The specialization, innovation, and coopetition relation in healthcare.

The specialization,

innovation, and

coopetition relation

in healthcare.

By Herman Geert van de Maat

Faculty of Economics and Business

Pre-master Technology and Operations Management Date: 20-06-2020

Henriette Roland Holstlaan 15 7741 RK Coevorden

+316 57754157

ABSTRACT

The relatively new concept of coopetition, which is often observed in the healthcare sector, and its dynamics are yet to be fully understood. But most research is done on the dynamics of coopetition by itself and not on other factors influencing it. To bridge this gap this study researches the dynamic coopetition has with two other factors in healthcare, namely innovation and specialization since these factors appear to be very important in this sector. Semi-structured interviews were conducted with five medical professionals to investigate their experiences concerning these factors and their connections. The results show that the three factors coopetition, innovation, and specialization have back and forth triadic relationships. This study broadens the existing coopetition literature on influencing factors in a healthcare context. Theme: Coopetition in care

INTRODUCTION

One of the most dynamic and interactive sectors in today’s society might be healthcare, but it is also a controversial one. For example, balancing care and wellbeing for patients with costs, healthcare providers are faced with the issue of the contradiction of their core job and an economical context their job is performed in. A concept that receives more attention these days, is the practice of ‘coopetition’ (Gee, 2000). This concept can often be observed in the healthcare sector. For example, care providers compete with each other for resources, while they also work together to provide the best care for the patients. Another important aspect is the continuous advancement in care technology which can alter the way care is provided (Peng & Bourne, 2009). With these advances, more specialization is created in the healthcare sector (Walsh, Szabat, & Grass, 2002). Specialization being defined as the increasingly narrowing of tasks that are more difficult to learn, to perform, and require new products or methods to be achieved. Specialization between two practitioners could create competition amongst them for the patient share which could be important for the hospital in financial terms. On the other hand, if two practitioners would combine their expertise they could achieve better results (Lee, Lee, & Garrett, 2019) in patient treatment.

Coopetition is relatively new making its appearance in management research in 1996 (Dowling, Roering, Carlin, & Wisnieski, 1996). Often coopetition has been connected to the healthcare sector since the contradiction between competition and collaboration has been observed here frequently (Gee, 2000; LeTourneau, 2004). Separately, the impact of innovation on healthcare is a heavily studied topic for its quick, visible effects on the sector and the patient. However, a gap exists in the existing literature since these concepts have not been related to each other. Even though steps towards this connection have already been made, like the relation between competition and innovation (Tingvall & Poldahl, 2006). Furthermore, the relation between collaboration and innovation has also been researched (Caminati, 2016; Cantner & Graf, 2004) but the final step to combine towards coopetition and advancements is still absent. Knowledge gaps in literature can lead to misapplications and risks in practice, which can be very dangerous for both practitioners and patients in the healthcare sector (Noor, Martin, & Treige, 2003). To fill this gap, this paper explores the relation of advancements, specialization, coopetition and their impact on healthcare. To investigate these relations a main research question has been formulated:

To answer this question the existing literature on innovation, specialization, and coopetition and their relations will be reviewed to provide the background for the case study. The case study will be explained in detail as support for the presented findings. Finally, these findings will be discussed to contribute to the current understanding of the relations between the factors of the research question.

THEORETICAL FRAMEWORK Innovation

Innovation can be described as the effective application of processes and products new to the organization and designed to benefit it and its stakeholders (Baregheh, Rowley, & Sambrook, 2009). The concept of innovation can be further described by the different stages, interactions, types, and aims it can take on (Baregheh et al., 2009). However, the nature of innovation can be widely different depending on the context it is put in (Edvardsson et al., 2018). For this paper, innovation will be seen as the technological advancements in a hospital that applies for processes performed and products used to increase the quality of care of a patient. Innovation is especially an important factor in healthcare due to the increasing demand and needs for improvements in the sector (Proksch, Busch-Casler, Haberstroh, & Pinkwart, 2019).

Specialization

The broad concept of specialization can be different per sector (Keon & Carter, 1985; Pugh et al., 1963; Thompson, 1961). However, a consensus exists on how specialization affects the task scope. Becoming more narrow as specialization enlarges, and that the knowledge needed to perform tasks needs to be more in-depth as specialization enlarges (Keon & Carter, 1985). Building on these definitions and sources (Keon & Carter, 1985; Lindlbauer & Schreyögg, 2014; Pugh et al., 1963; Thompson, 1961) in this paper, specialization will be defined as the increasingly narrowing of tasks which are more difficult to learn, to perform and require new products or methods to be achieved. Specialization gains an increasing role in today’s healthcare system and the way care is provided for a patient (Samiedaluie & Verter, 2019)

Competition

Competition can be described as the rivalry between businesses that provoke them to take action to acquire the patronage of consumers (Delp & Mayo, 2017). Companies will try to outperform other companies so they can have the largest share of customers. In this study, companies can be seen as hospitals and consumers as patients. Competition fuels companies to innovate and specialize in their business to keep old or acquire new customers (Delp & Mayo, 2017; Gee, 2000). Moreover competing can even result in mutual benefits for the company and the consumer. For instance, a sales war could instigate rival companies to outperform each other in price or quality, to the delight of the consumer (Kim, 2018). However, the nature of competition is not always as straightforward as is often stated since many different forms of competition exist, some even to the extent of helping each other (Cramer & Heuser, 1960). In healthcare competition, complexity exists too, both beneficial and disadvantageous for the patient (Markets, Jiang, & Savin, 2020). Furthermore, it was found that competition and innovation have an enhancing effect on each other, in theory (Chen, 2017). But no supporting literature was found of this being the case in practice.

Cooperation

Collaboration can be defined as a social mechanism to increase one’s capital while also increasing the capital of their partners (Reficco, Gutiérrez, Jaén, & Auletta, 2018). Building strategic alliances with other companies can create a synergizing effect that outperforms the capabilities and capacities of a single company (Lee et al., 2019). In healthcare, the synergy effect from cooperation is needed to combine disciplines for the best treatment-path for a patient (Peng & Bourne, 2009). Additionally, specialization increases the need for cooperation since healthcare professionals cannot perform a patient’s treatment on their own (Shetach & Marcus, 2015). Furthermore, competition can be a motivator for cooperation. Sometimes a company’s capacities are not enough to outperform competitors, so they will seek help. To do so companies rely on other companies as partners to help them get a larger market share by having extended resources (Liao, Hu, & Ding, 2017). Most desirably without having to share customers with the partners because they pursue a different market (LeTourneau, 2004).

Coopetition

time (Pathak, Wu, & Johnston, 2014; Peng & Bourne, 2009; Plochg, Delnoij, Hoogedoorn, & Klazinga, 2006). Competition and collaboration often happen simultaneously due to the complex interactions and relations between actors. Competition has been found to take place in organizational activities that are closer to the consumer, whereas cooperation took place in activities further from them (Peng & Bourne, 2009). As such, companies need a network of partners to survive, to still compete against other companies or networks (Rosi, 2016). In healthcare, such an effect can be observed too. Healthcare providers overcome competition over resources by forming partnerships/alliances/networks with other providers and collectively compete on the wider market (Plochg et al., 2006). Finally, it has been observed that coopetition and innovation can strengthen one another (Pekovic & Grolleau, 2020), although this has not been confirmed for the healthcare sector.

Theoretical framework

A theoretical framework is proposed based on the collected literature which is illustrated in Figure 1. This framework shows the triadic relationship between innovation, specialization, and coopetition that emerges when the different theoretical perspectives are put together.

METHODOLOGY Research design and setting

To answer the earlier proposed research question a multiple case study will be performed to gather empirical evidence to explain the expected phenomenon as described in the theoretical framework. This type of qualitative research is specially tailored to investigate real-life phenomena in complex and unique settings (Scholten & Schilder, 2015) and it is defined by (further) explaining relations of factors (Eisenhardt, 1989). Data in this type of research is often collected by conducting interviews. Therefore, it needs to be noted that because of the nature of qualitative data the outcomes are focused on explaining theoretical concepts with analyzed arguments rather than with the use of statistics like correlation which is better used in quantitative data research (Jüttner & Maklan, 2011). Furthermore, a case study works with a unit of analysis. A unit of analysis is the entity that will be analyzed in the study. A unit of analysis can be an artifact, individual, group, or social construct (Dolma, 2009). This study has focused on the dynamics of healthcare providers in a hospital context, so the unit of analysis is the interaction between these healthcare providers. However, the unit of observation is the healthcare providers working in a hospital since a dynamic can’t be interviewed.

Five cases were found who fit the unit of analysis. The cases include an intern, vascular physician, hematologist, endocrinologist, and physiotherapist from five different organizations. More detailed information about the care organizations and the function of the interviewees can be found in Table 1.

Table 1 interviewee information

Case name A B C D E Type of organization General hospital General hospital General hospital Academic hospital Physiotherapy practice Function of interviewee Intern Vascular physician

Hematologist Endocrinologist Physiotherapist Number of

employees

± 1100 ± 700 ± 700 887 8

Data collection

For this paper, data is collected through semi-structured interviews. This type of interview allows systematically addressing specific aspects, while also keeping the interviews a natural conversation that could provide additional (background) information (Nowak, 2018). Five semi-structured interviews were conducted with the same predefined interview guide (Voss, Tsikriktsis, & Frohlich, 2002), which can be found in Appendix A. Doing the interview multiple times increases the validity of the information because the information can be compared and double-checked (Voss et al., 2002). Interviews were held digitally, via Skype or phone and took approximately one hour. Within these interviews, all the interview guide questions were addressed while follow-up questions were used for clarification and further elaboration. Questions were divided into categories following the main factors of the proposed theoretical model. Afterwards, all interviews were transcribed and anonymized to be checked by the interviewee for correctness and privacy/ethical objections, to be adapted accordingly. Data analysis

Table 2 Codification

Construct Definition Sub-categories Description

Specialization

The increasingly narrowing of tasks which are more difficult to learn to perform and require new products or methods to be achieved.

Differentiation Generalness of activities. Difficulty How difficult something is. Learning Learning activities.

Individualization Activities that can only be performed by a very select group of people.

Innovation

The technological advancements in a hospital that applies to processes performed and products used to

increase the quality of care of a patient.

Process innovation The innovation of processes. Product innovation The innovation of products.

Context innovation

The innovation of the context in which activities happen.

Competition

The rivalry between businesses that provoke them to take actions to acquire the patronage of consumers.

Rivalry Actively working against an entity. Customer

acquisition Customer appeal.

Collaboration

Collaboration can be defined as a social mechanism to increase one’s capital while also increasing the capital of their partners.

Helping others Providing aid to other actors.

Working together A two-way offering of help between actors.

Interrelation between actors

The linkage of actors in the working process.

Coopetition

The need for a company to have a network of partners to survive to still compete against other companies or networks

Network against network

Multiple actors working together against another network of actors.

Need for partnering with actors other than colleagues

Partnering up outside of the vocal hospital.

Network against a common enemy

FINDINGS Innovation, Cooperation, and Communication

The data indicates that to cooperate well, communication is one of the most important and reoccurring factors. Communication and the training and integration of this, are taught from the start in study trajectories of physician education as stated by Case A. Good communication between specialists is very important. Additionally, clear communication between the different organizational levels in a hospital is just as important, as is shown in this quote:

“ (…) communication and cooperation are the two most important things in my regard. You need to communicate why you think specific things, why you do it and do that with other people to provide the best care for the patient. (…) Also the cooperation between doctors and nurses but also the

secretary or the radiologist, you communicate well. Give each other ideas about what do you think and come to a consensus.” (Case A)

In the analyzed data the impact of (new) technology on communication and subsequentially cooperation is a frequently reoccurring theme. Most cases stated the importance of computers, the internet, apps, and smartphones on the current state and developments of care. Progress made in technology can enable new ways of communication or evolve the old ways, mostly to break down distance or time-consuming barriers. Effects of this progress can be seen in instruction apps, directed by a specialist or patient analysis based on visual but not tangible materials (pictures, videos or streams) as stated in Case A, B and E. However, problems also arise with the new communication technologies as stated in Case A and E where specialist think that virtual information should never completely replace real-life inspection since a lot of contexts can be lost when not performed in real life. A final interference point that can hinder cooperation and stall the progress of communication technology is privacy laws. Since the latest laws, the AVG (‘Algemene Verordening Gegevensbescherming’) makes handling or sharing patient and any personal information very difficult, this also affects the way actors have to communicate as exhibited in Case E:

Innovation and specialization

A consensus exists across the cases regarding the central role of innovation in healthcare activities. Continuous research is done to provide better care for the patient or provide a better way for actors to perform their job. The result of these advancements is that the care or the way it is provided also keep changing, often building on previously used technologies. Doctors have to keep up with all these changes and keep learning which causes them to go even further in the specialization they are working. Otherwise, they can even get locked out of the specialization as exhibited in these quotes:

“Specialization is getting more and more important because there are more and more things to know. (…) healthcare is a very technology development heavy specific area. I can’t say if this is a question of days or months or years but it goes quickly and you have to be up to date with the new developments to be a good doctor.” (Case A)

“If you look at the older doctors who have studied for being a doctor who could do more things. They are now prohibited from doing certain operations because you have to operate several times per year to be allowed to do them.” (Case A)

Furthermore, the data shows that the relationship is not only a cause and effect but a self-enforcing loop. Within the now deepened specialization, research and development will continue to seek improvements, leading again to new technologies and so the cycle starts over. Finally, instead of a knowledge gap becoming large due to specialization, the data indicates that this is not the case. Learning and specialization happen at every level in the hospital. So relative to the level, the knowledge gap does not increase. For example, nurses now can also specialize themselves and be a very good contributor to the planning of the treatment process of a patient within their specialization as stated in Case A.

Competition ambiguity

healthcare is to keep up good communication to not let the patient care worsen because of this competition, as various cases mentioned. Finally, data shows that competition exists at an organizational level and is connected to specialization. Hospitals can compete with each other over patients to become a specialized hospital as presented in Case D:

“But there is some kind of competition between hospitals because if you see a kind of disease a lot, then you can become an expert center in this disease. This is something that hospitals try to achieve, to become an expert in a certain disease. This creates more competition among academic hospitals.” (Case D)

Coopetition symbiosis

Coopetition too was hard to pinpoint in the cases since most of the actors interviewed were not (too) familiar with the concept. Two kinds of coopetition stood out amongst the cases, namely coopetition between hospitals of different sizes and coopetition between actors against a common threat. Firstly, the size of the hospital can impact the kind of care that can be provided. Small hospitals mostly do not have the most specialized care. So they will have to send their patients with needs that exceed their capacities to a different (and most often bigger) hospital as stated in Case A and D. But often the patient will afterwards return to the smaller hospital for general care. Here it can be seen how an organization gives away ‘resources’ to a competitor, but the competitor does not take this as a win but will return the resource their job is done as can been seen in this quote:

“So if you send someone to another hospital because yours is too small. They have the right treatment of machine for you. Then most of the time you get sent back to the home hospital because it is closer and easier to visit etc.” (Case A)

Small hospitals can thus be seen more as a gateway to do first screenings and treatment so specialized hospitals can focus more on their specialization. This symbiosis of competitors enables both organizations to perform to their strengths. Secondly, actors who are normally competitors of each other work together against a common enemy. In healthcare, a hard to treat disease or general health issue can be seen as the common enemy and the cooperating actors as specialists who combine forces. Where in normal circumstances they have to compete with each other over the patient pool that comes to their specialization, they now work together to tackle a problem, according to Case D:

DISCUSSION Interpretation of findings

In line with Anjos and Fracassi (2018), the cases supported the relationship between innovation and specialization. The availability of new technology in the form of better equipment, medicine, and other resources allows medical professionals to dig deeper into their area of expertise. To provide the best care doctors continuously learn about what is new in their field, partly due to the nature of their profession and partly because they could otherwise be forced out of their function. This last part is enforced by regulations that could in a way act as a moderator in the relationship between technology and specialization (Law & Kim, 2005).

The suggested relation between coopetition and innovation by Pekovic and Grolleau (2020) was also found throughout all the cases where it was often noticeable and of increasing importance. A heavy emphasis laid on the importance of new information technology and how that impacts collaboration. In a fast increasing pace, more communication is done online with all the new possibilities the internet offers as opposed to a few decades ago. Not only between healthcare workers but also between healthcare workers and patients. So here we see how the healthcare sector just like other sectors is influenced by the trend of digitalization (Reddy & Sharma, 2016). Within this dynamic, it is also observed that regulations (most notably the AVG) have a moderating impact, although the full extent of this moderation is not known.

Furthermore, the findings support the notion that collaboration enhances innovation. With the changing collaborative advancements in healthcare, new technology is needed to support these advancements. Where new procedures or structures to collaborate are being designed, often new and more advanced equipment is needed (Liu, Qin, & Pan, 2017). Hereby the dynamic between the factors of collaboration and innovation is observed (Versteeg et al., 2018). For example, operating from a distance is an increasingly popular way to get professionals from different locations to perform operations executed by robots. Hospitals hereby make great use of the different resources (in the example the emerging use of robotics) available per location with the possibility to let professionals over great distance collaborate by using virtual extensions. From this example, we see how new technology and new ways to collaborate can enhance each other to reach breakthroughs in providing care.

Conclusion

With all this information the research question “How do innovation, specialization, and

coopetition affect each other between healthcare providers?” can be answered. To conclude all

three factors indeed have a dynamic, triadic relationship with each other. Literature predicted the relationships in isolation. However, up to this point, the combination of these relationships was not suggested by the theory but is now confirmed by this case study. Finally, there could be more factors in play here that impact the relationships, like regulation.

Literature implications

Practical implications

The implication in practice applies mostly to healthcare instances when they plan to make a change to either technology, specialization, and coopetition. When one of these factors is being influenced, this study suggests that the other two will be influenced too. When healthcare instances keep this in mind they may be better prepared for unintended effects caused by the implemented changes seen in an isolated perspective. Or on the contrast, they could use these relations to purposely indirectly stimulate more than only the focused on factor. Additionally with this model in mind currently developing technology could also be looked at from a different perspective. Instead of designing it only in a way to benefit the care, the question can also be asked how it would affect specialization or coopetition, or what changes are needed to make it beneficial for the other factors too. Thereby making it more valuable than just the standalone improvement, but also making it enhance the context it is placed in. Finally with the described trend of hospitals aiming to become a specialized hospital it can be worthwhile to investigate the effects of increasing the desired specialization to the other factors and how that would impact their goal or performance.

Limitations

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Appendix

A. Interview guide Intro

1. What is your function in this organization? (introduction) 2. What are your main activities in this job? (introduction) 3. What are side or supporting activities? (introduction) Technology

1. What tools do you use, which are the most important? (technology)

2. How do you experience the impact of technology on your work? (technology) 3. How often does the technology that is used in your work change? (technology) 4. How could new technology help you in providing better care? (technology) Specialization

1. How does this job and its activities differ from what you studied for? (specialization) 2. In what ways are the activities you perform only doable by you? (specialization) 3. In what ways has your work changed over the last decade? (specialization)

4. How does the degree of specialization of your job connect you, or distance you from other healthcare workers? (specialization)

Coopetition

1. With whom and why do you work together with others? (coopetition) 2. When do you experience competition in your work? (coopetition) 3. Why does this competition happen? (coopetition)

4. What influences the way you work with others? (coopetition)

5. What ways of competition and/or collaboration do you experience between healthcare practitioners? (coopetition)

B. Codification example

Link to RQ Data reduction (1st) Descriptive code (2nd) General theme (3rd)

Specialization

“Because specialization happened in the past few years. There is more and more specialization in healthcare based on new developments.”

Growing specialization of doctors because of changing context Specialization enforcing in healthcare “We learned many rare diseases you

do not see a lot but you have heard of them and know what it is and be like it could also be that. But in general healthcare you have a patient who is sick and has difficulty breathing, it isn’t always pneumonia or lung emboly. But the common flu. But you don’t immediately think of that. So we tend to start with very more rare diseases than the common ones.”

Learning towards specialization

Specialization enforcing in healthcare

“Because for very rare diseases you only see 3 times in a year for example. It is more or less important to have these centra because you need the experience of these people who work with the disease more than once. That is why the centra are needed.”

Specialization because of demand