A new service for General Practitioners in the province of Groningen: focus on giving high quality care.

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A new service for General Practitioners in the

province of Groningen:

focus on giving high quality care.

Machteld Burgler Student number: 1683012

Msc. Business Administration | Business Development Faculty of Economics and Business

Rijksuniversiteit Groningen November 2012 Eendrachtskade zz 92 9726 DA Groningen 06-20726220 machteldburgler@gmail.com

First supervisor: drs. H.P. van Peet

Second supervisor: dr. M.A.G. van Offenbeek Client: Wetenschapswinkel Groningen

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A new service for General Practitioners in the

province of Groningen:

focus on giving high quality care.

Abstract

This research focuses on the development of a supporting service for the GPs in the province of Groningen, provided by the DoktersDienstGroningen. The needs of the GPs and the requirements of the DDG are determined to end in a design of a supporting service through the following stages: forming a strategy, market problems and needs exploration, idea generation, idea screening and concept development. As an adjustment, stakeholder involvement is added to these stages. The different stakeholders involved in the process are analyzed, identified and compared with standard stakeholder involvement in NSD in other industries. When all stages of the NSD model were covered, two ideas remained in the concept stage: a pool of assistants and the bundling of ICT of the GPs. The stakeholder involvement is on first sight after conducting this research, not different than in other industries where only provider and consumer are involved in NSD. However, reason for this could be that this research has a non-medical context. Further research could test this.

Keywords

New Service Development, Primary care, GPs, health care, Service innovation, Stakeholder involvement.

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Preface

This thesis is written as a graduation project on behalf of the master Business Administration with the specialization Business Development, at the University of Groningen. The research is performed on behalf of the science shop of the University of Groningen at the DoktersDienstGroningen (DDG). Both organizations gave me the opportunity to develop my research within the Dutch primary care in the interest of the DDG. During the research, I did not only learn to do conduct research itself, I also developed insights in the business and I gained especially knowledge about the Dutch primary care. I want to thank drs. Gerda Boiten, Henk Supheert en drs. Ine Scholten of the DDG for their support and collaboration, drs. Martijje Lubbers of the university shop Groningen for the initiation and contact with the DDG and dr. Schipper, dr. Post and dr. Spanier for their help when I had questions and for joining the focus group.

I also would like to thank drs. H.P. van Peet for her supervision, help and critique while writing my thesis. Last of all I would like to thank all my good friends and family for their support and interest in my thesis.

Machteld Burgler October 2012

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1. Introduction

In this section the background, initiation and goals of this research are further explained.

1.1. General Practitioners (GPs)

Innovation is always important, especially in healthcare. In recent years many changes have taken place, and nowadays the environment is still continuously changing. In order to deliver high quality healthcare, GPs and organisations surrounding them have to adjust to those changes by innovating their services in order to keep up.

Back in the days the GP was a doctor with his own practice and mostly one assistant. His tasks were basically treating and consulting his patients. But the “job” evolved; now the GP is not only a doctor but also an entrepreneur with his own business: his practice. In order to do his work properly the GP needs to develop several administrative and entrepreneurial skills. This is mainly the result of the government and health insurers who demand transparency and quality, which leads to extra administrative work. The trend of growing GP practices, GPs grouping together and GPs grouping with other primary caregivers requires management tasks as well; since there are more employees and partners to work with. Besides, there is a differentiation in the administrational work for the GPs. In order to declare or perform other administrational tasks, the GP has to use different methods. Research of Bex, van den Hurk, and Sterrenburg for the Dutch Healthcare Authority (NZA) in 2008 indicates that a GP with an own general practice is occupied with those administrative and entrepreneurial tasks around 13 hours a week, and a GP with a shared general practice around 11 hours a week (see figure 1 and figure 2 p. 6).

Due to those developments there is a growing need for change in the organization and the tasks of the GP in the Dutch Healthcare system. With this change the GP should be able to refocus on his core service: giving a high quality of primary care. This change can be provided by organizations surrounding the GPs like the GP service association Groningen (Doktersdienstgroningen/DDG), Primary Care Advice North-Netherlands (Eerstelijns Advies Noord Nederland/ELANN) and the Districts GP Association (Districts huisartsen vereniging/DHV).

The DDG, the ELANN and the DHV are organizations highly attached to the GPs in Groningen. Those organizations have skills and resources that could contribute in developing a new service.

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enhance their practices. The DDG would like to know how they could provide the GPs with a new supporting service in non-patient related tasks and how such a service should be organized.

1.2. General Practitioner Service Groningen (DoktersDienstGroningen/DDG)

The DDG is an organization for primary care in Groningen that provides efficient and high-quality urgent GP medical care in the evenings, nights and weekends. The DDG is an overarching organization for all seven GP centres in the province of Groningen and has seven service cars, a call-centre and 150 medical assistants. The quality of GP medical care and the corresponding satisfaction of the patients are the top priorities of the DDG. The vision of the DDG is to deploy its content services, facilitating services and logistic services in the primary care in a responsible way.

Since 2002, the DDG employs all GPs who own a practice in the province of Groningen and the north of Drenthe. The GP centres from the DDG ensure high-quality and efficient 24-hour care with decent working hours for the GP.

The DDG wants to deploy its facilities and employees more to the service of the GP care in the province of Groningen. The organization wants to build a strong relationship within the primary care sector and thinks that expanding activities during the day may be an interesting expansion of their activities. However, in the environment of the DDG there are other organizations that provide GPs with helpful services. Therefore, the DDG wants to find out whether new services are wanted by GPs, and if so, what kind of services these are and how the DDG can offer them.

1.3. Business opportunity

The DDG sees an opportunity to support GPs in Groningen by taking over non-patient related tasks. Amongst others these tasks concern administrative and entrepreneurial tasks. The DDG thinks that if these tasks are taken over, the GP can spend more time giving care to his patients. This opportunity is caused by a growing time shortage of the GP, due to a growing existence of non-patient related tasks that have to be regulated. Next to this there are many organizations surrounding the GPs in Groningen.

In this research it is investigated whether the GPs in Groningen feel a need for such supporting services. If a need for services that enable a GP to spend less time on administration/entrepreneurial tasks and more time with patients is found, further research is

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conducted on how these services should be organized according, to the GPs in Groningen. This research will finish with a service design.

Figure 1. Non-patient related tasks per week in a group practice for GPs, assistants and physician assistants. OL=entrepreneurial tasks AL=administrative tasks (Bex et. al. 2008)

Figure 2. Non-patient related tasks per week in a solo practice for GPs, assistants and physician assistants. OL=entrepreneurial tasks AL=administrative tasks (Bex et. al., 2008)

It is assumed that GPs have a need for support in certain administrative and entrepreneurial tasks because of the research of Bex et. al. in 2008. This research shows that GPs spend an average of 27 hours a week on administrative and entrepreneurial tasks. This is a major part of a GP’s working hours.

Opmerking [pb2]: Ik denk dat het beter zou zijn als je beide figuren Engeltalig kan laten zien

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In this research it is investigated in which tasks the GPs want to be supported, how such a service should be designed and how the DDG can contribute to this service. Furthermore, it is tried to get a good oversight about which stakeholders are involved during the development of the service.

1.4. Research goals

The first goal of this research is to come to a conclusion as to whether GPs in Groningen have a need for support with entrepreneurial and administrative tasks. If such a need is found, the research will explore in what way this facilitation can be organized best by the DDG.

The second goal of this research is to give a contribution to the academic literature on New Service Development (NSD). This is done by looking at the different stakeholders that are involved in the NSD process. Existing NSD models already describe involvement of the client, front line employees and the provider, but in healthcare more parties are involved. This research will explore this by looking at which stakeholders are involved during which stage in the NSD process. Moreover, the relationships and interactions between the different parties in healthcare are often more complex than in other industries. Due to the fact that it is unclear which parties should be involved at which stage of the NSD process, this is also considered in this study. So, the research will give an overview of how those parties are involved and the position they occupy in the development process.

1.5. Value of the research

This research is valuable for the GPs in Groningen because the DDG tries to satisfy and investigate their needs. The opinion of the GP is of crucial importance in the development of a service which suits their needs and demands. Therefore, it is also investigated whether and how the GPs could be supported so that they can focus on giving a high quality of primary care. Furthermore, this research is valuable for the DDG. The DDG will gain insights in what kind of services the GPs wish to have, and it will increase the possibility that the GPs will use the new service because there is listened to the opinion of the GPs. The DDG can possibly use the opportunity to develop a new service, which will improve the fit with the GPs. The academic value of this research is that it contributes to both the NSD and the stakeholder literature by looking if the stakeholder involvement in the Dutch GP business is different than in other industries. If this would be the case it is possible that more stakeholders should be involved in NSD which could result in a more complex NSD process. In that case more stakeholders with different roles have to be held in account and because of this it could be

Opmerking [pb3]: Suggestie: Objectives in plaats van goals Opmerking [pb4]: Hier dan ook objective

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possible that other methods than in “normal” NSD have to be used. For example an extension of the existing models.

2. Theoretic framework: service development

In this section the theory relating to the research is further explained.

2.1. Services

The main goal of this research is to investigate whether a new service and/or a different way of dealing with the organization of the current service of the current service is wanted. If this service is wanted this research investigates how this service should be designed. There are many definitions of a service. Kotler and Keller (2006) define a service as “any act or performance that one party can offer to another that is essentially intangible and does not result in the ownership of anything”. While others define services as a performance or process (Lovelock, 1991: Zeithaml & Bitner, 2000). Johne and Storey (1998) define services as the predominantly intangible core attributes which customers purchase.

There are four basic characteristics that give more clarity about the nature of a service. Those characteristics are:

 Intangibility; contradictory to products, services are largely intangible. Due to the intangibility of services it is more difficult to predict customer expectations and it is harder to communicate the desires of the customer.

 Heterogeneity; services are particularly heterogeneous, this because services are based on perception. Since all people perceive things differently; they also perceive services differently, which causes heterogeneity. The difference between perceptions is enhanced due to the fact that services are mostly delivered by people and people are not able to deliver things exactly the same twice.

 Inseparability; service are delivered and consumed simultaneously, which means that people are more involved in the offering than with products.

 Perishability: services are consumed and produced at the same time and cannot be kept in stock (Vargo and Lusch, 2004).

2.2. New Service Development (NSD)

In recent years an extensive elaboration on New Product Development (NPD) was carried out. In these elaborations less attention is given to New Service Development (NSD). Therefore many NSD models are based on NPD models. Two examples are the fundamental model of

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Booz, Allen and Hamilton (1982) and Cooper’s stage-gate model (1990). On top of this, most NSD models are strongly biased: the majority of these studies are performed in the financial sector and not in other types of industries.

NSD is defined as the “overall process of developing new service offerings” (Johnson et al., 2000, p.). NSD models consist of a set of stages from idea to launch/implementation (Cooper et al., 1994; Booz et al., 1982). Most of these models contain the following stages: idea generation and screening, design, testing and implementation (Holopainen, 2010; Zeithaml, Bitner and Gremler, 2006). Although some models consist of more stages, or use different names, almost all models cover these stages thoroughly. This research focuses on the first stages of NSD. Reason for this focus is that the NSD of a potential facilitating service for the GPs in Groningen finds itself in the beginning stage. As a basis of this research the model of Papastathopoulou, Avlontis and Idounas (2001) was used. This model is formed out of the fundamental NPD model of Booz et al. (1982) and the innovation models of Davis (1997) and Scheuing & Johnson (1989). The model of Papastathopoulou et al. (2001) (figure 3) has until now only been applied on financial services. This model was used because it draws on fundamental development models and theories. The benefit of this established model is that it is already used and proven to work in practice in the financial service industry. Because the research context is the Dutch primary care, the model was slightly adjusted (see figure 4). The activities and definitions of these stages will be described more extensively in the methodology section (section 3.)

Figure 3. The initial stages of NSD (Papastathopoulou et al., 2001).

Opmerking [pb6]: Dit is de eerste keer dat je dit model benoemd, noem dan ook beide andere auteurs Opmerking [pb7]: Hier moet je consistent in zijn

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2.3. New service design

The final contribution of this research will be a new service design. Service design is the activity of planning and organizing people, infrastructure, communication and material components of a service in order to improve its quality and the interaction between service provider and customers. The main point of service design is “to design high quality into the service system from the outset, to consider and respond to customers' expectations in designing each element of the service” (Edvardsson, 1997, p. 31). This is why the customers, in this case the GPs, as well as the other parties involved, have to be considered while developing the new overarching service.

Customer involvement in NSD is defined as the extent to which service producers interact with current (or potential) representatives of one or more customers at various stages of the new service development process (Alam, 2006; Matthing, Sandén, B., Edvardsson, B, 2004). Customer involvement is considered to be more important for NSD than for tangible goods (Alam and Perry, 2002). Several articles argue that customer involvement in NSD and design is a main driver: “service suppliers must develop not only the precise form of the service product, but also the appropriate nature of the interaction with customers” (Johne and Storey, 1998 p. 186).

Secondly, some authors argue that front-line employee engagement and involvement in NSD is important in new service innovation success (Cadwaller, Jarvis, Bitner and Ostrom 2010). In their extensive review of NSD literature, Johne and Storey (1998) mention the following three groups of parties involved in effective service development projects:

1. the development staff 2. the customer-contact staff 3. the customers

However, in healthcare there are more parties involved. The following section will pay more attention to these parties/stakeholders.

2.4. Stakeholder involvement

In the healthcare sector customers, development staff and front line employees are not the only important stakeholders. Services in the public sector represent an important additional challenge of dealing with multiple stakeholders and the “contested” nature of innovation (Hartley, 2005). So, more stakeholders are involved.

Opmerking [pb8]: Heb je hier een bron bij?

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First, when designing a service, other organizations and processes are involved. Edvardsson (1997, p. 36) writes in his paper: “when designing the service concept, attention should be given to the fact that individual services often form part of a system together with other services, existing and/or new”. Stakeholders of an innovation project are those parties that have an interest in the outcomes of that project. For innovation projects it is likely that stakeholder involvement differs over the different stages (Vos and Achterkamp, 2006). There is a difference between the stakeholders who are actively involved and those who are passively involved (Ulrich, 1983 p.248). Actively involved stakeholders are those who possess at least one resource (expertise, political or financial, etc.) that can influence or contribute to the system. Passively involved stakeholders are those who are actually or potentially affected by the outcome of the system (Ulrich, 1983, p.248). In this research stakeholder involvement will be researched as well. This because it is assumed that in healthcare stakeholder involvement is different than in other industries, therefore in this research there is an extra stage (stage 0) before the stages of the model of Papastathopoulou et al. (2001). Before exploring the stages of the NSD model in this research the stakeholders in every stage have to be identified in order to execute the stages in a good and complete way. Thus, before the stages of Papastathopoulou et al. (2001) stage 0; stakeholder involvement will be considered. This stage will be added to the model (figure 4).

Figure 4. The NSD model adjusted from Papastathopoulou (2001) used in this research Identification of the stakeholders involved

Formulation of a new service development strategy

Concept development

Market problem and needs exploration Idea generation

Idea screening

Opmerking [pb9]: Quote? Dan aanhalingstekens

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2.5. Academic gap

Currently, the majority of research has focused on NPD, while less attention has been given to NSD, especially in healthcare. Almost all the articles that were found while doing the preliminary literature research are focusing on other industries. The articles that did focus on innovation in healthcare were directed at product development, hospitals or the primary care in Great Britain; where most things in healthcare are organized different than in the Netherlands and thus are not comparable. So one gap that is tried to be filled by means of this research is NSD in Dutch primary care, which is hardly investigated before. Articles found on the Dutch primary care sector show a complex network of many stakeholders, while in research in other industries only customers, R&D staff and customer-contact staff are involved (Johne and Storey, 1998). The second gap that this research is trying to contribute to is that it will try to investigate whether stakeholder involvement would be different in healthcare. It will try to identify the possible stakeholders involved in every stage and how they could be involved.

2.6. Conclusion

To conclude, it can be said that there is not a lot of elaboration on NSD in relation to the health care sector. The model of Papastathopoulou et al. (2001) has been used for NSD in the financial sector, but not yet in healthcare. The assumption is made that multiple stakeholders are involved in NSD in healthcare. This research aims to fill an academic gap in terms of mapping the initial stages of the NSD process in Dutch primary healthcare and by identifying which possible stakeholders are important during what stage of this process, and how they can

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3. Methodology

The kind of research conducted was academic problem solving, but instead of a business problem, there was a business opportunity seen by the DDG. The difference is that concerning a business opportunity there is a need for a new design instead of a redesign. The stages of the academic problem solving cycle (figure 5) are used for this. This research made use of a qualitative method of researching. This because in-depth information about the needs of the GPs was needed, and qualitative research enables to ask for explanations and further details. Only the results of the market problem and needs exploration are quantified, this to make the results more clear and come to an objective conclusion about the needs of the GPs. Qualitative methods are oriented at the discovery of qualities of things, that is, the properties of objects, phenomena, situations, people, meanings and events (Van Aken, Berends, and van der Bij, 2007). The research methods used for collecting these data were internal documentation, semi structured interviews, a focus group and an online survey. In this study the quality of the current supporting services was studied as well as the desired properties of the new service and the properties of the DDG and the GPs in Groningen. The unit of analysis was the possibility of a new supporting service provided by the DDG for the GPs in Groningen. Since this research concerned designing a new service to create a better facilitation of GPs and thus better quality and focus in primary care. The focus was on the future, instead on what was already established. The goal of the research was to gain specific knowledge about a design for a new service to create a fit between the parties involved. This means this research was equipped in such a way that if an actor faces problems like (X) in setting (Z) then it should try out (Y). In which X represents the problems faced by GPs in the current setting Z and Y the new service design. (Van der Bij and Reezigt, 2012).

The research is also of academic interest. This is because the context of the research – the model applied to a health care project - could be seen as a gap in the current literature. Also the identification and involvement of stakeholders in healthcare was assumed to be different than in other industries. There was not a lot elaboration on stakeholder involvement in NSD in primary care. In the end of the research these literature gaps will hopefully be filled with knowledge that can be used in similar contexts and/or industries.

Figure 5. Regulative cycle adjusted from Van Aken et al. 2007

Business opportunity Data collection Data analysis Plan for a new service design Academic interest Reflection

Opmerking [S10]: Ik vind het niet heel duidelijk zo, kan je de Z en de Y toevoegen in het figuur?

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Van Aken et. al. (2007, p.) described a design as “a model of an entity to be realized, as an instruction for the next step in the creation process’’. In this research the entity was the service and the next step in the creation process would be NSD. The outcome of this research was thus not a developed new service but a model of a recommended service. This model should resemble characteristics that the new service should have.

The research was conducted while using a model adjusted from Papastathopoulou et. al. (2001) (figure 4); this model has proven its value in the financial industry. In the research the following information was needed at each step of the model.

0. Identification of the stakeholders involved. In this stage information was needed about which stakeholder was involved at what point in the upcoming stages. In order to identify the stakeholders who were actively involved, and thus those stakeholders that could affect the NSD, Vos and Achterkamp (2006) developed a method consisting of four steps. The most important point of the method was that it did not only classified the parties involved in the NSD, but also identified stakeholders, attributed roles to those stakeholders, and showed at what point in the development process these parties are involved. The steps were:

 Delimiting and defining the NSD project  Writing down all the possible stakeholders

 Listing parties who could possibly be involved in the project and their role  Deciding which party should be involved in which stage.

The identification of the stakeholders was done by members of the DDG: the head communication, the director and a project manager.

This method was used to identify the stakeholders and will be evaluated in the reflection.

1. The formulation of a new service development strategy. In this stage internal information was needed about the organizations involved in the development of the goals of for the new service. It was important that there was a fit between the strategic goals (internal) and the customer needs (external) (Scheuling, 1989). It was also important to look at the current situation (Davis, 1997). Information could be derived from literature, internal documentation of the DDG and earlier conducted research. To formulate the goals of the new service stakeholders had to be interviewed. These interviews were conducted with the director of the DDG and the project managers of the DDG.

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2. Market problems and needs exploration. In this stage information was needed about the GPs and the market. What were the most important trends in the market? What problems were the GPs facing? Do they really had a need for certain tasks to be taken over? What characteristics did the new service needed to consist of? This information could be derived from external research conducted in the industry, internal documentation about trends in the market and mainly from interviews with the GPs. 3. Idea generation. In this stage ideas were generated. Those ideas came from a focus

group. After presenting the results of step 1 and step 2 of this model, a group of 6 participants discussed and generated ideas. This group was formed out of GPs and members of the DDG. Initially, also members from the ELANN and the GP association Groningen (DHV) were invited. Unfortunately the members from ELANN and the DHV did not cooperate and that is the reason that only the DDG and GPs are in it.

4. Idea screening. In this stage the generated ideas were screened and the best ones remained. This screening was performed by the director of the DDG, together with a project manager and a financial director of the DDG, for they would make the decision regarding the implementation of the new service. The ideas were screened based on seven screening criteria based on the screening criteria of Papasthopoulou et. al. (2001): feasibility, technological consequences, time, costs, compatibility, advantage for the GP and market criteria.

5. Concept development. The ideas that made it through the screening were formed into a service concept. The information derived in the earlier stages was needed as well as literature about concept development, like the research of Edvardsson (1997) about the importance of a new service concept.

The stages of concept testing and concept development were left out of this research. The main reason for this was that the main focus was an advice for a design and including all stages would end in serious time constraints. Instead the research focused on developing a plan for a new service for the GPs in Groningen by the DDG.

3.1. Data collection

Data was collected through semi-structured interviews supplemented with an online survey, literature about the market and internal documentation from the DDG. In interviews prior to this research, two GPs and the DDG pointed out that GPs have a lot of surveys to answer and the response rate is low. Moreover, in this research information about unknown/latent needs

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of the GPs were needed which could not be derived from a structured survey. Therefore, semi-structured interviews were chosen to collect this information. Flick (2006 p.155) says: “one of the benefits of having interviews is that these are useful for assessing an individual’s attitudes and values, which are hard to observe”. The attitudes and opinions of the GPs with respect to a new service were very important; this was the reason that semi-structured interviews were the main method of data collecting. To complement these interviews there was an online questionnaire for GPs that were interested in the research but did not have time for participating in an interview. In exchange for their time the DDG paid a fee to all participating GPs. A focus group was used for data collection in the idea generation stage. So, five sources of data collection were used: semi-structured interviews, an online survey, focus groups, internal documentation and academic literature. Five sources were used instead of one because this enabled data-triangulation – the use of multiple data gathering instruments –, which in turn increases the validity of the research (van Aken et. al., 2007). Especially so in stage one and two of the model adjusted from Papasthopoulou et al. (2001). In stage one – the formulation of a new service development strategy -, internal and market related documentation was combined with interviews. In stage two – market problems and needs exploration – semi structured interviews were combined with an online survey. In order to formulate these interview questions internal and market related documentation were used.

3.1.1 Semi-structured interviews

The interview is one of the main methods of data gathering in almost all business problem-solving projects (van Aken et. al., 2007). A semi-structured interview is conducted because this type of interview leaves sufficient room for additional information (van Aken et. al., 2007). When conducting this type of interview, it is important that respondents for the interviews are positioned both inside and outside the client organization (van Aken et. al., 2007). In this research those informants were mostly employees from within the DDG (inside) and GPs (outside). The interview was introduced with a letter from three GPs -who were interviewed prior to the research in order to identify the problem- to all the GPs in Groningen. This letter was signed by the DDG and the researcher. This letter explained the research and asked for participation. The interview took about 30 minutes. In order to increase the response rate, the participating GPs were paid by the DDG in exchange for their time. The semi-structured interviews were conducted in step 2 of the adjusted NSD model of Papastathopoulou et. al. (2001). For practical reasons the interviews were held in the GP’s practice.

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The interview (appendix A) consisted out of five parts. The interview started by asking the general information of the GP; name, age, gender, type of practice and whether they worked full- or part-time, and why. This was done to start the conversation and to check the data in possession of the researcher.

The second part of the interview was about the view of the GP concerning his job and the problems he faced. This enabled a conclusion about latent needs. It is assumed that GPs want to be supported in problem areas and tasks that do not satisfy. Hereafter, questions about non-patient related tasks – what tasks does the GP have and how much time these tasks take up – were asked as well as the perception of the current support that is available. According to Davis (1997) it is important that the current situation is reviewed in this stage of problem and need exploration.

The third part of the interview focused on questions about the needs and wants of the GP. This made it possible to ask the GPs directly about their opinion and their need for support in non-patient related tasks. Interviews are a common method to gather information about user requirements (Courage and Baxter, 2004).

The fourth part consisted of questions about the environment the GPs find themselves in. This to see how the GPs adapt to the environment and how they perceive the environment with the different organizations now. In this part it could be seen whether the GPs wished a collaboration of the DDG with other organizations or that the differentiated environment that exists now was perceived as sufficient.

In the last part of the interview was about certain non-patient related tasks like the ICT, personnel management and the PR part. This to gain more information about the needs and wants on this part of the possible supporting service.

The interview ended with a look at the future and asked what the GP thinks his job will look like in a couple of years.

3.1.2. Focus groups

In this research a focus group occurred in the idea generation stage. A focus group is an interview with multiple people at the same time (van Aken et. al., 2007). This method was chosen because the overall purpose of this research was to design a supporting service for GPs, this was done through exploration. The group method that accompanied that type of research was according to Steyaert and Bouwen (1994) a focus group. The general size of a focus group is approximately six to ten participants (Morgan, 1991). However, it is also possible to have a larger or smaller number (Goss and Leinbach, 1996; Kitzinger 1995). This

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focus group had six participants. A focus group session lasts between one and two hours. It is important that there is a good balance in participants. If the group is too homogeneous certain opinions will not be revealed. If the group is to heterogeneous the differences between participants are likely to make an impact on the contributions of those participants. The focus group in this research existed out of a mix between employees of the DDG and GPs. This assured that there were both internal and external participants. To create more heterogeneity members of ELANN and the DHV were invited, but unfortunately they did not cooperate. In the focus group the researcher leaded the discussion. The researcher presented results of the market and needs exploration and asked questions in order to start the discussion. During a discussion based on those questions and results ideas were generated by the focus group.

3.1.3. Online survey

An online survey was conducted to complement the semi-structured interviews; and gave GPs that did not have time for an interview the opportunity to participate in the research. The online survey was structured with open questions and had approximately the same questions as the interview. This because qualitative information was needed and when the questions would be closed-ended it may not be possible to give a good answer on the question. However, not all questions were enclosed because it was assumed that some questions were too difficult to answer online and it was harder to capture the attitude of a GP without face-to-face contact. The DDG paid GPs that participated in the online survey a fee in order to increase the response rate.

3.1.4. Academic literature and internal documentation

There was also data available from within the DDG, this is called internal documentation (Flick, 2006); which was used in this research. Internal documents used were:

- The annual reports of 2008, 2010 and 2011 of the DDG

- A list of all GPs including their personal information like sex, age, practice, address. - A stream schedule of how the processes within the DDG work

- A list of all the GP groups (HaGro’s) in the province of Groningen and their members - A scheme with all the stakeholders of the DDG

Market specific information was used in form of earlier research of the Dutch Healthcare Authority (NZA) on the field of non-patient related tasks in the GP industry. Those researches were:

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- Bex, P.M.H.H., van den Hurk, J.J.F.M. and Sterrenburg, J. P: Meting Lasten

Huisartsen Onderzoek naar de lasten door administratieve handelingen en inhoudelijke verplichtingen voor huisartsen (2008)

- Nederlandse Zorg autoriteit: Huisartsenzorg 2008 Analyse van het nieuwe bekostigingssysteem en de marktwerking in de huisartsenzorg, Nederlandse zorg autoriteit (2009)

Academic literature was used to define theory concepts and to find a model to guide the NSD process in this research.

3.2. Sample

The sample was a select representation of the population of GPs in Groningen. Therefore information about the population was needed. This information was derived from internal spreadsheets about the population from the DDG.

There are 285 GPs in Groningen, distributed over 174 practices. Together they form 31 GP groups (HuisartsenGROepen/HAGRO’s) that are geographically divided over the province. 84 GPs (29,4 percent) are female. In total the GPs in Groningen work 238 fte (NZA, 2008), while Groningen has 573.614 inhabitants. This means that the average amount of inhabitants per full-time working GP is 2.410. The average in the Netherlands is 2.419 inhabitants per full-time working GP (NZA, 2008). So the amount of inhabitants per full-time working GP in Groningen is approximately equal to the average in the rest of the Netherlands.

Twenty GPs were interviewed, mostly from different HAGRO’s to assure that the province of Groningen is geographically covered. The sample was a representation of the whole population. It is made sure that the sample contained both:

- Group practices and solo practices - Male and female GPs

- GPs of different ages

- GPs out of all parts of the province of Groningen

Because in this research a realistic representation of the population was sampled, the sample had approximately the same percentage of certain characteristics of GPs. An overview of the sample could be seen in appendix B.

There are 285 GPs in Groningen, divided over 174 practices. From these GPs there are 111 working in a solo-practice this means that 39 percent of the sample existed out of GPs

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working solo. The sample existed out of twenty GPs this means that seven or eight GPs were working solo while the rest was working in group practices

From the 285 established GPs 84 are female, this means that 29 percent of the sample existed out of female GPs. This means that the sample had to contain six female GPs. In terms of age the sample contains:

Year of Birth Amount of GPs Percentage of

population Number in sample <1950 18 6% 1 1950-1960 116 40% 8 1960-1970 93 33% 7 1970-1980 55 19% 4 >1980 3 1% 0

It is made sure that the sample for the semi-structured interview has the characteristics described above. However, for the online survey it was not possible to select on these requirements because every GP had the possibility to answer this survey.

3.3. Data analysis

After the data was collected, it had to be analyzed. After each interview the audio recordings were listened back in order to write transcripts of the interviews as precise as possible. When all the interviews were held and transcribed, the data analysis started with open coding. Open coding made it possible to label the data and phenomena in concepts (Van Aken et. al., 2007; Flick, 2006). The codes had to fit the data and arose while reflecting on the transcripts. The data was constantly compared (Van Aken et. al., 2007). Theoretical coding in which the relationships between the concepts found in open coding will be discovered, followed the open coding method (Van Aken et. al., 2007). If there were no saturated concepts, selective coding took place to elaborate on the concepts and relationships found during the other coding methods. This was done to crystallize the results (Van Aken et. al., 2007)

3.4. Quality criteria

In this paragraph the different quality criteria are defined and worked out. It will start with controllability and will be followed by reliability, and validity.

3.4.1. Controllability

In order to achieve a high controllability of research, the way the study is executed has to be revealed (Van Aken, 2007). It has to be explained how the data is collected, which

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respondents are selected, what questions are asked, the circumstances of the study, how the data is analyzed and how conclusions are drawn (van Aken et. al., 2007). It is made sure that this research has a high level of controllability by revealing the execution of this study precisely in the methodology section of this research. In order to increase the controllability, all interviews and the focus group meeting will be recorded and worked out on paper. After this the transcriptions will be sent to the participants so that they can control the outcomes and approve them.

3.4.2. Reliability

The results of a study are reliable when they are independent of the particular characteristics of that study and can therefore be replicated in other studies (Yin 1994: Swanborn 1996). In relation to reliability, there are four possible biases: the researcher, the instruments the respondents and the situation (Van Aken et. al., 2007).

Researchers can cause biases in reliability. The research results will be more reliable when they are independent of the researcher. Letting somebody else repeat the conducted research can test the reliability but because of time constraints this is impossible to do. The reliability can also increase by using standardization. In this particular research there was chosen for semi-structured interviews. The structuration of the interviews made the interviews more standardized; respondents were asked the same questions. The interviews were not completely structured because the questions tried to gain information on latent needs. Therefore, sometimes it was necessary to go in-depth and deviate from the structured list of questions. Because surveys depend less on the researcher than interviews, this research was supplemented with an on-line survey.

Another bias in reliability is the instrument bias. This means that the results have to be independent of instruments used in the study (Van Aken et. al. 2007). Using triangulation of sources can decrease the instrument bias. This means the use of multiple research instruments. This is done in this study by making use of interviews, literature, a focus group and an on-line survey. Instrument bias problems can also arise within an instrument (Van Aken et. al., 2007); to reduce the instrument bias multiple questions about the same subject were asked in this research.

Another bias in reliability is the respondent bias. Having independent results from respondents can prevent respondent bias (Van Aken, 2007). In this study it is made sure that all types of GPs were interviewed, for example: diversity in age, GPs from sole and group

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practices, male and female GPs and GPs divided all over the province of Groningen. The researcher also talked to multiple DDG employees. So, many different types of participants are used to decrease the respondent bias.

The last bias in reliability is circumstances reliability; this means that the results are influenced by the specific circumstances under which the research is conducted (Van Aken et. al., 2007). This is prevented to occur by conducting the interviews at different times during the day/week. For example some interviews are conducted on Monday morning, while others are conducted on Wednesday or Friday afternoon.

3.4.3. Validity

A research result is considered to be valid when the result is justified by the way it is generated. This way should provide good reasons to believe that the generated way is true and/or adequate (Van Aken et. al., 2007). There are several types of validity.

The first type is construct validity; this is the extent to which a measuring instrument measures what it is intended to measure (Van Aken et. al., 2007). With construct validity the concept should be completely covered and the measurement should not have components that do not fit the meaning of the concept (Van Aken et. al., 2007). In this research the definition of concepts of NSD through literature in the theoretic framework increases construct validity. Triangulation can also be valuable in increasing construct validity (Yin, 1994), in this research semi-structured interviews, a focus group, literature and an online survey were combined in order to increase the construct validity.

The second type is internal validity; this concerns the conclusions about the relationship between phenomena. Internal validity has a causal part, which means that there has to be a good reason to assume that the proposed relationship is adequate. Internal validity also has a theoretical part, which means that the theoretical perspective has to be broad enough and suitable to study the problem adequately (Van Aken et. al., 2007). Internal validity is assured by studying the initial problem from multiple perspectives. This was done by interviewing three different GPs (from Leek, Groningen and Stadskanaal) and three different employees of the DDG (the director, the head financial administration and a project leader). Also multiple articles on NSD are used which could be found in the references section.

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The last type of validity is external validity; this type refers to the generalizability of the results and conclusions to other populations. This type of validity is less important in a business opportunity study like this research (Van Aken et. al., 2007). Reason for this is that this was a research for a specific organization: the DDG. Besides, the primary care is arranged differently in other provinces and abroad. For example, in some provinces most organizations are integrated and in other provinces, there is a hierarchical system of organizations. This made that the research is mostly not generalizable. However, the research could be generalizable for the needs of the GPs in the Netherlands. Reason for this was that the research of Bex et. al. (2008) that indicated that GPs spend a great amount of their time on entrepreneurial and administrational tasks was a national research. External validity was increased in this research by recognition of results and face validity. Recognition of results is the degree to which the problem owners and others involved recognize the results. Face validity is when the research seems to measure what it is attempt to measure (Flick, 2006). This was done by conducting a member check, the results were presented to the participants

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4.Developing a service

In this section the different stages of the NSD model used in this research (figure 4) are explored in order to come with a possible design for the GPs in the concept development stage.

4.1. Identification of the stakeholders involved

In this new service development process, eventually every stakeholder has an interest. However, in the initial stages not every stakeholder is as important as other stakeholders. Participants in this stage are the head communication of the DDG, the director of the DDG and a project manager of the DDG.

In this case several steps are applied to the project of new service development for the GPs in Groningen (Vos and Achterkamp, 2006):

o Delimiting and the defining of the NSD project. In this research this concerns the development of a new service to support entrepreneurial and administrative tasks (by the DDG) for the GPs in Groningen.

o All possible stakeholders involved are listed. This is done for both the DDG and the GPs. _ DDG 8. Ambulance care Groningen (AZG) 7. Regional consultation acute care (ROAZ) 6. Dutch GP society (NHG) 5. Reportingroom (meldkamer/CPA) 4. Lentis 3. Patients 2. Homecare 1. Pharmacies 14. Health inspection (IGZ) 13. Assurers 11. Employees DDG 12. Supervisory board 10. Care advocacy (zorgbelang) 9. Hospitals in Groningen GP 18. Other organizations surrounding the GP (ELANN, GHC, De Kring) 15. Advisory board 16. Government 17. Local government GP 8. Assesment care centre (CIZ) 7. Medical representatives 6. Dutch GP society (NHG) 5. Section (ELANN, DDG, LHV, GHC) 4. Dutch health authority (NZa) 3. Local government 2. Government 1. Health assurers 14. Health inspection (IGZ) 13. Assurers 11. CBS 12. Occupational health physicians, lawyers 10. Other providers of health 9. Training 15. Dutch competition authority (NMa) Patient 16. Pharmacy

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o The participants are asked, as a group, to come up with all the parties who can possibly fulfill one of the roles in the project. There are two roles: passively involved and actively involved. Actively involved stakeholders can have three sub roles:

 The Client role: whose purposes are being served;

 The Decision maker role: sets requirements regarding the innovation and evaluates whether the innovation meets these requirements;

 The Designer role: contributes necessary expertise and is responsible for the (interim) deliverables (Ulrich, 1993, p. 597).

Actively involved in this research are:

DDG: decision maker/designer. First of all, the DDG is a decision maker. This because the

DDG will set requirements regarding the innovation and will evaluate whether the innovation meets these requirements. The DDG will decide (together with other organizations involved) whether to develop a new service or not. Secondly the DDG can be seen as a designer: employees of the DDG will contribute by giving necessary expertise about the DDG, the new service and the environment. Last of all, the purpose of the DDG is to evaluate the current service and to possibly develop a new service for the GPs in Groningen.. The most important role of the DDG is the role as decision maker because they will have to make the most important decisions in the process.

GPs: client, designer. The GPs could be seen as a client because their purposes will be

fulfilled. In the end, the new service is of value for the GPs. Because the GPs can deliver specific knowledge and help generating ideas for the service, the GPs can be seen as designer as well.

Other organizations surrounding the GP (ELANN, GHC, DHV): decision maker,

designer. Those organizations involved and willing to develop the new service with the DDG are decision makers due to that they will (with the DDG) set the requirements that the new service has to satisfy they will also evaluate the degree of this satisfaction. Second of all, those organizations can contribute by giving resources like money for the development or knowledge and expertise.

DDG Employees: designer. The employees of the DDG will contribute by giving knowledge.

Most important passively involved stakeholders:

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declaration, but is also finances the DDG. This is done with a budget, which is approved by Menzis and since 2007 is Menzis the second largest health assurer. The NZA will decide the rate per transaction that the DDG can claim to the assurer (jaarverslag DDG, 2008).

Supervisory and advisory board: if it comes to a new service, they have to approve this

service.

NZA: the NZA supervises the Dutch healthcare. It is important that the DDG follows all the

rules otherwise the NZA will intervene.

o In the last step of Vos and Achterkamp’s identification model (2006) the participants have to indicate which identified party should be involved in what stage. A distinction has to be made between:

 Parties that definitely should be involved;  Parties that should possibly be involved;

 Parties that should not be involved in this stage of the project.

This is done for each step of the initial stages of the NSD model of Papastathopoulou et al. (2001). Therefore this paper tries to contribute to the NSD literature by introducing these other parties into the NSD model.

In this research the stakeholders that should be involved in each stage are described in following sections concerning the stages of NSD.

4.2. Formulation of a NSD strategy

This section concerns the first stage of the model of Papasthatopoulou et al. (2001). It will start with a brief introduction, then the visions and goals of the DDG, are treated followed by information about other organizations in the environment. It will end with a brief conclusion. Information in this stage is collected by reading internal documentation of the DDG (annual reports and documents), the website, conversations with the financial director and a project manager from the DDG, and an interview with the director.

In this stage the strategic business requirements that the new service intends to satisfy are identified (Booz et al., 1982). To achieve this identification, internal information about the goals of the organizations involved, marketing objectives and an environmental analysis are needed (Scheuing, 1989). This information is important because in the end a fit is needed between the strategic goals, the customer needs and the environment. Furthermore, is it important to look at the current situation (Davis, 1997) and the desired future situation. The

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stakeholder certainly involved in this stage is the DDG because the DDG wants to develop the service. Also the employees of the DDG are certainly involved, but not all employees. This because information is needed about strategy and it is not likely that all employees have the knowledge needed. Possibly involved could be the ELANN, DHV and GHC because the DDG wants to develop the service in association with those parties. Not involved are the GPs and the passively involved parties, this because there is information needed about the NSD strategy and they are not involved in this.

By researching whether the GPs want to receive more support in the form of a service concerning certain tasks and with – if wanted – developing such a service, the DDG wants to increase the satisfaction of the GPs by helping them. They want to listen to the GPs.

The mission of the DDG is taking care by delivering efficient and high-quality urgent general medical care in evenings, nights and weekends. The satisfaction of the patient is most important. The vision of the DDG is to deploy her content services, facility services and logistic services in primary care in a corporal and responsible way. Quality and customer satisfaction are the criteria for the functioning of the organization. Because the customer is important the DDG wants to explore if and how they can support the GP more, also during the daytimes. In this way the GP can concentrate more on helping patients instead of spending time on non-patient related tasks like administrational and entrepreneurial tasks.

In the current situation the DDG facilitates the GPs during evening, night and weekend shifts. The DDG also has a central call-centre where all the calls for the province of Groningen in evenings, nights and weekends are handled. Next to this call center the DDG has own service cars, medical assistants, and ICT and office staff. These resources could possibly be deployed different to provide a new service to support GPs. In the end this hopefully increases the quality of care and the satisfaction of the patient, which are the goals of the DDG. With a new service for GPs the DDG aims at making it as cheap as possible for the GP. The DDG does not want to make profit but wants to cover the costs with an eventual new service.

Next to the DDG there are other organizations in the environment that support the GPs. ELANN is an independent organization that supports the GPs with advice concerning the daytime. It is also possible for GPs to ask for support by ELANN concerning other tasks like personnel management and administration. The ELANN will give advice and it is also possible to get (for a fee) secretarial support. Next to this, gives training to GPs to keep them up to date in performing their jobs.

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The DHV is the district GP association; it is a sub-organization of the national GP association (LHV) and has as goal to look after the GP’s interests. Goals of the DHV, besides looking after the GP’s interests, are making regional policy and the development of a vision.

4.2.1. Conclusion

So, the DDG, the ELANN and the DHV all have a different function and provide service for GPs.

However, they have one overlapping factor: they all want to look after the GPs interests and improve their functioning and well-being. However, there is not a lot of collaboration between the DDG and these organizations. If they would cooperate this could improve the efficiency towards the GPs.

In the future the DDG desires to make sure that there are good facilities for GPs and patients, and that the patients are satisfied. They want to oppose the trend of grouping patients. The DDG can organize more work if the GPs want this and believes that in order to be more efficient and to realize their goals the organizations can work together.

Concluding, there is a lot of differentiation in organizations for the GPs. All these organizations have different tasks and there is not a lot of collaboration. With developing a new service the DDG wants to listen more to the GPs and increase the quality of the primary care delivered to patients. In order to have an eventual service compatible with the DDG and the GPs there has to be listened to both parties. Compatible with the DDG will mean, in line with the goals of the DDG. The DDG can deploy its resources also during the day.

4.3. Market problems and needs exploration

In this section the market problems and needs exploration is performed. This stage will start with a brief introduction, then the results of the semi-structured interviews followed by the results of the online survey. This section will end with a brief conclusion.

The market problems and needs exploration is originally the second stage of the model of Papastathopoulou et. al. (2001). Information in this stage is gathered by conducting semi-structured interviews with 20 different GPs combined with an online survey.

In this stage needs that are currently not met in the marketplace are explored (Davis, 1997). Qualitative research has to be conducted with the consumers (the GPs) to explore and identify their needs and problems in the problem area. In this research these would be the

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administrative and entrepreneurial tasks. It is important to involve customers in the development process and help them articulate their needs. In general, the more customer involvement, the better (Johne and Storey, 1998). There are 20 GPs interviewed. Another 8 GPs took the online survey. In this case the GPs are the customers, they have to eventually make use of the supporting service. That is why the GPs are certainly a stakeholder. Possible other stakeholders could be the DDG and the other organizations surrounding the GP as well as Menzis because those parties can help shape the environment and come up with market problems. The stakeholders considered are the GPs.

4.3.1. Semi-structured interviews

In this section gives an overview of the results of the semi-structured interviews. Each subject of questions will begin with a table with the results of the subject with afterwards a brief description of those results.

Most liked about being a GP amount percentage

Helping patients 6 14,29

Following patients through their whole life 16 38,10

Autonomy 6 14,29

Generalist 12 28,57

The ability to diagnose with little information 1 2,38 Being a GP combines good with the private life 1 2,38 Total (some GPs marked multiple upsides of the

job) 42 100,00

When asking the GPs about what they like about their job most of them answered that a GP has the ability to follow a patient through all the stages of their lives. A GP knows his patients and has a fixed population. All kind of medical aspects are seen, and that never bores.

Downsides of the job amount percentage

Nothing 2 6,67

Non-patient related tasks 13 43,33

Night shifts 4 13,33

Time constraints 5 16,67

Complaints 3 10

Dependent on policy makers at other places 3 10

Total (some GPs marked multiple downsides) 30 100

The downsides of the job, the tasks that GPs rather not perform, are the non-patient related tasks, which cause time constraints. This indicates that there is room for support on these

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points. Support in non-patient related tasks results in more time for the GP to perform patient related tasks. The GPs were asked to list their non-patient related tasks.

Tasks falling under this definition are:  Administrative tasks  ICT  Bookkeeping/financial management  Policy making  Managing

 Negotiating with other

organisations (the GP

group/HAGRO, hospitals,

specialists, health insurers, DDG etc.)  Training  Personnel management  Logistics  Purchase  Maintenance

 Meet the requirements of the health assurer and the government

 Quality improvement/accreditation

Problems amount percentage

No problems 6 30 GP shortage 2 10 Regulation/bureaucracy 6 30 Time constraints 5 25 Rate of change 1 5 Total 20 100

Moreover, when asking about problems when performing their jobs the GPs answer that next to no problems the regulation and bureaucracy are the biggest problems. This concerns non-patient related tasks such as filling out forms in order to be transparent and to deliver accreditation.

Facilitation in non-patient related tasks amount percentage

Wanted 11 55

Unwanted 9 45

Total 20 100

Also when asking for the need of support in non-patient related tasks, 9 GPs say they do not see the advantage of it. On the other hand, 11 GPs have the need of a supporting service.

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Type of support desired amount percentage

None 3 10,00

1 supporting organisation (to differentiated now) 6 20,00 Support in implementing business-related

facilities 1 3,33

A flex pool of medical assistants 8 26,67

An officer for non-patient related tasks 10 33,33

Unite to negotiate with health insurers 2 6,67

Total (some GPs marked multiple support types) 30 100,00

However, when asking what type of support the GPs would like only three GPs said they would not make use of any support at all. The other 6 that earlier said they did not wanted to be supported did say during the interviews that they would like a kind of support. Most of them said they would have a need for an officer for x hours a week/month that could help in performing those non-patient related tasks. A flex pool of medical assistants follows. When an assistant is sick currently all the GP practices have to arrange a new assistant to sit in for the sick one themselves. In worst cases the GP has to pick up the phone himself. This is especially indicated as an important service in sole practices.

Minimum requirements support amount percentage

The person who supports is independent 8 40

For support there is one contact person 1 5

The support is reliable and qualified 6 30

The support is payable 2 10

Does not want support 3 15

Total 20 100

When using a supporting service there are a few minimum requirements. The most important is that the person who delivers the supporting service has to be independent. The GPs are very busy and do not have the time to work someone in and to monitor the whole time; it is important that a supporting employee can come and start to work immediately. Furthermore it is important that the support is reliable and qualified.

Current support amount percentage

None 5 19,23

Nurse practitioner 5 19,23

Practice manager/practice coordinator 1 3,85

Financial manager/Accountant 2 7,69

Spouse 3 11,54

Elann 8 30,77

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ICT 1 3,85 Total (some GPs had multiple types of support) 26 100,00

Currently, there is already support. Some GPs hire a nurse practitioner while others are supported by their spouse. Also ELANN supports GPs. However, a problem is that the GP has to find out everything for himself, which costs a lot of time. If he wants support or he wants to develop something like new consultation hours he has to arrange everything himself. In other situations the GP can ask ELANN to help but when asking the GP has to know exactly what he wants and how he wants it done.

Performing tasks concerning personnel amount percentage

The GP 8 40

The GP together with supporting employee 6 30

The GP together with another GP (in group

practice) 3 15

A colleague GP or a supporting employee 3 15

Total 20 100

Concerning personnel management tasks, eight GPs perform these tasks themselves. Reasons for this are most of all that they want to know their personnel and keep the lines short. Remarkable is that a lot of GPs would like to make use of a service in the form of an assistant pool. When an assistant is sick they could make use of a substitute assistant, this also in case of pregnancies and other situations where a new assistant is needed on short notice. Requirement is that the assistant knows how to work with the GP information system (HIS) so that he/she can start working without requiring instructions.

ICT system (GP information system/his) amount percentage

Omnihis scipio 8 40

Micro his 6 30

Myra 5 25

Post his 1 5

Total 20 100

One ICT system for all GPs amount percentage

Pro 6 30

Con 3 15

Given up hope 3 15

Not one system, but systems have to be

compatible 8 40

A new service for General Practitioners in the province of Groningen: focus on giving high quality care.

A new service for General Practitioners in the

province of Groningen:

focus on giving high quality care.

A new service for General Practitioners in the

province of Groningen:

focus on giving high quality care.

Table of contents

1. Introduction

2. Theoretic framework: service development

3. Methodology

4.Developing a service