SERVICE MODULARITY IN CARE:
A MULTIPLE CASE STUDY
Thesis MSc TOM
By
Jasper Visser
University of Groningen
Faculty of Economics and Business
MSc Technology and Operations Management
Supervisor University of Groningen: prof. Dr. H. (Manda) Broekhuis
Co-assessor University of Groningen: prof. Dr. J. (Jan) de Vries
1
Student: Jasper Binne Visser
Student number: S3229947 Adress: Tj. Harkeswei 55 8409CM Hemrik 06-50587412 j.b.visser.1@student.rug.nl
Educational Institution: Rijksuniversiteit Groningen Faculty of Business and Economics Technology and Operations Management Postbus 72
9700 AB Groningen
Course data: Master’s Thesis TOM
EBM766B20
First supervisor: M. Broekhuis
h.broekhuis@rug.nl
Second supervisor J. de Vries
jan.de.vries@rug.nl
25-6-2018
MSc Thesis
2
Abstract
Purpose: The purpose of this thesis is to understand how sub-processes can be delivered more
effi-ciently way while balancing with person-centred care. This is researched by applying both a lean and service modularity perspective.
Methodology: This research consists of a multiple case study at two intramural care organizations.
Qualitative data is gathered by means of semi-structured interviews and documentation of both or-ganizations. This research will be conducted in three phases. The first phase of this research is focused on understanding how the balance between efficiency and person-centred care is described in the service module. This phase applies a theoretical framework. The second phase is focused on the cur-rent care process and in particular to understand the balance between efficiency and person-centred care in the current care processes. The final phase is focused at finding possible improvements in the balance between efficiency and person-centred care by applying both a lean and service modularity perspective.
Findings:
First, during the interviews new aspects of service modularity were discovered that were not
yet present or found in the theoretical background section. Among these are home visits, attending to the history of a client, a personal buddy, IT, and language of the care plan. These findings all have an impact on both person-centred care and efficiency. Second, the case studies uncovered that certain care activities, such as home visits, not only contribute to person-centred care but also to efficient deployment of human resources. Last, a lean perspective contributes to the balance of efficient de-ployment of human resources and person-centred care. This is achieved by creating awareness among employees in terms of how the current care process works and what can maybe further improved.Research limitations: First of all, the conclusions are based on two cases, totalling 10 interviews, what
helped to generate insights in how the different constructs of person-centred care and efficiency relate to each other, but it also limits the generalizability of the results. This multiple case study provided only a small basis for scientific generalisation of theory since this research used a small number of subjects with no more than 10 interviewees. Furthermore, the cases are only focused on the first six weeks when a client decides to move into a care organization. No other processes have been taken into account. Secondly, this research investigates the balance between person-centred care and effi-ciency by using two cases, differing in the lean perspective, but not in their current work processes. Therefore, an additional limitation is that other work processes have not been taken into account.
Managerial implications: First, this thesis shows that person-centred care activities contribute to
effi-cient deployment of human resources. Delivering person-centred care results in time savings and de-creasing workload for employees. These savings contribute to more efficient deployment of human resources, because employees can use these savings in other care processes. Second, organizations can use the lean perspective of involving everyone in improving operations to create awareness and a change in behaviour among employees. The service module is a good visualization to show how the care processes work. As a result, employees will start to improve their work environment. Third, clients should be more involved in the service module design. They are the most important stakeholders of the care process, because they are the people who receive the care directly. The service module only represents the best practices of which employees have indicated to be the best way of delivering care. One implication for managers is the awareness of how the performance of a service module should be monitored. The outcome indicators are a good instrument, but the care organizations have too much freedom in how they would like to measure the results. As a consequence, difference in measuring approach between organizations will therefore not result in the learning effect.
Originality/value: This thesis adds to the scientific field of service modularity how including a lean
perspective can optimise the efficiency of service modules in a care setting while meeting the need for person-centred care. Furthermore, it expands the literature on service modularity in the care domain by proving that person-centred care activities contribute to efficiency. This relation was not found in previous research.
Paper type: MSc-Thesis
3
Acknowledgement
4
CONTENT
1. INTRODUCTION ... 6
2. THEORETICAL BACKGROUND ... 8
2.1 Professional services ... 8
2.2 Modularity in professional services ... 9
2.3 Striving for person-centred care against reasonable costs ... 12
2.3.1 Modularity & efficiency ... 12
2.3.2 Modularity and person-centred care ... 13
2.4 Lean perspective on balancing efficiency and person-centred care ... 14
2.4.1 Lean in services & efficiency... 14
2.4.2 Lean in services & person-centred care ... 14
2.5 Summary of literature ... 15
3. METHODOLOGY ... 17
3.1 Research setting ... 17
3.2 Unit of analysis and case selection ... 20
3.3 Data collection ... 21
3.4 Data organization and analysis ... 23
3.5 Quality of research ... 25
4. FINDINGS ... 26
4.1 Person-centred care and efficiency in the service module ... 26
4.1.1 Content of service module ... 28
4.1.2 How the service module can contribute to person-centred care or efficiency ... 29
4.1.3 Formal service module: contribution to both person-centred care and efficiency ... 33
4.2 Case A ... 34
4.2.1 Differences and similarities between current practice and service module ... 35
4.2.2 How current practice contributes to person-centred care ... 38
4.2.3 How current practice contributes to efficiency ... 41
5
4.3 Case B ... 42
4.3.1 Differences and similarities between current practice and service module ... 43
4.3.2 How current practice contributes to person-centred care ... 45
4.3.3 How current practice contributes to efficiency ... 46
4.3.4 Improving current practice with service modularity ... 48
4.4 Comparing case A & B ... 49
4.4.1 Comparison between current practices between case A & B ... 49
4.4.2 Compare findings with literature ... 51
5. DISCUSSION AND CONCLUSION ... 54
5.1 Discussion ... 54
5.2 Conclusion ... 57
REFERENCES ... 60
APPENDICES ... 63
A: Service module Living with us ... 63
B: Interview protocols ... 64
C: Studied background documents ... 75
D: First initial coding book ... 76
E: Final coding book ... 80
6
1. INTRODUCTION
Modularity has been an interesting topic for many years (Frandsen, 2017) and received attention in different fields (Silander & Brax., 2017; Broekhuis, Offenbeek, Eissens-van der Laan., 2017; Eissens-van der Laan, Offenbeek & Ahaus., 2016; Vähätalo & Kallio., 2016; De Blok, Luijkx, Meijboom & Schols., 2010a, b, 2013, 2014; Meyer, Jekowsky & Crane., 2007). One of these fields is healthcare, which is a professional service. Due to more demanding customers, ageing population, changing regulations, and budget constraints the field of healthcare is facing pressure to redefine and redesign their service of-ferings. Healthcare organizations need to achieve cost reduction while at the same time the quality of care should be high and patient’s diverse demands should be met (Brax, Bask, Hsuan & Voss., 2017; Eissens-van der Laan et al., 2016; De Blok et al., 2013). A possible method that is worth exploring to provide variety and customization against reasonable cost is service modularisation (De Blok et al., 2010b; Schilling, 2000). In service modularity efficiency is achieved by decomposing complex tasks, processes or packages of services into simpler activities so they can be managed independently in a cost-efficient way (Eissens-van der Laan et al., 2016). While customization can be achieved through coupling or personalizing modules and demand driven care, also called person-centred care (Nay, Gar-ratt & Fetherstonhaugh., 2014). The term person-centred care (PCC) will be used in the remaining of this thesis. In this thesis, the term efficiency refers to achieving the greatest possible result given as few resources as possible
Striving for efficiency is not only important in service modularity but it also plays a key role in lean thinking (Mazzocato, Savage, Brommels, Aronsson & Thor., 2010; Joosten, Bongers & Janssen., 2009). Several lean practices aim to reduce waste and to improve efficiency. For instance, improve-ments by means of analysing processes and removing Non-Value Added activities (NVA), removing tasks that are performed twice, and managing artificial variability (Joosten et al., 2009; Litvak & Long., 2000). Applying lean principles in service modules might increase the efficient delivery of modules. Therefore, the aim of this research is to show how the adoption/application of lean principles in pro-fessional service modules might add to balancing PCC against reasonable costs.
7
however does not show how this striving for efficiency is balanced with the need for PCC. This research shows that both can be achieved by delivering PCC.
Currently, it is unknown how the efficiency of processes of service modules can be optimised by applying a lean perspective. This thesis tries to close this gap and focuses on how a lean perspective can optimise efficiency of service process modules, while keeping into account the balancing of effi-ciency and PCC. Due to the high labour intensity of professional service processes and accordingly ser-vice modules, a main question is what this balancing implies for the deployment of HR. For instance, how does the standardization of processes, output, tasks, and the need for more tight scheduling bal-ance with the need for variety and PCC? The aim of this study is to explore: how does the application
of lean principles to service process modules contribute to both the efficient deployment of human re-sources and person-centred care? This thesis makes two contributions to the scientific field of service
modularity. First, this is one of the first studies to analyse and discuss how lean practices and insights can optimise the efficient use of HR in service process modules in a care setting while meeting the need for PCC. Second, it expands the literature on service modularity in the care domain by proving that PCC activities contribute to efficiency.
8
2. THEORETICAL BACKGROUND
A review of the literature was used to create a theoretical framework of how service modularity and a lean perspective contribute to efficiency and PCC of professional service processes. First, professional services and the concept of service modularity will be discussed. The second part of this section will discuss how service modularity and a lean perspective contribute to efficiency and PCC of professional service processes.
2.1 Professional services
Professional services are characterized by a high level of input and throughput uncertainty. As ad-dressed in the studies of Eissens-van der Laan et al. (2015), customers may provide inputs to the service process, such as information or themselves. The extent to which these inputs are known before the service starts varies from service to service, this is called input uncertainty. Input uncertainty is influ-enced by two sources, namely heterogeneity of demand and customer’s personality to participate. Heterogeneity of demand refers to the uniqueness of the customer demand. The level of heterogene-ity is high due to the different kind of information and customers input. Healthcare, for example, has a high input uncertainty, because each patient is unique in terms of diseases and desired outcomes (Eissens-van der Laan, 2016). The latter refers to the participation of the customer in a service, which is often the case. As a result, throughput uncertainty, the second characteristic, arises. Throughput uncertainty refers to the reduced possibility to exactly predict and structure the service process and the important interdependencies between sub-processes. It is related to process variability and a lack of analysability (Lewis & Brown, 2012). Take the following example. In a healthcare setting two patients may have the similar demand, a knee replacement surgery for example, but yet the operating time and length of stay in the hospital might differ. This makes these care services highly uncertain in both input and throughput. To cope with these uncertainties in professional services, highly skilled profes-sionals are needed who know how to deal with these circumstances.
The study of Lewis & Brown (2012) describes professional services as: ‘A generic service type
with high levels of customer contact/service customization and fluid/flexible processes with low capi-tal/high labour intensity’ (Lewis & Brown, 2012, p. 1). As can be seen there are similarities with the
study of Eissens-van der Laan (2015), regarding input and throughput uncertainty. What Lewis & Brown (2012) add is the level of PCC in a service. According to de Blok et al. (2013, p17) (as cited in Pine, 1993), PCC/customization is defined as ‘The configuration of products and services that meet
customers’ individual needs’. Lewis & Brown (2012) further state that a professional service mostly
9
are produced and consumed at the same time (Voss & Hsuan, 2009). This is the result of customer participation in the service process and that people play the most important role (Voss & Hsuan, 2009; Avlonitis & Hsuan, 2017; Parasuraman et al., 1985).
Managers in professional services such as in healthcare are asked to be able to (a) guarantee the quality of care and (b) achieve cost effectiveness. If professional care service providers want to resolve the aforementioned challenges they will have to invest more effort into finding adequate ways of organising their care services (Vähätalo & Kallio, 2016). Modularisation has been suggested to coun-ter these aforementioned challenges. Service modules can result in cost reduction, PCC, and improve-ment in quality of care (Eissens- van der Laan, 2015). There are different ways to incorporate service modularities in professional services (de Blok et al., 2010b; Schilling, 2000; Eissens-van der Laan et al., 2016; Brax et al., 2017; Blok et al., 2013). Below, the concept of service modularity in professional services will be further discussed.
2.2 Modularity in professional services
There is no universal definition for modularity (Vähätalo & Kallio, 2016; Bask et al. 2010). Rather, the concept of modularity has several definitions in the current literature. While the definitions seem to differ to some extent, they are not contradicting and most of them have similarities with the other definitions. Examples of definitions are provided in table 2.1. There are a few definitions which show some similarity. Schilling (2000) refers with a module to components which can be separated and re-combined. This is similar in the definition of Eissens- van der Laan (2015), who also explains that a module has components that can be recombined in many different ways. There is also a similarity in the definitions based on that a module consist of different components or parts (Eissens- van der Laan, 2015; Bask et al., 2010; Schilling, 2000).
Still, what exactly is a service module? Eissens- van der Laan (2015, p.78) expresses a service module as: ‘Breaking a complex offering, such as healthcare, into simpler parts that function
inde-pendently and in which in turn can be recombined in many different ways’. So first, a service offering
needs to be decomposed into simple sub-processes or parts which are functioning independently, then these decomposed service parts or service sub-systems (these are also labelled as components) in turn can be recombined into other service modules. A combination of components results in service mod-ules. This thesis adopts the modularity definition that was developed in a health setting of Vähätalo & Kallio (2015) who defined modularity in a professional care context as: ‘Highly modular health services consists of numerous services modules that are flexibly and uniquely compatible, and which are typi-cally produced by multiple providers’ (Vähätalo & Kallio, 2015, p. 926). This definition is rather abstract
10
providers is rather vague. Although this definition remains rather abstract, it can be considered appro-priate for this thesis as this definition highlights some of the important characteristics of the care con-text, such as the heterogeneous needs, process flexibility and different providers. Furthermore, this definition is applicable since this thesis has a similar focus on healthcare.
TABLE 2.1
EXAMPLES OF DEFINITIONS OF MODULARITY
Author (year, page) Definition
Schilling (2000, p. 312) “Modularity is a continuum describing the degree to which a sys-tem’s components can be separated and recombined, and it refers both to the tightness of coupling between components and the de-gree to which the ‘rules’ of the system architecture enable (or pro-hibit) the mixing and matching of components.”
Vähätalo & Kallio (2016, p. 926) “A highly modular health service consists of numerous services modules that are flexibly and uniquely compatible, and which are typically produced by multiple providers.”
Bask et al. (2010, p. 366) “A modular system is built of components, where the structure (ar-chitecture) of the system, functions of components (elements, modules), and relationships (interfaces) of the components can be described so that the system is replicable, the components are rep-licable, ant the systems are manageable.”
De Blok et al. (2010, p. 78) “Modularity is an approach for organizing complex products and processes efficiently by decomposing complex tasks into simpler ac-tivities so they can be managed independently.”
Eissens- van der Laan (2015, p. 10) “Breaking a complex offering, such as healthcare, into simpler parts that function independently and in which in turn can be recom-bined in many different ways.”
11
several components that provide a specific service, e.g. house cleaning of elderly people. The last step consist of defining the interfaces. These interfaces manage the interactions and connections of mod-ules when they are combined into a final service offering that is offered. Interfaces can be at the level of modules or the service package (De Blok et al., 2014). Interfaces on the level of modules are ex-pected to manage content interactions and therefore are concerned with the interfaces between cli-ents and personnel. Interfaces on the level of the service package are expected to manage service provider interactions and therefore are concerned with the flow of information. According to the au-thors, interfaces can aim towards variety or coherence. They discuss that interfaces on the module level can aim at creating variety at the level of components. This is a result of allowing choices to be made from the offered services. Other interfaces can aim at creating coherence among components. This means that the components are logical and consistent. Thus, interfaces are critical. In healthcare, interfaces ensure that the right patient gets the right treatment at the right time.
12
FIGURE 2.1
SIX TYPES OF SERVICE MODULARITIES Source: Eissens-van der Laan et al. (2016)
2.3 Striving for person-centred care against reasonable costs
This section discusses how service modularity can improve efficiency and PCC.
2.3.1 Modularity & efficiency
13
The optimisation of services by designing modules also has an impact on the organizational resources. De Blok et al. (2010a) found that the interaction between client and provider resulted in savings in terms of time and effort invested in assessing the needs of the clients. Due to interaction with the client, the needs could be assessed for the long-term which allowed efficient and effective planning of process activities. Moreover, since modules exist in a pre-specified, transparent, and orga-nized range of service options, clients and care professionals can better interact with each other when specifying their requirements. This in turn results in time savings of employees which make the service more value added (Mazzocato et al., 2010). Instead of seeing this as savings in HR, De Blok et al. (2010b) argues that these resources saved can, in turn, be redeployed to those processes that are of need. These can be seen as the processes which are too complex to address with standardization and mod-ularization. By redeploying HR, efficiency improvements can be achieved as it results in the less need of extra people, i.e. the same work can be carried out by the same number of people by the savings of service modularity.
2.3.2 Modularity and person-centred care
14
2.4 Lean perspective on balancing efficiency and person-centred care
This section discusses how lean perspectives can improve efficiency and PCC.
2.4.1 Lean in services & efficiency
Lean is one of the latest management imports to the healthcare sector and describes certain ways to improve efficiency (Mazzocato et al., 2010). The literature review of Mazzocato et al. (2010) identified the tools, methods, and outcomes of lean application in care. Lean uses many tools and methods to achieve efficiency improvements by (for instance) striving for standardization or 6S. The study of Maz-zocato et al. (2010) divided the methods to achieve efficiency improvements into two components. The first component is based on understanding processes in order to identify and analyse problems (i.e. get familiar with the processes). Understanding the processes is crucial before entering the im-provement stage. Second, methods to organize more effective and/or efficient processes are applied. These methods are, among others, 6S or designed pull systems. The aforementioned methods help increasing efficiency in a few ways. First, by identifying wastes (such as waiting time for patients or scheduling double tasks) it is possible to optimise offered services by removing these NVA. Second, by removing waste. Factors such as timeliness of service, process steps, walking distance for employees and time to resolve errors can be reduced. These are a few examples of the possibilities of improving efficiency of the service organization by removing waste.
Although it seems lean in healthcare only discusses wastes (Mazzocato et al., 2010; Roemeling, Land & Ahaus., 2017), another view on efficiency in services is to reduce uncertainty by removing arti-ficial variability, which is caused by dysfunctional management. Artiarti-ficial variability unnecessarily in-creases the cost and inefficiency organizations are trying to control (Litvak & Long, 2000). The issue of artificial variability is that it is non-random, and therefore manageable. The goal is to eliminate all artificial components of each of the variabilities identified. Artificial variabilities can be either flow- or professional variability caused by a dysfunctional process within the healthcare delivery system. For example, professional artificial variabilities, such as late arrival to the operating room or leaving junior unexperienced surgical staff to finish a case, can be handled administratively. Other variabilities, such as unfamiliarity with a new technology, can be eliminated through education and certification. Coping with both mentioned variabilities will result in efficiency improvements through decreased process time.
2.4.2 Lean in services & person-centred care
The key concept in lean thinking is ‘value’. Value is defined as: ‘The capability to deliver exactly the
15
& Janssen., 2009, p. 342). Lean does not really tell in a step wise manner how to make PCC of services possible, it merely has its focus on how value can be improved in the eyes of the customer.
According to Joosten et al. (2009), process steps should be divided into Value Added (VA) and NVA activities. VA activities are the activities a customer wants to pay for. As a result, NVA activities should be removed. After removing NVA a greater level of PCC is achieved due to the improvement in quality and value of the service offered. However, lean does not recognize a third value: Business Value, which is a process step that is necessary for future or subsequent steps for the business but is not noticed by the final customer. PCC of services is possible when (a) the flow in processes is improved by finding and removing NVA and therefore delivering more value, and (b) by involving and participa-tion of everyone (Sundbo, 2002; Nicholas, 2011). The involvement of customers makes it possible to understand their desires and requirements, thus by involving customers PCC can improve. The down-side of lean is standardization of service processes. Lean strives for maximizing value by designing standards. Standardization as a lean principle is not easy to apply in services, because the goal of a service market is to cater to the customer. Application is especially difficult for professional services with high diversity (for example, brain surgery) because every patient needs individual and different treatment (Carlborg, P., Kindström, D., & Kowalkowski, C., 2013).
2.5 Summary of literature
Table 2.2 presents the main findings on how modularity and lean can influence the improvement in efficiency and PCC. The aim of modularization is to find a balance between efficiency and PCC, while lean has more focus on efficiency by removing wastes and therefore delivering more value by involving employees and customers. With modularity efficiency can be improved by standardizing processes within the module, or the output, or outcome of service. Furthermore, with modularity employees are able to perform parallel tasks which contributes to efficiency. In addition, interaction with the clients in service modules results in a better assessment of the needs for the long-term. This kind of interac-tion allows for efficient and effective planning of process activities. PCC takes place when modules are combined to address the required care for clients or personalization by (e.g.) reflecting client’s de-mands or involvement of the customer. The aim of modularization is to find a balance between effi-ciency and PCC, while lean has more focus on effieffi-ciency by removing wastes and therefore delivering more value.
16
Some sub-questions need to be addressed before the research question can be answered. First, it is interesting to know how service process modules contribute to balancing efficiency and PCC. So, how do service process modules contributes to balancing efficiency and PCC? How does balancing occur in the described service module and in practise? Second, the same question can be applied with lean to understand how a lean perspective can make service processes more efficient and person-centred. So, how does lean contributes to the balance of efficiency and PCC in service processes? The theoretical framework in table 2.2 will be used to conduct a complete analysis. The sub-questions will help to understand the current situation and explain the balance between efficiency and PCC for the status quo. The next step is to look for improvements. How can a lean perspective further improve the balance between efficiency and PCC?
TABLE 2.2
THEORETICAL FRAMEWORK
Focus Service modularity perspective Lean perspective
Efficiency Standardization of processes within a module
Output or outcome standardization Parallel work of employees
Interaction with client to determine long-term needs
Standardization of processes Remove wastes
Reduce artificial variability and man-age natural variability
Person-centred care Combining modules Personalization Client involvement Involvement of customers
17
3. METHODOLOGY
According to Karlsson (2016), a case study design allows that the research can be conducted in its natural setting, which enables researchers to observe through actual practice and therefore achieve a better understanding of the phenomenon. Especially for asking ‘why’ and ‘how’ questions case study design is helpful (Yin, 2014). Furthermore, case research relies on theoretical generalization instead of statistical generalizability. This research is categorized as explanatory and aimed at theory testing, also called deductive research, to research if the stated theoretical promises can be substantiated with empirical evidence. Furthermore, with less cases the more opportunity there is for an in-depth study. Multiple cases help against observer bias and augment external validity. But on the contrary, more time and resources are needed and the level of depth per case is less.
This chapter covers the methodology part of the paper by discusses the setting, the unit of analyses, and case selection. Furthermore, the data collection plan will be explained. At the end, data organization and quality of the research is discussed.
3.1 Research setting
This research applied a multiple case study at a care organization – called NorthCare- which operates in the north and in the centre of the Netherlands. The company consist of a group of six care organi-zations. These organizations deliver different kinds of care, such as elderly care, traumatic care, and care for mental disorder problems (North Care, 2016). From strategic reconsideration, the organization started a transition project. In 2016 the organizations within NorthCare acknowledged that a joint ap-proach was needed to match customer demand and to deliver more PCC against low cost. The aim of the transition project is to design and implement service modularities and create a learning effect be-tween organizations towards continuous improvement (North Care, 2016). Before the actual designing of the modules start, NorthCare designed five formulas (also known as zichtbaar beter). These formu-las describe their portfolio of care activities and are tangible for their clients.
18
The modules are designed along the five formulas which are seen as important promises to their clients, the community, and employees. NorthCare found out that the promises are focused on behaviour of employees. Furthermore, it is about how questions: communication, informing, and co-ordination. These are the promises on which NorthCare wants to focus and to differentiate. For North-Care a module is a set of interdependent activities in the care process were communication, informing, and coordination are central. The modules describe how a part of a healthcare process ideally should be executed (North Care, 2017). They often refer with this ideal state to a golden standard, because it is the best way identified by employees to deliver care.
In the eyes of NorthCare the modules are a set of activities that have a clear function aimed at a broad group of client and underlying components have a high interdependency. Modules are de-signed based on two strategies. First, identify different patient groups. Second, the care processes are analysed, and if possible, divided into different service modules. The modules are formed by integra-tion of the best practises. These best practices are, according to the employees, the best way of exe-cuting a process. Subsequently, indicators are developed to express and monitor if a module adds to the promises.
The transition or implementation project consists of three stages. Namely, building (knowing
and wanting), realisation (wanting and being able), and phasing out (we are able) (North Care, 2016).
19
FIGURE 3.1
20
3.2 Unit of analysis and case selection
The unit of analysis is the service module called Living with us (in Dutch: Wonen bij Ons). The unit of analysis is presented in figure 3.2. The actual service module can be found in appendix A.
FIGURE 3.2 UNIT OF ANALYSIS
This research is carried out in collaboration with two care organizations within NorthCare. These selected organizations are similar in the following aspects: (a) they both are a professional ser-vice organization focused on intramural care, besides extramural care; (b) professionals are the main HR; (c) both organizations apply lean perspectives but do differ in the level in which lean perspectives are used; and (d) both organizations will use the service module to improve their care processes in the future. To understand the impact of service modularity in a broader perspective a multiple case study was conducted.The multiple case study is aimed to understand (a) how efficiency and PCC is balanced in the formal module; (b) how the process described in the module is currently performed in practise and how balance efficiency and PCC is balanced; and (c) how a lean perspective can further improve the balance between efficiency and PCC. One case selection criteria was applied based on characteris-tics which were previously identified in the theoretical section.
Organization A and B differ in terms of a lean perspective. Organization B has a certain history with lean, rather negatively in the sense that lean was used as a way to achieve cost reductions. Cur-rently, organization B applies certain lean methods, such as week starts and glass walls, and uses a more process-centred approach instead of the previous old business perspective. Compared to organ-ization A, they apply lean since 2010 and won a lean award during their campaign in 2014. They using a process-centred approach with taking the client in perspective.
MODULE
21
3.3 Data collection
Three ways have been carried out to answer the research question. First, researching how the module is described on paper and analysing the module on how efficiency and PCC are balanced. Multiple sources were used, such as the described service module on paper and interviews. The balance be-tween efficiency and PCC as described in service module was analysed by applying the theoretical framework. Second, an analysis of how the current process is carried out in both organizations (the process as described in the module). This research is based on interviews with 8 people and analysing process descriptions in the database of the organizations. Third, by asking employees how they see the balance between efficiency and PCC and if they see more possibilities to improve their care pro-cess. Qualitative data is collected by semi-structured interviews with personnel and management, but also, - informal meetings, - and analysing additional background information.
The primary phase of this research is focused on the multiple case study. This phase consisted of semi-structured interviews with employees and management, combined with informal meetings and data retrieved from information systems and documentation in order to analyse the current situ-ation compared with the service modules, use and deployment of HR, and the value of the activities and processes within the service modules.
The interviewees chosen for the three phases were the employees in the organization that knew most about (a) the service modules in the sense that they were designers; (b) current practice in the sense that they stood very close to the daily care processes; and (c) the use of lean within an organization in the sense that these employees had a black-belt certificate or the role of lean consult-ant. The interviews for phase one were with researchers within NorthCare, trajectory coordinators, and formulae managers. Phase two consisted of interviews with care specialists, site and quality man-agers, trajectory coordinators, and lean experts. The third phase, seeking improvements for the care process, was with all interviewees.
The interviews helped to understand, for example, how a module should be read and which activities were focused on the client. 10 colleagues were interviewed in total. A number of 3 interviews for case B and 5 interviews for case A was in order to reduce respondent bias, so increasing reliability. This will increase the richness of the data (Karlsson, 2016). Furthermore, 2 interviews were conducted with 2 employees of NorthCare who were involved in designing the service module. Table 3.1 presents the interview schedule.
22
functions of colleagues. The first protocol was focused on researching the service module, second pro-tocol was aimed at understanding the current practice and implementation of the service module, the third protocol had the focus on lean within an organization, and the fourth and last protocol was about the quality measurement of care services. The interview protocols can be found in appendix B.
TABLE 3.1 INTERVIEW SCHEDULE
The duration of the interviews ranged from 37 minutes up to 120 minutes. On average a con-versation lasted 63 minutes. The interviews were held at the respective locations were the employees worked. Two interviews were at a different place. One conversation was held at a place where a col-league lived and one conversation was arranged at a restaurant where both parties could meet more convenient due to travel time. To understand how a module works in practise, process descriptions and interviews were the preferred methods.
Additional background information was derived from reviewing company documents and hav-ing informal conversations with people from the care organizations. These additional data sources were used to achieve reliable data. Furthermore, using additional and different data sources plus methods improves data triangulation. Consequently, this helped to improve the validity and reliability of this study (Karlsson, 2016). Appendix C presents which documents were studied. The informal con-versations had the focus of checking facts, the interview results, or seeking for clarity for some topics that were not entirely clear.
Function Service module: Living with us Current care process Implementation at a location
Lean application in the organization
Date of interview
Duration
Employee 1 NorthCare X 30-4-18 72 min
Employee 2 NorthCare X 30-4-18 97 min
Employee 3 organization B X X X 16-5-18 37 min
Employee 4 organization A X X 15-5-18 40 min
Employee 5 organization B X X 25-5-18 58 min
Employee 6 organization A X X X 15-5-18 57 min
Employee 7 organization A X 4-5-18 52 min
Employee 8 organization A X X 8-5-18 120 min
Employee 9 organization B X X X 8-6-18 53 min
23
Table 3.2 shows the data collection plan of this study. First, it was important to understand the service module on paper and the current situation. This is achieved by going through documenta-tion and the database. Interviews were planned to gather addidocumenta-tional data and to verify the module on how efficiency and PCC is balanced on paper. Second, visits at both care organizations was necessary to understand how efficiency and PCC is balanced in the current practice. Within this phase the focus was on understanding the current processes and therefore understand how a lean perspective could further improve the balance between efficiency and PCC.
TABLE 3.2
DATA COLLECTION PLAN
X= primary source
⃝= secondary source
3.4 Data organization and analysis
The interviews were analysed by following the three steps as suggested by Miles and Huberman (1994). These three steps are data reduction, data display, and conclusion. The coding procedure ap-plied to this research is visualized in figure 3.3. First, reducing the data was achieved by transcribing the interviews. Second, the researcher applied inductive coding to the quotes in the transcripts. This resulted in 66 first order codes and these can be found in the final coding book in appendix E. The next step was clustering these codes into second order codes. This step was achieved by applying the the-oretical framework. Similar codes (i.e. codes with almost similar content or codes that all relate to an overall concept) were clustered into a second order code, such as focus on the client. Some
codes/con-Research objective: Interview Database Documentation Informal conversations
Field notes Service module:
- Analysing module designed on paper in terms of: o Complexity
o Uncertainty
o Balance between efficiency & PCC
X
⃝ ⃝ ⃝
Balancing efficiency and PCC:
- Organization A & B
o Current care process as described in module o Determine the level of lean perspective applied in both
organizations
o Apply theoretical framework to search for improve-ment in the balance between efficiency and PCC o Determine with employees possible improvements
24
cepts were not present in the theoretical framework, for example a personalized care plan and plan-ning of employees. The last step was aimed at get a complete data display. This was achieved by label-ling the different second order categories under different dimensions (third order codes), such as standardization relates to efficiency and focus on the client relates to PCC. Both the initial first coding book and final coding book were checked by a colleague at NorthCare, the first supervisor, and two fellow students to prevent subjectivity. The entire first initial coding book can be found in appendix D, even as the final coding book which is also presented in appendix E.
FIGURE 3.3
CODING PROCEDURE
Coding procedure
Interviews
Transcribing
Inductive coding First order codes
Reflection with theoretical background
Second order codes
25
3.5 Quality of research
To guarantee the quality of the research it is important to make sure validity and reliability are covered. There are three validity aspects and one reliability (Karlsson, 2016). The first is construct validity and is the extent to which correct operational measures are established. Construct validity is assured in this research by seeking triangulation by using different methods and sources that address the same concept. Furthermore, this was strengthened by letting key informants reviewing the analysis. The second is internal validity, which is the extent to which a causal relationship can be established. This was strengthened by typing out the interviews directly after they took place and letting these reviewed by the respective interviewees a few days later. Furthermore, selecting the appropriate people for an interview is also important in internal validity. The most important people were identified by analysing the transition documents and asking colleagues in NorthCare. Another opportunity to improve internal validity was to present and discuss preliminary conclusions with the stakeholders, i.e. the selected interviewees. And at last, two transcripts were coded by two fellow students. This resulted in less sub-jectivity of the researcher. The third is external validity and is about understanding whether a study’s findings can be generalized. This generalization goes beyond the actual case study. By using multiple cases the external validity of the research increases (Voss et al., 2002). No predefined amount of cases, no matter how large the research is, is likely to deal satisfactorily with the criticism that it is challenging to generalize from one case to another (Yin, 2003). The last one is reliability and refers to the extent to which a study’s processes can be repeated towards achieving the same results and with absence of errors or mistakes. This study has enhanced reliability through documenting the research procedures that have been taken and through data triangulation (Eisenhardt, 1989). Yin (2003) further suggests that one should conduct case study research as if someone were always looking over your shoulder. This was exactly the case, because the supervisor of this thesis reviewed this work several times and provided accurate feedback. Furthermore, the defined relations between codes were checked by a colleague within NorthCare and two students which also increased reliability.
26
4. FINDINGS
This chapter is divided into four sections and together they discuss the findings of this research. The first phase of this study researched the balance between efficiency and PCC of the formal service mod-ule. These findings are not related to the case studies but is more specifically focused on how the service module aims to provide both efficient and PCC. These findings will be discussed in the first section. The second phase of this study researched the balance between efficiency and PCC in the current care processes and how this differentiated compared to the service module. These findings are related to case A & B and will be discussed in section two and three. A comparison between the two cases will be discussed in section four.
4.1 Person-centred care and efficiency in the service module
NorthCare uses service modules as a method to deliver noticeably better care for the client. According to an interviewee the service module should be seen as a customer journey: ‘The service module really
takes the client into perspective along the entire care process of the first six weeks’ (1). The journey
27
FIGURE 4.1 SERVICE MODULE
6 weeks
Customer journey: service module Living with us
Person-centred care
Personalization 1 personal buddy Home visitsEfficiency
Person-centred care
Personalization Living quarters PetsEfficiency
ECD Personal buddy for the first week
Person-centred care
Efficiency
Care plan
In the language of the client Personal: standard things left out
Send to family and client before next meeting
Matching demand
No long-term care needs included
Involvement of client and respective family
Employees Awareness needed Focus needed Ownership needed + + + -+ + + + +
PHASE 1: Getting familiar PHASE 2: Moving into the care organization PHASE 3: Creating and signing a care plan
LEGEND +: positive effect -: negative effect : Related to + +
Multi Disciplinary Meeting
Relevant stakeholders meet together
28
4.1.1 Content of service module
This section will discuss the content of the service module. This section will explain the service module in terms of aim, design, and future implementation.
The module has a standard duration of 6 weeks: ‘The goal is that a care plan must be ready
after the first 6 weeks. It is a process that is present in all organizations and differentiation is not pos-sible (1). The colleague further explained that the service module is applicable at almost all
organiza-tions that follow a similar process for intramural care. Besides the outcome of care plan, the focus of this service module is to get familiar with the client, retrieve valuable information such as wishes and demands, and ensure the client feels at home. The service module focuses on the clients: ‘The aim is
to get as good as possible to understand the wishes and needs of a person in the first 6 weeks. Doing so, that the person feels at home within the organization, feels safe and feels well’ (2). Besides the
client, the respective family plays an important role: ‘Family is involved through the whole process.
They (family) can indicate what their needs and wishes are. They (family) must stay well involved. The family must be heard, because they also have their own wishes. It often happens that the family was involved in the care activities at a high point, and therefore often overburdened. That's why it’s im-portant to listen to what they think is imim-portant, not only for the client but also for them (2).
Further-more, the interviewee’s expresses that service modules makes learning between organizations possi-ble by using standardized outcome indicators. By using standardized outcome indicators NorthCare expects the care organizations will create synergy and will learn from each other when they share the results: ‘Organizations start to learn from and with each other and as a result a 1 + 1 = 3 effect arises.
The learning effect allows you to innovate faster and that contributes to the achievement and results of NorthCare’ (2).
NorthCare aims to present the service module at the organizations as a golden standard. This name was given by employees of the different care organizations that were involved in the design phase. All the steps in the module are named best-practices, because these steps are considered by employees as the best steps to noticeably better care: ‘The ist and the soll-situation were mapped on
basis of a VSM. Best practices came from the ist-situation of the companies in order to give shape to the ideal (soll) situation’ (1, 2). The upcoming phase of the project, measuring and improvement, care
29
‘bewijskracht’). As long as the organizations can prove they are making process on these 3 themes, they do well. Interviewees indicate they see some dangers with this approach: ‘The reasoning behind
this freedom for improvement is that we (as an organization) would like the project not to be not a NorthCare project. The module should be their own thing and not something that we commend. Own-ership plays therefore an important role that could be a major pitfall’ (1). To summarize, at a first glance
the service module has the focus on the client to ensure he or she feels at home. The goal of the entire process is achieving a care plan.
4.1.2 How the service module can contribute to person-centred care or efficiency
This section will discuss how the service module adds to the provision of efficiency and/or PCC. First, activities that contribute to PCC will be discussed. Second, the same will be discussed for efficiency.
As confirmed by colleagues of NorthCare the service module can be divided into three phases. These phases are: (a) get to know the new client; (b) moving into the care organization; and (c) design-ing and signdesign-ing the care plan. See figure 4.1 for the overview. Table 4.1 presents and explains which activities results in efficiency, PCC, or both. Below, the results will be discussed per phase.
The first phase aims to get to know the new client. Different activities are carried out to make the client feel welcome, such as home visits, personal buddy, and an Electronic Client Dossier (further named as ECD). The home visits help to understand (a) what the client’s home looks like, (b) how they live and what is important to them, and (c) that a client experiences that people are interested in their life. The importance of get to know the client was explained: ‘Because it (moving) is a big step in
someone's life. For that person it is often the last move, the last place. This needs to be taken very seriously and they should experience that we will take good care of them. It is not that they often want to, but they have to. This impact must be well organized and recognized’ (2). These home visits
30
information. Furthermore, the ECD should be shared with the client and client’s family. The ECD can result in PCC as it is a personal file. It only contains relevant information, i.e. that it is personal and linked to the client, and care needs of the client. Furthermore, the ECD is accessible for the client and client’s family. This can also contribute to PCC, because the ECD can ensure that care activities and information regarding the client is comprehensible for client and family.
A few activities are carried out that can contribute to efficiency. Among these are discussing expectations for both the client and care organization and an information guide that the client re-ceives. Both can contribute to efficiency as the client can use the information to think ahead of what he or she would like in their care plan compared to the possibilities. This can result in time savings in future meetings to see if there is any match between wishes and possibilities offered. Furthermore, the information guide prevents that the care giver has to explain everything in detail. This can result in time savings for employees.
TABLE 4.1
CONTRIBUTION TO PERSON-CENTRED CARE & EFFICIENCY IN THE FORMAL SERVICE MODULE
Steps in Living with us Aim Person-centred Efficiency
Welcoming the client - A personal buddy - Tour of the organization
- Making the client feel welcome
- The focus is on the get to know the client. Therefore, client feels like he or she is welcome at the care organ-ization
- Personal buddy contributes to PCC as it is a familiar person for the client with whom he or she feels com-fortable with
- Personal buddy can result in burden relief for care em-ployees. Not all employees have the workload of helping different clients with differ-ent questions. It results in a more structured and divided workload
Get familiar with client and family - Home visits
- collect care demands and wishes
- Jointly decide placement of client
- Get familiar with each other and re-trieving information about care demands and wished
- Client is involved in terms of joint decision making - Family of the client is
in-volved to understand their wishes and demands - Home visits are personal. It
results in understanding the client’s history, what is important for the client, and the client sees that the organization is interested to get to know him or her
- Retrieving valuable infor-mation in an early stage can result in time savings in later stages
- Employees have the possibil-ity to skip certain surveys to retrieve information as they can collect information by these home visits. This results in time savings and burden relief for employees - Placement that fits with the
client wishes results in less extra work if there would be a mismatch in later stages ECD
- Making a personal file - Make space for client’s history - Shared with client and family
- Controlling interfaces between all relevant parties
- Each ECD is personalized in terms that only relevant cli-ent’s wishes, demands, and personal information is presented
- Accessible for client and family. They stay involved in the care processes
- Accessible for all colleagues. They can access the ECD at any place and any time. Con-tributes to efficiency as they do not have to be at a spe-cific computer location or a dossier locker to read client’s profile
31
The second phase is focused on the movement of the client into the care organization. Clients should feel safe in the way that they are home. To realize this feeling the service module has many options. Clients can, for example, bring pets into their new home. Furthermore, they can choose which day of the week they would like to move. The service module ensures that the client feels welcome at the organization. Examples are a welcoming gift, a tour, and a personal buddy for the first week. These are focused on the client to ensure a pleasant welcome and giving the opportunity to design and live in the apartment as they like. Therefore, these activities and possibilities can contribute to PCC.
correctly in line with care de-mands
- Good readable and more concise compared to paper dossiers. Can result in effi-ciency as employees can win time savings
Rehousing
- Arrange transport - Decorate client’s home - Ensuring client’s home is
fin-ished when client move in - Welcoming the client by
pre-sents, allowing pets, and let the client choose a personal buddy for the first week.
- Decorating and fur-nishing the apart-ment to make client feel like he or she is at home
- Client involvement in re-housing is high - Personalized living space - A personal buddy for the first week at the organiza-tion contributes to PCC as it is a familiar face for the client. Furthermore, client has the option to choose his or her own buddy that fits with the client’s per-sonality
- Welcoming gifts are aimed to making the clients feel welcome at the organiza-tion. It contributes to PCC as the focus in at the client
- Client involvement makes sure the living quarter is de-signed as requested. Contrib-utes to efficiency as employ-ees do not have to re-furnish-ing the apartment
- Burden relief for employees as the client has his or her own personal buddy. Ensures employees do not have to guide and help different cli-ents
Designing a care plan
- Plan and have two Multi-disci-plinary Meetings (MDMs) - Get further acquainted - Designing a first concept of
the care plan
- Write in language of the client - Send concept to family and
client
- Review, adapt, and sign care plan
- Come towards a per-sonal care plan
- Client and family are in-volved in writing the care plan
- Get further acquainted in terms of retrieving detailed wishes and care demands. This contributes to PCC as the focus is on the client - Care plan in language of the client. Contributes to PCC as the care plan is in understandable language for client and family - Care plan contributes to
PCC as the care plan only contains the care demands, wishes and actions of care providers that fits with the client
- Care plan is in understanda-ble language of the client. Can contribute to efficiency, in terms of time savings, as employees do not have to ex-plain difficult language/verbs to the client
- Get further acquainted re-sults in prevention of errors in care plan as it ensures the right wishes and demands are collected
- Concept of care plan is send to client and family for re-view. As a result, time savings at the next meeting are achieved as the care plan is already read
32
Besides the focus on PCC there is also a contribution to efficiency. Furnishing the living space, in agreement to the client wishes, ensures that the new home is in line with the wishes of the client and results in no severe adaptions: when the client moves into his or her new home it represents their idea of being home. Another efficiency win is related to the employees. The client chooses a personal buddy who helps the client within the first week of living with the organization. By letting the client choose 1 employee, other employees will not be burdened with same sort of questions and workload. The third phase is focused on designing a personal care plan. The first activity that can con-tribute to PCC are the Multi-Disciplinary Meetings (further named as MDM). These take place before the care plan can be signed. These meeting(s) are arranged to meet with relevant stakeholders which are related to providing care for the client, such as a physiotherapist and a general practitioner (further named as GP). Besides the relevant stakeholders, the client and client’s family are also present. The aim of the MDMs is to collect all targets and actions of relevant stakeholders in a client’s care plan. This can contribute to PCC as it results in a plan for the client with the most relevant stakeholders, or care providers, involved. Furthermore, the most important care services are taken into account. Be-sides the MDMs the organizations also have a meeting with the client and client’s family or relatives. This meeting can result in PCC as the focus is again on the client and family to understand their wishes and demands. This meeting is meant to get further acquainted with each other and retrieving detailed wishes and care demands, while the previous meeting (home visits) were merely meant to get a good impression and knowledge of the client.
After these MDMs and a second meeting with the client and family, a first concept of the care plan is set-up and shared with the family and the client. The care plan can be personal in terms of writing it in the language of the client, representing the wishes and demands of the client, and ensure the client has access to his or her care plan. Often, this is not the case: ‘Care specialists do often think
in terms of goals for a client and this is wrongly translated into the care plan. This plan does not always match what the client wants. Such as a walking policy. This link (between client’s needs and translating it into a plan) is often absent in the care plan. The module requires a different approach in the sense that it asks to make the aforementioned aspects explicit’ (1).
Both the family and client can read the plan beforehand the upcoming final meeting of signing the care plan. This ensures that everyone can read the concept in their own environment and be pre-pared for the next meeting, which can contribute to efficiency as the next and final meeting can start directly discussing the content of the care plan. In this final meeting the care plan is presented on a screen. This idea of presenting the care plan on a screen can contribute to efficiency in terms of time savings for employees since possible adaptions are directly visible to everyone: ‘This (visibility of care
33
meeting’ (2). The care plan in the service module does not include long-term care demands. The reason
behind this was quite simple, but rather harsh: ‘Long-term care demands are often not included. Most
of them die in a certain time. Average life expectancy is 2 years. But I do think there is too little attention for long-term stays’ (2).
Between the first and last phase, some efficiency problems can occur. The service module de-scribes two meetings that take place in the first and third phase. Both have sort of the same goal: get acquainted. The real differences are that the first meeting is more aimed at get to know someone and the second meeting more at understanding detailed wishes: ‘Conversation 1 is get to know the resident
and the family. You will get to know the resident better and at the end you make something: the care plan. Conversation 2 is more detailed: You create an image back and forth, what does someone need and what can and do we offer? It ensures that there is a good care plan that is really focused on the wishes of the client’ (1). The module does not describe this distinction, between the two meetings,
concrete enough and therefore it should be warned that inefficiencies, such as having different people doing these conversations or a chance of repetition, can come into play: ‘Organizations must be aware
that they prevent repetition from happening with organization these meetings’ (1). When different
people do both these meetings, repetition of asking similar questions can occur, which can result in inefficiencies.
4.1.3 Formal service module: contribution to both person-centred care and efficiency
The previous section discussed how the service module could contribute to either PCC or efficiency. This section will discuss which activities in the service module can contribute to both PCC and effi-ciency.
The first phase has a few activities that can contribute to both PCC and efficiency. Home visits can not only contribute to PCC but can also lead to efficiency: ‘When you make a good acquaintance
at the beginning, matching the client with the right place to live becomes easier. Efficiency and person-oriented care will be possible at the same time. For example, someone had a wish to walk, however the client was placed where this was not possible’ (1). Furthermore, get familiar with a client also helps in
34
all the interfaces, but the ECD is also accessible for the respective families and the client. With this access the care organizations make it possible to inform families of the care service and the state of their relatives. Furthermore, the client can check whether the dossier is correct, up to date, and match-ing their demand and wishes. As a result, efficiency can be ensured in displaymatch-ing the correct infor-mation in dossier of the client. As a consequence, the right care can be given. The ECD can also be efficient in terms of sharing information between colleagues. The ECD is accessible for everyone and the intention is that information is easily readable and understandable. There is also a danger in this first phase in terms of inefficiency between the buddy’s, home visits, and retrieving information: ‘We
should be aware when these steps (home visits, personal buddy, and retrieving information) are not executed by different people. As a consequence, you have a chance of repetition. Between these steps there is a certain overlap that could cause inefficiencies’ (2).
Another activity that can contribute to both PCC and efficiency are the outcome indicators. NorthCare sees the outcome indicators as a tool to show that improvements are made on both as-pects: ‘The outcome measures, focused on customer value, will be a trigger to see if the organizations
stay on the right track. Because if improvements are made on efficiency but customer value does not improve, an alarm will go off’ (1).
4.2 Case A
This section discusses the findings of the first case study at organization A. Case A is based on a care organization which has 14 locations in the north, east, and the central of the Netherlands. Case A is focused on intramural care and specifically aimed at nursing homes. Two locations with two different patient groups are researched in this case. One location gives care to elderly people who cannot live anymore at their own house due to illness or other personal problems. The other location gives care to people with dementia. The two locations are similar in their work processes in the sense that both locations have similarity in the processes when a client decides/needs to live at a care location. Both locations have a customer service centre where people can ask and choose which care and location they would like to choose and both end with a signed care plan.
35
4.2.1 Differences and similarities between current practice and service module
This section will discuss the similarities and differences between current practice and the service mod-ule. The first similarity is that whole process from start till end is similar to the service module, so it can be divided into the same three phases as discussed in previous sections, see figure 4.2.
The first phase, get to know the new client, begins with get to know the client and client’s family or relatives and is according to organization A important: ‘The starting moment is the most
im-portant phase for PCC. It starts from the first acquaintance. I also hear from others that people can remember the first moment very good’ (A, 4). Furthermore, clients recognize employees: ‘They recog-nize people (employees) and a kind of bond is created’ (A, 6). Different activities are carried out to make
the client feel welcome and understanding their needs and wishes. Organization A applies certain per-son-centred activities to accomplish this feeling. The first are home visits, which both locations do: ‘We
call this transfer of closely care. We work closely with extramural care for these home visits. We just did it twice now and it works very well. Our employees can see how people have lived at home’ (A, 10).
Both locations argue that these visits are very helpful in terms of (a) get familiar with the client, (b) attend to a client’s history, and (c) collecting valuable information, such as how someone lives and what kind of hobbies or interest someone has. This is valuable as it can be used as input in the care plan. Visits only take place when the client agrees, it is not a mandatory activity. This differs with the service module as the module states it as a mandatory activity. Both locations also assign a personal buddy to a client. This ensures the client can rely on someone for all their questions.
One activity that both locations do differently, are open days. This is the possibility to come to the location every last Thursday of each month. This kind of activity is not included in the service mod-ule and therefore differentiates from the intended design. Another deviation from the service modmod-ule is that this same location does not have an ECD. They still use paper based dossiers which are locked up behind doors in a closet. The reason is that when this location was built, no thoughts were given to install an ECD: ‘Get the ECD in order. That is the challenge for me and one of the first things that really
needs to happen’ (A, 10). Another deviation within this location is related to the personal buddy for
the client. The service module states the client chooses the buddy, but this location chooses for the client: ‘Within this location we do it somewhat different. We choosing the buddy for the client. The
client does not have the option to choose their own buddy, as it can result in extra work burden for one specific employee if he or she is wanted by multiple clients’ (A, 10).
