Realisation of the ‘poli op naam’: from design to implementation.

Realisation of the ‘poli op naam’:

from design to implementation.

Master of Science in Business Administration

Specialisation Business & ICT

Faculty of Economics and Business

University of Groningen, the Netherlands

Author

Realisation of the ‘poli op naam’:

from design to implementation.

Master of Science in Business Administration

Specialisation Business & ICT

Faculty of Economics and Business

University of Groningen, the Netherlands

Author

Bert Meijeringh, BSc

S1479199

l.meijeringh@student.rug.nl

Supervisors:

University of Groningen

University Medical Center

Faculty of Economics and Business

Wenckebach Institute

1

supervisor

2

supervisor

supervisor

drs. D.J. Schaap

prof. dr. A. Boonstra

drs. E. Jippes

3

Abstract

Realisation of the ‘poli op naam’: from design to implementation.

Keywords

Longitudinal patient contact, competence based training, intervention, out-patient clinic, aios, UMCG.

Word count

24.134

Research theme

The organisation of longitudinal patient contacts for aios.

Introduction

The Dutch healthcare is a sector where, over the last couple of years, changes have occurred in a high tempo. Examples of this are changes in laws and legislation, in the insurance system and the gradual introduction of competition and market forces in healthcare. Hospitals are hereby stimulated to have another look at the management with the aim to organise the care processes more efficiently and more effectively. By devising and implementing technological innovations, a large contribution can be made to fulfil these objectives. The implementation of a new training plan for the aios (in dutch: arts assistent in opleiding tot specialist) within the department Obstetrics and Gynaecology (O&G) of the university medical centre Groningen (UMCG) is a measure to improve the effectiveness in the field of care, research and education. With the introduction of the new training plan the instructor of the department O&G wants to bring about the possibility for the aios to follow specific out-patient clinic patients in a longitudinal manner. Furthermore, with the renewed training plan, the instructor wants to achieve the extension of the innovative projection with respect to other specialties. As a result of which the distinctive capacity of this department will increases and by which the department can improve and gain a better position in the competitive care market.

4 The problems were mainly caused by the hospital computer system Xcare, which wasn’t adapted to the implementation of the new training plan. To realize the ‘pon’ for the department O&G the main research question mentioned below has been formulated:

How does the design of the ‘pon’ look like, (2) what kind of alternative solutions can be distinguished to realize the design and (3) in which manner can the most suitable alternative be implemented within the out-patient clinic of the department O&G?

Besides the implementation objective, an evaluation objective has been formulated for the ‘pon’. By means of this objective, this research provides insight for the instructor of the department O&G into the long term effects concerning the implementation of the ‘pon’. For the realisation of this objective a main research question has also been formulated:

What are (1) the possible effects and implications of the ‘pon’ on the management and education by the implementation of the ‘pon’ for the department O&G, and (2) how is it possible to evaluate the effects with respect to the management.

To be able to answer these two main research questions, both have been divided in sub questions in which each aspect has been answered separately. The following method has been used.

Method

5

Results

By answering the subquestions for ‘part II design’ and ‘part III evaluation’, an answer on both main research questions has been given. There has been identified how form and contents can be given to the design of the ‘pon’. Furthermore, from three alternative solutions the most suitable option has been chosen. This alternative has been implemented by following the steps of implementation, as described in the research. The possible impact on both management and education and the realisation of the evaluation instrument has become transparent by means of the research.

The design and the product specification of the ‘pon’ have been formulated by using the situation in which the problems arose as a main point for the design of the ‘pon’. From the design, it appeared that the several subadministrations and self-made solutions for the realisation of the operational planning needed to be replaced by a central application. By forming a relation between the appointment data of the patients and the agenda codes of the aios it was possible to assign specific patients to the aios. By doing that, the ‘pon’ became possible. The results of the product specification led to an inventory of the minimum functionalities the ‘pon’ had to fulfil in order for the information system to be effective for the users. Firstly, the ‘pon’ has to create the possibility for the input of operational planning for the aios. Secondly, the aios have to be able to be assigned to specific patients by the information system. Thirdly, the ‘pon’ must facilitate the planning and finally, management information has been generated by the information system.

When choosing a suitable alternative to put into practice the minimum functionalities which the ‘pon’ must accommodate, the conditions stated by the instructor were taken into account. Three possible alternative solutions were presented. For each alternative, a description of the advantages and disadvantages has been given. The most suitable alternative solution ‘parallel usage of Xcare and Harmony’ has been selected on the basis of the degree in which the design could meet said conditions. Furthermore, the alternative had to be convenient in use for the organisation of longitudinal patient contacts. The ‘pon’ has been realised by following the implementation steps, as described in the research. From the evaluation, the possible impact on the management education by implementing the ‘pon’ has become transparent for the instructor. The evaluation instrument has been designed, by which the impact on the management can be evaluated. By organizing the out-patient clinical results by means of the ‘pon’, the runtime and the waiting period will decrease strongly while the reliability of the delivery of the process of care will increase.

6 Mutual exchanges of patients are strongly limited for the aios by the implementation of the ‘pon’. Aios cannot exchange ‘cumbersome patients’ and patients with ‘cumbersome disorders’ between themselves. Another negative impact of the ‘pon’ is that a wrong diagnosis and/or a less effective treatment has a smaller chance to be noticed by a colleague aios. This can be overcome by the application of strong supervision and intervision.

Conclusion and recommendations

7

Table of contents

1. Description of the University Medical Centre Groningen ... 11

2. Management problem ... 14

3. Methods and techniques ... 22

4. Conclusion ... 30

Part II. Design ... 31

1. Design problem statement ... 31

2. Design and product specification ... 35

3. Generating alternative solutions ... 41

4. Choosing the most appropriate alternative ... 45

5. Realisation and implementation ... 46

6. Conclusion ... 51

Part III. Evaluation ... 53

1. Evaluation problem statement ... 53

2. Theoretical concept ... 55

3. Hypotheses ... 58

4. Results ... 64

5. Conclusion ... 68

Part IV. Discussion ... 70

1. Reflection ... 70

Literature ... 75

Appendix I. Actor Activity Diagram current situation ... 78

Appendix II. Actor Activity Diagramming Syntaxis... 79

Appendix III. Arisen bottlenecks ... 80

Appendix IV. Actor Activity Diagram new situation ... 82

8

List of tables

Table 1. Organisation of consulting-hours within Obstetrics ... 50

Table 2. Expected long term effect on the management and the education. ... 66

Tabel 2. Expected influence of the ‘pon’ on the performance dimensions ... 83

List of figures

Figure 2. Schematic design of the current situation ... 15

Figure 3. Division of the problem statement to design and evaluation ... 21

Figure 4. Generic framework Cummings ‘planned change’ ... 22

Figure 5. Input/Output-model Daft ... 23

Figure 6. Contingency approaches to the measurement of organisational effectiveness ... 24

Figure 7. Implementation and evaluation feedback ... 26

Figure 8. Schematic design of the ‘pon’ ... 35

Figure 9. Product specifications of the ‘pon’ ... 38

Figure 10. Agenda structure of the current situation... 43

Figure 11. Agenda structure of the ‘pon’ in Xcare ... 44

Figure 12. Implementation steps to take for the realisation of the ‘pon’ ... 46

Figure 13. Performance indicators reflected in the polar diagram ... 56

Figure 14. Conceptual model ... 57

9

Acknowledgements

This thesis has been written as a result of the graduation paper that I have carried out as a crown on my MSc Study Business Administration with the specialisation Business & ICT to the University of Groningen. This thesis discusses the possibility for the aios (in dutch: arts assistent in opleiding tot specialist) to follow specific out-patient clinical patients in a longitudinal manner during the course of diagnosis, treatment, nursing until the readjustment. The developed innovation designed to make this possible is referred to as the ‘poli op naam’ abbreviated as ‘pon’.

The investigation has been conducted for the department Obstetrics and Gynaecology of the University Medical Centre Groningen (UMCG). This research was formed in association with drs. E. Jippes (supervisor) and dr. J. Pols (Coordinator of the Development platform of the Wenckebach Institute). I want to thank them sincerely for the excellent guidance and helpful feedback they have given me during my graduation in the UMCG.

Without the expert insight of dr. A. Hoek (chef the clinique of the department Obstetrics & Gynaecology), prof. dr. M. Mourits (instructor of the department Obstetrics & Gynaecology) and Mevr. F. Leijstra-de Ruiter (senior staff member of the care administration) it would not have been possible for me to conduct this research. Also, I wish to thank the remaining employees of the UMCG that are not mentioned whom - on whichever possible way - have contributed to making this research possible. For the guidance from the University of Groningen, I want to thank drs. D.J. Schaap. Also, I want to express my gratitude to prof. dr. A. Boonstra, who has taken the task of second reviewer.

Last but not least, I want to thank Anika Bergmans, Marjon Leever and Nanke Luursema for their companionship during the working hours, lunches and breaks.

10

Overview

This thesis consists of the following four parts: analysis, design, evaluation and concludes with the discussion. Because of structural reasons and in order to promote the readability of the document this classification has been chosen. Each part opens with a short introduction concerning what is treated in that particular part and finishes with a conclusion.

In ‘Part I Analysis’ a description is given of the UMCG, followed by the introduction of the management problem. The management problem is then split up in a problem statement for the design and a problem statement for the evaluation. This was necessary because these two problem statements each require a different approach. From the management problem statement on, there will be references to each separate part in which the associated objectives and research questions are treated. Before this part ends with a conclusion, it discusses the methods and techniques that are used by the author.

Next up is, ‘Part II design’. It starts with the problem statement for the design, followed by the design and the product specification of the ‘pon’. Then, out of three alternative interventions one solution will be chosen by which the ‘pon’ can be put into practice. Afterwards, the steps that have to be taken to realise and implement the ‘pon’ are described, whereupon this part finishes with a conclusion.

In ‘Part III Evaluation’ the problem statement for the evaluation is treated. The theoretical contexts will be discussed from which the conceptual model for the evaluation is distilled. The long term effects and the implications for both management and education of the department Obstetrics and Gynaecology are then poured into several hypotheses. Furthermore, the evaluation instrument by which the long term consequences of the ‘pon’ can be evaluated for the management is presented. Like in the previous two parts, part III will finish with a conclusion.

11

Part I. Analysis

In this part the UMCG and the department Obstetrics and Gynaecology (O&G) will be introduced. Then, a description of the current situation within the department O&G is given. Furthermore, the arisen bottlenecks are taken into consideration. Also, the desired situation that is the intended result of this research is described. The structure of the research method is elucidated and attention is given to the techniques that are applied in this research. This part finishes with a conclusion which is related to the analysis.

1. Description of the University Medical Centre Groningen

1.1 Description of the organisation

The university medical centre Groningen (UMCG) is the only university medical centre of the north of the Netherlands. Patients from the Northern provinces are referred to the UMCG when they have a rare disease that is difficult to diagnose. Patients go to the UMCG for both basis hospital care and for very specialist clinical care such as organ transplantation, complex neurosurgery, neonatology, clinical genetics, in vitro fertilisation (ivf), oncology, kidney dialysis and traumatology. With more than 8500 employees and 1300 beds the UMCG is one of the largest hospitals in the Netherlands. A hospital is sometimes called a city in a city, because of the architecture of the building. The building consists of covered streets which lead to the several departments and out-patient clinics. Thousands of employees provide daily divergent services to the visitors and patients of the hospital. The organisational structure of the UMCG has been based on a divisional structure (reflected in Figure 1) that is headed by the board of directors and exists from six different sectors, namely:

Sector A Long term care, arteries; Sector B Short term care, abdomen;

Sector C Children, propagation, rehabilitation, psychiatry; Sector D Oncology;

Sector E Supporting specialists; Sector F Development and transfer.

12 Policymaking in the field of staff and organisation, finances and quality management are carried out by the UMC-staff. The research takes place in sector C ‘children, propagation, rehabilitation, psychiatry’ within the out-patient clinic of the department O&G.

Supporting services Building and Infrastructure Board of directors UMC staff

Sector A Sector B Sector C Sector D Sector E Sector F

Figure 1. Organisation structure of the UMCG

1.2 Department O&G

The area the department O&G covers is the care for the human propagation, for diseases and deviations of the female genitals and for psychosomatic and sexual problems. The core functions of the department are providing top clinical- and top referent care, performing research and providing education. The department has 74 beds and 16 cradles, divided over 3 nursing departments (K3, L3, L4), a centre for obstetrics, a centre for propagation, a day treatment unit and an out-patient clinic. Approximately 2100 labours, 1000 ivf-treatments, 40.000 out-patient clinic consultations and 5300 admissions take place. The department is divided into two main medical specialisms namely obstetrics and gynaecology which are each subdivided into a number of sections.

Sub-section Obstetrics:

- antenatal diagnostics: to trace, diagnose and treat structural deviations of the foetus (the unborn child);

- clinical obstetrics: care for mothers threatened by sickness and deviations or the threatened child during pregnancy, childbirth and maternity.

13

Sub-section Gynaecology:

- oncological gynaecology: centre for the 3 northern provinces for the care for women with cancer to the genitals (uterus, ovaries and vagina);

- general gynaecology: care for women with menstruation and hormonal disorders;

- sexual/psychosomatic: care for disorders in the reciprocal interaction between physical functions and mental well-being in the field of the female genitals and sexuality (multidisciplinary cooperation with among other things: urology, medical psychology); - propagation: research and treatment at fertility disorders.

1.3 Future anticipation

The society changes and therefore the health care must change. Key words in the process of change are demand and market forces. Hospitals will have to compete more and more with each other on price, care offer and quality. New care providers, such as private clinics, will be admitted to the care market more easily. With these renewals, the government wants to achieve that patients are able to make choices and that the costs of the healthcare for the society remain controlled. Hospitals themselves become more and more responsible for obtaining sufficient patients. Furthermore, they must clarify in which manner they want to distinguish themselves of other healthcare institutions (source: annual report UMCG, 2006). The UMCG will economise around 40 millions Euro up to and including 2009. To be able to provide care in the full breadth and to be able to conduct investigation, 15 millions Euro of this amount will be invested in care renewal, top research and continuing education renewal. The cuts in the expenditure are the consequence of increasing discounts by the government on all hospitals. The UMCG expects to realise a large part of the cuts in the expenditures by taking measures aimed at improving the efficiency.

Changes for O&G

The design phase of the curriculum ‘training to gynaecologist’ was rounded off in September 2005. The curriculum has been carried out, devised and has been described by the ‘Dutch association for O&G’ (in dutch: Nederlandse Vereniging voor Obstetrie en Gynaecology abbreviated as ‘NVOG’) and by the project group ‘Revision Training Obstetrics and Gynaecology (in dutch: Herziening Opleiding Obstetrie en Gynaecologie abbreviated as ‘HOOG’). This renewed training plan for O&G gives a description of the structure and contents from the training to specialist. The renewed training plan places emphasis on creating circumstances where the profession orientation plays a large role.

14

1.4 Research incentive

Beside the implementation of the new training plan as mentioned in paragraph 1.3 several reasons have been motivation for conducting this research. Below a short enumeration of the remaining reasons follows:

- reinforcing the competitive position of the UMCG in the field of price, care offer and quality; - the wish of the instructor and the doctor assistant in training to specialist (aios) to follow

specific out-patient clinical patients in a longitudinal manner;

- extending and preserving the innovative projection of the department O&G on other specialisms.

To be able to reinforce the competitive position of the UMCG, it is important to invest in the development of innovations to be able to build a projection with respect to other hospitals. One of these innovations is the implementation of the new training plan for the specialism O&G. This plan lays the emphasis on competence based training of the aios. Among other things, the impact of this will be that more initiative and responsibility will be asked from the aios during their training. A manner to shape the competence based training, is to develop the possibility for the aios to follow specific out-patient clinical patients in a longitudinal manner during the course of diagnosis, treatment, nursing and readjustment. The process of seeing specific patients again is organisationally complex and passes off suboptimal in the current situation. The problems are caused because the hospital computer system Xcare has not been adapted to the implementation of the new training plan. Because of this, the medical instructor, the aios and the patients are not satisfied with the existing service. To turn the tide, the goal will be the realisation of a more optimum situation in order for the instructor, the aios and the patient to be satisfied again concerning the care service.

2. Management problem

2.1 Diagnostic problem analysis

15

2.1.1 Description of the current situation

The instructor of O&G devises the training course (in dutch: called the ‘stagetrein’) by means of the training plan. It is referred to as such because, with a little bit of imagination, the overview is comparable to coupled train lorries. The ‘stagetrein’ is the long term planning within which the training period is outlined for the aios. By means of certain competences which are acquired, the instructor can implicate into a possible discount on the training period. The training periods have been subdivided in traineeships which are spread concerning the subspecialties obstetrics, propagation and gynaecology and each lasts 10 weeks. After the general introduction period of 6 weeks, the training period for the aios starts. In a summarised manner the course for approximately 15 aios exists from 6 weeks introduction traineeship, 50 weeks traineeship at obstetrics, 20 weeks traineeship at propagation and ends with an 80 weeks gynaecology traineeship. In principle, the aios passes through a fixed order in the traineeship course which is reflected in Figure 2 where the aios are coupled to a certain traineeship. Obstetrics O1 O2 O3 O4 O5 Propagation VPG1 VPG2 Gynaecology G1 G2 G3 G4 G5 G6 G7 G8 AIOS Poli Morning Afternoon Poli Morning Afternoon Poli Morning Afternoon S h o rt t e rm p la n n in g O p e ra ti o n a l p la n n in g Microsoft Excel

Figure 2. Schematic design of the current situation

16

Procedure for scheduling

The schedule worker of the aios gets the task from the medical coordinator to come up with a new schedule for the aios. Before the process of making the schedule can start, the schedule worker has to obtain information from the aios about desired days off, scheduled time for competence based study time (in dutch: competentie gerichte invulling abbreviated as CGI), etc. The schedule worker tries to take into account the individual wishes of the aios as much as he possibly can. After this information is obtained, the schedule worker establishes the schedules for the aios in the spreadsheet programme Microsoft Excel. Then, the first concept of the schedule is offered to the medical coordinator. The medical coordinator checks the schedule on bottlenecks whereupon the schedule is passed on to the policy employee planning and scheduling. The policy employee checks if the concept of the schedules complies to compensation for services, legal frameworks with respect to working hours and collective labour agreement. Furthermore, the schedule worker discusses the first concept schedules for the aios with the aios, the medical coordinator and the policy employee planning and schedule making. If necessary, they can carry out improvements of the schedule.

If bottlenecks have been found, the schedule is adapted by the schedule worker of the aios. He presents the second concept schedule to the medical coordinator for approval. If the medical coordinator grants its approval, the schedule worker of the aios gets the task to publish the definite schedule on the intranet. The aios are informed by the schedule worker that the definite schedule is placed on the intranet, so that they can examine the schedule. The definite schedule for the aios is put (ultimately two-and-half months for the commencing date) on the intranet of the UMCG, where it can be consulted by the aios. Modifications in the definite schedule of the aios are only carried out after consultation with the medical coordinator. A referral is made to Appendix I for an Actor Activity Diagram (Schaap, 2001) in which the process of this procedure has been modelled. See appendix II for a description of the AAD syntaxis.

2.1.2 Main problem of the current situation

17 The stakeholder group was represented by UMCG-staff with divergent functions such as: chef the clinique, instructor, gynaecologist, manager care, head of the care administration, head of the logistical management, policy employee planning and scheduling, aios, medical head, key-user Xcare, functional system manager and by an employee of the IT-department. The percepted problems of the stakeholders were collected and were arranged on problem category (see appendix III). It was quite clear that the majority of the bottlenecks could be reduced to the realisation of operational planning. The bottlenecks and the related problems appeared to be caused by:

- high complexity planning aios;

- complexity planning combination appointments; - too short planning horizon;

- tension between to traineeship and production; - reduced continuity and flexibility.

High complexity planning aios

In general, it applies that schedules must be made within the applying legal frameworks with respect to work, breaks, compensation for services (collective labour agreement) and legal provisions with respect to part-time appointments and parental leave. The schedule worker must take into account among other things: nights and weekend services, CGI, specific for nights and weekend services, specific holidays, holidays and schedule-free days, education and training days, course and congress days, parental leave, part-time appointments, competence, and the mutual exchange of shifts. Drawing up the operational planning for the aios happens manually by several schedule workers and is kept up by them in subadministrations such as Microsoft Excel and Microsoft Word. The complexity of the schedule making increases due to the many variables that have influence on the daily planning. Drawing up the planning depends on the skills and experience of the maker. Drawing up operational planning is shouldered by several persons. The chef the clinique is responsible for scheduling the traineeships, the schedules for the aios are made by representatives of the aios and the obstetricians draw up their own schedules. The absence recording of the aios is kept up by the department secretary. The ‘stagetrein’ is leading for the classification of the aios in the schedule for the traineeship.

High complexity of planning the combination appointments

18 For this reason, a possible modification in the agenda is communicated orally or in a simple writing to the aios by the employee of the care administration. If a combination appointment must be planned for both an echo and for a consult at the aios, this can lead to difficulties. The echoes are made by an independent practice outside the UMCG. Appointments for the echoes are planned manually by email by means of the agenda functionality of Microsoft Outlook. It is done like this because the agendas of the UMCG and the independent echo practice are not synchronised. Depending on the upheaval, the employee of the care administration tries to link up the appointments for the patient on the same day. This demands additional manual activities that have to be executed in the different agenda. During high pressure moments there is no time for manually searching the agendas, resulting in the situation that the patient has to come back several times to the hospital to settle the appointments.

Planning horizon too short

The employees of the care administration expressed their wishes to plan the future appointments for the patients in Xcare further than three months ahead. It occurs that aios plan their revision appointments on a date which lies outside the planning horizon of Xcare. The employees of the care administration cannot plan these appointments because the operational planning is not yet introduced in Xcare. The appointment forms are then collected, piled up and processed at a later time (when the new operational planning is ready) by the employee of the care administration.

Arisen tension between training and production activities

When a shortage in staff occurs, it is possible, due to the combination of simultaneously training and executing out-patient clinical consultations, to choose to put the gravity point with the production as to not endanger the care of the patient. The consequence is that time reserved in the schedule for competence based work and following courses and attending congresses, is sometimes used to keep the out-patient clinical activity on its feet.

Reduced continuity and flexibility

19 ‘… Planning and control is the activity of deciding what the operations resources should be doing, then making sure that they really are doing it…. (Slack, 2004). The aim of planning and control is to ensure that the production processes are running effectively and efficiently. Although planning and control are frequently named in one breath, they differ substantially from each other. These terms are defined by Slack (2004) as:

‘planning is the formalization of what is intended to happen at some time in the future’.

A planning is no guarantee for the implementation of future operations, it is rather an

intention to carry out a certain operation. It can occur that in case of absence of the medical staff the planned operations can not be realised. The process in which these changes are handled is called control.

‘control makes the adjustments which allow the operation to achieve the objectives that the planning has set, even when the assumptions on which the plan was based do not hold true.’

The nature of planning and control depends on the time. As a certain point is approached where planning works towards, it is all the more difficult to adapt the planning. The planning period must not be too short but it must not be too long either. When the planning period is very short, the staff has too little certainty. If the planning period is too long, it quickly leads to unreliable planning because in the course of this period many modifications might appear. Making a reliable planning in a hospital is often a complex puzzle. Mietus (1994) conducted a study about the planning question on a nursery department of a hospital. In the conceptual model she discusses, it is entered how service rosters can be drawn most efficiently for nurses. By replacing the nurses in this model by the aios and by replacing the head nurse (responsibly for the drawing of schedules), the model of Mietus appears useful within the context of this research. By examining this model from the planning perspective, the task field of the schedule worker can be subdivided in three parts. The first part problem exploration refers to the exploration of the problem: there is point from where the planning process is started. The second part that is discussed in her research is administration. This part is related to the information that focuses on the characterisation of the staff. The third and last part can be labelled as problem

solving in which the aspects of fitting the staff into the roster are fixed. A schedule worker must cope

with several variables that have influence on the field of producing a reliable planning.

20 The planning of staff and capacity are complex and specialist work. Because of these many variables that can be of influence on the schedule, it is unfeasible to carry this out by hand. Planning software can be an extremely useful instrument to simplify the planning task of the schedule worker.

2.1.3 Description of the desired situation

As mentioned in the previous section, it has already been said that through a good organisation of the resources, the reliability of the operational planning improves. This results into more continuity in the caretaking process. According to de Vries (2001) continuity of care has been linked inextricable with the aspects time, place, contents and care worker. The factor time is of vital importance to the diagnostic stage. An assessment can be made between a fast runtime and the time needed by the patient for reflection and settlement. In general, it applies to most patients that they do not like to come to the hospital (place). The objective is to call the patient less often for a consult. Furthermore, it is necessary that the care activities do not contradict each other, have been coordinated and show no duplications. Many patients appreciate a certain sense of security. Building some sort of bond or relationship with one or more care workers becomes a valuable experience to the patient. Also, restricting the number of care workers consulting the patients is an aspect of continuity. Given from the perspective of the patient continuity in care has the following meaning to Francke and Willems (2000):

‘for the continuity of care it appears that patients and their family appreciate it if they have a certain doctor, nurse or medical attendant all the time, who they can visit at fixed times. Both patients at home and patients in institutions experience this as pleasant, trusted and restful.’

To improve the continuity of care within the department O&G it is the intention in the desired situation of the ‘pon’ that aios can follow specific patients in a longitudinal manner during the total course of diagnosis, treatment, nursing and readjustment for the department O&G. By introducing the ‘pon’ patients do not have to cope with different doctors, but they are assigned to ‘fixed’ aios. To prevent misunderstandings about the meaning of the ‘pon, it is defined as follows:

‘the pon is a fixed out-patient clinic consulting-hour during the traineeship of an aios within the department O&G, during which it is possible for them to plan their own specific patients.

21

2.2 Management problem statement

After conducting the diagnostic problem analysis, it became clear that the reduced continuity of the care taking process is mainly caused by the problems with the operational planning. By uniting the aspects time, place, contents and care worker and combining these to an improved method for the operational planning the expectation is that the continuity of the care taking process and the effectiveness of the department O&G will increase. To realise this, the objective of this research is (1) to design the desired situation and to (2) evaluate the impact of said design with respect to the department O&G. A clear problem statement and including research questions must be formulated for both objectives. According to de Leeuw (2003), two types of research exist as it happens, the design alternative and the traditional alternative. This research contains both alternatives. To be able to realise the design of the ‘pon’ it is necessary to have a problem statement for the design part. To evaluate the long term effects of the ‘pon’ it is necessary to have a problem statement for the evaluation part. For this reason the author has chosen to develop a separate problem statement for both the traditional and the design alternative which is reflected in Figure 3.

Diagnostic problem analysis

Design problem statement

Evaluation problem statement

Design alternative

Traditional alternative

Figure 3. Division of the problem statement to design and evaluation

22

3. Methods and techniques

3.1 Research method

In this research, qualitative research methods have been used because the researcher wants to move himself into the specific context in which the problems arise. Qualitative research has been defined according to Patton (2002) as:

‘each type of research where conclusions and recommendations have not been based on statistic methods or other quantitative procedures.’

In quantitative research methods causal connections, forecasts and generalisation are important to the researcher. A researcher who uses qualitative research methods tries to understand context-specific problem for which directions to the solution are carried out (Hoepfl, 1997). The method used to conduct this research has been based on the generic frame model of Cummings (2001). This model that is reflected in Figure 4 distinguishes the four basic activities which must be carried out to implement planned change.

Entering and Contracting Diagnosing Planning and implementing change Evaluating and Institutionalising change

Figure 4. Generic framework Cummings ‘planned change’

The four basic activities are connected with each other by means of arrows. The four typical stages are reflected as successive activities ‘entering and contracting’, ‘diagnosing’, ‘planning and implementing change’ and ‘evaluating and institutionalizing change’. The arrows that link the different activities emphasise that a change in the organisation (such as the innovation ‘pon’) does not concern a linear process but that overlap exists between the different activities. The theory that belongs to every stage of the generic framework of planned change is elucidated below.

1. Entering and contracting

23 Furthermore, the initial parameters are determined for the necessary steps. The initial phase in which a number of orientation conversations has been conducted with the constituents belongs to this stage.

2. Diagnosing

Diagnosis is the process in which it must become clear how the organisation functions at a particular moment. The diagnosis has been carried out by conducting a diagnostic problem analysis which provides the necessary data for a possible intervention in the organisation. An intervention is a coherent scheme of activities which is undertaken to change an existing situation into the direction of the desired situation (Swanborn, 1999). In this research the department O&G of the UMCG is considered as an open system (Harmon, 2003) in which elements are delivered from the surroundings (input) after the transformation to the surroundings (output). This simplification of input into output is necessary to get an overview of the processes at a high aggregated level which take place within the department. In Figure 5 this process has been depicted (Daft, 2004).

Input

Aios Untreated patient

Business System

Obstetrics & Gynaecology

Output

Trained specialist Treated patient

Figure 5. Input/Output-model Daft

The core functions of the department O&G exist from providing top clinical and referential care to the patients and providing high-quality education to the aios. Therefore the aios and the patients can be considered as an input for the transformation process. Within the transformation process the treatment of the patients and the training of the aios take place. The treated patient and the trained assistant to specialist can be considered as the output of the transformation process. For the department O&G it is very important to run the process of input to output as effective as possible. Because effectiveness is a term that can be used in a broad concept, the definition of effectiveness, stated by Daft (2004), is used in this research: ‘effectiveness evaluates the degree in which the objectives are reached’.

24 This phenomenon is stated as ‘silo suboptimalisation’ (Rummler, 1990). This must be prevented as much as possible. The accent must be put on steering the output. This means concretely for the department O&G that the instructor, the aios, the employees of the care administration and the employees of the functional management must join their strengths to optimise the production process as a whole. By adding all of these functional areas and providing them with a common aim (provide trained aios of good and offering high quality of care to the patient) the model arises as depicted in Figure 5. To be able to measure the effectiveness of the department O&G, the model of Strasser (1981) contingency approaches to the measurement or organisational effectiveness is applied. The model of Strasser (1981) assumes just like the model of Daft (2004) that input is converted to output by means of a transformation process, but focuses on the different components of the organisation with the aim of improving the production process of the organisation in its whole. This is done by means of the ‘resource-based approach, the ‘internal process approach and the ‘goal approach. In the original model of Strasser (1981) the author reflects the internal processes and activities as a black box. By substituting the black box in the abstract model with the department O&G, the model that is reflected in Figure 6 arises.

Obstetrics and Gynaecology

Resource Input Service output

Resource-based approach Goal-based approach Internal proces approach Transformation

Figure 6. Contingency approaches to the measurement of organisational effectiveness

25 The goal-approach to reach organisation effectiveness is related to the output side of the transformation process. In this approach, it is the intention to find an answer to the question in what extent the organisation succeeds in reaching the desired aims. Indicators on which this can be reviewed are productivity, quality of the end product and satisfaction of both employee and customer. From the problem analysis it has become clear that the provided product or service output of the department O&G does not agree to the aims that are put by the management such as: high productivity, high experienced quality of care by the patient and a high satisfaction of the aios with their traineeship. According to the model of Strasser (1981 ) this can be blamed on resource input. For this reason, the diagnostic problem analysis is mainly aimed on the resource-based approach.

3. Planning and implementing change

This component is devised to develop the intervention to reach the desired situation. Then, the manner of implementation and the planning for the implementation strategy is described. This stage is treated in part III of the research.

4. Evaluating and institutionalizing change

26 Diagnosis Design and implementation of the intervention Alternative intervention Implementation of the intervention Measurement of the implementation effects Proces evaluation Measurement of the long term

effects

Product evaluation

Implementation feedback Evaluation feedback

Part II Design

Part III Evaluation Part I Analysis

Figure 7. Implementation and evaluation feedback

27 For this reason, it is important to examine whether the implementation that consists of several steps has taken place well. Swanborn (1997) indicates this with the term ‘process evaluation’ that consists of periodic questioning and observing the organisation members who are charged with the implementation. Measuring the long term effects of the intervention during the evaluation feedback phase is labelled by Swanborn (1999) as the product evaluation. Here, it becomes clear to what extent the objectives of the ‘pon’ have been reached. To be able to conducts this evaluation, a sound and reliable evaluation instrument is required. The development of this instrument is treated in this research in ‘Part III evaluation’.

3.2 Techniques

In this research several (qualitative) research methods have been used. The use of a ‘mix of methods’ within one research is defined by Thurmond (2001) as triangulation. The following research methods have been used:

- literary study; - document analysis;

- stakeholder analysis/interviews; - actor activity diagramming (AAD); - observation.

28 Members of the organisation, who are involved in change, are more prepared to support the changes if they are actually involved and consulted during the change process. The resistance in this research has been overcome by involving the organisation members in the decision-making process, by organising plenary meetings, giving presentations and by conducting interviews. Interviews are an indispensable instrument for conducting qualitative research. The respondents have been identified during the orientation session. In this research, the respondents are indicated as stakeholders. Stakeholders are defined according to the traditional definition of Freeman (1984):

‘each group or individual, who has an influence on, or is influenced by the the aims of an organisation.’

Stakeholders are those whose support and collaboration is necessary for a successful project. All possible stakeholders have been informed in writing before the research concerning the project ‘pon’ took place. The aim of the stakeholder analysis was to inform the stakeholders more closely about the innovation, to get more insight in the possibilities and the restrictions of the project and to reduce possible resistance to the change. The semi-structured framework from Gramsbergen (1996) is used as the backbone for structuring the interview-based stakeholders analysis. By using his framework the interview was structured and because of this, it was possible for the interviewer to steer the conversation better. The duration of the interviews varied from 30 to 45 minutes, they had a relatively open structure and were built up as follows:

- Introduction ‘pon’, aim interview and duration; - Short explanation of the work activities;

- Asking interview questions and keep on asking on important matters; - Enumeration of what is observed in the conversation;

- Answering questions and room for additional comments; - Explain the procedure for processing the interview data; - Making a possible continuation appointment;

- End of the interview.

29

3.3 Methodological demands

A qualitative research generally aims more on the depth then on the width. On the basis of techniques to collect data that are mentioned in paragraph 3.2, the researcher tries to get a complete and detailed insight in the bottlenecks that occur at the department O&G. A disadvantage of this data collection method is, however, that it concerns a time consuming and labour-intensive method. As a result the qualitative researcher must work with a relatively small number of perceptions.

Role of the researcher

The relation of the researcher with the examined has a dependent character. The interactive nature of the methods that are used for collecting data during a qualitative research can result in a prejudiced researcher. The researcher is someone who takes part in the research (the researcher is an instrument too) and can influence his environment from that role. Besides the aforesaid aspect of dependence, the term ‘subjectivity’ is also an important point of interest in concerning the role of the researcher within qualitative research. How certain findings are interpreted, depends on its own notions or values of the researcher. To be able to secure the reliability and validity of this research, bias in the research must be prevented as much as possible. The researcher has prevented from not becoming too much emotionally attached to the research, because affection for certain persons and functions could lead to prejudice. However, the researcher has used his influence to exert the dependent stakeholders. Because of this, the resistance concerning the ‘pon’ could be reduced.

Reliability

30

Validity

A research is valid when it has studied what it has meant to study. The emphasis lies on the interpretations of the researcher and if conclusions that are stated by the researcher are valid in relation to the underlying data that is collected. The involvement of others such as colleagues and research participants is of vital importance at considering validity within qualitative research (Baarda, 2001). By delimiting the audit area the researcher tried to separate side issues from the main issues. The research has targeted itself on the organisation of longitudinal patient contacts for aios. As mentioned before, the stakeholders have been involved in the whole decision-making process. Before important steps have been carried out, the researcher has given responsibility to the guidance counsellor of the research of the UMCG and authorisation has been asked of the constituent of the department O&G. During the peer to peer-reviews and during the meetings with colleague researchers of other disciplines such as communication and change management, the researcher asked for their advice.

4. Conclusion

In this part, a description has been given of the UMCG and of the department O&G where this investigation has been conducted. From the problem analysis, it has become clear that the department has a reduced capacity for making the planning ready for use. This affects the degree of flexibility to anticipate on unexpected events. These problems are mainly caused because the planning of the aios being such a complex puzzle. Because of this, the area of tension between training the aios and production at the out-patient clinic has increased. By implementing the renewed training plan more emphasis was put on the organisation of the resources. This also demanded more of the digital hospital computer system Xcare.

31

Part II. Design

This part discusses the problem statement for the design in which the implementation objective and the associated research questions are treated. Furthermore, the design and the product specification of the ’pon’ are described here. Then, the three alternative solutions are introduced through which the ’pon’ can be put into practice. Out of these three alternative solutions the most suitable alternative is chosen for which the ‘pon’ can be realised. This part finishes with a conclusion that is related to the design part of this research.

1. Design problem statement

1.1 Objective of the implementation

The instructor of O&G wants to bring about that the aios are able to follow specific out-patient clinical patients in a longitudinal manner during their training, even if one changes from his traineeship to another subspecialism. The instructor wants to establish this by the implementation of the ‘pon’ for each aios during their training in the UMCG. It is hereby the intention that the aios are responsible for filling their own ‘pon’ consulting-hours during one or more day parts. For this wish the research has been translated into an implementation objective for the design of the ‘pon’. This objective makes it clear for whom the research is being carried out, what the end result will be (product of knowledge) and why it is important to them (De Leeuw, 2003).

Objective of the implementation

To enable the instructor and the aios of the department O&G to follow specific out-patient clinical patients in a longitudinal manner during their traineeship to specialist, so that aios can better behold the whole care route, as a result of which the continuity of the department remains guaranteed.

32

1.2 Research question

In this research, the activity ‘designing’ is defined as the inventing of a concrete model of a desired system. According to de Leeuw (2003), the main goal when designing a model is to devise a system that would be realistic to built in the future and which shows the desired behaviour in a specific environment. According to de Leeuw (2003), the realisation of such a model is a systematic and creative process in which the following steps can be distinguished: product specification, generating alternative solutions, choosing a suitable alternative solution and the realisation. The steps mentioned above have been processed in the main research question.

Main research question

How does (1) the design of the ‘pon’ look like, (2) which alternative solutions can be distinguished to realise the design and (3) how can the most suitable alternative be implemented within the out-patient clinic of the department O&G?

To be able to answer on the main research question, it has been subdivided in the subquestions mentioned below:

Subquestions

1. What does the abstract design of the ‘pon’ look like? 2. What are the product specifications the design must fulfil? 3. What alternative solutions can be distinguished?

4. Which alternative is the most appropriate solution? 5. How can the design be put into practice?

The subquestions one and two are answered in chapter 2 ‘design and product specification’. Question three is addressed in chapter 3 ‘generating alternative solutions’. The fourth question is answered in chapter 4 ‘choosing the most appropriate alternative’ and the fifth question is addressed in chapter 5 ‘realisation and implementation’.

1.3 Expectation, timing en necessity

33 steady aios. Furthermore, the expectation is that the responsibility of the aios for planning their own work activities will increase. The department O&G can preserve its innovative projection regarding other specialisms by the implementation of the ‘pon’. By preserving its competitive position with respect to the other clinics, a competition advantage arises through which the department can profile itself. The department O&G tries, among other things, to realise this by adapting the management to the traineeship. Preservation of the competition advantage is very important because the government improves the training market by assigning training funds and by taking additional measures to make the training market more transparent, more competitive and more governable. Given the fact that the transition period started on May 1st 2006 and people are preparing business processes, schemes and schedules for the new training scheme, it is now a good moment to introduce the ‘pon’.

The continuity of the department is in danger because the planning of the aios is a complex task. Aios pass through several traineeships, frequently work 90%, follow education, visit congresses, et cetera. As a result, it is difficult to realise continuity of the daily work on the out-patient clinic. Moreover, the process of aios seeing the same patients again runs suboptimal. Because of this, underutilisation of the out-patient clinical capacity can arise. This can have possible negative consequences on gaining the targets imposed by the management.

1.4 Limiting conditions

The limiting conditions reflect the restrictions to which research results and methods are liable. It also covers the demands and conditions which are covered by the constituent regarding the research and the results. To be able to conduct an in-depth research, it is important that the following minimum conditions are met:

- A serious effort needs to be made to come up with a structural solution which can be implemented in a short period;

- The investments must be as low as possible;

- The hospital computer system Xcare must remain preserved for recording the patient data; - It is important to identify all possible stakeholders and inform them correctly and swiftly in

order to create commitment to the project;

34

1.5 Demarcation

Context

The research takes place within sector C on the department O&G. The work area of this department is the care for the human propagation, for sicknesses and deviations of the female organs and for psychosomatic and sexual problems. The core functions of the department are providing top clinical- and top referent care, research and education.

Scope

The scope directs what will and will not be treated in the research. In part II of this research, a design is made for the ‘pon’ and a description is given on the way in which the design can be implemented within the department O&G. In part III of this research, the foundation is laid for the development of an evaluation instrument which a succeeding researcher can use to evaluate the long term effects of the ‘pon’. The implementation of the evaluation is not a part of this research. A possible task description for the evaluation is given in part IV paragraph 1.4 ‘recommendations further research’.

Relation with other projects

The project ‘roosteren’ has a relation with the project ‘pon’. For a long time, there has been a need for an integrated scheduling application, which can fulfil the requirements of the schedule worker. For a schedule application, the next definition is used:

‘a scheduling application is software that automatically generates and processes schedules of shifts for employees for a certain work area.’

35

2. Design and product specification

2.1 Design ‘pon’

In this paragraph the answer on subquestion 1 is given:

1. What does the abstract design of the ‘pon’ look like??

According to de Leeuw (2002), devising a model can be considered as a systematic and creative process of activities with the aim of making a representation of the desired future situation. In this process he considers devising a model as a transformation process in which a problem situation is converted to a solution. If the situation is changed in accordance with the design, then the total transformation process has the problem situation as an input and the improved situation as the desired output. The schematic design of the current situation that is reflected in Figure 2 serves as a basis for the design of the ‘pon’ that is reflected in Figure 8.

Obstetrics O1 O2 O3 O4 O5 Propagation VPG1 VPG2 Gynaecology G1 G2 G3 G4 G5 G6 G7 G8 AIOS Xcare Patient

Diagnosis Surgery Nursing After care/follow-up Linked at resource-code L o n g t e rm p la n n in g O p e ra ti o n a l p la n n in g Harmony Poli1 Morning Afternoon Poli11 Morning Afternoon Poli12 Morning Afternoon

Figure 8. Schematic design of the ‘pon’

36

Planning software application Harmony

The analysis has proven that the continuity of care within the department O&G has been strongly reduced because of the problems that arose when drawing up the operational planning. This was mainly caused because the operational planning for the aios was drawn up manually by several schedule workers and was administered in several subadministrations such as Microsoft Excel. The making of the schedule was complex and time-intensive because of the many planning variables such as nights and weekend services, compensation for nights and weekend services, specific holidays, etc which had to taken into account. A better balance needed to be found between the variables staff, aims and restrictions. This balance can be reached by introducing planning software at the department O&G. The introduction of planning software simplifies the planning task of the schedule worker. The schedule is no longer stored locally in several subadministrations and in home-made solutions, but has been centrally stored in the planning software. Because of this, it is possible for the aios to consult the schedule digitally by means of both the intranet of the UMCG the Internet. At the same time, the introduction of Harmony fulfils the wish of the management to automate the scheduling UMCG-wide. The project ‘roosteren’ is incorporated into the design of the ‘pon’ in this way.

Linking aios to the patient

37

2.2 Product specification ‘pon’

In this paragraph the answer on subquestion 2 is given:

2. What are the product specifications the design must fulfil?

In the product specifications of the ‘pon’, the functionalities are registered which minimally must be fulfilled for this information system to be effective for the employees of the out-patient clinic of the department O&G. Before the limiting conditions can be fixed it is necessary to determine the organisation level the system will support. Because the interests, specialisms and levels of an organisation differ enormously, four important types of computer systems (Laudon, 2002) who serve those different organisational layers are: operational systems, knowledge systems, management systems and strategical systems. The ‘pon’ is an operational system because the system makes it possible to both govern fundamental activities such as the agenda management of the aios and to follow specific out-patient clinical patients in a longitudinal manner. For this reason, the computer system aims at the operational level of the department O&G and can be seen as an operation processing system. Such a system is used to carry out and keep up the daily routine operations within the out-patient clinic. The most important aims of the ‘pon’ are answering routine operational questions and following the specific patient population of the aios. Examples of routine operational questions the system must answer are for example: which specific patients belong to the patient population of aios Y? ; by which aios is patient X treated? ; when do the treatment and a possible continuation treatment take place? Furthermore, the ‘pon’ can answer management questions such as: what is the average runtime time of the patients who belong to the patient population of aios Y? ; what is the average of the repeated consultations by aios? To answer this type of questions, the management information that is generated by the ‘pon’ must be correct, simple to access and up-to-date.

Product specifications

38

Harmony

Database Xcare Database

Poli op naam Database

Setup training plan

Setup long term planning aios

Input patient data

User interface

Gebruiker

Head care administration Key-user

Chef de clinique Aios

Employee of the care administration

Product specifications

Input operational planning aios (agenda structure) Assign aios to specific patient (patient population) Planning consultations (planning)

Generating performance data (management information)

Figure 9. Product specifications of the ‘pon’

39 To make it possible to follow specific out-patient clinical patients in a longitudinal manner it is necessary that the ‘pon’ fulfils the following minimum product specifications: building up patient population by the aios, assigning the aios to a specific patient, the scheduling of the operational planning, planning consulting-hours for the aios and patients and generating management information so that performance measurements can be carried out. By complying to the aforesaid minimum product specifications the ‘pon’ can contribute to improve the quality level of the department O&G. An information system such as the ‘pon’ can help, according to Laudon (2002), to improve the quality aims of the out-patient clinic by: simplification of the business processes, benchmarking, to introduce improvements on the basis of the question that are put by the customer and by shortening the product cycle. The influence of the ‘pon’ on the quality aims of the department O&G is treated further below.

Benchmarking and shortening product cycle

Many organisations improve their quality by making strict standards for products and services, and comparing the results to the standards of other organisations or internal departments. This process is called benchmarking. In the current situation, it is difficult for the department O&G to compare the delivered service quality with the standards. On the one hand, this is caused by the usage of one large aios-agenda in Xcare which hampers measuring the performance. No reliable performance measurements can be performed on aios-level. This is caused by the fact that standards have not been made by the management. By arranging the agenda structure in Xcare differently (each aios has his own agenda) in the situation of the ‘pon’, it is now possible for the management to measure productivity and performance. The head of the care administration can obtain management information by using the report possibilities in Xcare. Because each aios keeps track on his own agenda, performance measurements about the amount of first and repeated consultations can be done on aios-level. Furthermore, measurements on the runtime and on the access times of the treatment course can be done and can be compared more closely to the defined standards. Because aios learn to know the patients from their own patient population better, less repeating consultations are necessary. As a result, less delay arises by the definition of further treatment. Because of this, the time for passing through the service process (runtime) shortens.

Product improvement on customer demand

40

Simplifying the process

In the current situation for scheduling the operational planning for the aios, no planning software was used. In the new situation, scheduling the aios will be supported by planning software application Harmony. Before the advantages of the new situation will be discussed, the scheduling process is commented on below. The process is also modelled into an Actor Activity diagram in appendix IV.

The schedule worker of the aios receives the task of the medical coordinator to produce a new schedule for the aios. Before the schedule can be made, he has to obtain information from the aios concerning desired days off, scheduled time for CGI, etc. The schedule worker tries to take individual wishes of the aios into account as much as possible. After this information is obtained by him, he enters the restriction data into Harmony. The schedule software application processes the data and generates a first concept of the schedule. Then, the medical coordinator receives a message from the schedule worker of the aios saying that the first concept schedule is finished. The medical coordinator can log on into Harmony and check if there are points which could endanger the schedule. Afterwards, the schedule worker of the aios and the medical coordinator discuss the first concept schedule for the aios and carry out improvements if necessary. If problems have been found, the schedule will be adapted by the schedule worker of the aios. If the medical coordinator grants its approval for the adapted schedule, the schedule worker of the aios gets the task to publish the definite schedule for the aios. The aios are informed by the schedule worker about the placement of the definite schedule in Harmony and that they can consult it.