Coordination of care:

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how modular service design can contribute.

Master thesis, Msc Supply Chain Management University of Groningen, Faculty of Economics and Business

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Abstract

The use of coordination in health care is not always up to standard. Therefore, it is important to research how coordination can be managed in a more effective way. Service modularity can be used to help coordination in two ways. Firstly, it can reduce the need for coordination, and secondly, standardized interfaces can be used to manage the remaining coordination need. The question that arises is how the standardized interfaces as coordination mechanisms are used when there is a certain coordination need. Therefore, the research question of this research was: What kinds of

coordination mechanisms are used in process modules in a health care setting, and how do these add to the coordination need? This question was answered by conducting a case study at a healthcare

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Acknowledgement

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1. Introduction

Coordination between care providers in the home care sector is not always up to standard, although much effort has been put into this essential activity. Providers often communicate in an unclear way, do not communicate in a timely fashion, or they do not communicate with each other at all (De Stampa et al., 2012; Fairchild, Hogan, Smith, Portnow, & Bates, 2002). Communication is an important part of coordination (Forrest, Glade, Baker, Bocian, Von Schrader and Starfield, 2000; Gittell, 2002b_{), and a lack of communication can result in a lack of care coordination (De Stampa et} al., 2012). Care coordination can be defined as: “the deliberate organization of patient care activities

between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services (Shojania, McDonald, Wachter and Owens, 2007, p. 41.)”.

Because of specialization, multiple healthcare professionals are involved with the care for one patient, which means that providers have to align their tasks frequently. Specialization can lead to fragmentation, which means that extra attention has to be paid to coordination (Kodner, 2009; Stange, 2009). One promising way to optimize coordination between service providers is the use of service modules and a modular service architecture. Therefore, this research will aim at finding out how coordination is achieved in a modular service architecture, and if coordination is achieved in the best possible way.

According to Schilling (2000, p. 312) modularity is “a continuum that describes the degree to

which components of a system can be separated and recombined”. To be considered a module, 3

principles have to be fulfilled. The module has to have a specific function, has to be relatively independent, and has to have standardized interfaces (Eissens - Van der Laan, 2015). A module consists of integrated and mutually well aligned parts of a care process/package with a specific function. Service process modularity can accomplish flexibility and customization for customers in services (Bask, Lipponen, Rajahonka and Tinnilä, 2010). Flexibility, because there is a set of modules to pick from and these modules make it possible to add services at a later stage (Avlonitis and Hsuan, 2017), and customization, because the modules can be combined in any way (Avlonitis and Hsuan, 2017). An example of a modular design in health care is described in Broekhuis, van Offenbeek and Eissens-van der Laan (2017), i.e. they name several modules for example, staying fit, staying more self-reliant and staying at home. These are examples of outcome oriented service modules, while in health care also process oriented modules are developed. “A process module is a

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focused on delivering (part of) a process, while an outcome oriented module focuses on delivering the outcome that is its goal. In this research process-oriented modules were studied.

A module itself is standardized, i.e. it contains similar main components irrespective to whom the module might be delivered. This means that not for each customer these parts have to be aligned separately. When looking at a modular health care design, a process module will also include several health components that are provided by multiple providers, which contribute to better coordination as long as there are mechanisms for coordination built into the module. Once a care process/package has been developed well -including the appropriate coordination mechanisms-, alignment is not required for every separate patient. Therefore, modularization can reduce the coordination costs by delivering a module including predefined coordination, while still delivering a customized service.

A second way that modules might contribute to lower coordination costs is by combining modules and providing a customized delivery. Modules can be combined, which is facilitated by the use of standardized interfaces. Combining modules through these standardized interfaces might also decrease coordination costs (Eissens – Van der Laan, Broekhuis, van Offenbeek and Ahaus, 2016), because coordination through these standardized interfaces is less complex as the way of coordination is standardized.

Finally, outcome indicators that are related to the clear function of a module can be another way of improving coordination within a modular service design. These outcome indicators set a clear objective of what the result of a module should be, and therefore, make it clear what has to be done without the need for more detailed coordination. Outcome indicators are a form of outcome oriented coordination, and not process oriented coordination, but it is possible to use outcome indicators in a process module. Furthermore, process descriptions are a form of premade coordination as well, as it tells a provider exactly what he/she has to do, eliminating the need for coordinating this for every single case.

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coordination need does not become clear. Researching the coordination need within modules and which coordination mechanisms are used will therefore provide information about how these can be aligned in a proper way. This leads to the following research question:

What kinds of coordination mechanisms are used in process modules in a health care setting, and how do these add to the coordination need?

To answer this question a multiple case study was conducted. Several modules developed in a health care setting were studied to find out what types of coordination mechanisms were used, the types of coordination need that were present, and if certain coordination mechanisms were underrepresented. This paper aims to provide insights into, and enhance the knowledge of the use of coordination mechanisms in modular architecture. More specific, what the relationship between the coordination need within a module and the coordination mechanisms used is.

From a practical perspective this paper will be relevant to health care organizations that are using modules, or want to use modules, because it can shed a light at how coordination need can best be managed with the use of coordination mechanisms. Therefore, when developing modules, organizations can keep the coordination need in mind, and design the module in such a way that the appropriate coordination mechanisms are present.

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2. Theoretical Background

2.1 Service modularity

In order to understand how modularity can contribute to coordination in health care, we first have to understand what service modularity is. According to Schilling (2000, p. 312) modularity as a system is “a continuum that describes the degree to which components of a system can be separated

and recombined”. The components of a modular system are the smallest individual parts that can

still fulfill a function but cannot be offered individually (Ulrich, 1995). Rajahonka (2013) describes a module in a service system as follows: “a module can be defined as a relatively independent part of a

system with a specific function and standardized interface”. These definitions all point to three

modular design principles, namely specific function, relative independence and standardized interfaces (Eissens -Van der Laan, 2015). We describe these three main functions in this section.

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The modules should also be relative independent, meaning that modules should be independent from each other, while components within a module should be interdependent (Eissens - Van der Laan, 2015). Changing one of the components in a module will not alter the composition of another module, but it will affect the relations between the components in that module. For example, changing the physiotherapist component in the module that deals with mobility issues will affect other parts in that module, but the outcome of the module should be similar (in case of outcome oriented modules). To find out how interdependent modules and components are, which determines the need for coordination, we use the interdependencies of Thompson (1967).

The last modular design principle is standardized interfaces. The main function of the standardized interfaces is to facilitate the connection between modules. De Blok et al. (2014, p. 186) define interfaces as: “the set of rules and guidelines governing the flexible arrangement, interconnections, and interdependence of service components and service providers.” This implies that De Blok et al. refer to components where other researchers refer to a module. However, the intention is the same: independent components/modules with a clear function need to be combined which is facilitated by using standardized interfaces. Second, also within modules coordination is required. The set of interfaces as described by De Blok et al. (2014) might also be useful to coordinate between sub parts within a module when this module contains multiple components each with a clear function.

Now that we know what service modularity entails, we have to determine how the coordination need can be established, and what types of mechanisms there are to manage coordination.

2.2 Coordination

2.2.1 Coordination need

Coordination between care providers is an important aspect of health care (Nolan, 1998, Fairchild et al., 2002). When there is no coordination, this can result in mistakes, which can lead to patient harm (Cope, Jonkman, Quach, Ahlborg and Connor, 2018). However, coordination between health care professionals does not always happen (De Stampa et al., 2012). Shojania et al. (2007, p. 41) define care coordination as: “the deliberate organization of patient care activities between two or more

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duplications of tests, a lack of communication among health professionals and patients receiving conflicting information (Blendon, Schoen, DesRoches, Osborn and Zapert, 2003). Coordination is especially important for elderly patients, as they often have multiple problems, and are thus treated by several health professionals (Wenger and Young, 2007). Failing to organize the care in a coordinated way can also result in wasted time and resources (Blendon et al., 2003); indicating that care coordination can also help reduce costs. Poor coordination can also cause frustrations with the patient and care providers. When multiple providers are involved with care this requires coordination, this stems from dependencies that arise.

Thompson (1967) distinguishes between 3 different types of interdependencies. Firstly, pooled interdependence is the loosest form of interdependence. When there is pooled interdependence the systems have completely separate functions, and thus do not depend directly on each other. They function together to achieve a certain goal to which they both contribute (Thompson, 1967). The second type of interdependence is sequential interdependence, in which one of the systems is dependent on the other system, as it needs the outputs of that system to be functional (Thompson, 1967). Lastly, the third type of interdependence is called reciprocal interdependence and this is the most complex form of interdependence. Here the output of one system is the input of the other system like with sequential interdependence, but here complexity is added by the fact that these outputs are then again inputs for the first system (Thompson, 1967). According to Eissens - Van der Laan (2015) it is preferable to have rather loose dependencies between modules, because when there are tight dependencies the need for coordination increases.

Depending on the type of interdependencies coordination is necessary between providers but also between parts of the service offering. In literature many coordination mechanisms are reviewed, and these will be discussed in the next paragraph.

2.2.2 Coordination mechanisms

Within management literature several ways of coordination exist. Mintzberg (1980) distinguishes between five different coordination mechanisms. Galbraith (1974) mentions three integrating mechanisms that can increase information processing capabilities, with four design strategies to support these integrating mechanisms.

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standardization by outputs, standardization by skills, and mutual adjustment. An explanation of these mechanisms can be found in table 1.

Table 1: Coordination mechanisms adapted from Mintzberg (1980) Coordination mechanism Explanation

Direct supervision One individual gives orders and coordinates

the work in this way

Standardization of work processes Introduction of standards about how to do the work itself

Standardization of outputs Establishing standard performance measures

about the output of work

Standardization of skills Workers are trained to use standard skills and knowledge

Mutual adjustment Workers communicate with each other

informally

In healthcare literature several authors have researched the use of these coordination mechanisms. For example, Gittell (2002a_{) describes that there is a positive effect of the use of} routines, boundary spanners, team meetings and relational coordination on the quality of care. The first three coordination mechanisms increase the levels of relational coordination (Gittell, 2002a_). When comparing the coordination mechanisms of Gittell (2002a_{) with the coordination mechanisms} by Mintzberg (1980) we see that the three standardizing mechanisms of Mintzberg (1980) (Standardization of work-processes, standardization of output and standardization of skills) correspond respectively with the routines of Gittell (2002a_{). The next coordination mechanism,} direct supervision, is called boundary spanner with Gittell (2002a_{) and lastly mutual adjustment is} called relational coordination. Furthermore, the team meetings that Gittell (2002a_{) describes can be} seen as a form of mutual adjustment. The model by Mintzberg (1980) is not the only model about coordination mechanisms in management literature. Galbraith (1974) also built a model about coordination mechanisms, but he calls his coordination mechanisms, integrating mechanisms.

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Table 2: Integrating mechanisms and design strategies adapted from Galbraith (1974) Integrating mechanisms Explanation

Coordination by rules or programs When tasks are routine and predictable, rules and programs can coordinate the behavior between interdependent sub-tasks. Situations that are predictable can be managed by making rules and programs

Hierarchy In case of more uncertainty there will be events

that no rules have been made for. In these cases hierarchy comes into play. Someone higher in the organizational structure will have to make a decision. When the uncertainty of the

environment increases, it gets more and more difficult to implement hierarchy, because the hierarchy will become overloaded

Coordination by targets or goals When the level of uncertainty is high,

organizations are more often using coordination by targets or goals. Because the events that occur are not predictable, employees are expected to behave in a way that leads them to certain targets or goals

Design strategies Explanation

Create slack resources Introducing slack resources has as effect that it

increases the planning targets. The increase in planning targets ensures that fewer exceptions arise

Creation of self-contained tasks “Change the sub task groupings from resource (input) based to output based categories and give each group the resources it needs to supply the output. .”(Galbraith, 1974, p.31)

Investment in vertical information systems The goal of investing in vertical information systems is to relief the hierarchical

communication channels from pressure. The mechanisms that can process information ensure that the hierarchical communication channels are loaded with less information.

Creation of lateral relations Examples of lateral relations are direct contact, liaison roles, task forces, teams, integrating roles, managerial linking roles and matrix organization.

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Table 3: List of coordination mechanisms used in this research Coordination mechanism Explanation

Direct supervision/Hierarchy Both direct supervision and hierarchy manage coordination by appointing someone that will be responsible for making decisions.

Standardization of work

processes/Coordination by rules and programs

Standardization of work processes is achieved by

implementing rules and programs about the way that work processes have to take place.

Standardization of outputs/

Coordination by targets or goals Both mechanisms manage coordination by outputs. Standardization of skills

Mutual adjustment/ Creation of lateral relations

These are both mechanisms that use more informal ways of coordination between providers.

Create slack resources

Creation of self-contained tasks Investment in vertical information systems

Names of coordination mechanisms that are underlined will be used in the rest of this thesis.

The coordination mechanisms described before are found in general management literature; however, within service modularity literature standardized interfaces are discussed. These standardized interfaces can also be considered coordination mechanisms, as they are used to create coordination between either providers or components. De Blok et al. (2014) find that the interfaces can be divided into 2 groups: interfaces between service components, and interfaces between providers in the care package. The interfaces between components deal with the flow of customers and focus on linking the modules where the interfaces between the service providers deal with the flow of information (De Blok et al., 2014, Eissens - Van der Laan, 2015). Furthermore, a distinction can be made between interfaces that are concerned with creating variety and interfaces that are concerned with creating coherence (De Blok et al., 2014).

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Table 4: Interfaces adapted from De Blok et al. (2014) Interface Interface between providers or components Interface for variety or coherence Explanation Continuous needs assessment

Providers Variety Guides information exchange with customers to detect changes

Established lines of

communication

Providers Variety Guides information exchange: whom to

inform about what Customer

Meetings

Providers Variety Multidisciplinary meetings to discuss changes Product books Components Variety Selection guide of individual components Pre-combined

package element

Components Variety Certain components are linked to certain conditions. For specific conditions, for example diabetes, certain components that are always needed for this condition are already combined.

Planning rules for safety

Components Coherence Planning rules state exactly which

components in a package are to be provided in what order for safety

Planning rules

for smooth flow Components Coherence Planning rules state exactly which components in a package are to be provided in what order for smooth flow

Organizational

arrangement Providers Coherence Strict division of labor between service providers Work schedules Providers Coherence Rules on who has to provide which

components when

Care dossier Providers Coherence Standardized means to exchange customer information

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Table 5: Comparing interfaces between providers with coordination mechanisms Interface by de Blok et al. (2014) Goal Coordination mechanism Explanation Continuous needs

assessment Variety Mutual adjustment Continuous needs assessment uses direct contact and therefore mutual adjustment.

Established lines of

communication Variety Mutual adjustment Established lines of communication is involved with knowing who to inform about

Customer Meetings Variety Mutual adjustment Customer meetings use direct contact and therefore mutual adjustment. Organizational

arrangement Coherence Standardization of work processes Documentation about who is responsible for what tasks is standardization of work processes. Work schedules Coherence Creation of

self-contained tasks Work schedules are creation of self-contained tasks, because they specify which provider has to provide which tasks, and when to provide these tasks.

Care dossier Coherence Investment in vertical information systems

The introduction of a care dossier is investment in vertical information systems, because it reduced the need for coordination by providing all information in the dossier.

Table 6: Comparing interfaces between components with coordination mechanisms Interface by de Blok

et al. (2014)

Goal Coordination mechanism

Explanation

Product books Variety Standardization of

outputs Product books specify which services can be delivered. They do not specify how to deliver the service, and therefore are standardization of outputs

Pre-combined package

element Variety Standardization of outputs Pre-combined package element specifies what services to use when there is a certain need. They do not specify how to deliver the service, and therefore are standardization of outputs

Planning rules for

safety Coherence Standardization of work processes Planning rules for safety explain in what order steps have to be delivered. Therefore they instruct providers how to provide a service

Planning rules for

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Now that has been explained why coordination is important, how the coordination need can be determined, and what types of coordination mechanisms exist, the next step is to see what relationship there is between the coordination need and coordination mechanisms.

2.3 Modular design and coordination

2.3.1 Modular design and coordination need

When designing a module the goal is to make it so it has a specific function, it is relative independent, and there are standardized interfaces. The reason for this is that a module with a specific function can be delivered on its own (Eissens – van der Laan, 2015). When the module is relative independent, it means that the coordination need between modules is decreased (Eissens – van der Laan, 2015) and the standardized interfaces are used to coordinate the modules and components when there is still a coordination need (Eissens – van der Laan, 2015). This implies that service modularization can help coordination in 2 ways. Firstly, it diminishes the need for coordination by making sure the modules are relative independent, and secondly, when there still is a coordination need, this need is addressed within the design of the module, by using standardized interfaces. This research focuses on the coordination need within modules, and not on coordination need between modules.

2.3.2 Interdependencies within modules and coordination

When the interdependencies within modules indicate that there is a coordination need, modules should include the use of coordination mechanisms. Standardized interfaces include several types of coordination mechanisms, see tables 5 and 6. According to Thompson (1967) there should be alignment between the coordination need and the coordination mechanisms that are applied. This principle should be valid in a modular design as well.

Thompson (1967) links the three types of interdependence to three types of coordination. He finds that when there is pooled interdependence, standardization as coordination is appropriate. Standardization involves “the establishment of routines or rules which constrain action of each unit or

position into paths consistent with those taken by others in the interdependent relationship”

(Thompson , 1967, p. 56) Sequential interdependence asks for coordination by plans, which involves “the establishment of schedules for the interdependent units by which their actions may then

be governed” (Thompson , 1967, p. 56), and when there is reciprocal interdependence mutual

adjustment should be used. Mutual adjustment involves “the transmission of new information during

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Thompson (1967) are a guideline about what types of coordination are needed when creating a module, and can give guidance about the coordination mechanisms that should be included at certain steps of the module. Table 7 gives an overview of what coordination mechanisms should be used when which type of interdependency is present. All interdependencies can be linked to certain coordination mechanisms. As can be seen in table 7, pooled interdependencies can use a whole range of coordination mechanisms, while sequential interdependencies can only choose from two coordination mechanisms, and reciprocal interdependencies can choose from five coordination mechanisms.

Table 7: What coordination mechanism to use when there are which type of interdependencies

Interdependencies in a module Requires which coordination mechanism Pooled interdependence Standardization of work processes

Standardization of outputs Standardization of skills

Investment in vertical information systems Product books

Pre-combined package element Planning rules for safety Planning rules for smooth flow Organizational arrangement Care dossier

Sequential interdependence Creation of self-contained tasks Work schedules

Reciprocal interdependence Mutual adjustment Direct supervision

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Based on the theory we have discussed we can develop the following sub-questions:

1. How self-dependent are the modules formulated, and what value do process steps have?

This question aims to answer if modules have a clearly formulated function, and if the modules can be offered independent of each other. Furthermore, it seeks to find out if process steps have a function as well, and in what way these process steps add value.

2. How much coordination need is still left in the modules?

The second question aims to find out what types of interdependencies are present in the modules, and what coordination need is thus present in the modules.

3. Which coordination mechanisms are included in the modules?

The third questions seeks to find an answer to what types of coordination mechanisms, which include standardized interfaces, are present in the module.

4. Is there alignment between the level of coordination need and the coordination mechanisms

that are chosen?

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3. Methodology

In order to be able to answer the research questions, a multiple case study was conducted. Case study research is suggested for explorative, theory building, theory testing and theory extending research (Voss, Tsikriktsis and Frohlich, 2002). This research can be classified as theory testing, as it aims to find out if the use of interfaces and coordination mechanisms in actual modules is in line with what theory expects when considering coordination need. Furthermore, a case study is especially well suited for answering How and Why questions (Yin, 1994). The use of multiple cases increases the generalizability of the research (Yin, 1994), but the use of more cases can also result in less depth. Therefore, four cases were selected in this research, because this means that the results would be generalizable, but there was still the opportunity for in-depth study of the cases.

The structure of this chapter will be as follows. First, the research setting will be explained. Afterwards, the unit of analysis and case selection will be discussed. In the third part an explanation about the data collection method will be given. Lastly, the quality of the research will be discussed.

3.1 Setting

This research was conducted in a health care setting. Recently developed modules from a health care organization in the north of the Netherlands were studied. This organization is comprised of six individual organizations. The organization offers home care as well as care in care homes. The first step in developing the modules was creating five formulas (Northcare, 2016). These five formulas all had a different aim. The aim of the first formula is to ensure that the client could go home as quickly as possible, and thus did not have to stay in care longer than necessary. The next formula aims to let clients be themselves, and makes sure clients will be themselves again after care has been given. The third formula is aimed at feeling at home wherever you are, and thus making sure that a client feels at home even if he or she has to go to a care center or hospital. The fourth module makes sure that the neighborhood of the client is involved in the care process. The last module is aimed at ensuring protection for the client and society, by making sure that risks concerning the client’s behavior are being monitored. All modules that were developed fall in one of these categories.

3.2 Unit of analysis and case selection

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module, and how these add to the coordination need. The choice was made to look at the types of interdependencies that are present between process steps, and between providers, so within process steps. Therefore, it is important to study real process modules to find answers to this question. The modules used are: Need Assessment (behoeftebepaling), Rehabilitation and Recovery with Us (revalideren en herstellen bij ons), Living with Us (wonen bij ons) and Acute Care (integrale zorg bij een acute situatie). The module Living with Us can be found in appendix B. As these modules were all developed within the same organization, it is to be expected that they will deliver similar results.

3.3 Data collection and development case study protocol

The data for this research was collected by analyzing the modules the organization had developed. These modules were written down, with details on how they were supposed to work. Per module we assessed the following documents: a written description of the process, and a supplementary document in which the function of a module was described and in which the outcome indicators where discussed. Furthermore, three general documents were study. In these documents the aim of the organization to develop modules became clearer.

In order to analyze the cases, a case study protocol was developed. In the protocol questions where formulated that were answered by studying the modules carefully. The protocol was divided into 3 parts. Firstly, the main structure of the module was examined. Questions where posed about the function of the module and the function of the process steps. The function of the module could be determined by studying the promises that Northcare makes to its customers (Northcare, 2018a_, 2018b_{, 2018}c_{, and 2018}d_{). In these promises the function of the module could be found. The next} step was to identify the function of each process step, and to find out in what way each process step contributes value. Within the module all process steps are clearly defined, and the choice was made to define the function of each process step as completing the process step. For example, step 1 of the module acute care is: “See what has been agreed upon about how to act in an acute situation”. The function of this process step is then: preparation for an acute situation. To determine what kind of value each process step has, a distinction was made between real-value added (RVA), business-value added (BVA) and no-business-value added (NVA).

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dependent of step 1 there were sequential interdependencies. Lastly, when step 2 was dependent of step 1 and step 1 was then dependent of step 2 there were reciprocal interdependencies. To identify the interdependencies between providers first all steps in which more than one provider was present were identified. Afterwards, the interdependence between these providers was determined. This happened in a similar fashion as with the interdependencies between process steps, except for that in this case it was the dependence between providers that was studies. So, if provider one was not dependent of provider two and vice versa there were pooled interdependencies. When provider two was dependent of provider one, but provider one was not dependent of provider two there was sequential interdependence. Lastly, when both provider one was dependent of provider two and provider two was dependent of provider one there were reciprocal interdependencies.

In the third part of the protocol the coordination mechanisms were studied. Every module was analyzed to find if there were any coordination mechanisms present within process steps, but also between process steps. Table 7 provides a list of coordination mechanism to which each module was tested. In table 1, 2 and 4 all coordination mechanisms were explained, and these explanations were used to see if there where coordination mechanisms present in the modules. The analysis protocol can be found in appendix A.

3.4 Quality of research

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4. Results

In this chapter the results of the study will be shown. The first section discusses the function of the module and its components, and what value the components add to the module. The second part is concerned with the interdependencies within modules, i.e. interdependencies between process steps and interdependencies between providers. In the third paragraph of this chapter, the use of coordination mechanisms will be discussed. Lastly, a link will be made between the coordination mechanisms and the coordination need. To be able to sketch a clear picture, one analysis of the module acute care will be used as an example throughout the chapter. A sequence of the steps that were taken to analyse the coordination need and the coordination mechanisms used in this module are described.

4.1 Module function

The function of the modules that Northcare has designed is twofold. Firstly, the function of a module is to deliver a certain service process. Within the module Acute Care this function is: To deliver acute care to patients who already are clients of the care group. Secondly, Northcare makes certain promises to its clients which are relevant to this module. The promises are: we are familiar with

your neighbourhood and cooperate with parties relevant to you (Wij kennen uw wijk/buurt en

werken samen met voor u relevante partijen), and during an urgent situation we provide care at any

location best suitable to your needs. To achieve this, we cooperate to maximum capacity within the chain (Bij een acute situatie realiseren wij zorg op de voor u best passende plek. Wij werken

daarvoor optimaal samen in de keten) (Northcare, ₂₀₁₈b_{). These promises are further specified in} the themes: availability of current client information (Beschikbaarheid van actuele klantinformatie) ,

accessibility to care in an acute situation (Bereikbaarheid van zorg in een acute situatie), Quality of handovers in the chain (Kwaliteit van overdrachten in de keten), Person-centered care

(persoonsgerichte zorg) , Proper care at the right location (Juiste zorg op de juiste plek)and Chain

evaluation (Ketenevaluatie). Therefore, the second part of the function is determined by the

promises and themes, as the module also aims to fulfill these. These function descriptions confirm that the first of the three design principles, specific function, is present in the module. When developing the modules, Northcare made use of five formulas (see paragraph 3.1).These formulas where then reworked into several modules. Therefore, each module contributes to one of the formulas.

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Harrington (1991) describes 3 types of value adding. Real-value added (RVA) are activities that are necessary to provide what the customer is expecting, business-value added (BVA) are activities that do not add value for the customer but are required by the business, and no-value added (NVA) activities. Table 8 also contains the value added by each function. As can be seen, each process step has a certain function within the module. Furthermore, all process steps add value, either business- value or real-value.

Table 8: Process steps and their function and value of the module Acute Care

Process step Function Value

added 1 See what has been agreed upon about how to act in an

acute situation. Preparation for an acute situation RVA

2 Triage moment. Northcare care professional will assess the acute situation to see what the client needs (Client either goes home or goes to a hospital or inpatient treatment center)

Assessment of the

situation RVA

3a Stabilization of the disruption (Handover of patient (including patient information and files) to the

hospital/care center, securing a warm welcome for the patient)

Stabilization of the

situation RVA

3b Stabilization of the disruption (Discussion takes place about what the patient needs to address the situation, more home care, extra help from technological aids.)

Stabilization of the

situation RVA

4 Contact moment with care provider Northcare, the client, and care provider of the place the patient is at now. (discuss what to do after admission)

Assessment of the

situation RVA

5a Client goes home (See if there are changes in needs of the client)

Preparation for a new situation (Client at home)

RVA 5b Client will go to a care facility, relationship with the

patient ends; handover to the new residence is smooth. Preparation for a new situation (Client goes to care facility)

RVA 6 Client experiences a warm handover to their home

situation Attention for the client in order to make a smooth

transition

RVA 7 Agreed upon extra care or technological aids are delivered

immediately.

Delivery of extra care or technological aids

RVA

8 Situation is evaluated continually Continuous evaluation of

the situation. RVA

9 New equilibrium is achieved, situation is stable again. (Acute care is evaluated)

Evaluation of the delivered care

BVA

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weken dat de klanten bij ons komen wonen). The promises that are applicable in this module are:

“it’s your home, we are guests” (“Het is uw huis, wij zijn te gast”) and “We offer maximum well-being and safety, wherever your home may be” (“Wij bieden maximaal welbevinden en veiligheid, waar uw thuis ook is”). These promises are further specified in the themes: ‘feeling at home, well-being, and safety’. A table with the process steps, function of the process steps and value added by these

process steps can be found in appendix C.

The next module is Need Determination. The function of this module is to establish the needs and desires of clients, and to make agreements about what these needs and desires mean for care and support. The starting points of this module are: Attention to needs and desires (Aandacht

voor behoeften en verlangens), attention forall life domains (Aandacht voor alle levensdomeinen), considering the clients’ point of view (Eerst kijken door de ogen van de klant). For this module, a

table with the process steps, function of the process steps and value added by these process steps can be found in appendix D as well. The module Need Determination is less dependent because it is seen as a conditional module (Northcare, 2017b_{). The output of this module is used as an input for} the other modules (Northcare, 2017b_).

The last module, Rehabilitate and Recover with Us, has as a function to help clients recover quickly and effectively (Northcare, 2018c). The promises in this module are: After a part-time stay with specialised care we transfer you back to your home as soon as possible. (Wij zorgen ervoor dat

u zo snel mogelijk thuis bent na een tijdelijk verblijf met specialistische zorg), We are comitted to use more intensive care efficiently and for a short period. And We aim for a sustainable result and we promise a complete and timely transmissions from and to chain-partners. (Wij zetten ons in om zwaardere zorg effectief/kort in te zetten en gaan voor een duurzaam resultaat en Wij beloven een volledige en tijdige overdracht van en naar keten-partners). These promises are specified into: quick and effective, complete and timely handovers and sustainable effect. A table with the process steps,

function of the process steps and value added by these process steps can be found in appendix E. We can conclude that all modules have a specific function, and all process steps have a function within the module. Furthermore, the process steps either add real-value, so value for the client, or business-value, which is needed to be able to conduct business.

4.2 Interdependencies within modules and coordination need

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that exist between components influence the type of coordination mechanism that is most appropriate (Thompson, 1967). Therefore, the interdependencies between components of the modules were studied. In these modules there could be interdependencies between process steps (see 4.2.1.), as well as interdependencies between service providers (see 4.2.2).

4.2.1 Interdependencies between process steps

Each module consists of multiple process steps. We analyzed the interdependencies between these process steps. Table 9 shows the types of interdependencies for the module Acute Care (Acute zorg).

Table 9: Types of interdependence between process steps in the module acute care

Process

steps* Type of interdependence Explanation

1-2 Sequential

interdependence The preparation step (step 1) has outcomes that have to be accessed in step 2. The data collected in step 1 can be used to assess what the client needs.

2-3a Sequential

interdependence Outcome of the triage is used to establish which step (3a or 3b) will be chosen. The outcome will also be used in step 3 stabilization as information.

2-3b Sequential

interdependence Outcome of the triage is used to establish which step (3a or 3b) will be chosen. The outcome will also be used in step 3 stabilization as information.

3a-4 Sequential

interdependence In step 3a, an appointment is made for step 4. Therefore, step 4 depends on step 3a to happen.

4-5a Sequential

interdependence Decisions made in step 4 influence what to do in step 5a. For example: In step 4 decisions are made about possibilities of increasing the amount of home care, in step 5 this decision is used to prepare the possible increase of home care.

4-5b Sequential

interdependence In step 4a decision is made about the date the client will leave, this date is important in step 5b because this is the date this step will take place.

5a-6 Sequential

interdependence The care dossier of the client has to be handed over from the care facility to home care providers. This happens in step 5a. This dossier is very important to be able to make a smooth transition to the home situation. Step 6 depends on 5a to happen.

3b-7 Sequential

interdependence Decisions of step 3b are needed to be able to conduct Step 7

6-7 Sequential

interdependence Step 7 does not rely on step 6. However, Step 7 does need information decided on in step 4. So, there is sequential interdependence between step 4 and step 7.

7-8 Sequential

interdependence The outcome of step 7 determines if extra care is delivered. Step 8 involves an evaluation as to whether this care is still needed.

8-9 Sequential

interdependence Step 9 is to evaluate the process of delivery of acute care. Therefore all steps in the module are needed to be able to conduct step 9. So, step 9 relies on all other steps.

* An explanation of the process steps can be found in table 8

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related sequential interdependence between step 6 and 7, because there is no information exchange between these 2 steps. Certain interdependencies require different coordination mechanisms (Thompson, 1967). When there is sequential interdependence, coordination by plans is recommended. However, Thompson (1967) also says that pooled interdependence is always present when there is sequential interdependence. Pooled interdependence asks for the use of coordination by standardization. Therefore, the coordination need of the module Acute Care is the use of coordination mechanisms that are considered coordination by plans or standardization.

When looking at the other modules there is mostly sequential interdependence (see appendices F,G,H). The module Living with Us shows only sequential interdependence (see appendix F). In this module there is a distinction between time related and output related sequential interdependence as well. Most steps are time and output related dependent, but the first two steps are only time related dependent. This is because these steps are only sequentially interdependent because they cannot be delivered in another order, and the previous step has to be completed before the next step is started. As was the case with the module Acute Care, the coordination need of this module is coordination by plans and standardization

In the module Need Determination reciprocal interdependencies can be found between step 2 and step 3 (see appendix G). Step 3 (Client and care giver feel understood) is an ongoing process, and is dependent on information from step 1 and 2, while step 1 and 2 are depending on step 3 for information. Furthermore, step 3 stays important during the following steps as well. The module Need Determination is a circular process, so every time step 8 is finished, it starts at the beginning again. This means that there will be interdependencies between step 8 and 1, this is sequential interdependence, because the information about the client that is gathered during the process is still used in step 1 when the process starts over again. The rest of the process steps have sequential interdependence and like with the other modules there are time and output related dependencies. The coordination need of this module will mainly be coordination by standardization and plans. But as there also is reciprocal interdependence, coordination by mutual adjustment is also needed.

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When looking at the interdependencies between service providers that have to cooperate within the module it emerges that more than half of the interdependencies are reciprocal interdependence. Table 10 shows the interdependencies between providers in the module Acute Care.

By looking at the type of contact there is between providers it is possible to make a distinction in what type of interdependence there is between the providers. In most cases this is reciprocal interdependence in the module acute care. Having contact with another provider usually means that the two providers are dependent on each other. In some cases however, there is sequential interdependence. This is mostly true when there is an information handover. The provider that needs the information is dependent of the information to be handed over, but the person that hands the information over does not depend on anyone else to be able to fulfill this task. Some process steps have multiple contact points between providers, which can result in the occurrence of multiple types of interdependencies within one process step.

In the module Living with Us there are sequential and reciprocal interdependencies (see appendix I). As said before, this distinction is made based upon if one provider depends on another provider, or if the providers are mutually dependent. What stands out in this module is that not all process steps have interdependencies between providers. This is because some of the process steps involve only one provider.

Within the module Need Determination sequential and reciprocal interdependencies are present (see appendix J). Not all process steps in this module have interdependencies between providers. Like with the module Living with Us, this is because some of the process steps only involve one provider.

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1 Data in the client dossier is accessible for the client and all

Northcare professionals that are involved. Sequential Professionals add information to client dossier. Other professionals can access this information in the dossier. 2 24/7 availability for client, GP, General practice, emergency

department, ambulance service or mobile medical teams. The professional in question (district nurse, first responsible carer, care coordinator, ambulatory companion or care centralist can give information about current care and options for increasing care.

Reciprocal Other professionals can get in contact with a Northcare professional. This means that the other professionals are depending on the Northcare

professional to be available, but the Northcare professional also only has to act when this is asked for by the other professionals.

3a If desirable the GP or Specialist geriatric medicine is contacted. Sequential When there is contact between the Northcare professional and the general practitioner or Specialist geriatric medicine (Specialist ouderen geneeskunde), the Northcare professional contacts the GP or SGM.

3b Warm and uniform handover by the district nurse, first responsible carer, care coordinator or ambulatory companion to the care location.

Sequential For the warm handover of the client, the Northcare professional is handing over information to the other professional, otherwise the task cannot be achieved.

Handover of client dossier Sequential For the handover of the client dossier there is sequential interdependence. This is because the Northcare professional does not need input from the other professional to achieve the handover.

Arrange intermediate contact moment with the client and

coordinating care giver at the care location. Reciprocal For the making of the appointment the Northcare professional has to rely on another professional, therefore there is reciprocal interdependence. 4 Intermediate contact moment with the client, coordinating care

giver at the care location and the care provider from Northcare. Reciprocal Both professionals have to rely on each other. Otherwise the contact moment will not be effective. 5a If necessary consult the specialist geriatric medicine for advice. Sequential The Northcare professional needs advice from the specialist geriatric medicine,

the SGM does not need anything from the Northcare professional. Send dossier from care location minimal 1 day before discharge

date Sequential

5b Warm handover to residential care center Reciprocal In order to have a good handover there has to be mutual inputs from both professionals.

6 Client experiences warm handover at home. Reciprocal In order to have a good handover there has to be mutual inputs from both professionals.

8 In evaluation if necessary align with other professionals involved. Reciprocal There has to be alignment between Northcare professionals and other involved professionals, this means there is reliance on both sides.

9 District nurse, first responsible care provider, care coordinator or ambulatory companion make agreements with client about appropriate care, evaluation moments in the stabile situation and update client dossier.

Reciprocal Multiple providers are involved with making agreements, so they are dependent on each other.

If there are points that are concerned with the regional network, the district nurse, first responsible care provider, care coordinator or ambulatory companion will share these points with an employee who represents the organization in the regional network.

Sequential There is sequential interdependence because the Northcare professional will only handover certain information with another professional.

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use of the coordination mechanisms provided in table 3 will be reviewed. Afterwards, the modules will be reviewed to see what types of interfaces are built into the modules. The interfaces will be discussed separately because they give a more specific coordination goal.

4.3.1 Coordination mechanisms

In the module acute care several coordination mechanisms can be found. The location of the coordination mechanisms can be seen in table 11.

Table 11: Locations of coordination mechanisms in the module Acute Care

Pr ocess step s* D ir ect s up er visio n Sta nd ar diz ati on of wo rk p ro cesses Sta nd ar diz ati on of out puts Sta nd ar diz ati on of skil ls Mutua l a dj us tm en t Cr ea ti on of slac k resour ces Cr ea ti on of se lf-co nta ine d tas ks Inv est m ent in ver ti cal info rm at io n sy stem s 1 X X X X 1-2 X 2 X X X 2-3a X 2-3b 3a X X X X X 3b X X X 3a-4 X 4 X X X X 4-5a X 4-5b X 5a X X X X 5b X X X 5a-6 6 X X X 3a-7 6-7 7 X X X 7-8 8 X X X X X 8-9 9 X X X X

*An explanation of the process steps can be found in table 8

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The first mechanism that is found is standardization of work processes, as the module is composed of rules about what step has to be done at what point. This can be seen as a way of telling professionals how to do their job. Each step prescribes the jobs that have to be done in that step and the order that is established by the module. This means that standardization of work processes is used frequently. For example, at step 7 the agreed upon extra care or technological aids are delivered immediately. By describing this process step so clearly, the work process has been standardized.

The second coordination mechanism that is used is standardization by outputs. Performance indicators can be an example of standardization of outputs. The module Acute Care uses several outcome indicators. These indicators are divided in several themes. These themes are: availability of current client information, accessibility, quality of handovers in the chain, person centered care, providing the right care at the right place, and cooperation in the chain. Examples of indicators used in the module are experienced availability of the organization from the point that there was a need for acute care till the situation was stable, the experienced quality of handover after admission and if the patient received the right type of care. Because outcome indicators are used in this module, standardization of outputs is also used as a coordination mechanism. Furthermore, the function of a module and process step can also be seen as standardization by outputs. The function of the process steps represent a goal that has to be reached. Therefore, every process step has standardization by outputs.

Third, the design of the module ensures that care professionals deliver the service in each process step as is required to professional norms and values. This means that all providers follow a certain set of skills to perform the tasks. The steps in the module are designed to deliver a certain standard of care. Therefore it is likely that there are standards which the care has to meet. This can be seen as standardization of skills because there are norms and standards about how each step has to be performed. This results into a practice in which all providers are expected to follow the same standardized routine. However, these standards are not literally mentioned in the module.

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coordination as providers do not have to discuss the information in person.Direct supervision and creation of slack resources and self-contained tasks are not present at all in this module.

For the module Living with Us (see appendix L) the same coordination mechanisms are used as with the module Acute Care. These are: standardization of work processes, outputs and skills, mutual adjustment and investment in vertical information systems. It is remarkable that this module mentions the use of a care dossier, an example of investment in vertical information systems, only once. This indicates that there is a care dossier created, but the use of this care dossier is not designated in the module at other points.

In the module Need determination (see appendix M) the coordination mechanisms standardization of work processes, outputs and skills and investment in vertical information systems are used. Again, in this module the care dossier is only mentioned at the last step. While documentation of conversations with clients, agreements with clients, and discussed goals would seem to be important in this module. Looking at the module, we cannot say that the care dossier is not used at other steps, but it is not indicated clearly that it is used. Furthermore, mutual adjustment between providers is not present in the module, even though there are multiple providers involved.

Lastly, the module Rehabilitate and Recover with us (See appendix N) makes use of the following coordination mechanisms: standardization of work processes, outputs and skills, mutual adjustment and investment in vertical information systems. Within this module the use of coordination mechanisms seems to be thought out well. However, like with the other modules creation of self-contained tasks is not present, while creating modules could be a good opportunity to create these self-contained tasks. Because all the modules are described so explicitly, delegating a module to a team could be helpful, as coordination could be managed more easily if there are less professionals involved.

One thing that can be said about all modules is that there are hardly any coordination mechanisms build into the module between the process steps. Almost all coordination mechanisms are within the process steps. The only exception in the module Acute Care is mutual adjustment which is used between process steps.

4.3.2 Interfaces

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were not described by De Blok et al. (2014) will be discussed. The analysis of the module Acute Care will be used as an example. In table 12 the locations of the interfaces are shown.

Table 12: locations of interfaces in the module acute care

Pr ocess ste ps* Co nt inu ous n eed s ass ess m ent Esta bl ished lines o f co m m un icati on Cus to m er Mee ti ngs wit h custo m er Cus to m er m eetings wit ho ut cus to m er Pr odu ct bo oks Pr e-co m bined p ac kage el em ent Pl ann ing rules fo r s afet y Pl ann ing rules fo r s m oo th flo w Or ga niz ati ona l ar ra nge m ent W or k s ch edu les Ca re dossier Ev al ua ti on po ints Pl ann ing rules fo r qu al ity 1 X X X 1-2 X 2 X X X X 2-3a X X X 2-3b X X X 3a X X X X X 3b X X X X 3a-4 X 4 X X X 4-5a X X 4-5b X X 5a X X X 5b X 5a-6 6 X X 6-7 3b-7 7 7-8 8 X X X X X X 8-9 9 X X X

*An explanation of the process steps can be found in table 8

X = this coordination mechanism is present at this process step/between these process steps

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is an example of continuous needs assessment. . Established lines of communication can often be found in this module. The client knows who to contact when there is an acute situation, and care professionals know who to contact in which situation, because there are guidelines in the module. . In the module there are customer meetings present. Some of these meetings are with the client, and some are without the client. At multiple points in the module, it is said that certain professionals are responsible for certain tasks. However, most of the time it is not clear which professional exactly is responsible. For example, at the triage stage it says: “District nurse, first responsible carer, care coordinator, ambulant supervisor, or care operator in question can give information about current care and options for scaling up care.” (Betreffende wijkverpleegkundige, EVV’er, zoco, ambulant begeleider/ ambulant begeleider of zorgcentralist kan informatie geven over huidige zorg en mogelijkheden voor opschaling zorg.) This does not make it clear which professional specifically is responsible, but it could be an attempt at organizational arrangement. Considering the fact that there is a 24/7 availability of the service, it is to be expected that there are work schedules to make sure all services are delivered at the time they have to be delivered. However, there is no specific mention of these work schedules. A care dossier is available, at multiple steps this has to be accessed, either to find information about the client, or to add information about the client.

There are also interfaces which are harder to locate in the module. These are planning rules for safety and planning rules for smooth flow. The module can be seen as a set of rules. The module is designed in this order to provide safety. First there is a triage point to see what the client needs. There might be rules about the triage and how to ensure safety; however, these are not mentioned specifically in the module. Also, care has to be accessible 24/7, this can be for safety, but this is not specified.

Coordination of care:

how modular service design can contribute.

Abstract

Contents

1. Introduction

2. Theoretical Background

2.1 Service modularity

2.2 Coordination

2.3 Modular design and coordination

3. Methodology

3.1 Setting

3.2 Unit of analysis and case selection

3.3 Data collection and development case study protocol

3.4 Quality of research

4. Results

4.1 Module function

4.2 Interdependencies within modules and coordination need