully focusing on data-driven codes, contrary to deductive coding in which data is matched with theoretical insights (i.e. pattern matching). Inductive coding is suitable in cases of explorative research, and when no extensive theoretical framework is available beforehand. In this research, enablers and barriers are not known beforehand (only main layers are identified), so the inductive approach is very much applicable.
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4. CASE DESCRIPTION
Because this research is based on a pilot study, the pilot study will first be described in more detail. The first section explains the main characteristics of the pilot and the motivation for starting the pilot. The next section elaborates on the participants of the pilot. The third and fourth section of this chapter will zoom in on the process before the pilot and the process during the pilot respectively. To create a clear view of the processes under investigation, the steps in the processes will be described and visualized in process diagrams. Both the process before the pilot and the process during the pilot will be described in order to identify the differences and the potential places were benefits could occur. All parties receive their own calls and differ in their process. Therefore, in the old situation the processes will be described individually. For the new situation a general process is visualized in which the main areas for collaboration are indicated.
4.1 MOTIVATION FOR THE PILOT
This research is motivated by a pilot aiming to investigate the impact of coordination within acute care. More specifically, during the pilot there is increased collaboration during triage by means of the establishment of a co-location. Within this co-location, multiple acute care providers are sitting together and performing triage. The participating organizations will be elaborated on in the next section. The pilot covers the IJsselland region, excluding the municipalities Deventer and Steenwijkerland. This area covers around 400.000 people.
There are several trends within the acute care sector that have motivated this pilot. These include an increased inflow of patients (especially elderly patients), increase in extramural care, an increased amount of patients with complex/multiple needs and the social call for 24/7 availability of high quality care. Furthermore, large amounts of patients are referred to the wrong care provider. It is believed that this is partially caused by a lack of collaboration during triage, as all parties were performing triage individually, acting from their own location. The goal of this pilot is to respond to these trends by establishing better coordination in acute care, resulting in the right patient at the right place (i.e. at the right care provider) within the right time. By improving the accuracy of triage the pilot aims to a more efficient use of the limited resources available in acute care. Physical proximity of different acute care providers might facilitate this process, because people can communicate face-to-face and share information and knowledge more easily.
4.2 PARTICIPANTS OF THE PILOT
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4.1.1 Meldkamer Ambulancezorg
The Meldkamer Ambulancezorg (MKA) is part of the Meldkamer Oost-Nederland (MON), which is located in Apeldoorn. The MON is the emergency control center for the region IJsselland, North-Gelderland and East-Gelderland and is also operated by the police and fire arms. The MKA is responsible for all 112 calls related to patients with an urgent need for care. Generally these are calls with a very high urgency and based on a fast and accurate triage, the most appropriate response should be determined. The MKA collaborates with the EMS and is also responsible for allocating ambulances to an emergency situations (i.e. the patient location). In most cases, EMS will be send.
The MON works with two types of urgencies. One type of urgency is linked specifically to EMS care and represents the time within EMS should be on scene. The following urgencies are possible: A1 (on scene within 15 minutes), A2 (on scene within 30 minutes), B (no time standard, this represents elective care). Secondly, triage is performed using a triage protocol. This is the Nederlandse Triage Standaard (NTS). Urgencies reach from U0 (the highest urgency, which represents that reanimation is necessary) to U5 (the lowest urgency, which indicates that assessment by a physician is not necessary or can wait).
Note: Within this thesis both the terms EMS and ambulance are used. These two words have the same meaning in this thesis.
4.1.2 Medrie
Medrie is an organization facilitating and supporting GP‘s during out-of-office hours, i.e. during the evening, night and weekends. Medrie exists out of three Huisartsenposten (HAP) covering the following regions: Zwolle, Flevoland and Hardenberg. This area covers around 600.000 inhabitants. The HAPs are supported by a so called „triage center‘ in Zwolle. From this location, operators from Medrie (later on referred to as HAP operators) receive calls and allocate patients to the right care provider at the right place. Similarly to the MKA, HAP operators also use the NTS protocol. Calls generally represent people with an urgent need, who want to be seen at a HAP. Patients feel that they do not want to wait until the next day, but generally calls are considerably less urgent than calls received by the MKA. Mainly, these patients should be referred to the HAP, or patients are advised to visit their own GP the next day.
4.1.3 Zorgcentrale Noord
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4.3 PROCESSES: OLD SITUATION
The different parties receive very differing patient calls and requests. People calling 112 generally have a much more urgent need than people who call the ZCN. Therefore, the parties also differ considerably in their ways of working. Parties differ in their procedures for performing triage and for determining the right action for a patient. The procedures for the MON and HAP are fairly similar, but the ZCN procedure differs significantly. In order to be clear on the specific procedures and ways of working, the processes will be described individually.
4.3.1 Meldkamer Ambulancezorg Step 1: Assure the safety of bystanders
When a (112) call comes in at the MON, the first step in the process is to assure the safety of bystanders. The person in need for help might be in an unsafe environment, e.g. there might be explosion danger, fast traffic or burning fire. In order to be able to help someone, people must first assure their own safety. The worst case scenario would be that more people get seriously injured.
Step 2: Determine location of the patient
The second step in the process is the determination of the location of the person in need for help. This should be done before performing triage, because the goal for ambulances is to be on scene as fast as possible and they can only leave when a location is determined. Furthermore, there is the risk that a caller might lose the connection or might lose their consciousness (if the caller is also the patient in need for help). If the latter is the case, the operator might already have determined the location and can send help to the location.
Step 3: Activating an ambulance
When the location is determined, the operator instantly requests an ambulance to this location, in order to respond to the emergency as fast as possible.. Within the emergency control room one operator is responsible for dispatching mobile units to locations, while the other operators perform triage. This operator receives all requests and links the requests to an available ambulance. In some situations, based on the outcome of triage it might not be necessary for EMS to go to a situation. In this case, the EMS is deactivated as soon as this is concluded. Step 4: ABCD check
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Step 5: Determine urgency and the most appropriate response
ABCD unstable: when a patient shows instability on one of the aspects of the ABCD protocol, it should be determined if a patient is in need for reanimation (urgency U0) or if the patient is in a potentially life threatening situation, but is still conscious (urgency U1). This should be determined, because in all cases U0 patients should be transported to the hospital immediately, while in certain cases U1 patients can better be helped by a GP. When the most appropriate response is to send a GP, the patient including the responsibility and necessary information from triage will be transferred to the GP.
ABCD stable: when the ABCD approach shows that the patient is stable, the urgency of the patient‘s need should be assessed. This is based on a combination of the outcome provided by the NTS and the operator‘s own estimation and interpretation. The triage protocol in use is the Nederlandse Triage Standaard (NTS). Someone‘s own interpretation complements the triage protocol and might overrule it. Based on the outcome, the most appropriate response is chosen. In most cases it is not necessary to send an ambulance when a patient is stable, which means that the ambulance should be cancelled. There are exceptions, e.g. a broken hip bone. If a call turns out not to be very urgent, a patient might be transferred to a GP, to home care, to GGZ or take advice on the phone.
Step 6: Completing information
Whether a patient is referred to another provider or not, the last step in the process is to complete the information about the call. In order to respond fast and appropriate, EMS needs the following information about the patient: information regarding the specific environment (e.g. there might be a fire), NAW-data (name, address, hometown), information identified during triage (e.g. the patient has a certain disease), the specific demand for care and of course the urgency.
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Determine location ABCD check
Determine urgency and appropriate response Assure safety of bystanders Activate
ambulance Need for EMS?
Transfer to the most appropriate
provider Cancel EMS ride
Complete data for EMS personnel Yes No EMS Receive call NTS protocol HAP ZCN
Advice for self-care Process flow
Information/system use
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4.3.2 Medrie huisartsenzorg Step 1: Listen to the patient‘s complaint
The first step in the process is to listen carefully to what the patient has to tell, in order to form an initial idea of the patient‘s complaint and the sort of care which is needed. This also serves as a way to roughly identify if a call is very urgent or not.
Step 2: ABCD check
Similarly to the MON, the HAP is using the NTS protocol. Therefore, the next step in the process is to identify if the patient is stable, based on the ABCD protocol. This is not the first step in the process, because generally the HAP receives calls, which are considerably less urgent and in most cases it is not necessary to do the ABCD approach in an accurate and structured way (e.g. when someone injured their ankle during a soccer match).
Step 3: Determine the urgency of the patient‘s need
Subsequently, the operator should complete the triage based on the NTS protocol and an own interpretation of the situation.
ABCD unstable: when the patient shows instability on one of the elements of the ABCD approach, the HAP operator should first determine the location of the patient, because it will be very likely than an ambulance should be send. Subsequently, the triage should be finished based on the NTS protocol and own interpretation in order to determine if the urgency is U0 or U1. In case of an U0, the call should be transferred to the MON immediately. In case of an U1, the operator should identify if there is a need for EMS or if a GP visit is more appropriate. ABCD stable: similarly to the MON, the urgency should be determined based on the NTS protocol and someone‘s own interpretation. In case a HAP operator wants to overrule the NTS protocol by decreasing the urgency (e.g. U2 to U3), the GPshould check and give approval.
Step 4: Determine the right action and provider
Based on the urgency of the patient‘s need, the right action and provider should be determined. The most common response for the HAP is to plan a GP consult. This might be the same evening/night, but can also be the next time. If a call is somewhat more urgent, there might also be chosen for a GP visit. If a call is not very urgent, the operator might choose to provide advice (for self-care) or to arrange home care or informal care.
Step 5: Complete information
The last step is to enter the right information. The following information is required if a patient is send to a GP (center): NAW-data, information identified during triage, information on the patient‘s need for care and the determined urgency. Furthermore, the patient‘s own GP
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Listen to patient s
need ABCD check
Activate ambulance
Determine location
ABCD stable? Yes Determine urgency
No Determine urgency: U0 or U1 Choose provider U1 U1 U0 U1 Determine action and provider Receive call EMS GP visit GP consult ZCN NTS protocol Patient callmanager Process flow Information/system use
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4.3.3 Zorgcentrale Noord Inflow of the process
In contrast to the MON and the HAP, the ZCN receives a very broad range of demands and requests. Therefore, the different types of inflows will be shortly described. The two main sources coming in, are incoming calls (from patients) and patient alarms. These two types of inflow need a to responded to by means of performing triage, and therefore are shown in the process map. Furthermore, the ZCN also receives requests by mail and is responsible for checking medication prescriptions. These do not need a direct assessment/response and therefore fall outside the scope of this research.
Step 1: Listen to the patient‘s need
The first step in the process is to carefully listen to the patient‘s need. A significant amount of calls is presented by elderly people. Quite often, these patients are not very well able to communicate their complaint accurately. Therefore, initially it is very important to listen carefully to what the patient has to say, in order to get an idea of the patient‘s complaint and the kind of care this person needs.
Step 2: Assess the need for care
When an initial idea of the patient‘s complaint is formed, the next step is to assess the need for care. In contrast to the MON and the HAP, the ZCN is not making use of the NTS protocol. As for the other organizations, the ZCN nurse will assess the need for care based on a combination of a triage protocol and own interpretation. Furthermore, a ‗patient card‘ might be available, with medical information about the patient. As mentioned before, the ZCN will use the triage protocol of the organization that the call belongs to. The ZCN works for a large amount of different (home care) organizations, each with their own triage protocols.
Step 3: Determine action and provider
Based on the need for care, the right action should be determined. First it should be determined if this is a type of care that can be provided by the organization that the call belongs to (i.e. generally this means if the request can be provided by home care or advice). If so, the right action should be determined, which can be either (1) solely provide advice, (2) arrange informal care, (3) send someone from home care or (4) send a specialist team. If not, the patient should be transferred to the right care provider. If the person needs an ambulance, the call will be transferred to the MON. If a person needs to see a GP, the patient will be advised to call the HAP. There is no direct number to the HAP, so patients are not transferred directly.
Step 4: Complete information
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Listen to patient complaints
Assess the need for
care Determine action
Complete information Yes ZCN care? GP or EMS? No GP EMS Incoming call Alarm Triage procedure ZCN Patient card ZCN Transfer to MON Specialist team Advice to call HAP
Home care
Advice for self care
Informal care Process flow
Information/system use
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4.4 PROCESS: NEW SITUATION
4.4.1 Set-up of the new process
In the old situation, all parties where physically separated and had their own location for performing triage. In the new situation a care-coordination center is established, where the participating organizations are co-located in one room. The room exists out of 6 tables, each equipped with 4 workplaces. One of these six tables is determined for the different disciplines and is occupied by the following people:
MKA centralist (MKA)
ZCN centralist (ZCN)
Coordinating doctor‘s assistant (CODA)
General practitioner (Medrie)
During triage several important decisions have to be made. The new set-up provides opportunities for increased coordination in order to make the right decision. The different parties can quickly communicate, share information or expertise or quickly look in each other‘s system.
The other tables are fully occupied with doctor‘s assistants belonging to Medrie. The CODA has a coordinating role, as the name already explains. This person has a managing role and serves as a point of contact for the other HAP operators. In case a HAP operator has a medically related question, this is discussed with the GP, because he/she has the best knowledge and education to answer these sort of questions. Furthermore, if a HAP operator wants to overrule the NTS system by decreasing the urgency, this should also be approved by the GP. A simplification of the layout is visualized in Appendix III.
4.4.2 Contribution: main areas for increased collaboration
In general, the process during the pilot is the same as in the old situation. All three parties still have their own triage procedure and all steps in the old situation are also performed in the new situation, because these are essential in performing triage in a fast and appropriate way. There are however some changes in the amount of collaboration and interaction. During triage, there are several important decisions that have to be made. In order to make an accurate decision, the different parties can make use of each other, and can communicate and discuss to conclude what is the best option. This is only permitted if a patient is not in direct life danger, because in this case there should be handled as fast as possible and EMS should be send immediately. Discussion in order to make the right decision could delay this process. Figure 4 visualizes the main areas where collaboration can take place.
1. Determination of ABCD
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example in cases of chest pain. Sometimes this might be completely innocent, in other cases the patient might have a cardiac arrest. If an operator is not sure about the situation, the operator can rapidly discuss with someone from another discipline and possibly also get access to important information (e.g. a patient has had a cardiac arrest before), which can increase the accuracy of choosing the right response.
2. Determination of provider for U1 urgency
In case a patient is not stable according to an ABCD check and has received the urgency ‗U1‘, multiple responses might be possible. In most cases EMS will be sent to the patient, however in some cases a GP visit is more appropriate. This is for instance the case with patients who are known to the GP and the HAP, because they have a certain illness or disorder. In this case symptoms might be explained by the illness they have and the GP might very well know how to act on it. MKA centralists do not have any patient information, so in this case a fast moment of communication is beneficial in order to see if a patient is known at the HAP. In the old process, these calls would generally have resulted in the immediate sending of an ambulance, while this might not have been the most appropriate solution and might not have been necessary.
3. Determination of the most appropriate provider
~ 32 ~ Determine ABCD Determine urgency Determine urgency: U0 or U1 ABCD stable? No Determine provider U0 U1 U1 U1 Determine correct care provider
Yes informationComplete
Receive call
EMS
GP visit
GP consult
Advice for self care
Home care
Specialist team
Psychiatry
NTS protocol Triage procedure ZCN callmanagerPatient Patient card ZCN Process flow
Information/system use
Figure 6: Visualization of the process during the pilot
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4.4.3 Contribution: example cases better handled due to collaboration
The previous section has identified and visualized the activities in the process, in which there is increased possibility for collaboration. In order to create a better indication of the benefits of the new process, several types of cases are discussed below, that are expected to be managed more appropriately due to an increased amount of collaboration.
Palliative care patients: palliative care patients are generally very hard calls for operators. These are patients who are terminal ill. Often these patients do not have to long very long anymore or have a quality of life which is decreased considerably due to their conditions. In certain cases, it is questionable if a patient can be saved (e.g. if getting an attack) or it is questionable if the person wants to be treated when something occurs. When operators are close to people from other disciplines, they can discuss and exchange insights and opinions in order to make the right call. Furthermore, patients might have signed that they do not want to be treated or transported to the hospital, and in this situation it is very helpful if the MKA operator can get this knowledge from the CODA.
Cases that fall in between “U1 EMS” and “U1 GP”: in a considerable amount of
situations it is fairly hard to tell if a patient needs to be transported to the hospital by EMS, or if the patient receives sufficient care by sending a GP. This is for instance the case with chest pain, which often is related to a cardiac arrests, but is not always the case. In this case it is very valuable to communicate with someone from another discipline, especially for someone from the ZCN or HAP, because they are somewhat less familiar with these complaints. As was mentioned by a MKA operator during an observation: “The very urgent situations are easy to us, because we immediately conclude to send EMS. The cases that fall in between form the complex cases.”
Cases including multiple care providers: in certain cases, multiple care provided are needed to assist and help a patient. This is for instance the case with Treat-No-Transport calls. When EMS is send to location, but ends up not transporting the patient to the hospital, the patient might need other types of care (e.g home care or GP). In this situation it is very easy to manage such a demand.
Mental healthcare patients: The amount of patients with mental care requests and demands for psychiatric treatments are growing significantly. Although mental health services (GGZ) are planned to be included in the pilot, they are currently not. As mentioned during the observations all care providers receive these sort of requests and struggle to manage these as they have not the right education and knowledge to manage these. In a situation where mental healthcare service is included – which is still planned for the future – it will be much less complex to handle these requests.
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5. RESULTS
This chapter presents the results that have been identified based on the interviews. Section 5.1 will focus on the most important enablers and barriers for successful integration. Section 5.2 focuses on the role of physical proximity during triage of acute care. The table below shows an overview of the results. Section 5.3 will relate the findings to the accuracy of triage.
Enablers Type of SCI layer
1. Continuity Integration of actors
2. Completeness Integration of actors
3. Integrated triage system Integration of systems
4. Integrated patient database Integration of systems
5. Getting to know each other (organization) Integration of actors
6. Getting to know each other (personally) Integration of flows
7. Learning during triage Integration of flows
8. Involvement of management Integration of actors
9. Education and training Integration of processes
10. Single entry Integration of processes
Barriers
1. Integrated triage system: divergent patient demands Integration of systems
2. Integrated patient database: subjectivity Integration of systems
3. Integrated patient database: patient privacy Integration of systems
4. Distance from own discipline/colleagues Integration of actors
5. Overburdening of operators Integration of processes
6. Practical issues based on new process set-up Integration of processes
Role of proximity
1. Decreased barrier for communication 2. Increased information sharing
3. Increased expertise sharing
Table 1: Overview of results
5.1 ENABLERS FOR SUCCESSFUL INTEGRATION
This paragraph shows the most important enablers and barriers for successful integration during triage that have been found based on the interviews. The table below gives an overview of all the factors found. These will be described in more detail afterwards.
1. Continuity of the pilot
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small contracts, so I do not know everyone very well and it can take long before operators have adopted changes‟.
2. Completeness of the team
In order to realize successful integration of acute care providers, it is of utmost importance to involve all relevant disciplines. Acute care is characterized by a broad range of patient requests and multiple entries into the system. To accurately assess all the different requests that are coming in it is important that all the necessary parties are included in the care-coordination center. Currently some important disciplines are missing. Interviewees mention that the inclusion of the hospital and of home care could be beneficial. As multiple interviewees mention: “Contrary to all ambulances we are not able to monitor mobile units from home care, I think this would be a useful addition.” Furthermore, a very important entry into the acute care system, which is currently not included is mental health services (Geestelijke Gezondheidszorg, GGZ). There is a large amount of mental care demands coming in and these are very hard to accurately assess with the absence of the GGZ. This is supported with the following quotes: “I think the GGZ could play a very big role‟ and ‗Psychiatry is a missing link, I am very much aware of that‟. Completeness of the team at the care-coordination center is essential in order to accurately respond to the divergent patient demands.
3. Integrated triage system
Another important enabler for successful integration in triage is the use of a single triage system. When all participants are using the same triage systems, communication will be more fluent, because everyone is using the same ‗triage language‘ and urgencies. This is supported by the following quote: ‗the advantage of all disciplines using NTS is that you use the same triage language‟. Furthermore, another advantage of integrated triage systems is the possibility to transfer data that is entered in the system. Currently this is not possible, because systems are not linked. The following quote explains the value: „Currently the systems are not linked, which means that data in the system cannot be transferred. This would be a big win‟. An integrated triage system would create a structured way of working, create better understanding and make it possible to transfer triage information.
4. Integrated patient database
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5. Getting to know each other (organization)
In order to collaborate successfully, the different parties should have accurate knowledge about each other‘s capabilities and qualities. This subsequently increases the amount of trust in each other to manage certain complaints. This is very well expressed in multiple quotes: „many employees from the HAP and MON did not even know the ZCN beforehand‟ and ‗You know better what other parties are able to do. Especially with regard to home care this is valuable, because now we know for instance that they are able to replace a catheter‟. Furthermore, parties have a better understanding of the sort of requests that are received at other parties and know better which information to provide when a patient is transferred. This is understated by the following quotes: ‗Now I know better what kind of patient requests belong to other disciplines and when to make use of them and „Currently, I know better which information to provide when I transfer a call to the MON‟.
6. Getting to know each other (personally)
Another important enabler for successful integration is to get to know each other on a personal level. The barrier to discuss and interact with one another is considerably smaller when you know the person you want to contact. Although this might seem not very important, this was mentioned by nearly all interviewees. Examples of quotes by interviewees are: „How well you know one another, influences the amount of interaction you have‟ and ‗After some time you get to know each other better and people ask you for advice more often‟. This also holds when people are removed from each other again, which is expressed in the following quote: „When I work in Apeldoorn now, I reach out for contact [phone contact to Zwolle] more easily, because I already know the people sitting there and I recognize their voice‟.
7. Learning while doing triage
There are large differences between the procedures and interests of the different parties while performing triage. In an integrated fashion where multiple parties are co-located, operators can hear each other and learn from each other. MON operators are mainly focused on getting a clear image of the medical complaint, while operators from the ZCN are more focused on the communicative side. This is supported by the following quote: „The HAP and ZCN receive very different patient requests and manage these also very differently. We can learn from this.‟ and „We all act on a slightly different discipline, making it possible to learn from each other‟. Furthermore, in a co-located environment different disciplines can hear each other and are able to assist each when necessary. Also colleagues from different disciplines might give advice or tips when evaluating cases. All these things create a learning process. One of the interviewees mentioned the following: ‗I have received quite some tips and advices since I participate in the pilot. I have learned a lot since.‟
8. Involvement of management
