Management Control and Trust in self-directing teams within homecare

(1)

in self-directing teams within homecare

24

th

of June 2013

MSc thesis

Jasper Verhoef

S2224992

T: +316 2391 2667

E: jasper.verhoef@gmail.com

Supervisor:

A. Abassi

Faculty of Economics and Business

University of Groningen

P.O. Box 800

9700 AV Groningen

(2)

1. Abstract

Purpose – The aim of this paper is to investigate the relationship between management control

and trust in self-directing teams within homecare. Two important questions related to management control and trust are investigated: which tasks are performed by the teams and which are performed by supervisors? And what is the strength of trust?

Methodology – The study is based on a multi-case study carried out at three different

organizations in the Netherlands: A company that works with self-directing teams, a collaboration of self-employed care professionals and a traditional homecare organization. The main findings are based on a literature study and eight in-depth qualitative interviews with both nurses and managers from different organizations.

Findings – The results explain the relation between management control and trust. Working with

self-directing teams results in less management control, which leads to more trust. When managers are less occupied with making sure that resources are gathered and used effectively and efficiently in order to reach the objectives of the organization, trust will have to be higher to compensate for this. Trust enables or disables working with self-directing teams, since a lack of trust inhibits the possibilities to reduce the amount of management control. Notable observations in self-directing teams are: more planning and control activities are carried out by nurses, there is a tendency to function in the old way, a narrower selection of services is performed and trust is more eminent.

Research limitations / further research – The study was limited to three organizations which

function mainly in the north of the Netherlands in the homecare sector. Although this limits the risk that valuable insights are missed due to increasing complexity, further research should include multiple organizations from different regions to broaden the scope. Furthermore it is argued that achieving a broader insight into factors that influence the relationship between management control and trust would be a valuable aim for future research.

Practical implications – This study has important implications for medical professionals, both

managers and carers. Valuable insights in the relation between management control and trust is provided, which is essential when working with self-directing teams. Results show that the effects of a reduction in management control and the increase in trust are interrelated and this results in increased importance to ensure a holistic approach to achieve desired results.

Originality / value – Although working with self-directing teams has been high on the political

agenda, the literature has been scarce. Little is known about the relationship of management control and trust in self-directing teams within homecare. This research contributes to science by deepening our knowledge about self-directing teams and by explaining the relationship between management control and trust.

(3)

3

2. Introduction

Trust, control and self-directing teams are three much heard topics of discussion and have recently received a lot of attention. The financial crisis has led to an increase in the attention that is given to both trust and reforming the healthcare sector and at the same time the question rises what the influence of possible changes are on control. Governments realize that they have to save costs and since the healthcare sector is one of the biggest (and fastest increasing) expenditures, the reformation of the healthcare sector has been a point of discussion. The question that is posed is can we reduce the overhead cost of healthcare without reducing the delivered quality of care? (Litvak & Long, 2000)

In the Dutch ‘regeerakkoord’ (Rutte & Samsom, 2012) the government explicitly mentioned increasing the use of so called self-directing teams and ‘neighborhood-nurses’; Highly skilled employees work together in teams without the direct supervision of a manager (Vermeer & Wenting, 2012). As a result of the attention, self-directing teams are implemented in healthcare and specifically in homecare on different places and in different ways. A problem that arises is that the effects of implementing self-directing teams on management control issues are unclear. How is the organization controlled when self-directing teams are used? Are all self-directing teams comparable? While effects of using self-directing teams have been studied, there is little research on the implementation of self-directing teams within the specific and complex healthcare sector.

This thesis for the master of science in Business Administration – Organizational & Management Control will address this gap by developing a theory that explains the relationship between trust and management control in directing teams within homecare. Key characteristics of self-directing teams will be explained and different ways organizations use the concept in practice will be studied. Furthermore it will be investigated how the redesign of delivering healthcare affects trust and management control. A conceptual model will be made and refined to answer the main research question:

“What is the relationship between management control and trust when using self-directing teams within homecare?“

Sub-questions are:

 What are self-directing teams within the homecare sector?

 How is the concept of self-directing teams implemented within homecare?

 What are differences and similarities between different practices between different organizations that use self-directing teams in homecare?

 Which tasks are performed by the teams and which are performed by supervisors?

(4)

The goal is to (further) develop our understanding about the role and influence of control and trust in self-directing teams within homecare. Academic literature on self-directing teams within healthcare is scarce. This research contributes to literature by (1) reviewing current literature about these topics from a homecare perspective; (2) reporting the results of field interviews of people involved in self-directing teams in homecare; (3) developing a model that explains the relationship between management control and trust in self-directing teams within homecare; and (4) presenting suggestions to guide future research that is needed in this area.

What do you see when you look at self-directing teams from a management control and trust perspective? What are current practices in homecare and what are the differences and similarities? What are specific control and trust issues to consider and think about? This knowledge can be used by managers in the healthcare sector when implementing the concept of self-directing teams. Interesting research from a theoretical and a managerial perspective.

The following sections will start with a theoretical perspective on control, trust and self-directing teams. From this a conceptual framework is made, the methodology is explained and results are presented and discussed. In the end conclusions, limitations and recommendations for further research are given.

3. Theory section

Shrinking government budgets and the rising costs of healthcare have increased pressure to improve the control of healthcare processes. Control has different meanings and connotations. The term management control was explained by Anthony (1965) as the process of making sure that resources are gathered and used effectively and efficiently in order to reach the objectives of the organization. All organizations need to support processes and mechanisms that enable them to reach their goals. Favorable conditions and the right use of resources is needed. Chenhall states that the terms management accounting (MA), management accounting systems (MAS), management control systems (MCS), and organizational controls (OC) are used interchangeably (Chenhall, 2003). A management control system supports the decision-making process to increase the performance in order to achieve objectives (Carenys, 2010).

(5)

5 This framework (figure 1) concerns control and planning and covers a broad array. For this paper it is especially appropriate since it focuses specifically on the healthcare sector.

Figure 1: Example application of the framework for healthcare planning and control to a general hospital (Hans, Houdenhoven, & Hulshof, 2011)

In healthcare different types of indicators are used to measure the extent to which targets are achieved “They can be measures of structure, process, and outcome, either as generic measures relevant for all diseases, or disease-specific measures that describe the quality of patient care related to a specific diagnosis” (Mainz, 2003, p. 529). Indicators are used to monitor, compare, set priorities, make judgments and improve the care that is provided.

(6)

mechanisms have a small role and emerge over time, and trust plays a signiﬁcant role in achieving control.

Nooteboom (1996) distinguishes between competence trust, based on the ability of the partner to perform according to agreements and goodwill trust, which are about his intentions to do so. Ouchi also describes this kind of trust in his explanation of clan mechanisms: “Once the manager knows that they are trying to achieve the ’right’ objectives, he can eliminate many costly forms of auditing and surveillance.” (1979, p. 837). Langfield-Smith & Smith (2003) also use contractual trust, which is described in the model of Sako (1992). It is based on the moral standard of honesty and assumes that the agreement will be honored. It is about the expectation that the other person will keep his promises. The ‘contract’ can be in written form, but it does not have to be.

Different organizations have come up with concepts that use self-directing teams to organize care in the neighborhood. Self-directing teams are also known as autonomous teams, managed teams and empowered work groups (Janz, Wetherbe, Davis, & Noe, 1997). In self-directing teams the number of managers is minimized and managerial functions are performed by members of the team. Structural innovation like this concern the removal of barriers between organizational activities (Chenhall, 2003). This has a great influence on the design of the structure of the organization which can be seen in figures 2 and 3. These figures show typical organizational charts for a traditional organization which is based more on hierarchy and a company that works with self-directing teams.

(7)

7

Figure 3: Organizational chart of a self-directing organization (Vermeer & Wenting, 2012)

Self-directing teams provide a holistic view, focused on the specific needs of the patient, upon relationships, adapting to diverse needs and the importance of the collective endeavor. This relates to new professionalism as explained by Taylor and Hawley (2010).

Literature shows different opinions about the use of self-directing teams. Baron and Kreps (1999, p. 326) are positive and state that “Closely managed teams miss many of the advantages that internally autonomous teams can have, while possessing a number of the disadvantages.” while the results of DeVaro (2008, p. 686) show “no statistically signiﬁcant difference between the predicted gains from autonomous versus nonautonomous teams.”. Furthermore it is said that autonomy increases satisfaction and motivation, but the level of team development and the capacity of an organization to learn may be more important when you look at improving work outcomes (Janz, Wetherbe, Davis, & Noe, 1997).

There are different concepts like lean thinking (Joosten, Bongers, & Janssen, 2009) and cellular manufacturing (Hyer, Wemmerlöv, & Morris Jr., 2009) that have similarities with self-directing teams that have been applied to the healthcare sector. Hyer, Wemmerlöv and Morris Jr. (2009) performed a single site case study and investigated an integrated trauma center. They talk about cellular manufacturing and explain that it is used to locate people and equipment required to produce similar products. Drupsteen, Van der Vaart and Van Donk (2013) investigate which integrative planning and control practices are used in hospitals and provide support for the value of integration initiatives. Like self-directing teams these concepts also take a more holistic and integrated view of the processes and focus on the delivery of value for the customer, but they differ in the role that the managers have. Scientific research about the implementation of self-directing teams within homecare is limited, which leaves managers and researchers with questions about the way to use the concept. Leichsenring (2012) discusses the improvement of long-term care to meet the general challenges of healthcare by using more integrated care and cites that it “will remain an exciting area for further organisational development, training and research” (Leichsenring, 2012, p. 4).

(8)

this specific field has not received a lot of attention. A large part of the research has been performed commissioned by Buurtzorg Nederland and is from a really operational level (De Veer, Brandt, Schellevis, & Francke, 2008). It shows that self-directing teams positively influence team-culture, relationships with the patients and relationships with other caregivers. Nevertheless there has been some research from another field of research which contains interesting parts for this thesis. Annemarie van Dalen is an anthropologist and has written two books (Van Dalen, Uit de schaduw van het zorgsysteem, 2010) (Van Dalen, Zorgvernieuwing, over anders besturen en organiseren, 2012) in which she looks at this new way of organizing healthcare. She has performed extensive research during a longitudinal case study of more than 1,5 years. She argues that her research revealed organizational patterns that fit into a new era. Van Dalen argues that not the costs, nor the demands of the society determine the way they organize their work, but their vision care and the values that drive them. She claims that within the healthcare sector control and measurement drift has reached absurd levels and she sees self-directing teams as a way to stimulate workers to work with dedication, pride and attention to the cost of organizing care. As a result, the employees are able to provide a more holistic type of care, they take into account the patient and the context. The focus is more on personal values, goodwill and trust then on control.

This study contributes to the understanding of how working with self-directing teams influences the relationship between management control and trust in an organization. The conceptual model (figure 4) argues that working with self-directing teams will lead to a decrease in management control. As a result of this reduced control the strength of trust will be higher. This applies for contractual -, goodwill - and competence trust. For this research the definition of management control of Anthony is followed, but since the focus is on self-directing teams it is slightly adjusted to ‘the process of managers making sure that resources are gathered and used effectively and efficiently in order to reach the objectives of the organization’. This is done to emphasize that this research is not about a possible change in the effectiveness or efficiency of reaching the objectives of the organization, but merely in the way this is reached. The conceptual model argues that working with self-directing teams will show a situation where management is less likely to make sure that goals are reached. Managers will be responsible for less managerial areas and employees will receive more responsibility. Trust compensates for the reduction in control and the strength of trust will increase.

(9)

9

4. Methodology

Self-directing teams received a lot of attention in the media and by politicians in the last years, but it is clear that despite of the popularity of this topic, until now researchers have not been very active on this field. This gap is addressed by comparing different practices. Differences and similarities from a management control and trust perspective are looked at. The model of Hans, Houdenhoven & Hulshof (2011) is applied to see which tasks are performed by the teams and which tasks are executed by a coordinating office. Furthermore, also the three different types of trust (contractual, goodwill and competence) that are distinguished by Sako (1992) are used to gain a further understanding. The strength of these types of trust in the different organizations will be shown.

Research about this topic in this specific situation is limited and therefore an exploratory case study is used as suggested by Yin (2003) and Eisenhardt (1989). Multiple cases are investigated since the information that is gathered from such an approach is often more convincing than from a single case (Yin, 2003). Propositions that contain new processes and relationships within a certain context are according to Covaleski et al. (1996) best explained by using case study methods. These studies are good for identifying research problems and in developing theory. From literature and the case studies a conceptual model is made and refined that explains the relationship between control and trust. This model can be tested in further research.

Chenhall states that: “An important element of contemporary structures is teams. As yet there are few studies that have considered the role of MCS within team based structures.” (2003, p. 147). Although information about this specific subject is not available, there is extensive knowledge from other fields about the different topics that can be studied. Therefore the start will be a literature research about trust, management control and self-directing teams. Since some of the used research (f.e. Vosselman & Van der Meer-Kooijstra (2009)) is on interfirm level a critical view to possible consequences for the specific situation of self-directing teams in homecare is needed. The focus of this research will be on intrafirm level, although it could be argued that the relationship between a self-directing team and the coordinating office shows more like similarities with an interfirm relationship since the teams are autonomous. The advice of Chenhall is followed as he states: “When combining different levels of analysis, care is required in theory development and method to ensure that combinations of individual and organizational variables are theoretically and empirically legitimate.” (2003, p. 158).

(10)

contractor that works via different mediation agencies, one with a manager and one with a carer and a helper at Palet, a traditional homecare organization. Furthermore also retrieved documents where studied.

Palet is a care organization that works in the Northwest of Friesland in the Netherlands. Currently they have more than two thousand employees. They provide support in housing, welfare and care from care support locations and multifunctional centers. They aim to be near to the clients and provide the care that is needed. They don’t work with self-directing teams, but are thinking about the possibilities of using self-directing teams for the future.

The two organizations that work with self-directing teams in homecare that have been selected are Buurtzorg and Zorgteam Leeuwarden. The concept of Buurtzorg has been growing rapidly. The organization started in the Netherlands and is now expanding into Japan and America. It is a network organization which provides homecare via self-managing teams consisting of ten to fifteen nurses per team. Team tasks which they have to arrange include schooling, office work, planning, design duty lists and administration (de Veer et al., 2008). To support the teams Buurtzorg has a small coordinating office located in Almelo which provides certain services. With their formula Buurtzorg was crowned best employer of the Netherlands two years in a row in 2011 and 2012. This is reflected by grades like overall satisfaction given by employees of 9,0 out of 10 and an employee involvement grade of 9,7 out of 10. Moreover, the absenteeism measured in 2011 was only 2% and the productivity of employees is more than 10% above the benchmark of 50,9% (extramural care) (van der Kruk, 2010).

The third organization where interviews where held is a group of self-employed care professionals that work together in a partnership called ‘Zorgteam Leeuwarden’. A total of around twenty nurses who all work as independent contractors formed a collaboration to ensure that they could provide intensive care which is impossible to deliver when you are on your own. An example of this is a case where a patient needs care 24 hours a day. Teams of self-employed care professionals are often formed by an intermediary agency. By forming the collaboration the nurses agreed to do the tasks of the intermediary agency together. Their clients are mainly from the northern parts of the Netherlands, but also spread out throughout the Netherlands. Per client a small team of nurses is formed. Zorgteam Leeuwarden is not a registered organization, it is just the name of the collaboration. Consequently they don’t have headquarters or a coordinating office. Within the team a core of four persons has been formed who execute some of the overhead functions. Most of the times these activities are not reimbursed. Per client a team leader is appointed who receives a small part of the payment of her colleagues for the coordinating tasks that are performed.

(11)

11 The information that was received through the semi-structured in depth interviews is used to develop the theoretical model that explains the relationship between trust and management control. The results and the revised conceptual model can be tested and used in future research.

5. Results

The following part provides an overview of the results that are retrieved from the semi-structured interviews that were conducted. The information is divided in two parts. The first part concerns management control and planning. The second part gives an analysis of trust that is present within the self-directing teams.

Using the model of Hans, Houdenhoven and Hulshof (2011) for each of the organizations a clear overview is given which shows which of the tasks is performed by teams and which is performed by the coordinating organization.

Management control at Buurtzorg

Table 1 shows the division of control and planning mechanisms within Buurtzorg. It clearly shows which areas are performed by the teams, and which are performed by the coordinating office. The framework shows that within Buurtzorg the teams perform most of the tasks. For example all of the online and offline operational tasks are solely done by the teams without any interference of the coordinating company.

“The teams are just occupied with providing care and with making sure that everything is there to provide the care. They manage the network with other caregivers, the informal care. They plan and manage everything when it comes to planning and scheduling. They hire their own colleagues. In principle the team does all these sorts of things by themselves. Basically it all has to do directly with the continuity of the daily work. All of the teams do that themselves.”

- Director at Buurtzorg

(12)

“A lot of e-learnings can be found on the web so that you can guarantee the quality. Furthermore we have a new care planning system which allows us to keep the high quality of the work we deliver. There are a lot of teachings we can do in the fields of work, care and administration.”… “We have a certain amount of education hours, or schooling budget available per team. I don’t exactly know how much it is. There are a lot of teachings on the web, where you all have a personal site, the intranet. On there you can register. The e-learning are already paid for, and you can choose from them. You do have to discuss it within your team, since you have a certain budget.”

- Nurse at Buurtzorg

Performed by the coordinating office Performed by teams

Performed by teams and the coordinating office (hybrid form)

Table 1: The framework for healthcare planning and control specified for the case of Buurtzorg

(Hans, Houdenhoven, & Hulshof, 2011)

The coordinating office plays an important role in providing the teams with boundaries. These boundaries function like guidelines for the different teams and the way they work.

Managerial areas Medical Planning Resource capacity planning Materials planning Financial planning H iera rc hica l dec o mp o sit io ns

Strategic Teams add

protocols on web created by HQ, e-learning available online. Boundaries are set. Guidelines about team size, capacity

dimensioning and workforce planning, contracts with employees Warehouse design, ‘Webshop’ with suppliers created for all teams,

Contracting with insurance companies,

contract negotiation about offices, political

relationships Tactical Treatment selection, protocol selection (in collaboration with GP) Staffing, admission planning. Care indications. Supplier selection by teams, tendering and negotiation by HQ. PR by teams.

Budget and cost allocation, within limits. Local political

contacts with teams.

Offline operational Diagnosis and planning of an individual treatment Appointment scheduling, workforce schedule Materials purchasing, order sizes

(13)

13

“You have to set boundaries in a clear way so that the employees can arrange things together and also for the number of clients they can be responsible for.”

- Director at Buurtzorg

On the strategic level the coordinating office of Buurtzorg performs most of the tasks. They arrange the contracts for the employees, but also with suppliers and for the offices of the different teams. They also keep in touch with politicians on a regular basis to stay on top of developments with regulations and to positively influence the government. In contact with local political parties interested employees of teams can be active.

“There are regulations we have to follow. Especially Almelo keeps a close track of that. And we have one colleague who follows it. Honestly, I really don’t immerse myself into that. I just let it come by and if there is a change which involves our work we’ll hear about it. I do know that lately they have been talking frequently with political parties and two colleagues have visited them to talk about the influence on our work and to see what they know about homecare.”… “They check the data from the ministry and the consequences for us. Almelo selects the relevant information and posts it on the homepage. And one of our colleagues then reads that. We have one colleague that just really likes to get into conversation with all those political parties and wants to attend those meetings, so she just does that.”

A final thing which is seen within Buurtzorg is that there are different control mechanisms used by the coordinating office. Different guidelines about productivity, budgets, team size and the way work is done are present. Also data that is added by teams is checked. Control on the specific ways care is delivered is only checked by members of the local team.

“We request the applications ourselves, but they [coordinating office] check whether we have requested the indications for all of the clients. If there is a problem they will post a message on the web asking us, did you already request an indication? What is happening? Or for example, the indication has expired or you have too many hours. Keep an eye on it."

Overall it can be seen that the teams within Buurtzorg have a lot of autonomy and responsibility, but the coordinating office plays a large role in facilitating the teams. Especially on the strategic level they relieve, facilitate and check the teams by performing different control and planning functions.

(14)

Management control at Zorgteam Leeuwarden

Zorgteam Leeuwarden consists of a group of around twenty nurses. There is no coordinating office or headquarters of any kind. Within the group the founder and a couple of enthusiastic members formed a core team to speed up the execution of some of the overhead functions.

“After a year we have decided, ok this organization is a bit inert. If you have a meeting, not everyone is there since we have irregular working hours. Sometimes decisions have to be made quick. So at that moment we have formed a core team and it consists of four people.”… “to divide some of the tasks that are not directly related to the care, like flyers etcetera. But well, when a client comes in, usually the Titia [the founder] is the first contact.”

- Nurse at Zorgteam Leeuwarden

The self-directing team of Zorgteam Leeuwarden is merely a collaboration, which has implications for the control and planning framework which is shown in table 2. The members of the core team are also nurses that work in the teams, so this situation differs from the first case.

“We are a collaboration. We only have a name as umbrella, furthermore we are nothing, not a concern, not a foundation, nothing.”… “We are a collaboration, you are on the website, or you are removed from the website. That is the way you can see whether you are a member or not, that’s it.”

The team functions without an intermediary organization and they strive to conjointly perform the overhead functions. In biannual meetings, work agreements, ideas and strategies are discussed, but also outside these meetings there is contact among members of the team. In practice it is seen that this issue is often difficult and the core team performs most of the tasks.

“What makes this difficult is, well you want to go in a certain direction and does everyone agree? You are a collaboration of self-employed individuals, you are not really an organization, but you do have to deal with organizational issues. That is really a learning challenge.”… “We have a meeting twice a year where you can spout and say everything. And that is used. So everyone can think along. And things come from the core team. But everyone can participate, especially at those meetings. I would like this, I would like that, and why don’t we do it like this. Those meetings should be held more often. But that’s impossible to accomplish. That is difficult.”

(15)

15 Performed by the founder and/or core team

Performed by teams

Performed by teams and founder and/or core team (hybrid form)

Table 2: The framework for healthcare planning and control specified for the case of Zorgteam Leeuwarden (Hans, Houdenhoven, & Hulshof, 2011)

The vision of the collaboration is clear. The original plan was to perform the tasks which an intermediary agency normally does together as nurses. As the collaboration grew it turned out that part of the members were more active than others in performing coordinating tasks.

“I find it hard to explicitly take the lead, because I would like this to be self-directing. But often it asks to be managed, because if you don’t then people keep nagging.”… “and you don’t make any progress.”… “Actually I’m a bit like the head of the team. The original intent was, well it is a flat organization, but the plan was to have a team that was really self-directing, that was my intention.”… “ But it turned out to be really difficult because it is still very free of obligation.”… “People say: I’m an independent contractor, but in my opinion they are not really independent. It would mean that you also find your own work. You have to play a part in that. Those people are still looking for a traditional relationship where they think that I am their

Managerial areas Medical Planning Resource capacity planning Materials Planning Financial planning H iera rc hica l dec o mp o sit io ns

Strategic Minimal care of 4 hours a day.

Individual schooling, medical information shared in map per team.

Team size, workforce planning, job interviews, certification for nurses. Only external paths and suppliers. Website is being made.

Only personal budget care (PGB). No contracting with insurance companies. No political relationships. Tactical Treatment selection, protocol selection (in collaboration with GP) Block planning, Staffing, admission planning. Supplier selection. PR. Local network. One format for health records.

Budget and cost allocation. Prices per

hour. Offline operational Diagnosis and planning of an individual treatment Appointment scheduling, workforce scheduling. Materials purchasing, order sizes

(16)

employer. So very often I have to remind them, no, I am not an employer. I have to work for the full 100% myself. You have to participate to get work and to keep this organization running.”

- Founder of Zorgteam Leeuwarden

The Zorgteam Leeuwarden shows many similarities with the way intermediary care organizations work.

“How a team like this works? A new patient comes in via family of via an intermediary organization who then deploys us. We are asked if we want to participate in the team with a 24-hour set up. Well, then usually on average there are six to seven people in such a team.”… “In my view, their tasks are fairly limited. The people call for information to the intermediary organization, and they do a intake. So they explain what they have to offer. And they judge whether we can provide that type of care, whether they have the right people to do it. Consequently we approached and asked, well we have this people with this request, can you do anything for this patient? And then a team is formed. When it is composed, then rather quickly the intermediary organization retracts itself. What we have in this situation, is that they provide a care file and the documents that belong in it.”

- Nurse that works via intermediary organizations

While many of the strategic and tactical decisions are performed by the core team in collaboration with the members of the team it can be seen that certain fields are performed solely by the core team or even only by the founder. Examples are the intakes of new patients, job interviews with possible new team members and decisions about hiring and firing.

“Actually I am sort of the assessment committee. Well, actually up and until now I didn’t feel like making suggesting to the team shall we hire him or her? Actually this would be the way to do it, but now I just let people, people come and talk to me. And if I think, that one fits in the team, then he can join the team.”

When a new client comes a team of nurses is formed to provide the care. The selection of colleagues for a new team is also done by the founder.

“You have to make a choice, I don’t want you in the team, I want another carer.”… “At a certain moment you have to say, the team is too big, I have to make choices. And sometimes, I find that to be difficult.”

(17)

17 At the operational level the nurses function in small teams around the clients. One member of that small team is team leader and is responsible for the planning and the reimbursement, but also for the medical files and the contact with the family and the other medical disciplines.

“The question is who wants to become team leader? Then someone has to volunteer. That person does the planning and the contact with the family, and the billing. We pay money for that, but that’s only one euro per worked hour, for your college so to speak. What we have done is, we have a shared name, and we also have one format for the medical files, I made that. So that’s all the same.”

The small teams are centered around one patient and operate on their own. This creates difficulties for examples in the mutual alignment of the planning.

“A situation that we now face is, for example I work at three clients, then three schedules have to be made, with me in it. But I don’t know if I’m available. Because one hasn’t made the planning yet.”… “If you come at four clients at the same time, that’s hardly impossible. The fast planner is first, the leftovers are for the second planner. That’s just not convenient. In the future this can only fail.”

Overall it becomes clear that Zorgteam Leeuwarden is a dynamic collaboration. The ambitious self-employed care professionals have teamed up to function without the interference of an intermediary agency. Small self-directing teams are formed around individual clients. The vision is that the team is self-directing and coordinating tasks are performed by all the different members of the teams. As a result of practical reasons and the way the people are used to work, a core team has been formed which performs most of the coordinating tasks.

Management control at Palet

Palet is a company that provides care on a large scale. The organization functions fairly traditional with several hierarchical layers. The consequences to the division of planning and control activities is visible in table 3. For this research we simplify the situation and do not explicitly take into account the different hierarchical levels. We use the same division as in the other organizations, so the nurses, carers and helpers function as executioners and managers function in the coordinating positions.

(18)

“All the managers meet with the director. I believe that’s once every fourteen days, the management platform. And they talk the entire day, which is pretty intense. There is an awful lot that is talked about, because there are an awful lot of issues that concern us. And there they also follow that national line, what is relevant for us? And what are the politician going to decide? And that is not only for 2014, but also 2015. Because actually we know which direction it goes. And that then returns to us in the management meeting. And then the minutes of the management platform are emitted to the middle managers, so that in return we also stay informed.”

- Manager at Palet

Performed by managers

Performed by carers/nurses/helpers

Performed by carers/nurses/helpers and managers (hybrid form)

Table 3: The framework for healthcare planning and control specified for the case of Palet

(Hans, Houdenhoven, & Hulshof, 2011)

Managers arrange that medical information, schooling and medical exams are available and executed. In this way they strive to ensure that the employees stay skilled and competent when performing their jobs.

Managerial areas Medical Planning Resource capacity planning Materials Planning Financial planning H iera rc hica l dec o mp o sit io ns

Strategic Schooling and medical information, medical exams.

Team size, capacity dimensioning, workforce planning,

job interviews.

Supply chain and warehouse design.

PGB and AWBZ care, investment plans, contracting with insurance companies. political relationships Tactical Treatment selection, protocol selection (in collaboration with GP) Block planning, Staffing, admission planning. Supplier selection. PR. Local network. Checking health records.

Budget and cost allocation. Offline operational Diagnosis and planning of an individual treatment Appointment scheduling, workforce scheduling. Materials purchasing, order sizes

(19)

19

“And we have the skills that they have to remain proficient in, so the ‘BIG-book’. We have assessments for that. And there we work with BIG-examiners who remain educated continuously by our specialist team or by the hospital, with whom we have a relationship. And it’s to me to make corresponding policies, with the BIG-examiner. What are we going to test by the BIG-examiner that comes to our location?”

It is visible that the financial operations are solely performed by managers and employees at the coordinating office. The care providers have little to nothing to do with this field.

“We are purely for the care. I do know that we have to check in when we arrive at clients because there are costs involved. We have to stay within the indication.”… “It costs money, but how much exactly? We don’t know.”

- Carer at Palet

“No, I don’t know how that works. You should have asked a manager.”

- Helper at Palet

There is an extensive financial operations plan to ensure the correct processing of the data. The people that deliver the care have little or nothing to do with these activities.

“The indications come in and then we seek contact with the client to make agreements about the care. And then they, the care employees, send the data to the department of care administration, so that care is delivered to the clients. And they enter it into our systems. And on basis of the production agreements which I fill in every month, a bill is transferred to the central administration office in The Hague. And they calculate the fee on the basis of their collective income.”

Tactical decisions about medical planning are made in a meeting where nurses, carers, helpers and team leaders are present. In the work meetings they have incorporated a part for a discussion about clients so that everyone is up to date with the status of their clients. Also diagnosis and planning of individual treatments is done in this way.

“Basically we always have a part ‘client-discussion’ in our work meetings. To ensure that we keep talking to each other about the clients. For personal coaches it is also very good to keep in touch with the team to hear how their clients are doing.”

(20)

Most of the offline operational activities are performed by managers together with the nurses, carers and helpers. Examples are scheduling and ordering materials, but another good example is the tasks around the entry of a new client.

“When a new client comes in, we have to add the data, fix the keys, decide about the care agreements, make the map and add in the system that there is a new client. And you have to check the planboard to see if it fits. And then you go back to the client to say which time is has become and whether that’s alright. There is a lot to do and we do that together.”… “We are collectively responsible actually.”

- Carer at Palet

The online operational activities around materials planning, like rush orders, is also done in this way. The online operational tasks in medical planning and resource capacity planning are performed by the team members.

“We are really the people in the field. We don’t know a lot about leadership.”… “We as helpers are really working for the people you know. Sometimes we arrange little things next to providing the care, but we simply don’t have to. And that’s something I really like, to be with the people. We all do our own things.”

All in all it can be seen that Palet functions as a hierarchical organization with a strong division of labour. Activities from managerial and hierarchical areas are divided and managers are responsible for executing a broad array of tasks.

Trust

(21)

21 Case 1: Buurtzorg Case 2: Zorgteam Leeuwarden Case 3: Palet Contractual

trust Strong Strong Weak

Goodwill

trust Strong Medium Medium

Competence

trust Strong Medium Weak

Table 4: Overview of types of trust (Sako, 1992) present within case companies

Buurtzorg

At Buurtzorg the members feel responsible for the complete functioning of their team. Together they have to deliver high quality healthcare, get new clients, maintain a high level of production and keep the team running smoothly. Coordinating task and overhead activities are divided among the members. This results in a high feeling of ownership among the members. Everyone participates and no evidence was seen that showed that personnel would not keep the promises they made about the execution of the tasks. Furthermore it is clearly stated that working at Buurtzorg is not for everyone. In the job interviews and in the trial period they clearly explain to new colleagues that when you are not willing to contribute to the team, you should not apply. It is seen that the contractual and goodwill trust is strong.

“We do that within the team. We agreed with a couple of persons who does what. We just make agreements within the team. What do you think? What do you want? What are you good at? And then we align everything to see who does what.”… “We just provide homecare. From putting on compression stockings to providing terminal care. But then really like a team, we arrange everything ourselves.”

The third component that is distinguished is competence trust and is also seen to be high. The nurses at Buurtzorg show a high level of confidence in the professional standard of colleagues. They rarely function at the same time, but always one after another. As a result possible mistakes are seen by the consequences.

(22)

things you do and that you say, but also that you should be able to indicate whether you feel competent in the things that you do or not. If you don’t do that and you do something which goes wrong, well of course that would be a bit unfortunate. You have to be able to trust each other in those things. If you say you can do something, while in actually you can’t… well…”

Zorgteam Leeuwarden

The collaboration consists of self-employed care professionals. Therefore a high amount of individuality and professionalism is expected from the employees since all of them have to be able to work independently and manage their own administration. Consequently it becomes clear that the level of contractual trust is high. It is expected and trusted that individuals do what they say they will do. Furthermore Zorgteam Leeuwarden has plans to start with the use of a certificate for caregivers.

“What we would like is that everyone of us get a certification.”… “a certificate for self-employed care professionals ‘ZOZ-ers’. Mijnkeurmerk.nl is really a certificate for people like us, carers and nurses who are independent.”… “The certificate actually says two things. It’s for independent entrepreneurial caregivers. Your entrepreneurial skills are checked: do you have insurance policies? A job certificate? Is everything in order? And there is a part for nurses or carers. Which diploma’s do you have?”

The amount of goodwill trust that is present differs since the activities of the different members of the team vary a lot. The founder and the members of the core team do a lot of coordinating tasks and they do this mostly without getting any reimbursement for it. On the other hand it is also seen that many individuals don’t show any interest in providing support with the overhead activities. Some of the members are strongly committed and feel responsible, while for others the collaboration is more non-committal. As a result the amount of goodwill trust is medium.

“It makes us more committed, because then, and we have already reached that now, people feel like ‘we are doing this ourselves!’. ‘We don’t need an intermediary agency’.”

(23)

23

The employees of Zorgteam Leeuwarden function, comparable to Buurtzorg, most of the times not directly with their colleagues, but after one another. The level of competence trust in general is seen to be high, but as a result of some negative examples they are vigilant. Because of this the overall level is medium.

“Being critical at each other is important. I have removed people from the team because I thought they didn’t function right and they are not open for criticism. They don’t want to improve. Yes, in that case the collaboration stops, because it’s also a part of our business. The team should be the business card. It’s also my salary. If there is someone who doesn’t do his job right, and who can’t take criticism, who doesn’t want to work on it. In my opinion, that’s unacceptable. I have certain quality standards that you have to meet.”

“We have had someone who was a nurse, but she felt like, I rather won’t do this. She didn’t feel competent. That was not appreciated by another colleague who said, in that case I cannot build on you and I cannot deploy you. She was rather startled and eventually she left.”

Palet

Within Palet, with the traditional organizational structure, it is seen that managers perform many tasks and there are several mechanisms to check whether tasks are performed. The organization values control highly and contractual trust from the management towards thee employees is low.

“The files have to be arranged in order to meet the HKZ-norm, that is harmonization, quality, care.”… “And you are also tested on that. For that also organizations come by, external organizations that test you. And to see whether you do it in the way that you have worked it out. Because after all that’s the essence.”

(24)

“Connector is an employment agency. They take care of everything.”… “When we call they fix it. At every location when there is absence due to sickness or a holiday, then they can call Connector. And they have certain employees that can be deployed everywhere.”

Sometimes they encounter situations where they face a problem and the employees are forced to collectively solve the situation.

“We got a message saying ‘you have to solve it within the team’. So then I had to work in the evening and the day immediately after that. That’s something you simply do. That’s the way to solve it within the team.”

Spurred by the broad attention to working with self-directing teams, the organization is thinking about the possibilities to restructure the organization. The last years they have worked on empowerment and motivating employees to develop themselves. They have made progress, but all in all the strength of goodwill trust is still not very strong and therefore set at medium.

“When I go on a holiday, earlier on I always came back in a chaos.”… “When a client drops out and suddenly you miss a great deal of production. What a team should do is immediately change all of the routes. And inform our internal employment agency to tell them that a route is canceled and that they can withdraw the shifts etcetera, etcetera. If they don’t do that then within a couple of days you lose a lot of production. Nowadays they just do that.”… “people are willing to do something. It’s a lot about clarity and motivation. And with that you can see that the team has grown.”

Different mechanisms which Palet uses to check employees, their activities and skills, have already been mentioned. It is seen that within the organization there is a small amount of trust in the competence of employees. The employees are regularly tested to see if their abilities are at the required level.

“I can’t simply express my confidence, like: ‘if you are a carer, then I assume that you do everything correctly when it comes to BIG-skills and the competencies’. So that’s why we have the BIG-book, were all the skills are listed, which helpers, carers and nurses can get checked.”

(25)

25 Evidence shows that as an organization they are working on this topic. The environment is changing since they have to deliver more complex care with less resources. They are trying to upgrade the knowledge level of their employees and they want to let them work more independently. On the other hand they feel that now the skill-level is not yet sufficient and therefore they check the employees regularly. The competence trust is low

“Personally I am and always will be an enormous control freak, but I always say ‘you can deal with that in a nice way’. Because it has been less fun, since you give your employees the feeling that you don’t trust them. And maybe you take the jobs out of their hands. I’d rather do everything myself, or think everything out myself.”… “You need to have more faith in the people that they can do it. And at the moment when they can’t, you have to invest in that. What do they need to become capable?”

Overall the trust level within the organization is fairly low. The smooth operation of the organization seems to be more based on checking the employees than on trust.

6. Discussion

The aim of this research has been to contribute to the understanding of the functioning of self-directing teams in homecare. This is done by addressing two important questions related to management control and trust: which tasks are performed by the teams and which are performed by supervisors? And what is the strength of trust? The results clearly show that organizations that use self-directing teams have less management control and more trust is present. While this result is in line with the expectations, some unexpected patterns in how specific practices function within homecare organizations are found.

The results show that the three organizations function in different ways. The most notable observations about self-directing teams can be summarized in four points: (1) More planning and

control activities; the activities are divided in different ways between the teams and the

(26)

services which they provide and which they cannot provide. For practical reasons they chose not to deliver certain types of care. In this way they strive to reduce problems caused by complex situations and enable clear and fluent work processes. (4) Trust is more eminent; activities and competences are checked and controlled less and trust plays a more important role. It is seen that managers perform less planning and control tasks. The results show evidence for higher contractual, goodwill and competence trust in self-directing teams. Next to this, evidence showed that a lack of trust hold backs a reduction of management control. When trust is low, managers are reluctant to give up management control since they fear negative influences on operations of the organization.

The results have led to a revised conceptual model, shown in figure 5. This model shows the relationship between management control and three types of trust within homecare organizations. Working with self-directing teams results in a decrease of management control and an increase of trust. It should be noted that the decrease of management will not only result in stronger trust, but the level of trust that is present also influences the possibilities of working with self-directing teams. A high amount of trust enables working with self-directing teams and consequently a reduction in management control. And vice versa: The absence of trust is seen to prohibit working with self-directing teams and it functions as a suppressor of diminished management control. This is shown by the dotted line.

Figure 5: Revised conceptual model

The revised conceptual model explains the relation between management control and trust. Working with self-directing teams results in less management control, which leads to more trust. When managers are less occupied with making sure that resources are gathered and used effectively and efficiently in order to reach the objectives of the organization, trust will have to be higher to compensate for this. Trust enables or disables working with self-directing teams, since a lack of trust inhibits the possibilities to reduce the amount of management control. It is argued that achieving a broader insight into factors that influence the relationship between management control and trust would be a valuable aim for future research.

(27)

27 This study has important implications for medical professionals, both managers and nurses, especially since working with self-directing teams is high on the political agenda. The conceptual model provides valuable insights in the relation between management control and trust and can help when working with or planning to work with self-directing teams. Self-directing teams are less controlled by managers, and to enable this a higher amount of trust is needed in order to ensure a correct functioning of the organization. The combination of performing more tasks in different managerial areas and receiving more trust instead of being checked results in a higher feeling of ownership among employees that work in self-directing teams. These effects are interrelated, which entails that a holistic approach is essential to achieve the desired results.

A limitation of this study is that only people from three different organizations were interviewed. It could mean that not all of the specific control mechanisms have come forward. The organizations where all active in the homecare sector and most of the interviewees function in the northern parts of the Netherlands. Possible effects of working in this specific region have not been considered. Further research could adopt a broader perspective and investigate other organizations from other regions. However the risk of including too many cases is that it increases complexity and makes it less likely that important insights are distinguished (Vissers & Beech, 2005). Furthermore a point of discussion could be the placement of certain tasks within the framework of Hans, Houdenhoven and Hulshof (2011) in table 1, 2 and 3. A great strength of the model is that it focuses specifically on control and planning within the medical sector. Since not only medical procedures are mapped, a result is that certain overhead activities, such as networking with political parties, are not always easy to categorize. To deal with this the hierarchical and managerial levels are taken into account and decisions are made consistently.

It is seen that the organizations that work with self-directing teams use more highly skilled employees. Future research should investigate the influence of the skill level and the characteristics of the employees to deepen the knowledge of the composition of the teams. This is interesting research both for managers who are thinking about reforming an organization and for carers that intend to set up care using self-directing teams. It could provide them with valuable insights about the composition of the team and help them when hiring new colleagues.

(28)

7. Conclusion

This paper has explored planning and control practices and the role of trust in different organizations that provide homecare. The influence of working with self-directing teams has been studied to provide further insight in the relationship among these factors.

This study contributes through offering a comprehensive view of management control and trust in self-directing teams in homecare, a field where literature has been scarce. Organizations that work with self-directing teams have shown to perform more planning and control activities in a narrower selection of activities, there is a tendency to function in the old way, and trust is more eminent. Managers transfer tasks to employees and consequently they perform not only the online operational tasks, but also more offline operational and more tactical tasks. Furthermore they are more involved in strategic decision making. To prevent complexity and coordinating issues self-directing teams put more boundaries on the types of care that they provide. Also the strength of trust is shown to be higher in organizations that work with self-directing teams. This is necessary to compensate for the lower level of management control. A shared and commonly supported vision is essential to ensure that all of the employees collectively feel responsible for the correct functioning of the team. If this is not present the tendency to behave in the traditional way is lurking.

The results explain the relation between management control and trust. When working with self-directing teams managers are less occupied with making sure that resources are gathered and used effectively and efficiently in order to reach the objectives of the organization. The level of trust is seen to be higher, which is important to compensate for the lessening of management control. Trust influences the possibilities to work with self-directing teams directional, since the level of trust that is present enables or disables the possibilities to reduce the amount of management control.

(29)

29

8. Reference list

Anthony, R. (1965). Planning and Control Systems: a Framework for Analysis. Harvard: Division of Research, Graduate School of Business Administration, Harvard University. Baron, J. N., & Kreps, D. M. (1999). Strategic Human Resources: Frameworks for General

Managers. New York: John Wiley & Sons.

Bernard, H. (1994). Field notes: How to Take, Code, and Manage Them. In H. Bernard,

Research Methods in Anthropology. Qualitative and Quantitative Approaches. (pp.

180-192). Londen/New Delhi: Sage Publications.

Carenys, J. (2010). Management Control Systems: A Historical Perspective. International

Bulletin of Business Administration, 37-54.

Chenhall, R. H. (2003). Management control systems design within its organizational context: findings from contingency-based research and directions for the future. Accounting,

Organizations and Society, 127-168.

Covaleski, M. A. (1996). Managerial accounting research: the contributions of organizational and sociological theories. Journal of Managment Accounting Research, 1-35.

De Veer, A., Brandt, H., Schellevis, F., & Francke, A. (2008). Buurtzorg: nieuw en toch

vertrouwd. Utrecht: www.nivel.nl.

Devaro, J. (2008). The Effects of Self-Managed and Closely Managed Teams on Labor Productivity and Product Quality: An Empirical Analysis of a Cross-Section of Establishments. Industrial Relations: A Journal of Economy and Society, 659-697.

Drupsteen, J., Van der Vaart, T., & Van Donk, D. (2013). Integrative practices in hospitals and their impact on patient flow. International Journal of Operations & Production

Management, 1-25.

Eisenhardt, K. (1989). Building theories from case study research. The Academy of Management

Review, 532-550.

Hans, E. W., Houdenhoven, M. V., & Hulshof, P. J. (2011). A Framework for Health Care

Planning and Control. Enschede: University of Twente.

Hyer, N. L., Wemmerlöv, U., & Morris Jr., J. A. (2009). Performance analysis of a focused hospital unit: The case of an integrated trauma center. Journal of Operations

Management, 203-219.

Janz, B. D., Wetherbe, J. C., Davis, G. B., & Noe, R. A. (1997). Reengineering the Systems Development Process: The Link between Autonomous Teams and Business Process Outcomes. Journal of Management Information Systems, 41-68.

Joosten, T., Bongers, I., & Janssen, R. (2009). Application of lean thinking to health care: issues and observations. International Journal for Quality in Health Care, 341-347.

Langfield-Smith, K., & Smith, D. (2003). Management control systems and trust in outsourcing relationships. Management Accounting Research, 281-307.

Leichsenring, K. (2012). Integrated care for older people in Europe—latest trends and perceptions. International journal of integrated care, 1-4.

Litvak, E., & Long, M. C. (2000). Cost and Quality Under Managed Care: Irreconcilable Differences? The American Journal of Managed Care, 305-312.

Mainz, J. (2003). Defining and classifying clinical indicators for quality improvement.

International Journal for Quality in Health Care, 523-530.

Nooteboom, b. (1996). Trust, Opportunism and Governance: A Process and Control Model.

(30)

Ouchi, W. G. (1979). A conceptual framework for the design of organizational control mechanisms. Management science, 833-848.

Richards, L. (2005). Coding. In L. Richards, Handling Qualitative Data: A Practical Guide. (pp. 85-103). Thousand Oaks: Sage.

Rutte, M., & Samsom, D. (2012, oktober 29). Bruggen slaan, regeerakkoord VVD - PvdA. Retrieved december 19, 2012, from Kabinetsformatie 2012: http://www.kabinetsformatie2012.nl/actueel/documenten/regeerakkoord.html

Sako, M. (1992). Prices, Quality and Trust: Inter-Firm Relationships in Britain and Japan. Cambridge: Cambridge University Press.

Taylor, G., & Hawley, H. (2010). Key Debates in Health Care. Berkshire: The McGraw-Hill Education.

Van Dalen, A. (2010). Uit de schaduw van het zorgsysteem. Den Haag: Boom Lemma Uitgevers. Van Dalen, A. (2012). Zorgvernieuwing, over anders besturen en organiseren. Den Haag: Boom

Lemma Uitgevers.

Van der Meer-Kooistra, J., & Vosselman, E. G. (2000). Management control of interfirm transactional relationships: the case of industrial renovation and maintenance.

Accounting, Organizations and Society, 51-77.

Vermeer, A., & Wenting, b. (2012). Zelfsturende teams in de praktijk. Amsterdam: Reed Business.

Vissers, J., & Beech, R. (2005). Health Operations Management. New York: Routledge.