Patient-centeredness makes
the difference
- Part of the culture investigation at UMCG -
Gerjan Prins Student number: 1343319 Zuiderwalstraat 4 8081 CD Elburg Phone: 06 - 43 55 45 23 Email: gerjan_prins@hotmail.com University of Groningen
Faculty of Management and Organization MscBA Change Management
Landleven 5
Zernikecomplex Paddepoel 9747 AD Groningen
Internal supervisors
Prof. dr. J.I. Stoker & dr. C. Reezigt Internship institution / external supervisors Universitair Medisch Centrum Groningen (UMCG)
Drs. L.J. de Jong
Drs. M.R.M. Felten & drs. A.A.A.M. Koek Hanzeplein 1
ABSTRACT
TABLE OF CONTENTS
1. INTRODUCTION... 4
2. THEORETICAL BACKGROUND... 8
2.1DEFINITIONS OF PATIENT-CENTEREDNESS... 8
2.2PATIENT-CENTEREDNESS... 9 INTERMEZZO ... 10 2.3CONCLUSION... 12 3. METHOD ... 13 3.1QUESTIONNAIRE... 13 3.2DATA COLLECTION... 13
3.3SAMPLE AND RESPONDENTS... 14
3.4VALIDITY... 15 3.5RELIABILITY... 16 3.6MEASURES... 17 3.7ANALYSIS... 17 INTERMEZZO ... 18 4. RESULTS ... 19 4.1SECTOR LEVEL... 19 4.2DEPARTMENTAL LEVEL... 20 4.3FUNCTIONAL LEVEL... 22
4.4PATIENT-CENTERED ATTITUDE... 24
5. DISCUSSION ... 27 5.1SECTOR LEVEL... 27 5.2DEPARTMENTAL LEVEL... 28 5.3FUNCTIONAL LEVEL... 28 INTERMEZZO ... 29 5.4CONCLUSIONS... 29 5.5COMMENTS... 31 5.6LIMITATIONS... 32
5.7INDICATIONS FOR FURTHER RESEARCH... 33
1. INTRODUCTION
Today’s health care sector has to deal with demands and requirements of a changing financing structure, market mechanism and demands of patients. In order to meet those challenges the management of the Universitair Medisch Centrum Groningen (Academic Medical Centre Groningen; UMCG) has decided to reorganize the organization structure, and with that also the way of working. The new structure will be arranged around patient care processes and, in order to make this as efficient and effective as possible, existing departments will be clustered together into six sectors. As a result of this, employees need to work more in teams and need to cooperate with each other in a more extensive way. Because of that, not only the structure of the new organization plays an important role, the culture is important as well. Especially CRAZ (Customer Council Academic Hospitals) and the Works Council emphasized the significance of a cultural change as a condition for a successful organizational change. The management of UMCG has stated the request for an examination of the present culture of the organization. Based on this examination they would like to know characteristics of the present situation which are relevant for the well functioning of the new situation.
Underlying the reorganization, the following four principles can be stated (UMCG, 2005:9) which are also the principles for the new patient-care organization:
Focus on the patient
The management of UMCG wants to adjust the provision of care to the needs of the patient. The nature of the disorder, therefore, will become the starting point for designing and organizing the patient care routes.
Motivated employees
The management of UMCG wants to achieve that employees are motivated to work and have their jobs with pleasure. This will be achieved by giving them joint responsibility to design their daily work. Within a clear framework, employees get space to provide quality.
Adaptability
The management of UMCG wants to design the organization in a way that it is able to adapt to fast changing demands of the environment. This requires flexibility from employees as well as from the organization, and resources need to be placed where the need is the highest. Informal synchronization
The management of UMCG wants a structure which gives space to informal synchronization of activities. This will be achieved by putting the responsibility with clarified groups with a clear set of tasks and by putting the common support close to the primary process. This results in less formal rules and procedures.
In order to give an extensive overview of the present culture of UMCG, the research will focus on four main themes: leadership, interpersonal relationships, autonomy and patient centeredness. This research will focus on the theme of patient-centeredness.
It is important to have a clear overview of the present and new organization when comparing both with each other. Therefore, this research starts with an overview of the key variables (relating to the theme of patient-centeredness) of the new organization. These variables are to a large extent based on available literature about the new organization (UMCG, 2003; UMCG, 2004; UMCG, 2005) and on conversations with employees of UMCG.
With a paradigm shift in health care during the past few decades, the patient-centered approach has been widely acknowledged as a crucial determinant of high-quality care (Ishikawa et al., 2005). Mead and Bower (2000: 1087) also state that “a patient-centered approach is increasingly regarded to be crucial for the delivery of high quality care by physicians”. Various studies have indicated that at least some elements of patient-centered consultation have positive consequences on patient health outcomes as well as utilization of health care resources (Ishikawa et al., 2005). Little et al. (2001) found that patients want a patient centered and positive approach. If they do not get this, they are less satisfied, less enabled and may suffer greater symptom burden (Little et al., 2001).
UMCG is also realizing that patient-centeredness is a very important theme in a world of competition for grace of the patient. Because all employees of UMCG have to work patient-centered in the new structure, it is important to have a clear overview of the differences between the present and the new organization. Therefore, an overview of the new organization will be given first.
New organization
Task groups
UMCG states that an efficient and effective treatment of patients with different and complex illnesses is only possible by putting employees of different expertises together. This means that different disciplines will cooperate horizontally in teams to serve the patient in the best possible way (UMCG, 2004: 16). At least two disciplines (dermatology and neurology for example) are structurally involved in the care process of a patient category in a task group. The task group is an independent medical basis entity of multidisciplinary patient care. A care process will comprise all the operations around a specific patient category, where the continuity of care is an essential point of interest. Putting employees of different expertises together make it possible to coordinate care for unique patients with different, complex illnesses in an efficient and effective way (UMCG, 2004). A multidisciplinary team consists of physicians from different disciplines, and of care supporting employees, guided by a medical coordinator. The medical coordinator is the functional leader of the task group and coordinates the whole care process. Concluding, task groups lead to more patient-centered care, which has to be achieved by more personal attention for each patient, more mutual communication and better communication to patients, and a focus on the whole care process in stead of focussing on the own department. This means that employees have to change their behaviour when working in task groups.
Patient categories
Each patient is unique, but hardly any patient has a unique illness. It is the task of the physician to recognize a pattern in the presented illnesses, which should be the starting point for closer research and therapy (UMCG, 2004: 17). A group of related illnesses can be bundled to a coherent category, for example diabetes, breast cancer or infertility (UMCG, 2004: 17). A group of patients with related illnesses form a coherent patient category together. The care process take the care needed for a specific patient category as starting point, and will be arranged that way. The physicians concerned with the care for a patient category will form a task group together. To make patient categories a success, the management of UMCG has to emphasise employees to think and work in care processes. The whole care process of a patient category has to be known by all employees concerning this category.
Characteristics new organization
From the principles underlying the reorganization can be concluded that the present organization differs from the new organization on several important aspects. The organization should be organized around the patient and it will be important to look to his1 wishes and expectations. The present organization however is based on wishes and demands of employees and facilities. The responsibility for a patient often stops presently at the ‘wall’ of a department. In the new organization each employee has to contribute to the whole care process and chain care should be the leading principle by organizing the care processes. Another difference with the present organization is that more cooperation between departments in the new organization is needed. In the present situation, most departments do not cooperate closely with each other. To put the patient in the centre, departments have to cooperate more in order to serve the patient in the best way possible. At last, mutual communication as well as communication to patients are important themes of differences. In the new organization more attention is needed for communication to patients and their families. The mutual communication has to change also to overcome misunderstanding in the care process, and the communication to the patient. Concluding, the starting point within the
1
new organization are the needs of the patient and it is important to measure to what extent the present situation satisfies the requirements of the new organization.
From the above described new situation can be concluded that patient-centeredness has clear implications for all employees of UMCG. The structural changes will result in an adjustment of the way of their daily work and way of behaviour. However, to successfully change the organization, the consequences should be taken into consideration. Therefore it is important to have also a clear picture of the present organization. When both situations are known, characteristics of the present situation which are relevant for the well functioning of the new situation can be indicated. It is important to know which characteristics of the present situation can make it easier to change (advancing factors) or make it harder to change (obstructing factors) to the new situation. The main question of this research is therefore: Which obstructing and advancing factors in the present culture can be indicated when the present structure is changed to the new structure?
Advancing factors are factors which are the same in the present structure as in the new structure or which satisfies the requirements of the new structure. These factors will not make the reorganization more difficult. The obstructing factors on the other hand are those factors which make it harder to change from the current structure to the new structure, this because there is a large discrepancy between the current situation and the new situation.
2. THEORETICAL BACKGROUND
2.1 Definitions of patient-centeredness
Before researching which characteristics of the present culture are important when changing to the new structure it is of course important to know how patient-centeredness can be defined. In the past 30 years, an extensive body of literature has emerged which has been advocating a ‘patient-centered’ approach to medical care (Mead and Bower, 2000). Many definitions of patient-centeredness are presented in the literature. In the table below some definitions are stated which all have some aspects relevant for UMCG.
TABLE 1
Definitions of patient-centeredness
Author Definition
Balint (1969) Understanding the patient as a unique human being
Byrne and Long (1976) Patient-centeredness represents a style of consulting where the physician uses the patient's knowledge and experience to guide the interaction
McWhinney (1989) Patient centered approach is an approach in which “the physician tries to enter the patient's world, to see the illness through the patient's eyes”
Grol, de Maeseneer, Whitfield and Mokkink (1990)
Giving information to patients and involving them in decision making have also been highlighted
Laine and Davidoff (1996) Patient-centered care is “closely congruent with, and responsive to patients' wants, needs and preferences”
Lowes (1998) Patient centered, in this context, means treating patients as partners, involving them in planning their health care and encouraging them to take responsibility for their own health
From the above stated table can be seen that all definitions contain aspects of personal attention to patients, involving the patient in the caring process and informing the patient about their treatment. All these aspects are also relevant and important for UMCG. These definitions comprise of only a small segment of used definitions in research on patient-centeredness. Lack of a universally agreed definition of patient-centeredness has hampered conceptual and empirical developments (Mead and Bower, 2000). With this information on the background, the following definition is used during the research process: “patient-centered care is closely congruent with and responsive to patient’s wants, needs and preferences by understanding him as a unique human being and uses the patient's knowledge and experience to guide the interaction”.
shown how elements of patient-centered care positively affect patient satisfaction, trust, and psychosocial outcomes, as well as health and functional status (Duggan et al., 2005). On the basis of such evidence it is fair to conclude that patient-centeredness leads to better outcomes for patients (Duggan et al., 2005). Therefore, also seen the situation in the health care market, it is very appropriate that UMCG stimulates and facilitates patient-centeredness.
2.2 Patient-centeredness
Now a definition of patient-centeredness is given, different elements of patient-centeredness which are of importance for UMCG can be taken into consideration. From the several different elements of patient-centered care that have been described in the literature (e.g. Bensing, 2000; Epstein et al., 2005; Mead and Bower, 2000; all in Zandbelt et al., 2006), this research will focus on observable variables of patient-centeredness, which can be noticed by patients directly, and which correspond to the new UMCG organization. In relation to this, multidisciplinary cooperation, the ability of employees to design their daily work, personal attention, clear communication and an overview of the whole care process are of importance. Seen the context of UMCG, this research focus especially on the latest three variables, which are outlined in more detail below.
Personal attention
Levenstein et al. (1986) stress the importance of eliciting each patient’s expectations, feelings and fears about the illness (Mead and Bower, 2000). The goal, according to Balint (1969), is to “understand the complaints offered by the patient, and the symptoms and signs found by the physician, not only in terms of illnesses, but also as expressions of the patient’s unique individuality, his conflicts and problems” (quoted in Henbest and Stewart, 1989 in Mead and Bower, 2000). For example, a compound leg fracture will not be experienced the same way by two different patients; it may cause far less distress to the office worker than the professional athlete, for whom the injury potentially signifies the end of a career (Mead and Bower, 2000). Similarly, the medical treatment (even cure) of disease does not necessarily alleviate suffering for all patients (Mead and Bower, 2000). Cassell (1982 in Mead and Bower, 2000) describes how one young woman’s cancer treatment threatened her sense of self and perception of the future. The implication is that, in order to understand illness and alleviate suffering, physicians must first understand a patient’s personal meaning of the illness (Mead and Bower, 2000). Only when physicians and nurses are informed about the unique situation and individuality of a patient, they are able to give them the correct personal attention. Summarizing, personal attention is concerned with understanding the patients’ experience of illness. To develop full understanding of the patient’s presentation and provide effective guidance, physicians and nurses at UMCG should strive to understand the patient as an individual personality within his or her unique context.
Communication
difficult to describe but is related to the physicians ability to grasp their patient’s communicative style and adjust his or her own to it in order to improve efficiency and satisfaction for both (Ruiz-Moral et al., 2006). Usually, this means that physicians should be committed; show respect, empathy and interest in their patients’ ideas, fears, expectations and opinions; accept their wish to share decisions, and provide information that is clear and adequate to their needs and education (Ruiz-Moral et al., 2006). “Health care it is not only concerned with the delivered care, but increasingly with subjects as communication, acceptable waiting times and pleasant treatment” (UMCG, 2004).
Behaviour in accordance with critical path
There are a number of different terms associated with the general concepts of critical paths (Coffey, 2005). A critical path defines optimal sequencing and timing of interventions by physicians, nurses and other staff for a particular diagnosis or procedure. This is designed to better utilize resources, maximize quality of care and minimize delays (Coffey, 2005). It can be thought of as a visualization of the patient care process (Coffey, 2005). Critical paths feature (Coffey, 2005): “a) comprehensiveness: critical paths do not only deal with physician decision making, but with the decision making, services and interactions among all providers of services for the patient covered by the critical paths; b) timelines: critical paths contain specific timelines for interventions to occur; c) collaboration: critical paths are jointly developed by multiple health care professionals; d) manager: patients on critical paths have a case manager or case coordinator, usually a nurse”. Although a critical path represents the typical or expected progression of interventions, it can and must be adjusted to meet the patient’s individual needs (Coffey, 2005). Critical paths are developed for patients with common or specialized procedures or diagnoses and can be used for any practice that is replicated for patients with similar, identifiable conditions (Coffey, 2005). In short, critical paths are very important to come towards the wishes of the patients. In summary, at UMCG an environment should arise in which every employee has to look further than his own department. The ultimate goal is to organize the organization in such a way that patients experience as less possible disturbing changeovers as possible from the beginning of the care process till the end (UMCG, 2004).
INTERMEZZO
convenience called patient-centered attitude, which underlies patient-centered behaviour, will lead to new, additional insights. However, to do this, it is necessary to indicate what is said about the relation between attitude and behaviour in the literature. Therefore, below a literature overview about the relationship between attitude and behaviour is presented first. Patient-centered attitude can be defined as “characteristics of a physician that may best be assessed by self-report (e.g., the belief that asking about psychosocial issues is a necessary part of assessing a patient’s condition, or that a physician ought to share information, power, and control with patients)” (Duggan et al., 2005). Social psychology theories have shown that attitude is the core concept that contributes to the intention preceding the performance of behaviour (Jansen, 2005). Therefore, this intermezzo will focus on the attitude of physicians and nurses of UMCG to their patients. The basic assumption is that the way physicians and nurses handle their patients is dependent on their attitude towards the different aspects of patient-centered behaviour. The theoretical relation between attitude and behaviour will be delineated below.
Several theories underscore the relation between attitude and behaviour, such as the social cognitive theory (Bandura, 1999), and the Theory of Planned Behaviour (Ajzen, 1991 in Jansen, 2005). The Theory of Planned Behaviour is an extension of the Theory of Reasoned Action (Jansen, 2005). The Theory of Reasoned Action (Fishbein and Ajzen, 1975) addresses the issue of ‘causal antecedents of volitional behaviour’ (Jansen, 2005). The Theory of Planned Behaviour was designed to predict behaviours not entirely under volitional control by including measures of perceived behavioural control (Jansen, 2005).
FIGURE 5.1
Conceptual framework of staff behaviour (adapted from Ajzen, 1991)
PSYCISIAN BEHAVIOUR INTENTION PERCEIVED BEHAVIOURAL CONTROL SUBJECTIVE NORM ATTITUDE TO PATIENT
Therefore, the relationship between attitude and behaviour will be handled with care during this further research.
2.3 Conclusion
It can be concluded from the above that displaying personal attention, patient-centered communication and behaviour in accordance with critical path are important elements of patient-centeredness in literature. Besides that, these elements are also important for the new UMCG, who have to make their physicians and nurses aware of these elements. However, firstly it is necessary to indicate to what extent physicians and nurses are patient-centered already, on basis of which advancing and obstructing factors can be identified when changing to the new structure. Before looking at advancing and obstructing factors, it should be clear what the patient-centeredness presently is, and what it will be in the future. The new organization is described clearly in the introduction as well as in this chapter. Therefore, in order to give an answer on the main question of this research (“which obstructing and advancing factors in the present culture can be indicated when the present structure is changed to the new structure?”), in the following chapters the present organization will be analyzed en described. However, to give an answer on the main question, the following questions need to be answered first:
- What is the present level of patient-centeredness at sector level?
- What is the present level of patient-centeredness at departmental level? - What is the present level of patient-centeredness at functional level?
- Does the present level of patient-centeredness correspond with the desired level in the new situation?
3. METHOD
In this part, the methods used for the research are outlined. In the previous part of this research an overview of the new UMCG is given. To answer the main- and sub questions of this research it is important to have a clear picture of the present situation at UMCG as well. Therefore, this part of the research describes how the mentioned elements are measured in the present structure.
The population related to the research consist of 1414 employees of the departments and task groups who in the new organization will belong to sectors A (long-term and vessels) and B (short-term care and stomach) of UMCG. The data collection took place in different departments and task groups within these sectors and was done by means of a questionnaire. The questions asked in Dutch can be found in Appendix 2. Appendix 3 shows the context-variables-indicators-operators scheme. The relationships between the context of UMCG and the asked questions in English are presented here.
3.1 Questionnaire
No suitable questionnaire for measuring patient-centeredness at UMCG was found in the literature. Existing questionnaires discussed in the literature were mainly focused on the perspective of the patient and some general questions about the topic of patient-centeredness were answered with socially desirable answers. Therefore, the questionnaire used in this research is developed by the researcher who based the questions on interviews with physicians and nurses at UMCG. In these interviews, physicians and nurses were asked about their patient-centered behaviour. After developing the questionnaire, it was tested by 7 employees within the organization: 2 head nurses, 1 control nurse, 2 managers, 1 employee of the staffing department and 1 quality employee. The feedback from these tests was taken into account and several adjustments were made after which the final questionnaire was developed.
3.2 Data collection
3.3 Sample and respondents
Participants for this research were physicians and nurses who in the new organization will belong to sector A and B. 600 questionnaires were distributed randomly in proportion among the physicians and nurses. To increase the response rate (which turned out quite low the first two days) and to be able to make more reliable conclusions on the departmental level, another 519 questionnaires were distributed randomly one week after the first distribution. This means that totally 1119 questionnaires were distributed, 731 in sector A and 388 in sector B. The total population of the two sectors consists of 1414 employees, 932 in sector A and 482 in sector B. The total response rate was 33%. An overview of the percentages of the responded population and the response rates per sector can be found in table 3.1.
TABLE 3.1 Response per sector
Sector Sample Response rate Percentage of
population
Sector A 731 32.8% 25.8%
Sector B 388 33.2% 26.8%
Total 1119 33.0% 26.1%
The functional composition was approximately 17% Physician, 23,5% physician assistant, 5,4% head physician, 11,4% head nurse, 34,3% nurse and 0,5% manager. An overview of the percentage of the responded population and the response rate per department can be found in table 3.2.
TABLE 3.2 Response per department
Department Sample Response rate Percentage of
population
Internal medical science 337 30.3% 24,0%
An overview of the percentages per function can be found in table 3.3. In table 3.3 one can also find the category control nurse. Some of the control-nurses have hierarchical responsibility. The function of a control-nurse with hierarchical responsibility is comparable to the function of a head-nurse. The function of a control-nurse without hierarchical responsibility is comparable to the function of a regular nurse. That is why the control-nurses will be divided between the head-nurses and the nurses. The number of control nurses with hierarchical responsibility is unknown as well as the number of nurses without hierarchical responsibility. Therefore there no response rate and percentage of the population is shown for the head nurses, control nurses and nurses. The managers and the head physicians fall under the category divisional head.
TABLE 3.3 Response per function
Function Sample Response rate Percentage of
population
Physician 227 27.8% 26.8%
Resident 221 39.4% 37.8%
Head physician 40 50% 55.0%
Head-nurse (including control nurses with hierarchical responsibility) Nurse (including control nurses without hierarchical responsibility)
Total 1119 30.5% 24.1%
3.4 Validity
Factor analysis is a multivariate method for assessing the interrelationships between variables, and it identifies the variables that together make up unified concepts (Resnikc and Jenkins, 2000 in Latvala, Saranto and Pekkala, 2004). An exploratory factor analysis (EFA) using principal component analysis with varimax rotation was used to test the construct validity of the instruments. Because it is not only important to explain mutual variance but also the unique variance of the questions, principal component analysis was chosen. Varimax rotation was chosen to get as much interpretable components as possible. EFA was chosen over confirmatory factor analysis because the whole questionnaire is developed for this research. Floyd and Widaman (1995 in Heubeck and Neill, 2000) suggest that exploratory factor analysis is most appropriate in the initial stages of model development whereas confirmatory factor analysis provides a more powerful tool in the second stage of research when a model has already been established. It is important to find out whether the questions within a variable share the same component. A decision rule of including only items with a clear loading of .60 on the ‘right’ factor and a maximum loading of .40 on the ‘wrong’ factor was used. The scale with special questions for nurses was deleted, because SPSS was not able to present an outcome of the factor analyse with this scale included.
more additional items. The remaining items loaded on the dimension of attitude and the three remained dimensions of behaviour.
TABLE 3.4
Rotated component matrix attitude and behaviour
,761 6,453E-02 7,238E-02 -5,27E-02
,779 -2,52E-02 ,181 3,037E-02
,889 -4,21E-02 4,775E-02 6,486E-02
,846 9,414E-02 -2,39E-02 2,625E-02
3,305E-02 ,120 7,369E-02 ,821 6,421E-02 2,381E-02 ,690 ,215 ,142 ,180 ,685 ,327 3,854E-02 ,193 ,671 -,224 7,898E-02 ,427 ,617 -,328 2,643E-02 ,821 6,722E-02 ,169 -2,98E-02 ,857 ,154 ,145 8,276E-02 ,749 ,269 -,151
Every patient must be involved entirely in the choice for a medical treatment
Every patient is unique and needs individual attention and care Every patient is entitled to all information about his/her medical treatment Every patient must have complete clarity concerning the nature of his/her disorder I make time available to talk with the patient about 'cows and calves' I check, by asking several questions, or the patient understand the information supplied by me
When I do not understand the patient very well, I take the time to retrieve what the patient means I point out to the patient about leaflets and information brochures about his/her illness I advise the patient concerning a good continuation of the treatment at home I know how the care processes of all my patients look like I know of all my patients which care phases he/she will have had and which he/she will have My patients know after their dismissal from the hospital how they must recover at home further
1 2 3 4
Component
Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser Normalization.
3.5 Reliability
and Ingram, 1991). The Cronbach’s alpha of the four variables in this data set can be found in table 3.5. Based on this table one can conclude that the scales are reliable.
TABLE 3.5
Cronbach’s alpha per variable
Variable Cronbach’s alpha
Patient-centered attitude 0.84
Personal attention *
Communication 0.65 Behaviour in accordance with critical path 0.78
* 1 item is used to measure personal attention
3.6 Measures
The construct and their measurement are described below. The scale items can be found in appendix 2. The Dutch translation of these can be found in appendix 3.
Personal attention
The Cronbach’s alpha of this variable was always below 0.60 when two or more questions were added. To be still able to measure personal attention, one question will be picked which best represents personal attention of physicians to patients. After analysing the questions, question one was chosen because in the interviews held with physicians and nurses about personal attention, talking with patients about cows and calves was most often mentioned. The respondents were asked how frequently (always, often, sometimes, rarely or never) they really make time available for their patients to talk about ‘cows and calves’. The option “not applicable” was also added to prevent that an answer was given randomly.
Communication
The frequency was measured on a 5-point scale (always, often, sometimes, rarely or never) and also the option “not applicable” was added to prevent that an answer was randomly given. Sample items are “I have to explain medical things several times to the patient before he/she actual understand what I mean” and “When I do not understand the patient very well, I take the time to retrieve what the patient means”.
Behaviour in accordance with critical path
This is one of the most important themes within the new structure. The frequency of this scale was measured on a 5-point scale (always, often, sometimes, rarely or never) and the option “not applicable” was also added to prevent that an answer was randomly given. Sample items are “I ensure that an appointment with a patient is coordinated on other appointments the patient has on the same day with colleagues” and “I know of all my patients which care phases he/she have had and which he/she will have”.
3.7 Analysis
means indicate agreement. When significant differences are indicated, it can be said where the reorganisation is needed most and where resistance will probably be highest. This can lead to obstructing and advancing factors which were necessary to answer the main question of this research. The independent sample T-test is used to test the significance of the differences between the two sectors. There was chosen for the independent sample T-test because the number of response for both sectors was above 30 and therefore considered normal. In order to test the significance of the differences between the departments and the functions, the Mann Whitney test is used. This test is chosen seen the fact that the results of the questionnaire are not divided normally. Besides that, for some of the groups the minimum number of 30 respondents was not reached. The Mann Whitney test is used to test if there are significant differences between the mean score of a segment in comparison with the mean of the total group without that segment. When a significant difference on a segment is identified, this segment will discussed further in detail. For all tests a confidence level of 95% is used, which means that differences are significant when the significance level is below 0.05.
INTERMEZZO
Measure
Patient-centered attitude
The four-item scale for measuring patient-centered attitude is developed by the researcher. The items were measured on a 5-point Likert-scale ranging from “strongly disagree” to “strongly agree”. Sample items of the scale include “Every patient is unique and needs individual attention and care” and “Every patient is entitled to all information about his/her medical treatment”.
Validity and reliability
In order to make sure that all scales are valid and measure different factors, a factor analysis was done in paragraph 3.4. From this factor analysis can be concluded that all scales measure different factors. In table 3.4 one can see that the four items measuring patient-centered attitude clearly differ from the others. The loadings on the component of patient-centered attitude were very high (all above 0.75) and the loading on other components are all below 0.18. It can therefore be concluded that the scale of patient-centered attitude is valid.
The Cronbach’s alpha of the variable of patient-centered attitude was also calculated earlier in this research. One can found in table 3.5 that the reliability of the scale is 0.86 which indicates that the scale is reliable.
4. RESULTS
The results of the research are presented in this chapter and will answer the sub-questions as presented in chapter two. A distinction is made between the results on sector level, department level and functional level. It should be noted that especially with the analyses on department level response rates often are very low, which could indicate quite low reliability of the results.
4.1 Sector level
In order to get an overview of the questionnaire results for sector A and B, table 4.1 give an overview of the means of personal attention, communication and behaviour in accordance with critical path for both sectors.
TABLE 4.1 Means per sector
3,4000 4,0125 3,9935 230 233 231 ,69055 ,52144 ,58449 3,3226 3,9959 4,0282 124 123 124 ,65702 ,53984 ,59078 3,3729 4,0068 4,0056 354 356 355 ,67907 ,52717 ,58609 Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation Sector Sector A Sector B Total Personal attention Communication Behaviour in accordance with critical path
1=never, 2=rarely, 3=sometimes, 4=often, 5=always
TABLE 4.2
Independent samples T-test on sector level
1,128 ,289 1,023 352 ,307 ,0774 ,07565 -,07136 ,22620 1,039 263,024 ,300 ,0774 ,07453 -,06933 ,22417 ,090 ,765 ,282 354 ,778 ,0166 ,05883 -,09912 ,13229 ,279 241,028 ,781 ,0166 ,05947 -,10056 ,13372 ,000 ,983 -,532 353 ,595 -,0347 ,06531 -,16317 ,09373 -,530 249,392 ,597 -,0347 ,06553 -,16377 ,09433 Equal variances assumed Equal variances not assumed Equal variances assumed Equal variances not assumed Equal variances assumed Equal variances not assumed Personal Attention Communication Behaviour in accordance with critical path F Sig. Levene's Test for Equality of Variances t df Sig. (2-tailed) Mean Difference Std. Error
Difference Lower Upper 95% Confidence
Interval of the Difference t-test for Equality of Means
Seeing Levene’s test for equality of variances, the score of all questions is < 0.05, which indicate that both sectors have approximately equal variance on the dependent variable. From the results of the Independent Samples T-test can be concluded that no significant differences between sector A and B exist.
4.2 Departmental level
TABLE 4.3 Means per department
3,4898 4,0458 3,9517 98 100 100 ,72147 ,49455 ,63621 3,3288 3,9909 4,0305 73 73 71 ,66781 ,62199 ,66027 3,5000 4,1500 3,7396 16 15 16 ,51640 ,49821 ,48675 3,3871 4,0242 4,0645 31 31 31 ,49514 ,37835 ,39832 3,3889 3,9028 4,0185 18 18 18 ,69780 ,47850 ,36555 3,2131 3,9221 3,9500 61 61 60 ,66118 ,59974 ,59209 3,7500 3,9792 4,1111 12 12 12 ,62158 ,62576 ,41030 2,2500 3,9375 4,1667 4 4 4 ,50000 ,23936 ,19245 2,5000 4,3125 4,3333 4 4 4 ,57735 ,23936 ,54433 3,0909 4,0625 3,9103 11 12 13 ,53936 ,41458 ,57581 3,5417 3,9896 4,2361 24 24 24 ,65801 ,42656 ,57718 3,3693 4,0047 4,0009 352 354 353 ,67934 ,52583 ,58428 Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation Department Internal medical science Thorax centre Dermatology Neurology Neurosurgery Surgery Orthopedics Plastic surgery ENT Ophthalmology Oral surgery Total Personal Attention Communication Behaviour in accordance with critical path
1=never, 2=rarely, 3=sometimes, 4=often, 5=always
variables of the departments which significantly differ from the other departments are given. All statements have a reliability of 95%.
Personal attention
From table 4.4 becomes clear that the departments Internal Medical Science, Surgery, Plastic surgery and ENT significantly differ from the total group. When looking back at table 4.3 it can be said that Plastic surgery and ENT scores, compared to the other departments, really low on this variable. Internal Medical Science and Surgery are scoring quite normal.
TABLE 4.4
Significant differences on personal attention at departmental level
Department Significance
Internal Medical Science 0.026
Surgery 0.043 Plastic Surgery 0.003
ENT 0.015
Communication
No significant differences can be found for the variable of communication. Behaviour in accordance with critical path
No significant differences can be found for the variable of behaviour in accordance with critical path.
4.3 Functional level
TABLE 4.5 Means per function
3,3710 4,0860 4,0053 62 63 63 ,63333 ,54501 ,67863 3,1395 3,8075 3,9828 86 87 87 ,68878 ,47725 ,56321 3,1000 4,1125 4,4167 20 20 20 ,64072 ,47624 ,37268 3,5152 4,1667 4,0000 33 31 32 ,56575 ,51415 ,58659 3,5440 4,0302 3,9503 125 127 124 ,66604 ,53180 ,56827 5,0000 3,7500 4,1667 1 1 2 , , ,23570 3,3792 3,9990 4,0041 327 329 328 ,68053 ,52632 ,58726 Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation Function Physician Resident Head physician Headnurse Nurse Manager Total Personal Attention Communication Behaviour in accordance with critical path
1=never, 2=rarely, 3=sometimes, 4=often, 5=always
Although differences can be seen between functions, it is unknown if these differences are significant. In order to evaluate which functions significantly differ from the general picture, the Mann-Whitney test is used. Below a division is made based on the three variables. For each variable the functions which significantly differ from the others are given. All statements have a reliability of 95%.
Personal attention
From table 4.6 becomes clear that Residents, Nurses and Managers significantly differ from the general picture. When looking at table 4.5 it can be said that Nurses and Managers scores, compared to the other departments, high on this variable. Residents score quite lower than the other functions.
TABLE 4.6
Significant differences on personal attention at functional level
Function Significance
Communication
Table 4.7 shows the two functions which significantly differ from the others; Residents and Head nurses. When looking at table 4.5, it can be said that Residents score almost lowest on the level of communication. On the other hand, Head nurses score highest on this variable. The two functions can be found together with the significance of the difference in table 4.7.
TABLE 4.7
Significant differences on communication at functional level
Function Significance
Residents 0.000
Head nurses 0.041
Behaviour in accordance with critical path
Table 4.8 shows that Head physicians significantly differ from the general picture. When looking at table 4.5 it can be said that Head physicians score, compared to the other functions, highest on this variable.
TABLE 4.8
Significant differences on communication at functional level
Function Significance
Head Physicians 0.000
INTERMEZZO
4.4 Patient-centered Attitude
Sector level
Just as above, it is also important to know how employees score on the variable of patient-centered attitude. Next to that, it is important to evaluate if there are significant differences between the two sectors. Table 4.9 show the means of patient-centered attitude per sector.
TABLE 4.9 Means per sector
ATTITUDE 4,3042 240 ,66611 4,2617 128 ,78298 4,2894 368 ,70817 Sector Sector A Sector B Total Mean N Std. Deviation
TABLE 4.10
Independent samples T-test on sector level
,005 ,945 ,547 366 ,585 ,0424 ,07758 -,11012 ,19501 ,521 226,070 ,603 ,0424 ,08148 -,11810 ,20300 Equal variances assumed Equal variances not assumed Patient-centered Attitude F Sig. Levene's Test for
Equality of Variances t df Sig. (2-tailed) Mean Differenc e Std. Error
Difference Lower Upper 95% Confidence
Interval of the Difference t-test for Equality of Means
It can be seen from table 4.10 that significant levels exceed 0.05 for the variable of patient-centered attitude. Therefore it can be concluded that no significant differences exist on sector level.
Departmental level
Besides sector level analyses, scores and significance numbers for the variable of patient-centered attitude are also evaluated on departmental level. Table 4.11 shows the means per department.
TABLE 4.11 Means per department
ATTITUDE 4,3529 102 ,68520 4,2468 77 ,62631 4,2812 16 ,43661 4,2016 31 ,72001 4,4167 18 ,48507 4,2109 64 ,88889 4,5417 12 ,53122 4,4375 4 ,31458 4,8125 4 ,23936 4,2143 14 ,73286 4,1875 24 ,93323 4,2889 366 ,70954 Department
Internal medical science Thorax centre Dermatology Neurology Neurosurgery Surgery Orthopedics Plastic surgery ENT Ophthalmology Oral surgery Total Mean N Std. Deviation
Although differences can be seen, it is unknown if these differences are significant. In order to evaluate if departments significantly differ from the total group, the Mann-Whitney test is used. In this test the mean of each department is compared with the means of all other departments together.
Functional level
Table 4.12 show the means of patient-centered attitude for each function at UMCG. From the table becomes clear that there exist differences between the functions but these are rather small.
TABLE 4.12
Means of patient-centered attitude per by function
ATTITUDE 4,2937 63 ,81881 4,1839 87 ,61054 4,2125 20 ,94686 4,1524 41 ,86400 4,4035 127 ,64476 4,5000 2 ,70711 4,2860 340 ,72257 Function Physician Resident Head physician Headnurse Nurse Manager Total Mean N Std. Deviation
The mean is for all function over the answer ‘degree’ (the fourth answer) which means on a five point scale that the answer reaches the end of the scale. However, to evaluate which functions significantly differ from the total picture, the Mann-Whitney test is used. In this test the mean of each function is compared with the mean all other functions together. The functions which significantly differ from the others are given in table 4.13. All statements have a reliability of 95%.
TABLE 4.13
Significant differences at functional level
Function Significance
Residents 0.022
5. DISCUSSION
In the previous chapter of this research, the present situation concerning patient-centeredness at UMCG is presented. With these results, advancing and obstructing factors can be identified when the present organization is changed to the new organization. In order to answer the main question, sub questions are stated which will be answered below by analyzing the results stated in the previous chapter. After that, the main question of the research (“Which advancing and obstructing factors in the present culture can be indicated when the present structure is changed to the new structure?”) will be answered. At the end some comments, limitations of the research and some recommendations will be given.
In order to make a comparison between the present- and the new situation at UMCG, and to be able to give an answer on the main question, it is important to know which scores represent the new (desired) situation. Therefore scores are, in consultation with UMCG, quantified. This means for all four scales that they should be displayed as much as possible in the new organization. Therefore, means should at least equal 4 and should not score below 3. A mean between 3 and 4 indicates that special attention is needed to prevent a factor to become obstructing. The complete quantification is stated in table 5.1. It should be noted that a factor is obstructing when it needs to change from low to high. When a turnaround is needed, resistance can be expected which make it harder to reorganize. A factor is called advancing when it is already at the level of the new organization, or close to the stage of the new organization.
TABLE 5.1 Quantified means
Factor Mean
Advancing ≥ 4
Nor advancing / nor obstructing
but does deserve some attention < 4 and ≥ 3
Obstructing < 3
5.1 Sector level
Personal attention
Employees at both sectors slightly display personal attention to their patients. However, as concluded before, no significant differences can be indicated for the variable of personal attention on sector level. Despite this, results on this variable show that sector A and B need some extra attention, because the means fall down between 3 and 4.
Communication
When analysing the answers of the respondents, it can be seen that differences between both sectors are very small. Significant differences cannot be indicated for this variable. Results show that sector B needs some extra attention because the mean fall down between 3 and 4. However, it can be said that communication will be an advancing factor for sector A because the mean exceed 4.
Behaviour in accordance with critical path
because the mean fall down between 3 and 4. However, for sector B the mean exceed 4 which means that behaviour in accordance with critical path will be an advancing factor for this sector.
5.2 Departmental level
Personal attention
When examining the results of this variable on departmental level, it can be indicated that most departments needs extra attention because means fall down between 3 and 4. Besides that, Internal Medical Science, Surgery, Plastic surgery and ENT significantly differ from the other departments, whereby Plastic surgery and ENT have means below 3. This means that personal attention will be an obstructing factor for these two departments.
Communication
No significant differences can be indicated when examining the results of this variable. However, means show that communication will be an advancing factor for Internal Medical Science, Dermatology, Neurology, ENT and Ophthalmology. The remaining departments show means between 3 and 4, indicating that these departments require extra attention when changing to the new structure.
Behaviour in accordance with critical path
Also no significant differences can be identified for this variable. However, there exist differences between means of different departments. Means of Thorax centre, Neurology, Neurosurgery, Orthopedics, Plastic surgery, ENT and Oral surgery exceed 4, indicating that ‘behaviour in accordance with critical path’ will be an advancing factor for these departments. The remaining departments show means between 3 and 4, which means that these departments require extra attention when changing to the new structure.
5.3 Functional level
Personal attention
Seen the means between 3 and 4, this variable shows that all functions, except the Managers, require extra attention. Thereby, Residents, Nurses and Managers significantly differ from the other functions, whereas the managers show a mean above 4. This indicates that personal attention will be an advancing factor for the function of the Managers. From the means can also be seen that Residents show almost the lowest level of personal attention with a mean of 3.1.
Communication
Results on functional level show that Physicians, Head physicians, Head nurses and Nurses are advancing factors for this variable, because means exceeding 4. Residents and Managers show means between 3 and 4 indicating that extra attention is needed. Thereby, Residents and Head physicians significantly differ from the other functions, indicating that, seen the low score of Residents in comparison with the other function, most attention is needed for those group.
Behaviour in accordance with critical path
factor for this function. Means of Physicians, Head nurses and Managers also exceed 4, indicating that this variable is also an advancing factor for these functions. The Residents and Nurses show means between 3 and 4, indicating that extra attention is needed for these functions when changing to the new structure.
When answering the sub-questions about the level of patient-centeredness in the present organization, a considerable positive answer can be given. Some departments and especially the Residents need extra attention, but in general can be concluded that both sectors, almost all departments and almost all functions own a level of patient-centeredness which meets the level desired in the new organization.
INTERMEZZO
Based on the results presented in chapter 4, conclusions will be made about the present level of patient-centered attitude at UMCG. For indicating advancing and obstructing factors, the quantifications as presented in table 5.1 will be used.
Sector level
When analysing the answers of the respondents, it can be seen that the differences between both sectors are very small. Also significant differences cannot be indicated. However, the mean for both sectors exceed 4, indicating that patient-centered attitude is an advancing factor for sector A and B.
Departmental level
Also no significant differences can be identified for the attitude variable at departmental level. There exist differences between means of different departments, but means of all departments exceed 4, indicating that patient-centered attitude is an advancing factor for all departments. Functional level
Residents significantly differ from the other departments. Seen the mean of Residents (4.18) in comparison with the other functions, it can be said that the mean of Residents is low. However, a mean above 4 indicates that the variable of patient-centered attitude is an advancing factor for Residents, as well as for all other functions at UMCG.
Concluding can be said that patient-centered attitude is an advancing factor for both sectors, all departments and all functions. The attitude of employees satisfies the requirements of the new organization. In relationship with behaviour can be concluded that attitude and behaviour correspond considerable, but in the end the general picture of attitude is more positive. Looking back to the theory of planned behaviour this is not really strange because behaviour is not only decided by attitude but also by other factors.
5.4 Conclusions
changing to the new structure (means are below 3). Means between 3 and 4 indicate that the scale is not an advancing or an obstructing factor, but does indeed require some attention. Table 5.2 summarizes at which sectors, departments and functions variables will be an obstructing- or advancing factor.
TABLE 5.2
Summary of all obstructing and advancing factors
Variable Variable is an advancing factor in Variable is an obstructing factor in
Personal attention Managers Plastic Surgery, ENT Communication Sector A, Internal medical science,
Dermatology, Neurology, ENT, Ophthalmology, Physicians, Head
physicians, Head- nurses, Nurses Behaviour in accordance
with critical path Sector B, Thorax centre, Neurology, Neurosurgery, Orthopedics, Plastic surgery, ENT, Oral surgery, Physicians,
Head physicians, Head nurses, Managers
Patient-centered Attitude Both sectors, all departments, all functions
When looking at the advancing factors, it can be seen that personal attention could be an advancing factor for the Managers. Furthermore can be seen that personal attention could be an obstructing factor for Plastic surgery and ENT. Besides that, this variable needs extra attention for both sectors, the other departments and other functions.
Furthermore can be seen that communication is an advancing factor for sector A and three departments within this sector (Internal Medical Science, Dermatology and Neurology). Also communication will be an advancing factor for two department of sector B (ENT and Ophthalmology). This indicates that, for this variable, it is slightly easier for sector A to change to the new structure than it will be for sector B. The variable of communication will be an advancing factor for Physicians, Head physicians, Head nurses and Managers also. For this variable, no obstructing factors can be identified.
Behaviour in accordance with critical path will be an advancing factor for sector B and for four departments within sector B (Orthopedics, Plastic surgery, ENT and Oral surgery). It will be an advancing factor for three departments of sector A (Thorax centre, Neurology and Neurosurgery) also. This means that it is slightly easier for sector B to change to the new structure than it will be for sector A. The variable of behaviour in accordance with critical path will be an advancing factor for Physicians, Head physicians, Head nurses, Managers also. Just as the variable of communication, no obstructing factors can be identified.
Patient-centered attitude will be advancing factor for both sectors, all departments and all functions. This indicates that, for this variable, changing to the new situation will be equally easy for both sectors as well as for the departments and functions within those sectors.
TABLE 5.3
Summary of all variables needing extra attention
5.5 Comments
Paradoxically, in some situations it may be patient-centered to display less patient-centered behaviour (Zandbelt et al., 2006). Likewise, in an oncology setting a substantial minority of breast cancer patients, family and friends preferred a physician-centered consultation style, including more task-focused and high-controlling behaviour and less empathy (Dowsett et al., 2000 in Zandbelt et al., 2006). Patients may be uncomfortable with their physician behaving in a patient-centered way if such behaviour is unfamiliar, and a patient-centered style may not be appropriate to all conditions or circumstances (Bradley et al., 2000 in Zandbelt et al., 2006). If so, physicians should rather be flexible in their patient-centered behaviour (Zandbelt et al, 2006).
Another comment is that this research has been done among physicians and nurses. The results of a research among patients show other results concerning patient-centeredness. The Nederlandse Federatie van Universitair Medische Centra (NFU) has measured patient satisfaction at UMCG in 2005. For this research the Kernvragenlijst Patiënttevredenheid Academische Ziekenhuizen (KPAZ) was used. Patients gave their satisfaction rates about six aspects of care concerning the whole care process. UMCG receives 26 times an insufficient mark, especially at points of information and aftercare. The almost five thousand UMCG-patients were most satisfied about the reception at UMCG and the treatment, maintenance and handling of employees. Patients were unsatisfied about the information and explanation they received about their treatment, illness or medicine use and the results of research. Another conclusion was that employees have to communicate more clearly to colleagues and patients. Concerning communication a lot of mistakes were signalled, especially concerning mutual communication. Also more attention is needed for the communication to patients and their families. For example, it is important to check if each patient understands the prescription for a good revalidation at home. Summarizing, the results of the NFU research are less well than the results of this research.
A comment on the variable of personal attention concerns time pressure. A lot of the respondents presented time pressure as reason for their low score at this variable. Examples of comments are: “There is too little time for personal attention to patients”, “Work pressure is
Variable Variable needs extra attention in
Personal attention Plastic Surgery and ENT), all functions (except Sector A, Sector B, All departments (except Managers)
Sector B, Thorax centre, Neurosurgery, Surgery, Orthopedics, Plastic surgery, Oral surgery, Residents, Managers
Communication
Behaviour in accordance with critical path
Sector A, Internal medical science, Dermatology, Surgery, Ophthalmology, Residents, Nurses
high, there is little time for explanation to patients and their families, little discharge conversations which results in questions of the patient over the telephone” and “Only with enough time and space it is possible to give enough attention and support to the patients”. This means that the time pressure prevent these employees to give patients the personal attention they needed.
5.6 Limitations
Although several conclusions can be abstracted from the results of this research, several limitations should be kept in mind. Results on department level are often based on very few respondents (often only 1 or 2). Although these results are taken into account when drawing conclusions, it should be noted that conclusions are mostly not very reliable when basing them upon only one or two opinions; it is therefore also questionable whether these results represent total departments.
The research is carried out in a turbulent environment. The execution of the reorganization is approaching, which, in all probability, had an effect on the employees. On the one hand, because of the turbulent situation, employees were probably not informed or informed not well enough. This probably caused some resistance towards the survey. On the other hand, employees started realizing that the reorganization really was going to change. From reactions given to the researchers can be abstracted that not everyone sees the usefulness of the reorganization. This clearly had an effect on the willingness of those employees to cooperate with the research. The lack of response and the occurrence of extreme answers can, at least partly, be explained by this. Furthermore, employees could have given very positive answers because they value their current situation as insecure. Despite the anonymity of the research, employees might, for example, be afraid of what happens when they do not rate their supervisor in a positive way.
The questionnaires were distributed on paper and digitally. It was not possible within these channels to prevent employees from turning in the questionnaire more than once. It is assumed that no one turned it in several times, but this cannot be ruled out completely.
The questionnaire was only distributed in sectors A and B. This means that the results that are presented cannot automatically be generalized to the whole organization. The results only give information about sectors A and B. Some sectors, departments and functional groups might be comparable to the ones researched. Other sectors, departments and functional groups might not work with patients, have fewer relationships between physicians and nurses, and in some other sectors and departments work a lot more paramedics. To make statements about these other sectors, departments and functional groups, research should be done in these segments first.
5.7 Indications for further research
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