The Design and Use of Management Control Systems
in Multidisciplinary Care Centres in Hospitals
Master Thesis, MSc BA, Organisational Management & Control
University of Groningen, Faculty of Economics and Business
January 2014
JOHAN DOUMA
Student number: 1788981
De Sitterstraat 1
9721ET Groningen
(+31) 623573988
Doumajs@gmail.com
Supervisor/ University
dr. B. Crom
Supervisors / field of study
dr. M.J. Siebelink
Abstract
Process orientation recently has entered healthcare organisations. Its main purpose is to improve patient’s journeys through the hospital, primarily in areas of quality and efficiency. In order to accomplish this improvement, currently many multidisciplinary care centres (MCCs) are being formed. One factor that potentially affects the success of these MCCs is the support of a well-designed and correctly used management control system (MCS). Authors have shown worries concerning the appropriateness of existing MCS with regard to the increasing focus on processes. This study contributes to the existing literature in that it provides insights in the design and use of MCS for multidisciplinary care centres in university hospitals. Findings show that different designs and uses of MCS are required in different stages of the centre formation process. Moreover, when designing an MCS, the focus, positioning, responsibilities and funding are important factors to consider.
Table of Content
Abstract ...2
1. Introduction ...5
1.1. Problem description ...5
1.2. Theoretical relevance ...6
1.3. Design of the study...7
2. Theoretical framework ...8
2.1. Multidisciplinary care centres ...8
2.2. Management Control Systems ...9
2.2.1. Introduction ...9
2.2.2. Different uses of MCS ... 11
2.3. MCS in process orientation ... 12
2.4. MCS in healthcare setting ... 13
2.4.1. Introduction to the healthcare context ... 13
2.4.2. Areas of responsibility ... 14
2.4.3. Type of control in hospitals ... 15
2.5 MCS in small growing organisations... 16
2.6 Propositions for the design ... 17
3. Methodology ... 18
3.1. Qualitative research ... 18
3.2. Sampling and Data Collection ... 18
3.3. Data Analysis ... 20
4. Results ... 21
4.1. Background of the Comprehensive Transplant Centre ... 22
4.1.1. Pre-formalisation period ... 22
4.1.2. Formalisation period... 24
4.2. Management control system design ... 26
4.2.1. Focus of multidisciplinary care centres ... 26
4.2.2. Positioning of multidisciplinary care centres ... 28
4.2.3. Responsibilities of multidisciplinary care centres ... 28
4.2.4. Potential indicators for performance ... 30
4.2.5. Funding of multidisciplinary care centres ... 30
4.3. MCS design for the CTC ... 32
4.3.2. Positioning of the CTC ... 32
4.3.3. Responsibilities of the CTC ... 34
4.3.4. Potential indicators for the CTC ... 34
4.3.5. Funding of the CTC ... 35
5. Discussion ... 35
5.1. MCS in stages of the centre formation process ... 35
5.2. Design of management control system ... 36
5.2.1. Focus of the CTC ... 36
5.2.2. Positioning of the CTC ... 37
5.2.3. Responsibilities of the CTC ... 37
5.2.5. Funding of the CTC ... 38
6. Conclusions ... 38
6.1. Theoretical and practical relevance ... 38
6.2. Limitations ... 39
6.3. Future research ... 39
6.4. Acknowledgement ... 40
7. References ... 40
8. Appendix... 46
1. Introduction
Today, most businesses strive in a dynamic, rapidly changing environment that is becoming increasingly complex. Organisations for which this certainly holds are healthcare organisation, and in particular hospitals. Molleman et al. (2010) argued that the complexity increases due to a multiplicity of possible diagnostic and treatment approaches, all requiring extensive specialization, and with patients who are increasingly suffering from comorbidity and chronic conditions. In order to deliver high quality care, collaboration is essential. Hence, in clinical settings, multidisciplinary medical teams dealing with patients with complex health problems, such as cancer, diabetes, organ failure, or chronic respiratory diseases, have become part of everyday life (e.g., Grumbach & Bodenheimer, 2004; Haward et al., 2003; Lemieux-Charles & McGuire, 2006). A recent trend in hospitals is to formalise the collaboration and create ‘multidisciplinary care centres’ (MCCs). Van Harten en Rodenhuis (2012) described their oncology centre as “(part of) a hospital in which oncology patients are being treated multidisciplinary by medical specialists and other professionals who exclusively, or almost exclusively, deliver oncological care”. Similar descriptions hold for other centres delivering different types of care. The focus seems to shift towards multidisciplinary care instead of monodisciplinary care. This emphasis on multidisciplinary care is strongly related to the process orientation in Health Care Organisations (HCOs). Process orientation has been a trend over the last decades in the private sector, but recently has made its entrance into the health care sector and organisations as well. The main purpose of process orientation is to improve patient’s journeys through the hospitals (Karstberg and Siverbo, 2013). Hence, clinical pathways (CPs) are described and used to organise multidisciplinary care by creating lateral connections between those specialisms involved with the particular clinical pathway. Clustering CPs might eventually lead to the formation of multidisciplinary care centres. Therefore, the link between process orientation and centre formation is evident. The main focus of interest in this study is the process orientation that brings with it the abovementioned formation of MCCs in hospitals. In addition, this research focuses on one particular problem of a University Medical Hospital (UMH) in the Netherlands that is introduced in the next paragraph. This hospital currently is structured as a traditional functional organisation, based on specialisms. The kind of process orientation that is focused on relates to a shift towards a matrix organisation, where the traditional structure remains, but is complemented by processes developed for specified patient groups.
1.1. Problem description
exclusively, deliver care for this patient group. Among others, centres are formed around oncological care, patients receiving treatment for cardiovascular diseases, transplantation care, and care related to the spinal column. Similar centres are (most often organically) formed in the hospital of analysis as a step towards a more process oriented health care organisation. Professionals themselves (physicians, surgeons, etc.) initiated these processes, as they argued more collaboration was needed. Starting as informal organisations, MCCs might become formalised and embedded in the formal hierarchy. In this phase, questions arise with regard to the design and control of these MCCs, followed by questions related to how these centres could be embedded in the organisation. To date, (senior) management of the hospital, in collaboration with the heads of care centres, have not been able to design and implement a suitable management control system (MCS) for these centres. Moreover, no suitable approach has been developed on how to smoothly embed the care centres in the existing organisation. Therefore, the problem arises that currently these (organic) care centres are uncontrolled and still informal (i.e. not formalised and embedded in the organisational structure). Hence, this research will attempt to design a management control system for one multidisciplinary centre based on a thorough analysis of existing literature complemented with extensive field research. The case that is analysed concerns a comprehensive transplant centre (CTC). A detailed description of this particular case is presented in chapter four.
1.2. Theoretical relevance
to as ‘internal hybrids’, i.e. collaboration across internal (functional) boundaries of organisations. They argue that research progress is being made in respect of management control and new forms of organisations, but the challenge for management control is ‘to develop concepts and systems that orchestrate both horizontal and vertical relationships’ (p.11). In their review of recent literature, they discuss promising developments that indicated the need for a redefinition of the concept of responsibility accounting (Rowe et al., 2008) by focusing on managing groups of functionally differentiated managers working on common organisational processes. Moreover, they present literature (Dent, 1987; Frow et al., 2005) in which researchers observed deliberate violation of the controllability principle. The aim of this violation was to create tensions encouraging unit managers to engage in informal social interaction beyond functional boundaries. Berry et al. (2008) argue however that much more research is necessary that might “yield insights into how organisations can develop effective rules and procedures to regulate and control horizontal relationships”.
With regard to multidisciplinary care centres, this gap also can be identified. Although literature can be found on the need for, the advantages, and use of centres in hospitals (e.g. Montgomery et al., 2003; Elsayem et al., 2004; Salahudeen et al., 2013), no research has focused on how these centres should be controlled, and for what responsibilities they should be held accountable. Therefore, the aim of this study is to provide new insights in the design and use of MCS for this new form of organisation, with process orientation as a central concept. In order to develop a suitable design for the hospital being analysed, the following research question will be answered: How should a MCS be designed for a multidisciplinary care centre in hospitals, to orchestrate both horizontal and vertical relationships? The following research questions aid in answering the main RQ: What management control mechanisms should be utilised in different phases of successful centre formation processes? What should be the role of the multidisciplinary care centre, i.e. what position will it take in the organisational structure of the hospital? What should the responsibilities be for multidisciplinary care centres and who should be held accountable? How and by whom should the care centre be financed? Before introducing the theoretical framework which aids in answering the research questions, the design of the study is outlined in the following paragraph.
1.3. Design of the study
highlights the contributions of this research, and imitations and suggestions for future research are outlined.
2. Theoretical framework
2.1. Multidisciplinary care centresmultidisciplinary care centre. Healthcare organisation can choose how to position these centres, and what roles they might be given. One opportunity is to give up all functional units and to organise in multidisciplinary centres around the major groups of patients. These centres sometimes are called to be organised around chains, as they include all stages of the patient journey: prevention, diagnosis, therapy and recovery. With this option, full responsibility is given to the care centres and they can be identified as profit centres (being responsible for both revenues and costs). The other possibility is to combine these centres with the existing functional units (i.e. medical departments), which leads to a matrix structure (Durlinger, 2011). Obviously this choice has major implications for the role and responsibilities given to these centres, and how these ‘new organisations’ have to be controlled. As the hospital that is being analysed will not choose to reorganise majorly in the upcoming years, the main focus of this study is to investigate the design and use of MCS in a shift
Figure 1. Organisation of a care program.
towards a matrix organisation. Below, literature will be reviewed on (the use of) management control systems in general, MCS and its utilisation in the context of process oriented organisations, and (the application of) MCS in healthcare the healthcare setting.
2.2. Management Control Systems 2.2.1. Introduction
“provides information that is intended to be useful to managers in performing their jobs, and to assist organizations in developing and maintaining viable patterns of behaviour” (Otley, 1999). Over the years, the content of information in MCS has evolved. Whereas initially the information was focused on the provision on more formal, financially quantifiable information, today it embraces a much broader scope (Chenhall, 2003). The content now includes e.g. also external information (e.g. information concerning customers, competitors and markets), non-financial information (e.g. related to production processes and predictive information), and informal personal and social controls. Management Accounting Systems (MAS) are a key part of MCS in which accountabilities and responsibilities are allocated and organisations are sourced with information (Karstberg and Siverbo, 2013). Whereas MAS traditionally were designed for hierarchical (i.e. vertical) organisations, in process organisations MAS may be complemented to support the horizontal dimension as well. This dimension focuses on the control behaviour and support decisions in processes. Karstberg and Siverbo (2013) labelled those parts intended for horizontal use HMAS, and VMAS for where MAS was intended for vertical use. Next to MAS, management control systems also encompass other controls such as personal or clan controls (Chenhall, 2003). However, Malmi and Brown (2008) stressed the importance to define what should, and what should not be included in the MCS definition. Before the different uses of MCS are discussed, first the definition requires further elaboration.
As the above paragraph has outlined what should (management controls), and should not (decision-support systems) be included in the MCS definition, the next paragraph will discuss possible ways of utilising the MCS.
2.2.2. Different uses of MCS
As this research is exploratory in nature, it is essential to discuss the several uses of MCS that are identified in earlier literature. Although other researchers highlighted other possible uses of MCS (Mellemvik et al., 1988), this research focuses on the two most prevalent utilisations of MCS, including the diagnostic and interactive use (Simons, 2000).
Control function of MCS
Coordinative use of MCS
Next to the two main uses of MCS (diagnostic and interactive), several authors have argued that another use of MCS can be identified. This is known as the coordinative use of MCS. Tomkins (2001) argued that the coordinative use of MCS basically is about the mastery of events. Lean management literature has highlighted the importance of this use of MAS (being a key part of the MCS), emphasising how they help to run processes smoothly (Graban, 2009; and Liker, 2009). Two ways through which the mastering of events can be achieved are identified by Hansen and Mauritsen (2007); through hierarchical coordination, or a non-hierarchical sense of self-coordination. The latter use for coordination gives the coordinative responsibility to actors jointly responsible for the horizontal flow (Karstberg and Siverbo, 2013). A MCS could be used differently in both hierarchical and lateral use, but the importance of a suitable and thus supportive MCS is evident.
A management control system thus could be used diagnostically, interactively, and in addition argued by some authors, for coordinative purposes. It is important to remember the different uses of MCS when designing a new management control system for both hierarchical and non-hierarchical relations in the hospital of interest. Before literature on the use of MCS in the healthcare setting is presented, first the use of MCS in process orientation is investigated to fully understand this key element of the study.
2.3. MCS in process orientation
techniques (e.g. JIT or TQM) were introduced, quantitative and qualitative research showed that process orientation supported by horizontal MAS based on non-financial measures (e.g. quality, throughput, and customer satisfaction) linked to rewards improved performance (Kalagnanam and Lindsay, 1998; Fullerton and McWaters, 2002; Lind, 2001; Van der Meer-Kooistra and Scapens, 2008; and Kennedy and Widener, 2008). Financial measures thus were complemented by non-financial measures. In a review of recent literature, Berry et al. (2008) discussed several studies that show how management control theory has to develop through reconciliation. On the one hand, it should cover the needs for predictability, central control and synergies, but on the other hand it must develop more informal horizontal relationships. One example is to redefine responsibility accounting more broadly (Rowe et al., 2008), in the sense that interdependent activities are included, in which groups of responsibility centre (RC) managers are jointly held accountable for their aggregate performance. Again, this relates to a shift from focusing on a control system for managing vertically, towards using it horizontally through managing groups who work on a common organisational process. Concerning the regulation of horizontal relationships, Van der Meer-Kooistra and Scapens (2004) argue that minimal structures are required to provide rules and procedures, but simultaneously, there should be room left for manoeuvre to enable parties to act in a flexible way, share information and create opportunities for learning.
The above review of literature on MCS in process orientation gives only limited guidance to MCS design and use in process oriented health care. For example, above research does not always specify whether the horizontal MAS operate within a pure process organisations (in which responsibility centres are based laterally around products or customers) or matrix organisation. Furthermore, most research has been conducted in the manufacturing setting. However, it does seem that an orientation towards processes is not facilitated by tightly used vertical MAS or vertically focused MCS. It therefore should be supported by HMAS and MCS containing non-financial measures and rewards as well.
2.4. MCS in healthcare setting
2.4.1. Introduction to the healthcare context
Control in healthcare organisations has gone through major changes over the last decades. A central role could be attributed to the introduction of New Public Management (NPM). NPM is defined as “lessening or removing differences between the public and private sector and shifting the emphasis from process accountability towards a greater element of accountability in terms of results to improve the performance of the public sector” (Hood, 1995; Pollitt and Bouckaert, 2004: 8). The underlying idea of NPM is that through this public-private shift, hospitals are made accountable for their results, aiming to increase accountability for performance, transparency and efficiency (Flynn, 2002; Hood 1991; and Lane 2000). The hospital owner (often the state) is demanded to implement evaluation programmes to assess efficiency and effectiveness. The focus of this research however is on process orientation in hospitals, which according to (McNulty and Ferlie, 2004) could be characterised as a post-NPM movement. Their argument is that process orientation ‘downplays organizational units’ individual responsibilities and instead emphasizes units’ common responsibilities for patients and patient flows’ (p.247).
2.4.2. Areas of responsibility
The process orientation view obviously has a strong focus on collaboration. Of course, collaboration is not a new concept in hospitals and therefore this paragraph will discuss how this collaboration (most often) is controlled for.
Mintzberg (1979) argues that adhocracy or temporary project teams could regulate a performance process in situations where collaboration is a means towards high quality work. In their article, Nyland and Pettersen (2004) state that in many respects, the majority of the work in hospitals can be compared to the work of project teams, jointly performing tasks in patient treatments. The coordination of individuals’ contributions is characterised by mutual adjustment, which is based on rules specifying goals and results. Often, interaction of professionals takes place within limited time periods. However, especially in university hospitals, administrative tasks and care and patient treatment are intertwined activities. Professionals have to rely to a large extent on clan modes of control, considering the coordination of (clinical) knowledge and tasks (Ouchi, 1980). These modes of control depend on professional norms, values and beliefs. According to Ouchi’s framework of clan control, professional bureaucracies seem to best describe the governance structure in hospitals. Based on frameworks of Williamson (1975) and Ouchi (1979), it can be stated that hospitals work under environmental uncertainty. To a large extent, according to Jacobs (1994), this influences the choice of control systems.
in a fragmented hospital make sharing increasingly difficult. However, focusing too strongly on a hierarchical form of accountability may induce negative consequences for individuals and organisations, and ultimately this might even lead to negatively influencing the quality of care. This obviously is not a desired state.
Two main areas of responsibility are identified by Nyland and Pettersen (2004): the administrative and clinical area of responsibility. The administrative area could be identified according to organisational entities governed by hierarchical systems of authority based on individuals’ compliance to rules. The authority system in this first area is based on accounting information used for individual performance evaluation. The second area, the clinical area of responsibility follows patient across accounting entities, and therefore cannot be attributed to autonomous entities in hospitals. The authority system therefore is said to be based on communal values and collaboration.
2.4.3. Type of control in hospitals
Hospital organisations are typified as professional bureaucracies (Mintzberg, 1979). According to Mintzberg, a professional bureaucracy is characterised by a large operating core controlled by professionals, for which standardisation of skills is the main control mechanism. As has been mentioned above, two main types of control can be identified: formal administrative and informal control mechanisms (Abernathy, 1996). Administrative controls include both budgeting and Standard Operating Procedures (SOPs), according to Merchant (1985). Budgeting is described as a ‘results’ form of control e.g. through target setting, where SOPs are an ‘action’ form of control through regulating behaviour by specifying actions. Within a professional bureaucracy however, the professional autonomy and dominance of the operating core constrain the influence of the administrative components. Informal, social controls better suit this professional bureaucracy. Van de Ven et al. (1976) argued that in work units where tasks are highly interdependent or where ambiguity exists with regard to the desired performance standards, informal control is likely to be more appropriate. Clan control, described in the previous paragraph is said to be effective in these circumstances (Merchant, 1985a). These forms of control are found to be consistent with the professional model of behaviour. In this model, professionals often expect the behaviour of themselves and of colleagues to be controlled only through self and peer control processes (Freidson, 1980; Freidson and Rhea, 1963; and Mintzberg, 1979).
measurement. A typical and commonly known hybrid type of management control is the balanced scorecard (BSC). Over recent decades, the management control systems have been ‘modernised’ by many health care organisations (Aidemark and Funck, 2009). Where university hospitals often used the BSC, the introduction of diagnosis-related groups (DRGs) triggered general hospitals to implement responsibility accounting. Departments within hospitals were indicated as responsibility centres through which decision rights and accountability was decentralised (Horngren, Datar, & Foster, 2006). The focus in these hospitals primarily shifted towards financial measurements. Both type of hospitals however of course controlled for quality, being a central performance indicator for hospitals, and other aforementioned non-financial measurements.
The current MCS for the hospital being analysed however are designed for the current functional structure, in which care centres have not been embedded yet. Whenever care centres become embedded in the functional structure, they have to be controlled as well. Therefore measurements and responsibilities have to be assigned to the care centres, complementing the existing structure and MCS. To date, no studies have designed such a MCS for a multidisciplinary care centre, and discussed the consequences for existing management control system. Therefore, this study adds to the existing literature by filling this gap. Before propositions will be presented for the design of MCS, the next paragraph reviews literature on the emergence of MCS in new organisations. This is relevant as this might provide insights on which control systems can be expected to exist in the care centre already. When these systems exist, they might serve as a useful basis for further design.
2.5 MCS in small growing organisations
Simons, 2000, p. 310), and can be found in Merchants’ (1998) personnel controls (formal introduction in the organisations’ culture instead of informal communications), action controls (need for codifying organizational processes because they clarify expectations, facilitate coordination, and simplify control through organizational rules and employee roles) and result controls (the manager does not have enough information to evaluate each member, and as size increases, new employees might put more weight on tangible rewards and they become formalised). Age also is related to the emergence of MCS. First of all, age is related to experience and learning and can only be acquired over time. Processes are executed again and again until a dominant design is chosen. MCS emerge by codifying routines, as routines are part of action control systems (Howard-Grenville, 2002; Nelson & Winter, 1982).
As this paragraph concludes the literature review, the following paragraph introduces propositions that guide the data collection and design of a suitable MCS.
2.6 Propositions for the design
Unfortunately, the existing literature does not provide clear design principles with regard to MCS for multidisciplinary care centres. This reinforces the abovementioned need for research on the design and use of MCS in process orientation in hospitals. The below presented propositions however might aid in developing an appropriate MCS design.
First of all, in growing organisations, informal MCS should shift towards more formal MCS, as an increase in size and scope hinders efficient control and coordination (Davila, 2005). These formal controls (e.g. administrative or cultural controls) enable further growth and development (Greiner, 1972; 1998). However, as a MCC focuses on horizontal dimensions, Van der Meer-Kooistra and Scapens (2004) argue that these organisations only should have minimal structures to provide rules and resources, but simultaneously, there should be room left to act flexible, share information and through cooperation, create opportunities for learning. Thus the increase in formal MCS should restore the opportunity for further growth (through assuring efficient coordination and control), while simultaneously leaving room to act flexible, share information and create opportunities for leaning through cooperation. As none of the above mentioned authors conducted research in a health care environment, one cannot speak of a fully valid design principle. Therefore, the term proposition in used.
organisations (horizontally), care centres should be designed as profit centres, being responsible (and held accountable) for revenues, costs, and non-financial measures (Durlinger, 2011). The alternative, to use MCCs as complements to the existing functional structure. Karstberg and Siverbo (2013) refer to this as a matrix structure, where non-financial measures focused on processes are developed as complements to the existing management control systems. These then might focus on measures such as customer satisfaction, quality and throughput. Also this insight is referred to as a proposition, as it is based on first insights on process orientation in healthcare, not MCC in particular.
These two main propositions should aid in designing a suitable MCS system with clear responsibilities. The next chapter presents the methodology that has been adopted for this research, including the data collection and analysis to find additional evidence for an appropriate design.
3. Methodology
As this research adopts a qualitative research approach, this chapter first shortly explains why this approach is chosen (see paragraph 3.1). Paragraph 3.2 discusses the sampling and data collection procedure, elaborating on the research period, methods of data collection, and the concept of triangulation. Information concerning the data analysis and quality controls of this study are presented in paragraph 3.3.
3.1. Qualitative research
Qualitative research methods facilitate exploration of a phenomenon within its contemporary context using a variety of data sources (Eisenhardt, 1989; Yin 1989, 1993, 1994; Baxter and Jack 2008). This study has an exploratory focus as it investigates the little-understood phenomena concerning the design and use of MCS for multidisciplinary care (Marshall and Rossman, 1999). The emphasis on this study is on description and explanation more than on measurement and prediction, and therefore a qualitative approach seems most appropriate for this research (Fitch, 1994).
3.2. Sampling and Data Collection
aspects of that data for this research, as this provided highly useful insights on the development of the Comprehensive Transplant Centre (CTC), and the current design and use of MCS. Therefore, the data is also analysed and utilised for this research.
The goal of this first data collection period was to explore and assess the scope and focus of the study and provide a solid basis for further data collection. The data resulted from this collection procedure also aided in choosing the right respondents for this study. As mentioned above, data were gathered around the development and formation of the CTC, and highly useful for the identification of the current control mechanisms that are present.
3.3. Data Analysis
As mentioned above, qualitative research facilitates the exploration of a phenomenon within its temporary context. Therefore, data arising from the interviews was coded inductively to explore which MCS and responsibilities were suitable for different stages in the centre formation process, and to identify the factors that influence this decision. The data analysis was conducted following the constant comparative analysis as described by Corbin and Strauss (2008). This method of analysis takes information gathered during the data collection and compares it to emerging categories (Hutchinson, 1993). The coding process consisted of three stages: open coding, axial coding and selective coding (Charmaz, 2006). The coding was executed using Atlas.ti software (Muhr, 2004). During the open coding, codes were collected either in vivo or in the respondents’ own words, in order to organize the thoughts, meanings, ideas of these interviewees into categories. An example of the open coding process is presented in figure 2.
Figure 2. Example of open coding
Next, the axial coding process was executed which included the investigation of categories within their conditional context. The focus of axial coding is to create a model that details conditions that give rise to a phenomenon’s occurrence, as has been described by Brown and Stevens (2002). Therefore, this second stage allowed the researcher to search for relations and connections within the various categories that were identified initially (see figure 3). The third stage of coding entails the selective coding process. Corbin and Strauss (1998) argued that this stage consists of refining and integrating categories around a central explanatory concept or category. For this study, the central explanatory concept is the choice for particular type of responsibility centre (in each stage of the centre formation process).
discussed. Through a comprehensive examination, categorisation and comparison of the data by the researcher, the documents could serve as a basis for the analysis of the current and future (desired) situations.
Figure 3. Example of code to category formation
In order to increase the reliability and validity of this research (Van Aken et al., 2012), several aspects have been considered during the research process. First, during the interviews, statements of the respondents were summarised to confirm the adequacy of the understanding. Moreover, all interviews were tape recorded and transcribed following each interview, and compared to the notes that were taken during the interviews to ensure the quality. Next, the researcher listened to the audiotapes and read the transcripts simultaneously to identify potential errors. Subsequently, transcripts were sent to respondents for review to ensure the quality and adequacy as a last stage of control. As all interviews were in Dutch, data were translated to English by the author who is fluent in English.
4. Results
results arising from the interviews that guide the design of the management control system for the (so far very) successful comprehensive transplant centre, discussed in chapter 4.3.
4.1. Background of the Comprehensive Transplant Centre
While this study is conducted in less than a year, the time horizon of analysis is three years and separated into two main periods. These two time periods were selected after a series of conducted interviews, complemented with a thorough review of documentation (e.g. memos and vision documents). Moreover, the selection of time periods was executed in consultation with members of the CTC to ensure that they represented the most appropriate event windows, capturing the major changes in the newly developed organisation. Members could identify with the selected time periods:
Pre-formalisation (beginning 2010 – beginning 2012); and,
Formalisation (end 2012 – to date).
This time dimension enables the researcher to capture the changes in usage of MCS mechanisms over time. The pre-formalisation period represents the initiation of the CTC and the formation of a guiding coalition leading the change effort. The formalisation period has been commenced and lasts for just over one year now. This period so far can be characterised by first steps towards formalisation concerning the organisational structure, roles, etc. Below, the two stages will be introduced and analysed on the usage of management control mechanisms.
4.1.1. Pre-formalisation period
Approximately three years ago, a symposium was organised at which trans-disciplinary, transplant related topics (e.g. nutrition and dietetics, physiotherapy) were discussed. Professionals from various disciplines and levels were invited and exchanged experience and ideas on transplant related care. They noticed that although they worked in the same organisation and field, little was known about care practices of other disciplines. One manager stated:
“Professionals from different disciplines explored that other disciplines developed procedures or approaches that could be useful for their own discipline as well. They found it rather odd that they worked under the same roof, yet didn’t know exactly how other disciplines worked.”
MM 1: “Head of departments, who have a lot of power in this organisation, always opposed these initiatives concerning centres as this transcends their power. These initiative threaten their revenues and cash flows”
MM 2: “Project leaders seemed to rather pursue their own interest instead of achieving the common objectives.”
The common objectives of the current centre formation process were similar however to earlier attempts: increase the quality of care for transplant patients, enhance efficiency of working practices, and promote the UMC as the hospital for transplant related care. After the symposium, representatives of all disciplines dealing with organ transplantations (e.g. heart, lung, and kidney) were invited to a meeting arranged by the initiator of the project, to explore where potential added value could be identified. The representatives consisted of medical specialists, known for their expertise in transplant care in their field. This group of professionals was deliberately chosen, as the underlying idea was these discussions had to be content focused, not power or finance related. If e.g. the heads of departments were invited (like the approach in previous attempts), the discussion logically would shift from content, to protecting departmental or personal interests, whether this is power or financially driven. Potential added value was identified related to e.g. quality and efficiency, in three main pillars of a university medical hospital; care, research, and education. A shared urgency for collaboration was created and the informal organisation was born. The initial guiding coalition consisted of eight professionals, remaining stable over the first year. As support was provided by the Board of Directors to continue this development of the CTC, the comprehensive transplant centre could take next steps and grew in both size and scope. In addition to the support of the BoD, the important norms and values creating a very open culture contributed to a significant increase in members as the guiding coalition grew from 8 to 55 members in two years:
Man1: “We always advocated a culture of transparency and openness in which professionals can visit our meetings and join the coalition if they desire to do so.”
plans, have to be done in professionals their ‘own’ time as these activities are not part of their normal tasks.
4.1.2. Formalisation period
The formalisation period (entered approximately one year ago) is identified by respondents as a rather difficult period. As mentioned above, earlier attempts failed during this stage as the conversations shifted towards power and financial issues. Some reactions showed this difficulty:
MM 2: “The formalisation of other centres caused many difficulties. In those centres, still no head is appointed as stakeholders cannot agree on who this should be.”
MS 1: “For other disciplines formalisation can be an obstacle. If transplantation would be pulled out of the monodiscipline, this will cause major problems due to power and financial reasons. One should be very careful.”
However, respondents also stressed the need to formalise:
MS 1: “This is the right time to formalise. If we wait much longer, we will lose the enthusiasm of the professionals.”
Man2: “Formalisation is necessary in order to guide and control the CTC, and to assure progress is being made.”
A paradox therefore emerges, resulting in the question what degree of formalisation is desired in this stage. The need for formalisation also related to the growth in size and scope of the guiding coalition. As mentioned in the previous paragraph, over time, the CTC grew in members from 8 to 55. The manager of the centre felt the need for structure:
Man1: “The organization becomes too large for me to manage efficiently. I cannot constantly keep every member up to date and chair every meeting that is organized. In order to increase our efficiency again, we need more coordination and structure.”
A new organizational structure that has been developed is shown in figure 4. One can see that the three key pillars of a university hospital serve as a basis: care, research and education. Task forces were installed around these three pillars, each consisting of a multidisciplinary group of professionals. With regard to the responsibility of these task forces, a manager argued:
Board of directors
Steering Committee
Training &
education Patient care
Transplant
policlinic Communication
Maintainance
equipment Donation
Research
Figure 4. The contemporary organisational chart of the Comprehensive Transplant Centre
This latter plan however has not been executed to date, as the leader still chairs every meeting of the task forces. Through the development of task forces, to a greater extent it became evident what areas are covered by the transplant centre. Increasingly, people know what is, and what isn’t expected from them. Also, structural meetings were introduced for both the steering committee and task forces with a desired frequency of once a month. Some initial goals (formulated around the three pillars of the hospital) have been set, but no clear responsibilities have been assigned to the task forces for which they can be held accountable. For example, one of the major objectives of this centre is to develop a transplant policlinic, where all transplant related patient visits, consults, and meetings can be organised. However, to date the steering committee neither has prioritised these goals, nor has set any formal deadlines. For these goals to be achieved, financial resources are a prerequisite. Currently, when financial resources were needed, either the sector directors of the hospital, or the BoD provided these funds. This however is not a continuous flow of funding, but is rather sporadic. A design for structural funding is needed.
Thus, although some first steps towards formalisation have been set, the question arises how many steps should follow, i.e. what aspects should be formalised at which stage of a successful centre formation process. Respondents differed in this respect:
Medical Specialist 2: “You should formalise the collaboration first, and not create a totally separate entity from the start. This leads to financial and power issues”
Medical Specialist 1: “It is about time that new structures are formalised, and the CTC becomes embedded in the existing organisation.”
However, one key aspect is evident: without a certain extent of formalisation, the organisation cannot be embedded in the existing organisation (for the existing organisational chart, see figure 5). Thus, albeit the above results show that first steps in the formalisation period have been taken, major steps are still necessary to assure progress is being made. At this point of the centre formation process this research is conducted, with the aim to design a suitable management control system, building upon the already existing management control systems.
Figure 5. Organisational chart of the university hospital (in Dutch)
4.2. Management control system design
As mentioned above, this second part of the result section presents the main findings resulting from the interviews that were conducted with the second group of respondents in both university hospitals (UH) and general hospitals (GH). These interviews showed interesting results in the following areas: the focus, positioning, responsibilities, performance indicators, and funding of the multidisciplinary care centres. These areas were either deliberately asked for during interviews (see appendix 1), but some also arose when analysing the data. Results therefore will be presented and structured based on these areas.
4.2.1. Focus of multidisciplinary care centres
can be separated in an external and internal focus. The external focus seems to relate to the market and was salient across respondents:
UH1: “We have an oncological centre. This is the oncology theme, complemented with all organisational areas that participate in providing oncological care or research. These disciplines together are positioned in the market as the oncological care centre.”
UH2: “The centre could function as our calling card for the insurers and patients. It could enable us to keep certain care in-house and is good for PR activities.”
In addition to the external importance, also potential added value can be identified internally. Multiple respondents referred to the organisation of care, and the potential gain that could be achieved when focusing primarily on care chains (processes):
GH1: “Albeit every discipline (specialism) has optimised their processes internally, still problems could occur in the care chain. It is this multidisciplinary process where the largest potential gain is situated.”
UH4: “The ultimate focus is to organise care around the patient, or patient groups. Care centres might be a very suitable organisational form for achieving this.”
Similar statements concerning the role of multidisciplinary care centres were stressed by other respondents. The shift towards process-thinking is also highlighted:
GH2: “A patient often visits multiple physicians and they often do not stay in one discipline. I think we are moving towards process-based control, and perhaps even towards product-based or customer-product-based.”
This process- and multidisciplinary element is practically evident in clinical pathways and clinical trajectories (the latter including the total journey of patient through the hospital). Clinical pathways, formal procedures and descriptions of processes, are described and used in all hospitals that have been visited. The primary reasons for the description of clinical pathways included:
UH3-2: “Quality, but also patient satisfaction and efficiency. You rather don’t ask the patient several times to visit the hospital for a diagnosis. The main focus is to provide high quality care as efficient as possible, from diagnose, to treatment, to follow-up.”
Centres could be formed by clustering the clinical pathways, and thus combining processes. This process orientation is strongly related to the structure of the organisation, and the question where to position multidisciplinary care centres.
4.2.2. Positioning of multidisciplinary care centres
Across respondents (and thus also hospitals), the positioning of multidisciplinary care centres is still quite problematic. One care centre manager of UH3 argued:
“Currently we are still positioned outside the existing structure. For the time being it is designed as a matrix organisation, and our centre can be described as a virtual, instead of a physical centre.”
This confirms that care centre, like the transplant centre, have not been embedded yet in the existing structure. The question on how to embed the multidisciplinary care centres is answered differently with regard to long run. Within the short term however, similar responses were noticed, e.g.:
UH1: “For the long run we are still working on the position of these centres. Within a few years though, I do not see the whole organisational structure being tilted and organised in comprehensive care centres, i.e. from a vertical towards a horizontal organisation.”
For the long run, some argue that the existing structure will prevail and is complemented with multidisciplinary centres, while others do see a major structural change towards centres instead of the current specialisms. Several controllers however mentioned the potential difficulties of a pure matrix organisation:
UH3-1: “It is highly difficult for controllers to maintain a correct overview in a pure matrix organisation”
UH1: “Centres and specialisms (departments) can coexist, but than one should be held responsible for financial performance and budgets. A joint budgetary and financial responsibility would create a mess, as it becomes increasingly difficult to separate aspects from one another. “
The latter remark emphasises the importance of clear responsibilities for both the specialisms and care centres in order for them to be controlled properly. The next paragraph will discuss the results concerning this area.
4.2.3. Responsibilities of multidisciplinary care centres
UH5: “Whenever the hospital is being organised in centres, you should establish responsibility centres. These then function as a hospital within a hospital, and can be classified as profit centres.”
Full responsibility for both financial and non-financial measures resides with the comprehensive care centre in this scenario. A controller from UH2 however stated:
“A profit centre seems odd to me, as we are talking about non-profit organisations. I would therefore prefer the term responsibility centre, with quality being the main responsibility.”
When the functional units (specialisms) and comprehensive care centres coexist, these responsibilities have to be clearly identified and separated, according to several respondents:
UH3-2: “The ultimate responsibility either resides with the functional unit, or the centre. Not both partially.”
UH4: “Physicians should stay under control of their own functional unit, as the medical responsibility resides with the backbone of specialisms. Others cannot judge them.”
To the question on what then should be the responsibility of a multidisciplinary care centre in a structure that coexists with the existing functional structure, respondents were unanimous in stating this should concern non-financial responsibility, i.e. process focused responsibilities. Only if the hospital was to change its structure radically towards centres, the centre should be held responsible for both non-financial and financial measures.
The first step towards process orientation as respondents mentioned, entailed the descriptions of clinical pathways. According to multiple respondents, these pathways enable control in several areas:
GH1: “Primarily quality, but also patient satisfaction and efficiency”.
UH1: “The clinical pathways started from a quality perspective but, over time, I see also patient satisfaction and perhaps even financial responsibilities being incorporated.”
With regard to process orientation, and in this case the clinical pathways, difficulties arise with regard to who should be the owner of such a clinical pathway. In some hospitals the head of the port specialism becomes responsible for this process. Other hospitals show a joint responsibility, each for its own part. The conclusion can be drawn from the interviews that assigning responsibility can be problematic, i.e. so far no best solution has been found. Providing efficient and high quality care on a clinical pathway requires increased collaboration. When asking how this could be achieved, a controller noted:
UH1: “one could cluster clinical pathways within a multidisciplinary care centre, and make it e.g. a responsibility centre.”
Thus, concerning process orientation, (in forms of clinical pathways and when clustered, care centres) focus is given to non-financial measures that make processes more efficient and enhance their quality. The next paragraph therefore will elaborate on the performance indicators that relate to this focus on processes.
4.2.4. Potential indicators for performance
As mentioned in the previous paragraph, non-financial measures for performance are most suitable to be linked to a comprehensive transplant centre, where the centre is added to the existing organisational structure. Main areas in which indicators should be looked for are quality, efficiency, and goal achievement through collaboration. The following table presents the indicators either mentioned by respondents, or process-oriented indicators found in documentation.
4.2.5. Funding of multidisciplinary care centres
In the first group of respondents, as the above presented results show, clear evidence was found regarding the finance-related difficulties when considering the centre formation process. Financial issues were identified as a main barrier towards the formation of the comprehensive transplant centre. This was confirmed by the second group of respondents, as a respondent noted:
UH3-1: “Professionals do find each other considering multidisciplinary ideas. Unfortunately, every time it fails due to money issues. Apparently we have determined the allocation of financial resources too strictly, as there is no room for these initiatives”.
Indicator Definition
Patient Care Quality
Quality of life, post-transplantation
Number of complaints
Patient satisfaction
Patient participation Efficiency
Average length of stay
Average bed occupancy
Occupancy policlinic
Mental and physical conditions after transplantation
Number of registered complaints Scores on patient satisfaction survey
Involvement of patient representative groups in decision-making
Number of hospitalisation days/ number of stays Number of hospitalisation days/ bed capacity 1-(number of cancellations + number of reschedules + number of no-shows)/total of planned consults
Research and Education
Number of publications
Number of top publications
Level of education and training on transplant care
Set up education regionally and (inter)nationally
Number of publications in journals related to (multidisciplinary) transplant care
Number of publications in top 10% journals Level of accreditations
Number of students Goal achievement
Realisation of short term goals
Realisation of long term goals
Number of multidisciplinary (knowledge sharing) meetings
Realisation of goals set for within one year Realisation of goals set for over a year Number of formal meetings where
multidisciplinary teams share knowledge and information
Table 1. Potential indicators for the CTC, based on respondents and documentation
However, as was also mentioned, financial resources are needed to execute the plans and to make progress towards a formalisation. Again, the funding is closely tight to the positioning of the care centre, as discussed above. When hospitals will be organised into centres, they might be appointed as profit centres and thus be responsible for their own revenues. The current situation for the CTC is different however, as it aims to complement the existing organisational structure. To date, financial resources were requested centrally (i.e. from the BoD):
UH3-2: “Besides the allocation of financial resources towards the sectors and specialisms, there is budget left and is allocated to projects, initiatives, etc. by the BoD. We need this to execute projects and plans. It is an alternative in pending on a model in which care centres are embedded”.
UH4: “By showing the added value, and concrete results of finished projects, scepticism will decrease which makes future embedding easier”.
Whenever this added value is shown, structural financing of the centre could be provided by either sectors or specialisms. This financing could be exercised e.g. equally or proportionally (e.g. activity-based), according to respondents. Managers then could be held accountable for the results of the projects by the Board of Directors and other disciplines.
Having presented the results on the focus, positioning, responsibility, indicators and funding of multidisciplinary care centres, the next paragraph presents the possible new design of multiple MCS.
4.3. MCS design for the CTC
The design of the management control system will be structured utilising the same areas that have been presented in the previous chapter, including the focus, positioning, responsibilities, indicators and funding of the comprehensive transplant centre (CTC).
4.3.1. Focus of the CTC
In order to design an appropriate MCS, it is important to discuss the aim and focus of the CTC. Two main areas can be identified: an internal and external focus. The former concerns the positioning of the university hospital as the place to be for high quality transplant related care. It is to strengthen the position in the market, by becoming uniformly visible for patients, insurers (e.g. joint negotiations) and grant providers. The internal focus points towards process orientation, and the potential gain in quality and efficiency that can be achieved through increasing collaboration. Crucial however in the formation of the CTC is the credo of ‘adding without taking away’. This phrase results from the previous attempts that failed caused by power, autonomy and financial issues. The perception in previous attempts was that these centres were about to take autonomy and revenues away from the specialisms and they resisted cooperation as a result. Therefore, it is important that everyone within the CTC speaks uniformly about the centre, its vision and mission. Therefore, official mission and vision statements, and statements of purpose should be developed, and accessible to everyone in the entire organisation. This increase in cultural control strengthens the identity and shows that only improvements should be expected, not a loss of power or autonomy.
4.3.2. Positioning of the CTC
Figure 6. Potential positioning of the CTC in the existing structure.
structure. The back bones (main medical specialists) remain in the vertical structure, but a horizontal dimension is added with the formation of MCCs (see figure 6), under direct responsibility of the BoD. The implications for its responsibilities and funding will be presented in the following paragraphs. This horizontal dimension preferably stimulates horizontal relationships characterised by collaboration, information sharing, learning and flexibility. In order to realise this desired state, the organisational structure of the CTC should be designed accordingly, as structure could be used as a control device encouraging certain types of contacts and relationships. Hence, a flat organisational structure for the CTC seems most appropriate with a strong decentralisation of decision-making. This in line with respondents, as they stated that those possessing the expertise should be the ones making decisions, not the ones that are hierarchically responsible. The steering committee should consist of two or three members of the management team (responsible for the daily control and acts as communicator to higher management on behalf of the CTC), and preferably all six chairs of the task forces. Next to the increasing coordination and control possibilities, this form has two major advantages, as it keeps lines of communication between task forces and between task forces and steering committee as short as possible (highly important for e.g. sharing information and flexibility), and the vision and direction of the CTC can be translated directly from the steering committee to the task forces through the chairmen. In addition, a fitting governance structure should be adopted (e.g. implementing structural meetings and meeting schedules) to ensure and control the desired collaboration and facilitation of learning.
4.3.3. Responsibilities of the CTC
First and foremost, the CTC being of complementary value, it is important to note that clinical responsibilities has to reside within the back bone (medical disciplines), as is also state by law. Also, financial and budget responsibility should reside with the functional units (medial specialisms), as the credo is ‘adding without taking away’. Previous attempts to centre formation failed because of financial and power issues, and therefore these areas should not be entered if possible. Moreover, controllers argued the difficulties when providing partial financial responsibilities to the MCCs. Pure matrix organisations are highly difficult to control, according to the respondents. The added value of the CTC can be found in non-financial responsibilities, as is shown in theory and by respondents. Perhaps the overall responsibility for the first couple of years, is to show the added value to the BoD (who financially supports the CTC, see 4.3.5.) and the departments (“to eliminate their scepticism”, as a respondent noted). The added value can be shown internally and externally, as shown in paragraph 4.3.1. Externally, as a uniform transplant centre, and central contact point for patient-organisations, insurers and grand providers. Internally, the added value can be found within the process orientation and collaboration of multiple disciplines; i.e. top quality care, research and education and an increase in efficiency. Performance measures on these areas are presented in the following paragraph.
In order to reach this point where added value is shown through convincing results, tighter control is needed. First, the steering committee has to prioritise short term goals (less than a year) and long term goals (more than a year). Then, deadlines have to be set at which specific goals have to be achieved, not only to show the added value, but also to ‘keep members committed and involved’ as a manager noted. This tighter control is needed, as to date it is too informal (no-strings-attached). However, when money is invested by the BoD, a return obviously is demanded.
Having discussed which areas of responsibility should be appointed to the CTC, and how they should be controlled for, the following paragraph will present the possible performance measures.
4.3.4. Potential indicators for the CTC
4.3.5. Funding of the CTC
Findings clearly showed that until the added value has been shown, the CTC has to be financed by the BoD or sector directors by providing project funding. As previous attempts to develop transplant centres failed because of financial and power issues, the discussions around these topics should be evaded first. By showing vast improvements on the indicators presented, scepticism will decrease and doors will be opened that were closed before. Then, the CTC should not be financed through ‘project based funding’, but structurally by either the sector directors or the disciplines involved in the CTC. They might agree on providing financial resources equally, or based on activity.
5. Discussion
This study uses theory and research data to design an appropriate MCS for a multidisciplinary care centre in a university hospital. Process orientation in hospitals needs a supportive MCS design in order for care centres to be successfully developed and used. The theory and evidence presented are important additions to the management control literature, because prior research does not consider MCS design and use in multidisciplinary care centres in hospitals focused on process orientation. Below research questions will be answered to show consistencies and inconsistencies with, and contributions to the theoretical framework.
5.1. MCS in stages of the centre formation process
Thus, although the formalisation period has not been completed, research data revealed that some MCS already are present. They are required to ensure efficiency, and to make sure progress is being made. This need was mainly due to the increase in size and scope of the MCC. One of the first steps towards a more formal use of MCS was to design an organisational structure, due to the inefficiencies resulting from having no structure at all. Multiple authors have identified organisational structure as a control device, as it can encourage certain types of contact and relationships (Abernethy and Chua, 1996; Alvesson and Karreman, 2004; Emmanuel et al., 1990). Malmi and Brown (2008) consider organisational structure as an administrative control system. As it was important to still grow organically, a flat organisational structure was chosen to stimulate collaboration, discussions on content, flexibility, and decentralised decision-making. This desire resulted from past failing attempts to centre formation, where discussions focused on power and autonomy issues instead of content. Therefore, minimal structures were designed, being consistent with the proposition based on Van der Meer-Kooistra and Scapens (2004), where internal hybrids require minimal structures to provide rules and resources, but at the same time leave room to act flexible, share information and create learning opportunities.
To conclude, in the successful pre-formalisation period the interactive use of clan control mechanisms are desired to encourage collaboration, freedom to create ideas, and growth in size and scope. The start of the formalisation period, thus far successful as well, required an increase in more formal MCS (e.g. administrative controls), due to the increase in size and scope. The next paragraphs will discuss the other research questions.
5.2. Design of management control system
5.2.1. Focus of the CTC
5.2.2. Positioning of the CTC
The research data confirmed the choice concerning the positioning and thus role of the MCC (Christis, 2011): either organise the entire organisation as a horizontal, process organisation structured around care programs, or position the MCC as a complement to the existing functional structure. Respondents argued that this choice majorly influences the associated responsibilities and design and us of the MCS, which is consistent with research of Durlinger (2011). During interviews, respondents also stressed the influence of this choice on the organisational structure of the MCC. When given a complementary role, i.e. being positioned as complement to the existing structure, respondents argued only some structures are required to coordinate and control activities within the centre. The structure should not hamper collaboration, flexibility and learning. This is in line with research by Van der Meer-Kooistra and Scapens (2004) on other settings who argue, concerning the regulation of horizontal relationships, that minimal structures are required to provide rules and procedures, but simultaneously, there should be room left for manoeuvre to enable parties to act in a flexible way, share information and create opportunities for learning. Zuurbier and Hartmann (2012) confirm the advantages of decentralisation, consisting of 1) more local information, better decisions, 2) increased involvement and motivation, and 3) flexibility.
5.2.3. Responsibilities of the CTC
whereas the latter has a strategic focus and establishes goals and actions for the medium and long run.
As the research data revealed, in order to reach these goals with the provided financial resources, tighter and more formal management control is needed. This shift from informal to formal management control seems to be explained by a different use of MCS, as explained in the theoretical framework. Whereas more interactive mechanisms were required to date (such as discussion, informal meetings and events, mission statements), data revealed the shift towards rather diagnostic mechanisms such as goal setting, schedules, formal meetings, and project plans (Dornbusch and Scott, 1975.) to control the ‘projects’ that are being started. Important to keep in mind, especially when working with professionals, is that if controlees have the possibility to participate in the design of the control process, they are more likely to accept control which makes it more effective (Nieminen and Lehtonen, 2008). Through the whole process, the coordinative use of MCS seems to be evident (the mastery of events), which is consistent with findings of Karstberg and Siverbo (2013).
5.2.5. Funding of the CTC
Consistent with Christis (2011), research data showed that only when organising around care programs (and thus MCCs), these centres should be responsible for their own revenues. Otherwise, respondents provided clear insights that, until the added value has been shown, the MCC has to be financed by the BoD through project funding. As previous attempts to develop transplant centres failed because of financial and power issues, the discussions around these topics should be evaded first. By showing the added value, scepticism will decrease and doors will be opened. By then, those specialisms will notice the added value for the process or their group of patients, and will be more likely to support a structural funding e.g. equally, or based on activity (Activity Based Costing, Kaplan and Cooper, 1991).
