Coordination of Cross-Domain Collaboration in a hospital with a patient- centered approach

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Coordination of Cross-Domain

Collaboration in a hospital with a

patient-centered approach

By

Tristan Koen

S2311461

Tristankoen@hotmail.com

Thesis supervisor: dr. H. C. Bruns

Thesis co-assessor: dr. I. Maris-de Bresser

Total word count: 12975

24-06-2019

Master Thesis

MSc Change Management

Faculty of Economics and Business

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Abstract

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Introduction

In recent years, organizations have grown to become complex systems that require intensive coordination and communication among collaborators. There has been an increase in cross-domain collaboration, since its benefits of increased innovation and knowledge development are widely acknowledged (Bruns, 2013). This phenomenon did not fly by organization practicing healthcare. Many hospitals have shifted from a physician-centered approach to a patient-centered approach (Kreitzer, Monsen, Nandram, & de Blok, 2015; Felder, Van de Bovenkamp, Maaijen, & de Bont, 2018). The patient-centered approach is characterized by multidisciplinary collaboration among the various care givers, to provide care that focuses on the problems of the patient (Klink, 2008). This has led to hospitals with reformed organizational structures where individuals from various domains and with different specializations have to cooperate in novel collaborations. The diversity in expertise can impede this collaboration since it often stimulates differences in understanding (Bunderson, & Sutcliffe, 2002). Therefore, coordination efforts to counter these misunderstandings have become increasingly paramount in the new forms of multidisciplinary collaborations in Dutch hospitals.

Abundant literature addresses the shift to a patient-centered approach in various healthcare systems now that it is being developed or considered in multiple countries (Van de Bovenkamp, Trappenburg, & Grit, 2009; Ikkersheim, & Koolman, 2012). For example, Villa, Barbieri and Lega (2009) analyzed redesign projects from three hospitals that are implemented to adhere to this new approach. Eijk, Nijhuis, Faber and Bloem (2013) reviewed the benefits of this approach for patients with Parkinson’s disease. Additionally, Betteridge, Boehncke, Bundy, Gossec, Gratacos and Augustin (2015) state that patients with psoriatic arthritis have an apparent need for patient-centered care as they benefit from the associated multidisciplinary collaboration. Although these scholars focus on the patient-centered approach from various viewpoints, they also have one thing in common. They fail to elucidate how these multidisciplinary collaborations are actually put into practice and how it is coordinated to prevent ineffective teamwork.

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4 among various collaborators (Fox, & Reeves, 2014), and thus, other forms of coordination are required to make the patient-centered approach effective.

Even though the topics of multidisciplinary collaboration in a patient-centered care approach and the importance of coordination in multidisciplinary collective work have individually been addressed thoroughly in preceding literature, thus far, the combination has been neglected. The deficiency with scholarly articles addressing the shift to a patient-centered approach is that even though it is evident that it requires multidisciplinary collaboration, it remains unclear how this actually unfolds in practice. The importance of coordination practices in cross-domain collective work in a non-healthcare context is already obvious since its absence can make teamwork ineffective (Cronin, & Weingart 2007). This makes coordination practices even more relevant in multidisciplinary collaborations within healthcare systems since it can affect peoples’ actual well-being. This applies to hospitals in particular where there are life threatening situations on a day to day basis.

Hence, new insight is needed that examines the occurrence of coordination efforts in hospitals that have shifted towards a patient-centered approach since it requires novel forms of cross-domain collaboration. To fulfil this need, this study intents to answer the following research question:

RQ. How does coordination of multidisciplinary collaboration occur in a hospital that adopts a patient-centered approach?

To provide an answer to this question, I conducted a qualitative case study in Nij Smellinghe, a Dutch hospital that has reformed their organizational structure to comply with the patient-centered approach. Nij Smellinghe’s organizational change was large-scale and structural, where previous departments were abrogated and new ones were created out of workers from various departments and domains. By conducting a qualitative case study in this setting, this study aims to contribute to theory in the area of coordination in multidisciplinary collaboration within hospitals that facilitate patient-centered care. The findings will provide us with a better understanding of how coordination actually unfolds in this specific setting.

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5

Literature review

Coordinating multidisciplinary collaboration

Collaboration among diversified disciplines is regarded fruitful, as it enables the development of unique types of knowledge that could not be developed within a single discipline alone (Cumming, & Kiesler, 2007). It combines diversely specialized parties which cultivates creativity and creates unique capabilities (Sik, 2016). Despites these benefits, the complexity of this type of cross-domain collaboration is recognized as well. Opposing views and dissimilar understandings emanate from varying expertise, making this type of collaboration precarious (Cronin, & Weingart, 2007). In addition, Keller (2001) indicated that this can lead to dissatisfied collaborators, high stress levels, elusive agreements and even conflicts. Hence, effective multidisciplinary collaboration necessitates adequate coordination practices (Bruns, 2013).

In its fullest sense, “coordination can be seen as the process of managing dependencies among activities” (Malone, & Crowston, 1994), and can occur in many systems. Though, in organizational theory, it refers to the integration of varying views, alignment of conflicting perspectives and mental models by enhancing communication and information (Auh, & Menguc, 2005). Abundant scholars have studied this principle of coordination. Consequently, the literature is full of different definitions (Faraj, & Xiao, 2006). Therefore, in this paper, I refer to coordination as follows: “Coordination work consists of making relevant domain-specific details transparent and arranging empirical manifestations of contributions according to a shared objective” (Bruns, 2013). Several scholars have demonstrated the significance of this type of coordination among collaborators with varying expertise. It is determined that cross-domain coordination stimulates the effect of team diversity on innovativeness in top management teams (Auh, & Menguc, 2005).

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6 one of the most effective methods of coordination in multidisciplinary collaboration is the practice of sharing knowledge (Cummings, & Kiesler, 2007).

Transferring knowledge can be seen as the exchange of information. When a specific person produces or contains information that is used by another person, we refer to the transfer of this information from the first- to the second person as ‘communication’ (Malone, & Crowston, 1994). Hence, within cross-domain collaboration, the transfer of knowledge can cross boundaries from one domain to another. Not only does this enable specialists from varying disciplines to learn from each other, it also allows for the integration of domain specific knowledge for potential synergistic effects (Cummings, & Kiesler, 2007). However, in this sense, communication can be more difficult due to an increased chance of misunderstandings resulting from the varying backgrounds (Bunderson, & Sutcliffe, 2002). This makes the coordination practice of sharing knowledge troublesome. In order to effectively transfer knowledge across boundaries, the varying specialists have to possess some common knowledge. Grant (1996) state that “the importance of common knowledge is that it permits individuals to share and integrate aspects of knowledge which are not common between them”. This common knowledge can be achieved by frequent interaction and additional communication (Nyssen, 2007).

The patient-centered approach

As is the case in many other countries, the Dutch healthcare system suffers from various issues such as: an increasing dissatisfaction from both patients and caregivers, increase in costs, decrease in quality (Kreitzer et al., 2015). As a reaction to these issues, the Dutch government restructured their healthcare system in 2006 with the implementation of a market-oriented system (Helderman, Schut, van der Grinten, & van de Ven, 2005), and three years later with the introduction of The Primary Focus program to counter fragmentation in the healthcare system (Felder et al., 2018). With these reforms, the Dutch Minister of Health strives to depose the fragmentation in their healthcare systems and opt for patient-centered care by means of an integrated system with multidisciplinary collaboration (Klink, 2008).

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7 look for the complete picture. In recent literature however, the definition does not stop there. Nowadays, the patient-centered approach is supplemented by two additional characteristics: active participation; and integration. In this context, active participation indicates that instead of caregivers’ paternalistic relationship with patients, caregivers and patients become partners during treatment (Van de Bovenkamp et al., 2009). This emanates from the patients’ desire to have open communication channels with their caregivers and to participate in important medical decisions (Eijk et al., 2013). The integrated characteristic of the patient-centered approach must counteract the previous fragmented nature of healthcare systems. This fragmented nature is derived from the rapid expansion of medical knowledge and specialization of caregivers, which results in specific bits of knowledge being possessed by various caregivers (Singer, Burgers, Friedberg, Rosenthal, Leape, & Schneider, 2011). This makes healthcare not only fragmented but also in efficient, incomplete and ineffective. This is especially the case for patients with complex and/or chronic illnesses (Eijk et al., 2013). Hence, multidisciplinary collaboration among differing caregivers represents this integrated characteristic. This provides numerous improvements such as: shorter lines and more frequent contact between caregivers; increased awareness of each other’s competencies; enhanced referrals and communication between caregivers; improved and comprehensive treatment (Klink, 2008).

It is noticeable that the embodiment of a patient-centered approach within a healthcare system has an impact on its healthcare organizations. To illustrate, there are examples where healthcare organizations have changed their policies due to negotiations with insurers (Van de Bovenkamp et al., 2009). However, complying with the terms from a negotiator are not the only reason for healthcare organizations to adhere to the patient-centered approach. Luxford, Safran and Delbanco (2011) mention that healthcare organizations increasingly strive to enhance their services by redesigning organizational policies that support movement towards patient-centered care. Besides changing their policies and services, Singer et al. (2011) also state that healthcare organizations that fit their patient-centered policies with their organizational design actually improve their healthcare services. Hospitals are no exception in this respect. Johnson et al. (2008) declare that hospitals were first to begin to implement a patient-centered approach and they recommend that their organizational structures should administer it. Therefore, in order to effectively adopt the patient-centered approach, hospitals have to redesign their organizational structures accordingly, and thus have to execute an organizational change initiative.

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8 relevant due the recent popularity of the patient-centered approach (Ikkersheim, & Koolman, 2012). For hospitals, this approach induces a new structure with patient-centered units to facilitate the collaboration of workers from various disciplines. To ensure effective collaboration with minimal errors due to differences in understanding, the employees in those units will have to perform coordination practices. This study’s aim is to acquire insight in how coordination in cross-domain collaboration occur in hospitals that have implemented a patient-centered approach.

Methods

A qualitative case study design was used to answer the aforementioned research question of this paper: ‘How does coordination of multidisciplinary collaboration occur in a hospital that adopts a patient-centered approach?’ Considering that this is a ‘how’ type of question, its answer will enrich our understanding of a phenomenon (Kross, & Giust, 2019). A case study is an appropriate method to understand the dynamics present in a particular context (Eisenhardt, 1989). In addition, the question addresses a contemporary situation over which I, the researcher, have no control. Hence, a case study as a research strategy seems most adequate (Yin, 1994). This study aims to develop theory on coordination practices in cross-domain collaboration within hospitals adopting a patient-centered approach. Additionally, to ensure the validity and reliability, this study will make use of triangulation by collecting data from multiple data sources (Hayashi, Abib, & Hoppen, 2019.)

Research Setting

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9 The new structure has been operative since January 2019 and consist of the following six different responsible care units (CRU): CRU – Care Empowerment; CRU – Mobility; CRU – OR / Trauma Center; CRU – Mother & Child; CRU – Outpatient clinic / Diagnostics & Substitution; and CRU – Gastroenterology. Each unit has a similar structure which is presented in figure 1 below. Within each unit, the focus is on the type of care that is represented by their names. The CRU – Management Team has both tactical and strategic responsibilities within their unit of care. This consist of the following dimensions: content of care; logistics; finance; continuity; information and communication; organizing; employees; systems and juridical coherence. Additionally, this team is also responsible for setting new standards and protocols for the content of care since the patient-centered approach and the current organizational structure has only just been implemented.

The case study is conducted within the CRU – Care Empowerment’s management team. This CRU provides care for patients with chronical illnesses such as Parkinson’s disease and COPD. Treatment for this type is often complex and demands integrated and coordinated care from multidisciplinary caregivers (Singer et al., 2011; Eijk et al., 2013). Hence, there is a sufficient amount of diversity in terms of expertise and specialization within this unit of care. This diversity is also represented within its management team. The team is composed out of 10 individuals that formed the core of my study. The various positions and a brief description of tasks are displayed below in table 1. Team members have educational backgrounds in medicine with a specialization in oncology and hematology, master of business administration, sociology and nursery school. Additionally, four of them have never even worked in a hospital before. Although it looks as if the various positions have individual tasks, they have to collaborate intensely as the findings section will show.

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Table 1: Functions within the CRU - Care Empowerment

Positions and number of individuals Task description

Team leader 1 Steering the team and guiding the team members

Team leader secretary 1 Planning meetings and writing minutes. Assisting the team in any way possible

Chain director 1 Managing the patient’s journey within the CRU Team managers 3 Steering teams of caregivers within the CRU Change agent 1 Aiding the team members during the transition Project managers 2 Implementing new care projects within the CRU

Medical specialist 1 Connecting management with caregivers and providing the team with medical knowledge

Data collection

The primary source of data for this study is obtained by semi-structured interviews since this has proven to be a highly efficient method to gather empirical data (Runfola et al., 2017). I had the opportunity to interview all team members once, resulting in a total of 10 interviews. These interviews were audiotaped after consent and conducted in small meeting rooms at the hospital out of convenience for the interviewees. Transcriptions were made verbatim and as soon as possible, but always within two days after the interview. Due to a time constraint, I was not always able to transcribe an interview before a consecutive one. However, I made notes of interesting comments, which often provided me with additional topics for the following interviews. The interviews lasted approximately 49 minutes, with a minimum of 34 and a maximum of 68 minutes. To obtain a comprehensive picture of the diversity within the team, I started by asking the interviewees to elaborate on their background, their previous experience and their education. Thereafter, I asked them to describe their day-to-day practices and responsibilities both currently and during the organizational change initiative. I was mainly interested in how often they collaborate, how much they rely on each other, and how they are able to succeed in collaborating.

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11 consent and transcribed verbatim. By carrying out direct observations as a second source to acquire data, I enhanced both validity and reliability (McCutcheon, & Meredith, 1993). Another benefit of this data source is that it allowed me to get close to the phenomenon of study, as indicated by Yin in 1994 (Runfola et al., 2017).

Besides the acquired primary data, I also made use of a secondary data source in the form of documentation. The hospital provided me with several organizational documents which I have scrutinized intensely. These documents contain information about how the whole hospital and in particular the CRU – Care Empowerment should adopt a patient-centered approach. The same documents where distributed among the team members at the beginning of their collaboration to inform them about the altered vision, strategy and tasks. Unfortunately, I am not allowed to disclose these documents due to their confidential nature. However, analyzing them provided me with significant insight in the team’s responsibilities and their collaborations. This was especially useful in the beginning of the research since it aided in creating a greater understanding about the context of study. Moreover, the use of this secondary data source further contributed to the technique of triangulation (Tellis, 1997).

Analysis

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Findings

The findings from this study are presented in this section. To paint a clear picture, I start by clarifying in what way this team actually collaborates and what their objectives are. Thereafter, I will illustrate the coordination practices used by this team to facilitate this type of collaboration. It appeared from the data that the team members engage in four different types of coordination practices namely, consulting, joint assessment, personality profiling, and team designing. The first and the second type, consulting and joint assessment, are already well-known phenomena and have been discussed in abundant literature addressing coordination. However, the third and fourth practices, personality profiling and team designing, have not yet been recognized by preceding literature as coordination practices.

Collaboration within the Management Team CRU – Care Empowerment

After the organizational change within the hospital, the new CRU – Care Empowerment provides care for patients with chronic diseases. Its management team is collectively responsible for the unit’s overall strategy, its business operations, the budget and the overall quality of care. This requires a lot of collaboration from the team members, especially since this new structure is just in place. This type of collaboration is mostly executed by means of meetings. During these meetings the team members discuss their tasks and responsibilities to evaluate whether their unit is performing

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13 adequately. Here, the diversity in expertise among the team members can actually enhance collaboration as is evident in the following quote:

“There is also a new manager who actually comes from the hospital, while another manager, is a very senior manager who previously worked in high managerial functions in distinct organizations. That is very nice. This new manager can help the senior manager very well by telling what to focus on, which indicators and what is important here. That is what is happening within this team, there is a lot of reciprocity. None can do everything, so we are all different parts of the same puzzle. They need each other.” (Team leader)

So, the senior manager with all his managerial experience is guided by a rather unexperienced manager from within the hospital to become acclimated in the hospital’s environment. This exemplifies that this team benefits from its multidisciplinary composition.

Besides these regular managerial tasks, the management team has some additional strategic programs and projects which they have to implement. The intensive collaboration becomes particularly obvious within these tasks. There is a variety of such programs as the implementation of e-health, self-steering teams, positive healthcare, patient empowerment and so on. The implementation requires collaboration from various team members as is exemplified by table 2. The team leader notes that the implementation of such programs require intensive collaboration. The project managers often initiate such projects but they have to tune this with the chain director who ensures that it does not disturb the patient’s journey. The team managers, in their turn, have to apply these new programs within their teams and have to see whether it is actually feasible in terms of time and budget. Additionally, the medical specialist often helps by getting the physicians on board and providing the management with the required medical knowledge when needed.

Table 2: Interview portraying collaboration

Part of interview with team leader

I: “Alright, and has everyone within the team varying tasks and targets different aspects?” R: “No, there are two project managers and they have numerous contacts on the work floor that

will “spread the word” for them. So, these managers give workshops and go throughout the whole unit, or they discuss things with physicians. They have not done that yet but they will to provide feedback. A physician thinks that he/she listens carefully to the patient while often this is not the case. So, these are all programs that are set into motion.”

I: “So the two project managers are working on positive care and the others have different tasks?” R: “Yes, we have the uh . . . the team managers, they have to ensure that the people and material

are up to standards. To explain it simple, there is a unit where we heal lungs which requires several nurses and materials. That has to be managed. So that is up to the team managers. Line management to put it plane. However, the also have to take positive care into account. So, they are deemed…, well they have performance reviews with their managers. During these reviews, they have to inform their employees about these programs.

I: “So it is complementary?”

R: “Yes, exactly! That is what they are doing. We also have a chain director, so where the team

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14 practitioner also has to work with this program. So, the chain director directs this chain, both intern

as extern while the patient is at the center. So, this is what our chain director does.”

I: “This is also an example of the collaborations within this team?”

R: “Yes that is the idea. It is rather exciting because our chain director can for example indicate that

patients with COPD need 10% more nurses because a study deems this. But this will require more employees. Then the team managers respond that they have a shortage in their budget. So that is the game they have to play.”

I = Interviewer R = Team leader

Consulting as coordination practice

There is an immense amount of domain diversity within this management team. Some team members, as the medical specialist, have an impressive medical background while others have never even worked in a hospital before. Such a diversity can hinder effective collaboration (Cronin, & Weingart 2007). It often happens that team members have insufficient knowledge about a certain topic because this is simply not part of their domain. In order to cope with this, the team members consult with each other. It is a recurrent phenomenon that team members use their colleague’s expertise by asking for information about a certain topic. By analyzing the data, I found that the team members engage in three distinct types of consultations, namely, ‘asking/providing information’; ‘buddy system’; and ‘change agent’. Table 3 displays quotes that illustrate the three consultation practices used by the team members.

Table 3: Quotes displaying consulting as coordination practices

Asking/providing info Buddy system Change agent

“There are always some topics or an abbreviation that you do not get, but then you just have to ask someone and then that is that.” (Team manager)

“But everyone has their own buddy with whom you can discuss topics you run into.” (Change agent)

I often use the change agent for question about how particular things have usually been dealt with in the past. So, if I am working with teams and I encounter a certain dynamic, then I often check with her how it works. How is this dealt with in the past or how was it managed? (Team manager)

“As I have told you, the two project managers have naturally become my sparring buddies. So, if I encounter some difficulties then I often ask them what I should do or how they would tackle it. This relationship is vice versa which is nice.” (Chain director)

“Indeed, that is an example. That happens and works for sure. It is the idea that you can come to your buddy with any question you have.” (Chain director)

“Well a great deal of the communication happens during the weekly meetings. Additionally, we communicate by mail and WhatsApp. So, there are multiple occasions where people can inform each other about what they are working on. This is also my task, that there is a certain connection to ensure that they know from each other where they are working on.” (Change agent)

“I can ask when I do not get something. Or, when someone tells something that I do not

“Yes, we notice that it helps us. Especially for people who come from outside the hospital, you can

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15 understand, certain programs

which are completely new for example, then I will approach someone. I will tell them what I do not get and ask for an explanation so that they can explain it.” (Project manager)

see that there is a lot for them to take in. For example, this morning you have interviewed one of the team managers. For her it is particularly difficult since she just entered this sort of organization. Therefore, for her especially, it can be really helpful. She now has someone who can guide her.” (Change agent about the benefits of the Buddy system)

problems. For now, it is just to practice.” (Change agent advising the Chain director during the meeting)

As can be derived from table 3, asking/providing questions is a practice that comes rather naturally. It is not a method or planned procedure to counter misunderstandings, but rather a spontaneous solution that occurs instinctively. Team members provide suggestions to each other or clarify questions that are related to their domain specific knowledge. This happens on a regular basis and can happen with everyone. The team members diminish the burden of misunderstandings due to boundaries in expert knowledge by immediately asking for clarifications once they arise. In addition to the spontaneous consulting practice of asking/providing info, the team members enact two premeditated forms of consultation as well.

The first premeditated form of consultation is referred to as the Buddy system. This system allows the whole managerial layer, throughout all CRUs, to choose another manager as their buddy. When two persons are connected, they structurally consult with each other once every six weeks and whenever they deem necessary in-between. This often happens when they need advice or certain information. All management team members are allowed to participate in this system. Although participation in the Buddy system is voluntarily, almost all of the managers take part in this activity since it is regarded as very helpful, in particular for managers who have not worked in a hospital before. They use their buddy to familiarize themselves with the hospital’s distinct environment. Furthermore, due to the degree of diversity, many team members are assigned to a buddy with different expertise. Hence, these consultations create the opportunity exchange domain specific knowledge.

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Joint assessment as coordination practice

The second theme, joint assessment practices, has been found in previous studies addressing coordination and appears in this particular context also. This type of coordination practice happens a lot during meetings. Some team members can encounter difficulties in their work. During meetings, they can introduce these problems so that they can assess them collectively and arrive at a solution. There is great amount of resemblance between consultation and joint assessment. In both practices team members turn to each other when they encounter problems or difficulties. However, with joint assessment the team members conjointly evaluate issues and use each other’s expert knowledge to come to a shared interpretation, whereas, consulting can best be described as asking for- and providing suggestions from one expert’s domain to another.

Within this team, joint assessment as a coordination practice is apparent in two different types of meetings. The first type is termed as ‘Intervention groups’. The managers from the management team and the chain director come together during these meetings which are led by an intervention course leader. The group sets some collective learning goals that they will pursue in order the evolve as a group.

“We as managers, chain directors and project leaders participate in a one-year trainings process where we as a group can set a goal that we would like to pursue. What our learning goals are. We just started these intervention groups to grow as a team and to learn from each other. We recently participated in a two-day event with team development as the topic. From this, groups emerged that collectively reflect on issues with each other.” (Change agent)

The second type of meeting where joint assessment is present is referred to as ‘Pitch’ meetings. The CRU – Care Empowerment’s management team gathers twice a month to held this type. By taking turns, they all carry out a pitch where they present their recent activities. They describe what they have done, what is new and which problems they encountered. With this method they keep each other up to date which allows them to discover potential links that can foster collaboration. Additionally, team members can propose problems that then will be assessed as a group to arrive at a solution.

Table 4 contains part of an interview with one of the team managers that portray this type of

coordination practice and its benefits.

Table 4: Excerpt from an interview about the pitch Part of interview with team manager

I: “So during a pitch everyone presents their activities. Do they just tell a story without any interaction?” R: “Oh yes definitely yes, there is interaction. A person, for example a project manager talks about positive

care. She indicates what she has been doing and what it entails. I like to hear that. Then I think about the possibilities that positive care can offer me. That is it. I inform them about what I am doing, then we look for helpful connections that.

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I: “Do you have such an example from a pitch? That it facilitated collaboration?

R: “Let me think for a second.” Well, for example, I have recently done an employee satisfaction survey in

my team. Additionally, I know that the project managers are working with positive care. So, I thought to myself, I should connect these with each other. So the project managers are on my agenda. They will do their part in my team.”

I = Interviewer R = Team manager

The benefits from this type of meeting is twofold. First, they ensure that team members can collectively tackle problems that they encounter. Second, it facilitates swift connections between expert domains. Moreover, joint assessment is essentially a process where different perspectives come together to create a shared understanding. An example of this can be exhibited in table 5, an excerpt from the transcript of the meeting I have attended. During this meeting, the change agent introduced a complaint from the team managers that they do not perceive the pitch meetings as useful. As a result, team members have their priorities elsewhere and occasionally do not show up at these meetings.

Table 5: Excerpt from the meeting portraying joint assessment Part of meeting

Change agent: “We inform each other only about the exciting things that we are doing. I

believe that this is also the reason that the team managers are not showing up . . . They do not know what to pitch.

Team leader secretary: “But what is the purpose of the pitch?”

Project manager: “The purpose was to inform each other about what we are doing to facilitate

connections.”

•Everyone agrees on this•

Change agent: “We talk about this everywhere else (issues team members encounter) but not here. I

believe that this is the right place to discuss this.”

Project manager: “Yes, the purpose of the pitch is to inform each other. In a short presentation you indicate

what you are doing. That was the purpose. What you are saying now is that there are persons who encounter problems. Well, they then have to present them.”

Change agent: “Yes but you encounter problems yourself as well. You do not present them either.” Chain director: “But that is not part of the pitch.”

Project manager: “No not during the pitch.” Team leader secretary: “Well I believe it is.”

Chain director: “But it is also the purpose of the pitch to ask other for help when needed.” •Everyone agrees on this•

Chain director: “And not only present the success stories but also the struggles.” Change agent: “Or when you get stuck in certain tasks. Or other problems.”

Chain director: “But then, maybe we should approach it differently. As in, what are your struggles, or where

do you need help?”

This discussion continues until they agree that problems should indeed be part of the pitch. From this excerpt it is evident that multiple members had different interpretations of what needs to be included in a pitch. After they have discussed their varying perspectives and collectively evaluated the purpose of the pitch, they end up with a shared interpretation.

Personality profiling as coordination practices

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18 team puts a lot of effort in personality profiling. This was already initiated by the team leader when she composed the team as indicated by the following quote:

So, in terms of the colors from Caluwé, I try to manage in a white and green manner. However, this is not convenient for everyone . . . It can be difficult for some. But I specifically selected these people during interviews. Naturally, this also happened the other way around.” (Team leader)

Hence, the team leader purposely pre-selected candidates for the team that possess personalities that are alike. She gathered people that she believed would fit not only with her supportive style of leadership, but also with each other. By this, she ensured that despite the diversity in expertise, the team members have similar characteristics that allowed for smoother collaboration. This was also indicated in one of the interviews as can be seen in table 6.

Table 6: Benefits of pre-selection

Part of interview with team manager

I: “Yes that is possible. But within the CRU – Care Empowerment, is there a lot of diversity?” R: “Yes.”

I: “Does this sometimes create frustrations or misunderstandings?” R: “No, I do believe that we, our personalities, fit with each other.” I = Interviewer

R = Team manager

Furthermore, personality profiling is used in other forms within the team itself. The team members have taken multiple incentive- and personality tests. As a consequence, they became more familiar with each other. This led to a greater understanding of each other’s communication preferences and thereby reduces the occurrence of conflicts and misperceptions. Hence, it created a greater degree of common knowledge. It is likely that the fit in personalities also induced a shared vision within the team. Some team members indicated that their shared vision keeps pushing them forward, despite their differences. The following excerpts in table 7 shows how personality profiling is used and how it coordinates cross-domain collaboration.

Table 7: Quotes displaying personality profiling as coordination practices

Pre-selection Incentives tests Personality tests

R: “But we just have this new

organizational structure and I believe that we simply have to do our best. So, I do believe that we are all aligned in this. We are all going to do our best.”

I: “So everyone one has the same

vision?”

R: “Yes we do, I sincerely believe

that! Afterall, we are selected on this.” (Team manager)

“We have recently done an incentives test. We all did this. Because of this we now know who we are. This has made us aware of the different needs we all have and it explains why people sometimes react differently. Because of this we have identified our dissimilarities. Now we know who of us are alike. Because of this we also recognized why

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R: “I think it is nice that everyone

really wants to help each other. You can always ask questions.”

I: “But you do have to take the

initiative yourself?

R: “Yes.”

I: “Are there also colleagues who

do not take the initiative?”

R: “I do think that this is easier

for some than it is for others. But I do believe that we are all pre-selected on this characteristic.” (Chain director)

some people always agree with each other, they think alike.” (Chain director)

find it very helpful to look at people like this…. I use this a lot in our management team. When I recognize that one person resembles an Athena and thus focusses on power while a different person focusses on content, then I try to find out how I can ensure that they do connect. The team members themselves use this with the colors from Caluwé. That is how we try to find out what is happening and become more effective.” (Team leader)

I = Interviewer R = Team manager

Hence, personality profiling can be regarded as a coordination practice in cross-domain collaboration because of the following two reasons. By pre-selecting potential team members, one is able to gather a team with similar personalities, even though significant diversity in expertise is present. They will get along more easily because of their resemblances. Second, personality profiling within the team allows for a greater awareness of team members differences and similarities. They will be informed of each other’s preferences in terms of communication and collaboration. Hence, it increases common knowledge among the team members.

Team designing as coordination practice

The last theme that emerged from the data that contributes to the team’s collaboration is team designing. So far, team designing has not been regarded as a coordination practice in literature. However, I found that the particular manner in which the team is composed, strengthens their collaborative responsibilities. The main facets here are the team’s collaborative culture, their flat structure and the supportive leadership style from the team leader. Their collaborative culture results in a welcoming atmosphere that encourages open communication as indicated by the team leader secretary: “I find that they are way more open than during the old structure. So, in a way, if I speak for myself, I am significantly more part of the team. You are considered as a full member.”. Because of this, the team members become more willing to approach each other. The fact that they have flexible workplaces instead of personal offices represents such a culture. This is also apparent in the team’s flat structure and supportive leadership style. Within the team, everyone is regarded as equal and taking seriously. Perspectives are being shared among the openminded team members. This flat structure is intentional and favored by their team leader. The characteristics of this team design are shown in table 8 below.

Table 8: Excerpts portraying team designing

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20 “I often encounter the chain director in

the hallway. I talk to her then I or send her a text by WhatsApp. That is the same with the team leader. When I really need her, I simply send her a text. Then you ensure that you have contact. It is that simple.” (Team manager)

I: “What did this structural

reformation actually entail?”

R: “Well the organization was

basically restructured. The idea behind it was that we must do it with less managerial layers. The managers must be placed at the sidelines of teams. This must create self-managed teams.” (Change

agent)

I: “So there are basically none

hierarchical dimensions within the team?”

R: “No, no. It is a really flat

team. That is our team leader’s style. She wants to know how we see thinks, how we want to work. She is very open in this.” (Chain director)

I: “And during this process?”

R: “Well, we definitely focused on our

type of culture.”

I: “How did you do this?”

R: “We gave it a lot of attention during

out first meetings. It is an underlying feeling. Either it is there or it is not. It is hard to change. But, well, I do believe that you have to talk about such things intensely. You have to be inclusive. I also believe that it helps to approach people in a positive manner. You have to tell them if they are doing a good job. You can also constantly harass people when they do something wrong. But I do not believe in that, that is much less effective.”

I: “So that is the case here, a positive

culture?”

R: “Yes I believe so. That is most

definitely the case in our CRU.” (Medical specialist)

R: “We now have multiple

meetings because we noticed that we were doing a lot of things twice in the beginning.”

I: “So who decided that you

needed this?”

R: “We decided that by

ourselves.”

I: “So really the self-management?”

R: “Yes. This is also what is

expected from us. We have to manage this ourselves and find out what we need.” (Chain

director)

“Or for example physicians with nurses on the work floor. That is much more hierarchical. But if you focus on management you can see that it is the idea to make the hospital much less hierarchical. I believe that the hospital’s director is very approachable. Not that I often communicate with him but it is noticeable. Our team leader is also an asset in this idea. She is a very good team leader that does not focus on hierarchy.” (Team manager)

R: “I notice that everyone enjoys

talking about their profession. I have approached our medical specialist for advice about what it is that internists are doing. He can explain their complex tasks. . . Additionally, I have went to a diabetes nurse. She explained their responsibilities.”

I: “Alright, and this is all possible?” R: “Yes, that is very nice. That is what I

am saying, even though there is a lot going on everyone is still very open to talk about their job and to help others. . . Everyone really wants to help, you can always ask questions.” (Chain director)

I: “Yes, but everything is being

discussed? It is not directed from above?

R: “No no, definitely not. They

always want to know everyone’s opinion on the matter. As in, do you agree with this? Or, make a proposition.

I: “So, self-steering in that

sense?

R: “Yes. I have a good example.

Last week I have asked the team leader whether she wants to cancel the meeting since she could not attend. But she wanted it to go own. She said that we could do it ourselves.” (Team leader secretary)

I: “How is this within the team,

is it hierarchical?

R: “No that is not the case . . .

In particular, I believe that we have a very good team leader. She provides you with the space you need to shape your own tasks. Also, I consider her to be very good sparring partner. She know what she wants, but she can relate very well whit whom she is talking. She can assess a person’s capabilities. I found this very nice. Instead of being pushed in a specific direction she provides you with the opportunity develop yourself and go your own way." (Project manager)

I = Interviewer R = Respondent

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21 occurrence of conflicts, but also creates more frequent and shorter communication lines. Moreover, due to the lack of hierarchy, each team member is regarded as equal. This benefits their collaboration in twofold. First off, by evenly valuing the input from each specialist, they can rely upon a broader pool of knowledge. Second, it stimulates the team members’ creativity since they are empowered to decide for themselves. The lack of hierarchy is also advocated by the team leader. Additionally, due to the recent reformation to a patient-centered approach, previous protocols and policies have become obsolete. So, when a crisis emerges, the team cannot turn to policies but instead they have to come up with spontaneous solutions. As illustrated by the excerpts from table 9, the design of the team enables them to deal with these types of situations.

Table 9: Team designing stimulation effective collaboration Part of interview with team leader

R: “I can give you an example: Last week, our OR managers could not come to work. The OR is the lifeline

of the hospital. So, when this happens the whole hospital is at risk. So we had a severe crisis. We have decided that my chain director from a different CRU temporarily replaces these managers. However, this means that I removed a person with a rather important position from this CRU management team. Meaning that in a meeting I assembled both CRU management teams (CRU – Care empowerment and CRU – Mobility). I informed then about the different tasks and responsibilities from this chain director and asked who was willing to take over what. Then I noticed that this went rather smoothly. They cooperatively discussed with each other what tasks would fit with each person. Everyone easily agreed on who would be doing what.”

I: “Alright, so everything happened with deliberation? They did not simply appoint on and another? R: “No, no. In this way they all agree with the solution.”

I = Interviewer R = Team leader

Hence, the findings illustrate that the team’s collaborative culture, flat structure, and supportive leadership, facilitate and enhance their cross-domain collaboration. At first glance, it seems as if the coordination practice of team designing is not so much a practice, but can rather be considered as an environment with circumstance in which cross-domain collaboration can thrive. Nevertheless, this is not the case. I found that the team members enable these circumstances themselves. They are constantly working on their own team development by assessing their design and looking for improvements or alterations. Examples of this phenomenon are presented in table 10. Both the assessment of the design and the implementation of alterations are activities that facilitate enhanced cross-domain collaboration. For that reason, team designing should be regarded as a practice and not as a circumstance.

Table 10: The practice of team designing Excerpts from interviews

R: “But also during the meetings, we were looking

in ways to arrange this, what is useful, where do we talk about. But requires effort.”

I: “No, and there is no one who directs you?” R: “No, no.

I: “So, the team . . .

R: “We talked about this. About the purposes

within this team. How can we use this? What types of persons are we? Also, in which manner do we operate as a team.”

I: “So, it can developing?”

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22

R: “It is our team and the team leader and we are

looking a design. There is not a specific person who tells us what to do. We have to find our own way and how to deal with each other.” (Change agent)

R: “Yes so the approach (patient-centered) is set.

But how to reach this, that is what we are constantly looking for with each other.” (Team leader)

R: “I believe that we are a team in development.”

I: “Are you responsible for this development yourselves, or

are changes decided elsewhere?”

R: “We are all responsible for this. We actually

discussing this. Last week, we talked about our team’s future plan.” (Team manager)

I = Interviewer R = Respondent

Discussion

By conducting this qualitative study, I identified coordination practices that facilitate a highly diversified management team to collaborate effectively in a hospital with a patient-centered approach. In prior research, it was found that expertise specialization requires team members to enact in coordinative practices. This study identified four varying types of coordination practices that are enacted in a hospital’s management team adopting a patient-centered approach. First, the team members use each other’s expertise knowledge by means of consulting- and joint assessment practices. It was shown that these two types of knowledge sharing activities enhanced their operations. Third, they use personality profiling that allows for a greater understanding in each other’s communicational preferences. This reduces the amount of conflicts and misunderstandings. Fourth, from the data emerged that also the design of the team fosters effective performance. A collaborative culture, a flat structure, and a supportive leadership style created a stimulating atmosphere with short communication lines.

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23 team creates specific opportunities that allow knowledge to be shared. Besides creating the opportunity, these systems stimulate the transfer of knowledge by ensuring frequent and direct communication which is associated with greater trust, respect, and participatory norms (Cummings, & Kiesler, 2007). Lastly, these systems increase team members’ ability to recognize each other’s ability. This greater awareness of one another’s competencies results in short connections between the collaborators. Grant (1996) sates that “such mutual recognition permits successful coordination”.

Furthermore, I found that personality profiling also encourages effective multidisciplinary collaboration. This started already during the composition of the team. The team leader selected candidates that would fit with her management style. Such practices are not uncommon in organizations. Many companies evaluate their workers’ and potential workers’ personality, to see how well they fit with the company (Mccormick, & Burch, 2008). Autry and Daugherty (2003) favor such a selection process. According to them, employees’ compatibility with the leadership style can increase satisfaction and improve performance. However, this study exposes an additional benefit of personality profiling in the selection process. I found that it resulted in a team of collaborators with cohesive personality traits. Because of this, there exists a great sense of understanding among the team members. This prevents the occurrence of conflicts and enhances their collaboration. This is of significant importance in collaboration among differing specialists due to a relative greater chance of discord (Bruns, 2013).

Additionally, the team members themselves participated in personality profiling to become better acquainted with each other. In high levels of team diversity, there is a greater chance of disagreement due to communication problems and varying perspectives (Chung, & Meneely, 2012). I found that personality profiling can be a practice to prevent and deal with these discrepancies. It diminishes dissensions by enabling the team members to broaden their perspectives. It strengthens their ability to resolve conflicts emanated from the diversity in expertise, since they can better relate to one another. In this sense, it increases the amount of common knowledge among the team members which is regarded as crucial during cross-domain collaboration (Grant, 1996; Nyssen, 2007). Although personality profiling is a well-known phenomenon in literature, it has not received a lot of attention within the coordination of multidisciplinary collaboration. I could find only one additional paper that addresses personality profiling as a practice that can enhance multidisciplinary teamwork (Chen, & Lin, 2004).

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24 enhanced collaboration. Within organizational theory, the importance of such design characteristics are widely acknowledged. For example, Barczam, Lassk and Mulki (2010) declared that a collaborative culture is featured by high levels of trust, increasing the willingness of team members to share information and collaborate. This is especially important in multidisciplinary teams where effective collaboration relies on the integration of cross-domain knowledge. The other design characteristic, a flat structure, obtains support from preliminary findings as well. Grant (1996) declared that a hierarchical structure is inefficient when performance relies on the integration of various domains since it disables information to transfer upwards. Hence, cross-domain collaboration favors a flat/non-hierarchical structure. I found that this ensured open forms of communication where team members where regarded as equal. This is also an important aspect in terms of leadership. I found that the team leader’s supportive leadership style fosters creativity within the team. She delegates decision making authority and provides support when needed. Such empowerment encourages development, knowledge sharing, and creativity (Nauman, Khan, & Ehsan, 2010). An additional benefit of distributed authority is that it strengthens the resistance against over-dependency and miscommunication (Cummings, & Kiesler, 2007).

However, at first glance, team designing looks more as a particular context than a practice. Yet, I found that this is not necessarily true. The team members purposely enable these circumstances themselves. By assessing their team design for enhancements or adjustments, they constantly work on their development. Both the evaluation of the design and the implementation of adjustments must be regarded as activities. Additionally, these activities enhance their multidisciplinary collaboration, signifying that they are coordination practices. Cheruvelil et al. (2014) state that such practices of frequent assessment are not uncommon in high-performing collaborative teams.

Theoretical implications

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25 portrays the constant assessment and development of the design characteristics of the team to foster collaboration.

Practical implications

This study provides managers and collaborators with new coordination tools that enhance cross-domain collaboration. The findings suggest that personality profiling can be a useful method to create common knowledge within a multidisciplinary team. In addition, it shows that team design is not merely an environment in which collaborators operate. Instead, team designing can be used as a coordination practices by constantly assessing and adjusting its features. Lastly, it provides hospitals that are willing to implement a patient-centered approach with functioning examples to coordinate the multidisciplinary care.

Limitations

Naturally, this study has some limitation. First, there are some severe questions on the generalizability of the findings. I collected data from only one team, in one hospital that has adopted a patient-centered approach. Therefore, it remains unclear whether the coordination practices are effective in other situations as well. Future research can address this issue by replicating such a study in a different setting. The second limitation of this study stems from the fact that data collection was done by only one researcher. This can prompt observer bias which can impede the objectivity (Leonard-Barton, 1990). However, such biases usually occur in longitudinal studies where the observe becomes too involved with the concept of study. In this study, data collection lasted only two months where the observer interacted with each participant twice. The last limitation regards to the collection of data as well. I was only able to observe one meeting and interview each participant once. Because of this, it remains unclear whether data saturation was reached. Future research can address this issue by elaborating on this study.

Conclusion

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26 coordination practices that expand the theory on coordination, and confirmed two recognized practices in a new context.

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Coordination of Cross-Domain Collaboration in a hospital with a patient- centered approach