The effect of the adoption of the hospital physician on the structure of medical departments and the quality of care for patients admitted to medical departments in the Netherlands

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The effect of the adoption of the hospital physician on the

structure of medical departments and the quality of care for

patients admitted to medical departments in the

Netherlands

A.J. van den Berg s1984519

MSc BA Change Management Supervisor: dr. M.A.G. van Offenbeek

Second assessor: dr. O.P. Roemeling RESIT

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ABSTRACT

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TABLE OF CONTENTS

INTRODUCTION ……… 06

Theoretical and practical contributions ……… 07

THEORY ……… 09

The structure of hospital departments in the Netherlands ……… 09

Information-processing view of organizations ……… 10

The hospital physician ……… 12

Altering the vertical structure ……… 12

Altering the horizontal structure ……… 13

Quality of care ……… 14 Patient centeredness ……… 14 Caring ……… 15 Effectiveness ……… 15 Efficiency ……… 15 Timeliness ……… 15 Safety ……… 16 Equity ……… 16

Navigating the system ……… 16

Coordination ……… 16

METHODOLOGY ……… 18

Context and justification of the research ……… 18

Research design ……… 19

Data collection ……… 19

Interviews ……… 19

Survey ……… 20

Data coding and analysis ……… 21

Quality assurance ……… 21

FINDINGS ……… 22

Hospital A ……… 23

Context ……… 23

Reason for adopting the hospital physician ……… 23

Effect on structure ……… 23

Substitution and distribution of tasks ……… 24

Vertical differentiation ……… 24

Horizontal integration ……… 24

Information processing capability ……… 24

Information processing capacity ……… 25

Effect on quality ……… 25

Sub-conclusion ……… 26

Hospital B ……… 27

Context ……… 27

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Hospital C ……… 31

Context ……… 31

Hospital D ……… 35

Context ……… 35

Hospital E ……… 39

Context ……… 39

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Cross-case analysis ……… 46

DISCUSSION ……… 49

Effects on organizational structure ……… 49

Information-processing capacity ……… 50

Information-processing capability ……… 51

Combining capacity and capability ……… 51

Effects on quality ……… 52

Limitations ……… 53

CONCLUSION ……… 55

REFERENCES ……… 56

Appendix A. Codebook ……… 59

Appendix B. Results survey ……… 60

Appendix C. Interview protocol ……… 62

1) Interview protocol hospital physician ……… 62

2) Interview protocol medical specialist ……… 69

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INTRODUCTION

While the Dutch healthcare system is performing well compared to many other countries, it is still far from perfect and like in any other country, healthcare in the Netherlands faces major pressures to change (van Loghum, 2011; Schrijvers, 2014). One of these pressures stems from the increased life expectancy and a growing population (van Offenbeek, Kiewiet, Oosterhuis, 2006; van Loghum, 2011; Schrijvers, 2014). In the last years, patient expectations have risen and better treatments for chronic ill patients have increased survival rates (Schrijvers, 2014; Timmermans, van Vught, Peters, Meermans, Peute, Postma, Smit, Verdaasdonk, de Vries Reilingh, Wensing, Laurant, 2014). Additionally, these chronic diseases are becoming more complex and require more experienced specialists (van Offenbeek, 2004). To cope with the demand for specialized care, hospitals traditionally organized into specialized units. This way, medical specialists have been able to provide higher quality healthcare by focusing on their own specialty (Lega, DePietro, 2005). Over the years, the increasing complexity of diseases and the resulting demand for more experienced specialists have driven the medical specialists – and therefore the medical departments – into further specialization, or even super-specialization.

As a result of super-specialization, medical departments are at risk of forming organizational silos in which individual departments may perform well, but a lack of cooperation could influence the performance of the organization as a whole (Bundred, 2006). This has major implications for the coordination across departments, as a decreasing level of integration hinders the cooperation between departments (Scott, Hawkins, 2008). Paradoxically, it is especially the before-mentioned aging population that suffers from multi morbidity problems that require care across medical disciplines. As this group is increasing, demand for healthcare is likely to require increasing levels of cooperation between departments.

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nurses have taken up more responsibilities in the medical wards (Derksen, de Bakker, Spaans, Heilbron, Veenings, Haarman, 2007). Also, hospitals have tried to standardize their communication through the use of electronic patient files in order to increase integration. While these are both good solutions, they only address part of the issues arising from the increased demand for highly-specialized care.

A solution that addresses both the lack of coordination and the gap between basic care and (super-) specialization has been brought forward by the SOZG (Stichting Opleiding Ziekenhuisgeneeskunde, 2012). The SOZG proposed to add a medical professional to the existing skill-mix, who is responsible for both improving coordination between departments and bridging the gap between (super-) specialization and basic care. This medical professional would be the hospital physician. While this new profession seems to be a good solution, adding a medical professional to the skill-mix adds an additional layer to the vertical structure of the organization. This additional layer increases the information-processing requirements of the organization (Cawsey et al., 2014), which – when not addressed – result in even more fragmentation. This research therefore aims to shed more light on the effect of the adoption of the hospital physician on the organizational structure and the resulting effect on the quality of care. Doing so, the following research question will be addressed:

How does the adoption of the hospital physician affect the organizational structure of hospital departments and how does this affect quality of care?

Theoretical and practical contributions

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which the hospital physician is now utilized. The results of this paper shed more light on possible quality improvement using the new generalist profession, which can help hospitals to use the hospital physician to its full potential. Additionally, hospitals not currently using the new profession can use the information in their decision process of adding the hospital physician to their human resources. In terms of theoretical contribution, answering the research question provides more insight into the possibilities of improving quality by organizational change in both healthcare settings and other organizations where specialization has led to organizational silos. The results of this research show that it may be beneficial to look at the trade-off between increasing fragmentation by adding an additional layer to the vertical structure of the organization and adding a coordinating profession to the existing skill-mix.

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THEORY

The main goal of this research is to answer the research question: How does the adoption of the

hospital physician affect the organizational structure of hospital departments and how does this affect quality of care? To further specify this question, its variables will be elaborated on in the following

section. First, the structure of hospital departments will be further explained based on the theory of Mintzberg (1980) and past developments. After this, the information-processing view of organizations will be explained in relation to this organizational structure. Then, the characteristics of the hospital physician as a generalist profession will be elaborated on. Following this, the expected effects of adding this generalist profession to the skill mix on the organizational structure will be explained. Lastly, quality of care will be further specified.

The structure of hospital departments in the Netherlands

As explained in the introduction, the adoption of the hospital physician is expected to change the

existing structure of hospital departments. Since the 19th_{century, medicine has grown as a profession}

(Lega, DePietro, 2005). With this growth, professionals started organizing into specialties, focusing on types of diseases, parts of the body, age groups or other distinctive care-related characteristics (Lega, DePietro, 2005). The main benefit of these specialized units was that medical professionals could gain more in-depth knowledge of their specific specialty instead of spreading their capabilities over the full range of potential problems. Over the years, most hospitals have organized themselves around these specialties, enabling medical specialists to increase their knowledge and specify even further. According to Mintzberg (1980), the current structure of hospitals can be described as a professional bureaucracy. This type of organization is characterized by knowledge that is based in the workforce, consisting of highly skilled professionals. In this case, these highly skilled professionals are the medical professionals, who are organized into discipline-based departments and specializations (Lega, DePietro, 2005). According to Lega and DePietro (2005), this division into specialties has had a major impact on the progresses that were made in medical sciences. However, with the increasing complexity of care (van Offenbeek, 2004; Schrijvers, 2014) departments become even more specialized, potentially leading to super-specialization. This super-specialization divides the organization into organizational silos, which are a source of fragmentation of care.

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hospital structure. As a consequence, the increased need for coordination of care between specialized departments increases the information-processing requirements of the organization (Cawsey, Seszca, Ingols, 2016).

Information-processing view of organizations

In 1974, Galbraith introduced the information-processing view of organizations (Cawsey et al., 2016). According to this theory, the structural design choices of an organization should fit the information-processing requirements of the organization in order to reach organizational effectiveness. The author argues that this fit can be established by either decreasing the information-processing requirements or increasing the possibilities for information-processing in the organization (Cawsey et al., 2016). Strategies for decreasing the information-processing requirements are the addition of slack resources and the creation of self-contained tasks. As resources are scarce (van Offenbeek, 2004; van Loghum, 2011; Schrijvers, 2014, Timmermans et al., 2014) and cooperation between different departments is required to cope with the previously introduced multi morbidity problems, both the addition of slack resources and the creation of self-contained tasks do not seem to be viable solutions for restoring the information-processing balance.

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Horizontal information strategies include 1) increasing the horizontal communication capacity of the information system and 2) creating lateral relations (Cawsey et al., 2016). One way of increasing the horizontal communication capacity of the information system is the use of electronic patient files. However, like most strategies to increase capacity of the system, this is a costly development and further improving these systems would require resources that may not be available. The second strategy – creating lateral relations – would require a change in the current organizational structure. Altering the organizational structure to improve information-processing is supported by DeCanio and Watkins (1998). These authors argue that organizations are defined by the pattern of information exchange among their workers. However, while Galbraith (Cawsey et al., 2016) only includes formal relations in his model for information-processing capacity, DeCanio and Watkins (1998) also include the informal organization. They state that ‘Nothing intrinsically restricts the informational structure of

the firm; in particular, informal channels of communication may exist alongside the formal lines of reporting and responsibility’ (DeCanio, Watkins, 1998, p.287). This suggests that increasing

information processing possibilities is not restricted to changing formal relationships.

Another main addition of DeCanio and Watkins’ research (1998) to the information-processing view of Galbraith (Cawsey et al., 2016) is the fact that DeCanio and Watkins (1998) make a distinction between information-processing capabilities of the system and the intrinsic capabilities of the agent. The authors argue that in the creation of lateral relations, the mere sending and receiving of information is not sufficient in itself. One needs to be able to make sense of the received information for the communication to be successful. For example, in case of hospitals this could be illustrated by information transfer between the cardiology department and the traumatology department. Medical specialists at the traumatology department may receive information about a patients’ heart conditions, but this information does not mean anything if the surgeon does not take the heart condition into account when performing surgery. Based on the work of DeCanio and Watkins (1998), this research will therefore include both the capabilities of the communication channels (information-processing capacity) and the intrinsic capabilities of the agent (information-(information-processing capability) in the information-processing view of organizations.

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organization. In this regard, one solution to the information-processing misfit brought forward by the SOZG (2012) is the addition of the hospital physician to the internal skill-mix.

The hospital physician

The hospital physician is a highly skilled new profession within healthcare organizations. From a generalist perspective, this new profession should provide basic care for patients. Additionally, the hospital physician is expected to add to patient safety and continuity of care by initiating and participating in quality enhancing projects (SOZG, 2012). The role of the hospital physician is that of an intermediate professional who is supposed to bridge the gap between super specialization and basic care. Given his role as a team player combined with their expected skill level, the new profession is expected to alter both the vertical and horizontal structure of the organization. These changes in the vertical and horizontal structure are expected to alter the information-processing balance in the organization.

Altering the vertical structure. Next to the division of care in discipline-based specializations,

hospitals are known for their strong hierarchy. This hierarchy is based on professional quality and knowledge rather than formal structures (Mintzberg, 1980). Generally, within the medical departments, the medical specialists are the highest skilled professionals and the nurses are the lowest skilled professionals. Based on skill-level, the hospital physician is placed between the medical specialist and the nurses together with the physician assistant, assistant in training and the assistant not in training. The exact position of the hospital physician compared to the assistants is dependent on the latter’s moment of education and years of experience on the floor. While the skill level of the assistants may therefore vary a lot, the skill level of the hospital physician is expected to be relatively stable and consistently high, as they require a particular skill level to finish their education (SOZG, 2012).

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combination of basic care and specialized knowledge, with which he is considered to be in the ideal position to coordinate care not only within, but also between departments.

Altering the horizontal structure. Together with changes in the vertical structure of the

department, the hospital physician is expected to alter the horizontal structure. The before-mentioned improved coordination between departments is one of the expected benefits of the adoption of the hospital physician. Linking back to the information-processing theory of Galbraith (Cawsey et al., 2016), this means that the hospital physician takes an integrating role (Cawsey et al., 2016), as lateral relations are created between departments. This suggests an increase in the information-processing capacity of the department into which the hospital physician is adopted. Next to an increase in the information-processing capacity of the department, the hospital physician is expected to increase the information-processing capabilities. As the skill-level of the hospital physician is expected to be high (SOZG, 2012), the new profession is expected to be able to process the received information more efficiently. Additionally, as the hospital physician has a broad education in basic care, the new profession is expected to decrease the information-processing requirements of the department, as more knowledge is readily available. Conclusively, in this research, horizontal integration is expected to occur through a combination of both increased information processing capacity and increased information processing capability.

Based on the theory on vertical differentiation and horizontal integration above, the hospital physician can be seen as a generalist profession and the adoption of this new profession is expected to lead to vertical differentiation and horizontal integration in hospital departments. To gain more knowledge on what actually happens in the medical departments into which the hospital physician is adopted, the following research question has been created:

Sub-RQ1: How does the adoption of the hospital physician as a new generalist profession influence the vertical differentiation and horizontal integration of the medical department?

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Quality of care

As mentioned in the introduction, in the Netherlands a political choice has been made to regulate provision and direction of care on a national level (Wammes, Jeurissen, Westert, 2015). Therefore, quality of care is regulated through law ‘Wet Kwaliteit Klachten en Geschillen zorg’ [WKKGZ] (Rijksoverheid, 2016). While all healthcare organizations are subject to this law, the state does not participate in the actual provision of healthcare services (Taylor and Hawley, 2010). Following the WKKGZ, healthcare organizations have their own responsibility to design and realize the provision of care that falls within the general guidelines of this law.

While the need for quality improvement is increasing, there are many different perspectives on what ‘good quality’ in healthcare entails (Beattie, Shepherd, Howieson, 2012). To specify the meaning of quality of care, the American-based Institute of Medicine (IOM) has made specific recommendations for improving health care quality (Beattie et al., 2012). Doing so, they distinguish between six dimensions of quality of care: safety, timeliness, effectiveness, efficiency, equity and patient centeredness. While these six dimensions are widely adopted throughout the world, Beattie et al. (2012) argue that over the years, healthcare has moved towards a more patient-centered view on care provision and that these six dimensions may not be sufficient anymore for measuring quality of care. In their research, the authors have investigated whether the before-mentioned six dimensions of quality fit the patient-centered view on healthcare provision. They found that next to the six dimensions, ‘caring’, ‘coordination’ and ‘navigating the system’ should be added to complete the list of quality dimensions in healthcare (Beattie et al., 2012). In the Netherlands, the before mentioned aging society with multi morbidity problems asks for a more patient-centered view on healthcare. Therefore, the quality of care dimensions of Beattie et al. (2012) are used to define quality of care. In the following section, these quality of care dimensions are further explained together with the expected effect of the adoption of the hospital physician on the quality of care dimension.

Patient centeredness. The IOM describes patient centered delivery of care as respectful care

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instead of treated for the disease for which they are admitted. Considering patients as a whole is one of the main intentions of adding the hospital physician to the skill mix.

Caring. Part of the relationship between the medical professional and the patient is the

concept of caring. Examples of caring behavior include ‘demonstrating the ability to anticipate needs,

displaying empathy and concern, treating patients pleasantly and with courtesy’ (Beattie et al., 2012; 298). The authors also found that patients are very aware of how care is provided. Caring therefore is

an important aspect of patient centered care. Like for patient-centered care, the hospital physician is expected to increase the level of caring. However, caring is expected as a result of continuity in care (SOZG, 2012). Therefore, while caring can be considered an aspect of improving quality as a whole.

Effectiveness. Effectiveness is mostly considered from a technical or scientific point of view

(Beattie et al., 2012). However, Howie, Heaney and Maxwell (2004) distinguish between technical and interpersonal effectiveness. In this regard, technical effectiveness comprises the care givers competence to treat the patient. Interpersonal effectiveness means that communication should be useful and comprehensible to the patient. In the pilot study of the SOZG, adding the hospital physician is expected to increase technical effectiveness (SOZG, 2012). The broad knowledge base and generalist view of this new profession should increase the technical effectiveness of care. However, this knowledge can be expected to increase interpersonal effectiveness as well, because the hospital physician can provide patients with a complete and comprehensible picture of their health status.

Efficiency. According to the IOM (2001), efficient care is care that does not waste resources.

This means that there is no duplication, no unnecessary treatment and resources are used to their full potential. Efficiency can be regarded as one of the most important quality aspects from an organizational point of view, given the lack of both monetary and human resources. However, from a patient point of view, efficiency is expected to be a quality dimension of less importance. The adoption of the hospital physician is expected to increase efficiency (SOZG, 2012), because of the expected increase in information-processing capacity explained earlier (Cawsey et al., 2016).

Timeliness. Timeliness in care is mainly concerned with avoiding delays where they are not

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this, timeliness is expected to increase due to the adoption of the hospital physician, as they offer a combination of general knowledge and ‘being there’. With their broad view, the hospital physicians are expected to decrease time towards diagnosis and prevent complications (SOZG, 2012).

Safety. Together with timeliness, preventing complications leads to improved patient safety.

Based on the research of Beattie et al. (2012), safety is not often considered from a care receiver point of view. However, in the Netherlands, tolerance for medical mistakes and damage has reduced and shortcomings in patient safety need to be addressed (SOZG, 2012). Next to the prevention of complications, hospital physicians are expected to take on additional projects, which are focused on patient safety and overall quality improvement in the hospital.

Equity. While equity was considered one of the six dimensions for quality of care, it was only

mentioned as an important factor in a limited amount of papers (Beattie et al., 2012). Also, these occurrences appeared to be related to accessibility of care for all. In the Netherlands, accessible healthcare is regulated by the government (Wammes et al., 2015), meaning that equity does not play a major role in quality of care in this country. It is therefore not surprising that equity is not mentioned in the pilot study of the SOZG and there are not expectations on the influence of the hospital physician on this quality dimension (SOZG, 2012).

Navigating the system. While accessibility is regulated by the state (Wammes et al., 2015),

this term does not cover the challenges that accompany complex healthcare systems (Beattie et al., 2012). Equity in access to health care does not mean that all care is easily accessible and that patients are able to find their way in the complex system. Therefore, navigating the system has been added as an extra dimension of quality of healthcare. Again, the hospital physician is not expected to influence this quality dimension (SOZG, 2012).

Coordination. Coordination of care becomes increasingly important when organizational silos

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To research whether and how the changes in the organizational structure have led to improvements of quality of care, the following sub-question is created:

Sub-RQ2: How do changes in the vertical differentiation and horizontal integration of the medical department affect the quality of care for patients admitted to these medical departments?

Combining the previously constructed sub-questions, the main research question is as follows:

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METHODOLOGY

In the following section the way in which the research was conducted is explained. First, the context of the research will be elaborated on and the chosen research method is justified. After this, the method for data collection and coding is explained and lastly, quality assurance will be discussed.

Context and justification of the research

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to Karlsson (2015) and Yin (2003) a case study is most suitable for studying phenomena in their natural setting without the need for control of events. Additionally, the authors argue that case studies are particularly useful for answering ‘how’ and ‘why’ questions. The purpose of this study is to gain more insight into the effects of changes in the organizational structure that accompanies the adoption of the hospital physician to the skill mix.

Research design

The main goal of this research is to answer the research question:

How does the adoption of the hospital physician as a new generalist profession influence the vertical differentiation and horizontal integration of the medical department and how does this change in the organizational structure affect the quality of care for patients admitted to these medical departments?

To answer the main research question, two sub-questions have been selected to create a complete answer:

(1) How does the adoption of the hospital physician as a new generalist profession influence the vertical differentiation and horizontal integration of the medical department?

(2) How do changes in the vertical differentiation and horizontal integration of the medical department affect the quality of care for patients admitted to these medical departments? Data collection. To answer these sub-questions, a combination of two data collection methods is

used. A mix of both qualitative and quantitative research is considered most suitable, as the use of two different types of data collection contributes to stronger constructs and propositions (Eisenhardt, 1989). Qualitative data will be in the form of semi-structured interviews, which allows to study phenomena in its natural environment (Gephart, 2004). This way perception of the hospital staff is used to gain more understanding. Quantitative data will be obtained from surveys that cover both new questions and questions already covered in the interviews. Triangulation through the use of both interviews and questionnaires creates possibilities for comparison across cases and validation of interview questions.

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hospital physician, one interview with a nurse and one interview with a medical specialist. This way, for each adoption of a hospital physician, three different perspectives of the same case were included in the data. All interviews were focused on effect evaluation. Hospital physicians were only considered for interviews when they had been working in their current position for at least four months. This way, potential changes in the department had time to crystalize and other people in the department had time to get used and adjust to the implementation of the hospital physician.

With permission of the interviewees, the interviews where recorded and transcribed ad verbatim. All interviews were coded for further use in this paper. The interviews lasted between 20 and 95 minutes, with an average of 57:32 minutes. To ensure that information was not superfluous, and all topics had been covered, an interview protocol was used (Karlsson, 2015). This also ensured the comparability of answers, while at the same time leaving enough room for small adjustments where needed. The interview protocol is included in appendix C.

Survey. Next to the interviews, a survey was conducted in five of the six hospitals. In hospital F, the hospital physician was hired on an individual basis, meaning that this hospital was not part of the study and pilot of the SOZG. Therefore, no survey data exists for this hospital. The respondents were selected based on their involvement in the department in which the hospital physician was adopted to the skill-mix. Therefore, all nurses, medical specialists and hospital physicians at the department were asked to fill out the survey. The questions in the survey were similar to those in the interviews. The purpose of the survey was not to use the results in statistical analyses, but to gain more insight into the perceptions of the workforce in the department in which the hospital physician was adopted. The complete survey consisted of various subjects, each with a number of sub-questions. Of these subjects, 3 were used in this research, leading to a total number of 27 sub-questions. The questions used in this research can be found in appendix B. The number of participants in the surveys can be found in table 1. The results were used to complement the results of the interviews.

Hospital A B C D E F

Respondents 15 24 58 9 11 x

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Data coding and analysis. After transcribing the interviews, the transcripts were coded using

both deductive and inductive codes. Deductive codes were based on literature regarding the relevant quality dimensions identified by Beattie et al. (2012). Inductive codes were derived from the transcripts by means of pattern and first-level coding techniques (Karlsson, 2015). After the first round of coding, all interviews were recoded based on the emerged inductive codes. This way, more consistency in coding could be established. After coding all interviews, findings were derived and analyzed using both new and previously introduced literature. The complete code-book can be found in appendix B. Surveys were used as complementary to the findings of the interviews. Information from the interviews was compared to the survey results to create a more complete picture of the situation. No further statistical analysis has been conducted with the results of the survey. Based on the interviews, the new profession of the hospital physician had developed in different ways in the six hospitals. Therefore, all findings were first analyzed per hospital and after this, comparisons between hospitals were made in a cross-case analysis.

Quality assurance

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FINDINGS

In the following section, the results of the collected data will be presented. Findings are grounded in quotes from the interviews and result from surveys. First, for all hospitals, the context, reason for adopting the hospital physician, effect on structure and effect on quality will be presented. The structure of this is as follows:

o Table with results from interviews o Context

o Reason for adopting the hospital physician o Effect on structure

§ Substitution and distribution of tasks

§ Vertical differentiation

§ Horizontal integration

• Information processing capability • Information processing capacity o Effect on quality

o Sub-conclusion

After this, the results of a cross case analysis will be presented, following the same structure. The results of the survey can be found in table 10, 11 and 12 in appendix B.

Concerning the context, for all hospitals a distinction has been made between being a (large) teaching hospital or a (smaller) peripheral hospital. Also, this research differentiates between medical wards and surgical wards. In medical wards, patients receive medical care from a non-surgical physician, such as an internist. At a surgical ward, patients receive surgical care from surgeons.

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Hospital A

Medical specialist Hospital physician Nurse

Horizontal integration Information processing capability

Handover of care x (+) x (+) o (+)

Coordination x (+) x (+)

Less consults

Information processing capacity

Easily accessible o (+) Cooperation x (+) Point of contact Continuity o (+) x (+) o (+) Quality Patient centeredness o (+) o (+) Caring o (+) Effectiveness o (+) Efficiency o (+) o (+) Safety x (+) x (+) Timeliness Additional findings Critical view Broader view Learning climate Quality improvement Extensiveness o (+)

x (+) = positive experience, specifically asked for x (-) = negative experience, specifically asked for o (+) = positive experience, own words o (-) = negative experience, own words

Table 2. Results of interviews hospital A.

Context. Hospital A is a large teaching hospital. Within the department, the hospital physician

is adopted into a surgical ward.

Reason for adopting the hospital physician. Based on the interviews, the main reason for

adding the HP to the skill mix in hospital A is a combination of continuity of care and more in-depth knowledge. This in-depth knowledge is not restricted to having more knowledge on the main problem, but as the medical specialist mentioned ‘there is need for more continuity of care, but especially also

for a view beyond the injury itself’ (MS-A). Similarly, the hospital physician at the department

described the need for the new profession as ‘Increasing the quality of care and considering the

patient as a whole’ (HP-A). The nurses at the department share the view of continuity but make it

more specific by stating that ‘the most critical moments are in the handover of care’ (NS-A). To illustrate, ‘if we watch a movie, you may think it’s good while I think it’s not that good. Well, this may

be the same for patients’ (NS-A). With this, they say that the mere provision of data may not be

sufficient for high quality handover of care.

Effect on structure. The adoption of the hospital physician in the department has led to some

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information flows and the distribution of tasks. Findings for reorganized task distribution, vertical differentiation and horizontal integration are shown below.

Substitution and distribution of tasks. In hospital A, the results of the surveys indicate that the majority of the current tasks of the hospital physician were previously done by the assistant in training (29%), the assistant not in training (43%) and the medical specialist (12%). In the interviews, the respondents state that medical specialists have more time to devote to their specialty as they have to spend less time on daily care of patients. For example, the medical specialist at hospital A mentions that he is no longer involved in the discharge conversations with patients, because this task is now performed by the hospital physician.

Vertical differentiation. At department level, interviewees mention that vertical differentiation occurs through the addition of a new profession in the vertical structure. As the hospital physician says ‘Assistants in training to be a surgeon are working in this department. But they

are not in this ward. They assist in surgeries or work in the clinic’ (HP-A). When asked whether these

assistants would previously work on this ward, the answer was yes. Based on the interviews, vertical differentiation through the addition of the hospital physician to the skill mix has led to the fact that assistants now have different tasks and are no longer involved in the daily care at this ward.

Horizontal integration. Overall, the respondents believe that horizontal integration has increased in this hospital since the adoption of the hospital physician. Indications for improved horizontal integration were found in both an increase in information processing capability and information processing capacity. However, the hospital physician mentions further increase of horizontal integration as a specific goal for which there has not yet been enough space.

Information processing capability. In the interviews, information processing capability has

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Information processing capacity. According to all three interviewees, information processing

capacity has increased in the medical department. An example of this is the increased cooperation between the nurses and the rest of the department. According to the medical specialist, ‘Cooperation

between the hospital physician and the nurses is very good’ (MS-A) and the fact that there is always

someone to ask questions is experienced as very positive by the nurses. They state that ‘there is always

someone present during the day who is easily accessible (…) and available for questions’ (NS-A). This

is also noted by the medical specialist at this hospital, who mentioned: ‘They [nurses] have a very

positive view of course, because for them the accessibility and the possibility to ask questions right away has increased a lot’ (MS-A). Based on the interviews, information processing capacity has

increased.

Effect on quality. Quality aspects that have been mentioned by all three interviewees are

increased continuity and improved handover of care. The medical specialist explains the increased quality of handover of care to parties outside the hospital (discharge) as ‘I think that discharge

conversations are more precise now. Something that a patient really needs of course. So if they leave, they know exactly what kind of medicines they take home and why’ (MS-A). The improvement of

handover of care was also something that has been valued high in the survey. Especially the writing and sending of letters and the written handover of care to outside the hospital scored very high (4 or higher out of 5). Additionally, the quality of the written handover of care inside the hospital and oral handover of care outside the hospital scored much higher with a score of 3.8 out of 5. Because this handover of care is now a task of the hospital physician, this also illustrates that the hospital physician has a complete picture of the patient, which makes it possible to have these precise conversations. The hospital physician describes this as follows: ‘Before, there was only shortly noted down what kind

of surgery someone has been through. And now.. I write down all problems that patients have. And how they are treated. There is a complete picture in the system’ (HP-A). Also, he mentions that being

there all the time increases coordination of care: ‘Coordination of care.. that is much better now,

because.. well.. I am there and I have an overview of the complete patient’ (HP-A). This complete

picture is also something that the medical specialist acknowledges. She mentions that this is possible because of the increased continuity of care. ‘There is someone present 4 or 5 days a week, who knows

what we discussed yesterday and what we need to discuss tomorrow’ (MS-A). The hospital physician

also describes this as patient centered care and caring. ‘Yes, I hear from the nurses that I talk more to

patients. I take more time to talk to family and patients’ (HP-A). This is also seen by other medical

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more trust within patients: ‘You know.. patients have trust in the face that they see every day’ (NS-A). This trust, according to the survey, is not misplaced. When asked about the improvement of patient safety, the majority of the respondents rated patient safety after the adoption of the hospital physician as much better. The highest scores were given to medication policy (4.33 out of 5) and continuity of care in medical acts and information provision (4.27 out of 5).

Sub-conclusion. Overall, respondents of the survey and the three interviewees are positive

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Hospital B

Horizontal integration Information processing capability

Handover of care x (+) x (+)

Coordination o (+)

Less consults x (+)

Easily accessible o (+) o (+) Cooperation x (+) o (+) Point of contact Continuity o (+) o (+) o (+) Quality Patient centeredness x (+) o (+) Caring Effectiveness o (+) o (+) o (+) Efficiency o (-)(+) o (+) o (+) Safety Timeliness o (+) o (+) Additional findings Critical view o (+) Broader view o (+) o (+) Learning climate x (+) Quality improvement x (+) Extensiveness x (+)

Table 3. Results of interviews hospital B.

Context. Hospital B is a large teaching hospital. Within the department, the hospital physician

is adopted into a medical ward.

Reason for adopting the hospital physician. Based on the interviews, the main reason for

adding the hospital physician to the skill mix in hospital B is a lack of continuity. ‘Hospital physicians

can offer more continuity because they are there during the day. Every day.’ (NS-B). The medical

specialist adds to this: ‘For bigger problems, it is important that someone can offer more continuity.

They [patients] are almost IC-like and can deteriorate per hour’. Next to continuity, higher quality of

care is mentioned as a reason to use the HP: ‘Hospital physicians are more specialized. They are done

or are in the last phase of their education’ (NS-B). This higher quality is compared to the ANIOS or AIOS

who have been substituted by the hospital physician. The hospital physician in hospital B does state that the addition of a hospital physician is not the only solution to solve these continuity and quality problems; ‘they [AIOS or ANIOS] are on the floor for only a short period of time. If it could be organized

that they stay longer, that is fine as well’ (HP-B).

Effect on structure. The adoption of the hospital physician to the medical department has led

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are minor and concern information flows and the distribution of tasks. Findings for reorganized tasks distribution, vertical differentiation and horizontal integration are shown below.

Substitution and distribution of tasks. The results of the survey suggest that in hospital B, the majority of the current tasks of the hospital physician were previously done by the assistant in training (41%), the assistant not in training (27%) and the medical specialist (14%). The nurse at hospital B even states that ‘They [the hospital physicians] do the job of an assistant’ (NS-B). To the question if the hospital physician has additional value over an assistant, the medical specialists says ‘not for us, no. If

anything, we are losing production’ (MS-B). This loss of production is said to lead to more work for the

medical specialists, as the assistant in training or assistant not in training would also work in the clinic. However, when asked whether the hospital physician does not add value, her response is that this is not the case either, because ‘I do not have to organize all aspects of the medical visits’ (MS-B).

Vertical differentiation. At department level, vertical differentiation occurs through the addition of a new profession in the vertical structure. As shown above, this leads to a shift in the distribution of tasks, as the assistants no longer work on the floor in direct patient care. A critical note on this form of vertical differentiation is made by the nurse in hospital B. He states that while it is very good that the hospital physicians coordinate the department, ‘assistants should also have clinical

experience. On the floor. Not only at the OR’ (NS-B). Based on this, vertical differentiation is believed

to lead to fragmentation, because the education of assistants is more focused on specialized care rather than direct patient care.

Horizontal integration. Overall, the respondents believe that horizontal integration has increased in this hospital since the adoption of the hospital physician. Indications for improved horizontal integration were mostly found in an increase in information processing capacity. Additionally, there were indications for increased information processing capability.

Information processing capability. In the interviews, increased information processing

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Information processing capacity. Both the medical specialist and the nurse at hospital B state

that the hospital physician increases integration within the department through higher capacity. As the medical specialist states ‘we always have good contact, they have no boundaries to call us’

(MS-B). According to the medical specialist, the hospital physician adds to cooperation as ‘they are easily accessible, and we are too’ (MS-B). The medical specialist also rates the cooperation between nurses

and the hospital physician as very positive. The nurses agree with this and also note that ‘cooperation

is much easier’ (NS-B). As a reason for this, they not only mention increased capacity, but also include

the intrinsic capabilities of the agent, as they state that a hospital physician is more skilled than an assistant and can therefore answer their questions with more confidence.

increased continuity and improved speed. Nurses at the department state that ‘They much faster

move towards a diagnose’ (NS-B). According to the hospital physician, this increased speed is mainly

due to the increase in continuity of care: ‘I think we have more background [knowledge] to signal

things faster … than someone who is at the department for only a few days or weeks’ (HP-B). The

nurses agree with this, stating that this continuity leads to more in-depth knowledge of the department: ‘An assistant not in training does not have as much knowledge as a fully specialized

doctor. So a hospital physician is simply broader oriented.. has simply more overview of the whole process’ (NS-B). Also, they mention continuity from a patient centered perspective: ‘I think that the HP brings a lot of continuity. For us as nurses, but also for patients. Everyone knows that the current HP is present 4 days a week’ (NS-B), and ‘Before we heard a lot [from patients] “we see a lot of different doctors”, and that is actually true. We thought so too, because there were a lot of different shifts’ (NS-B). Continuity of care does not only show in the interviews, but also in the results of the survey.

Respondents at hospital B rate continuity of care (medical acts), continuity of care (information provision) and continuity of care (psychosocial guidance) above 4 (out of 5). Not only does this bring more continuity for patients, but also for the medical specialists at the department. The hospital physician states that ‘they [medical specialists] are very happy with the fact that there are always

doctors, and that these doctors are hospital physicians that manage to organize a lot without feeling the need to call them all the time’ (HP-B). The medical specialist has trusts in the hospital physician

and states that ‘they are doing their job well and are easily accessible’ (MS-B). To conclude, the medical specialist mentions both quality and continuity of care by stating ‘Continuity of care, and therefore

quality of care, has increased. The quality at the department has increased. If they are not there it is worse’ (MS-B). While continuity has increased according to both the survey and the interviews, the

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profession or in the person: ‘If I am there, or another HP [it doesn’t matter]. But that is not entirely

true, because if you have another doctor on Monday than you have on Tuesday, then it may be two hospital physicians, but you lose the benefit that patients don’t have to tell their story twice’ (HP-B).

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Hospital C

Handover of care x (+) x (+) x (+)

Coordination x (+) o (+) x (+)

Less consults o (+)

Easily accessible o (+) o (+) o (+) Cooperation o (+) Point of contact o (+) o (+) Continuity x (+) o (+) Quality Patient centeredness o (+) o (+) o (+) Caring o (+) o (+) Effectiveness o (-)(+) o (+) o (+) Efficiency o (+) o (+) x (+) Safety x (+) x (+) Timeliness x (+) o (+) o (+) Additional findings Critical view Broader view o (+) Learning climate x (+) o (+) Quality improvement o (+) o (+) Extensiveness

Table 4. Results of interviews hospital C.

Context. Hospital C is a smaller department related to a large teaching hospital. Within

department, the hospital physician is adopted into a medical ward.

Reason for adopting the hospital physician. The medical specialist mentions that ‘at our clinic, we had a problem with the quality of basic medical care’ (MS-C). This suggests that the broad

knowledge base of the hospital physician would be one of the main reasons to choose for this new profession. The nurses at the department also recognize this need, stating that ‘The medical specialists

are very focused on their own part of the job’ (NS-C). More specifically, they note that ‘they [medical specialists] are taking shifts at the clinic, in the evening, at night, what we see is that they do not really know when a patient is in danger of failing kidneys or heart failure’ (NS-C). Based on this, both

increasing continuity of care and improving the quality of basic medical care are the main reasons for the adoption of the hospital physician at this department. The hospital physician also states that this continuity is not only for patient safety and timely diagnoses, but also for patient satisfaction. He mentions ‘I notice that they [patients] feel the need to see a doctor. The medical specialist has a more

coordinating role’ (HP-C).

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Substitution and distribution of tasks. In hospital C, the results of the surveys indicate that the majority of the current tasks of the hospital physician were previously done by the assistant in training (21%), the assistant not in training (13%), the physician assistant (22%) and the medical specialist (35%). The nurse at this hospital stresses the change in workload for medical specialists:

‘From the moment that the hospital physician was hired at the department, the medical specialist is not physically present at the clinic anymore. (…) They do not do intakes and screening anymore’ (NS-C). Also, the hospital physician notes that he takes over work from the medical specialist, stating ‘I deeply respect them, because It surprises me how they have been able to do that. Maybe they did not do it as extensive as I do, that has to be the case’ (HP-C). Additionally, he states that the physician

assistant also did a lot of the work he does now.

Vertical differentiation. At department level, vertical differentiation occurs through the addition of a new profession in the vertical structure. While the fragmentation of care and the resulting lack of basic care was one of the main reasons for hiring a hospital physician, the medical specialist has a critical side note: ‘is the intention really that the basic care is no longer done by medical

specialists? I see some sort of impoverishment at organ-specialists. They only see the organ and do not consider the patient as a whole’ (MS-C). This is in line with what the hospital physician at the

department says: ‘Medical specialists are developing a tunnel vision because they are working so much

on their specialization’ (HP-C). With this he means that while the problem of a lack of basic care must

be solved, there is a downside to adding an additional profession to do so.

Horizontal integration. In hospital C, both information processing capacity and information processing capability have been evaluated as increased. However, most of the changes were seen in the information processing capacity of the department.

Information processing capability. When asked what his main role was as hospital physician,

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Information processing capacity. In the interviews, information processing capacity has been

mentioned by the hospital physician. He noted that he has a lot of connections in the hospital and that other parties in the hospital often think of him when they need the specialty of the department. ‘They [doctors at the hospital] know, oh, (name), he works at (name department), call him’ (HP-C). While the nurse at the department in hospital C was concerned about the increased level of differentiation due to an additional profession, he also notes that the hospital physician focuses on working together to improve quality. The hospital physician himself also stresses this by stating that ‘we need to work as a team. We all need to be on the same page and share a vision’ (HP-C). With this, not only the department itself is considered, but also the hospital with which they work together. Additionally, communication within the department has improved. As the hospital physician says: ‘[working together with] our nurses and paramedics.. very positive. They can always contact me and

the same goes for the other way around’ (HP-C). This improved communication also shows in the

results of the surveys. In hospital C, 68% of the respondents indicated to be very positive about the cooperation between professionals at the department. Also, the cooperation between the hospital physician and nurses (88%) and the cooperation between the hospital physician and medical specialist (77%) has been rated as very positive.

increased coordination, timeliness, communication with patient (and family) and the transfer of care. When asked what patients notice about the new profession, the medical specialist answered ‘Before,

it was all about the professional plan and now we see that this becomes a combination of the professional plan and what a patient wants and is capable of’ (MS-C). The patient is more involved in

the whole process and the hospital physician spends more time on conversations with the patient:

‘Having a conversation with patients has a higher priority for the hospital physician [than for other professions]’ (MS-C). This is also visible in the results of the surveys, where the communication with

patient and family scored a 3.89 (out of 5). According to the hospital physician, patients value the increased contact. ‘Patients are satisfied and they express that as well. I believe that satisfaction is

very important, because when people are satisfied, they experience healthcare as better’ (HP-C).

Additionally, patients know who their doctor is and have someone to contact in case of need. When asked how care has changed since the adoption of the hospital physician, the medical specialist answers: ‘Recognizably of the doctor, that the patients recognize this is my doctor and there I can go

for questions, that has really improved’ (MS-C). Not only communication with and about patients has

improved, but also the whole patient is considered. According to the medical specialist, ‘What I think

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sense, it really is a generalist’ (MS-C). This is also reflected in the high survey score on patient-centered

care (3.89 out of 5). The highest scores in the survey are again found in continuity of care. Respondents rate continuity of care (medical acts) and continuity of care (information provision) 4.05 and 4 (out of 5) respectively.

When asked what patients may notice of the new profession, the head of nursing explains that adding the hospital physician has two major benefits: ‘I think there are two aspects. On the one hand direct

contact with the hospital physician. But also fast reaction to symptoms and signals that the patient gives’ (NS-C). Fast reaction to symptoms is also stressed by stating ‘He recognizes signals fast and knows which interventions are needed. I see a huge difference in competence’ (NS-C). According to the

head of nursing, this competence reflects in the competence of the nurses at the department: ‘What

we see is that the competence of the doctor influences the nurses, which makes that they are becoming more professional in their job’ (NS-C). This competence together with better communication increases

coordination of care. As the nurses noted: He is easily accessible, when patients are not feeling well,

he knows what needs to be done (NS-C).

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Hospital D

Handover of care o (+)

Coordination o (+) o (+)

Less consults x (+)

Easily accessible Cooperation o (+) Point of contact o (+) Continuity o (+) Quality Patient centeredness o (+) Caring Effectiveness o (+) o (+) Efficiency o (+) Safety x (+) Timeliness o (+) x (+) Additional findings Critical view Broader view o (+) o (+) Learning climate x (+) Quality improvement o (+) Extensiveness x (+)

Table 5. Results of interviews hospital D.

Context. Hospital D is a smaller peripheral hospital. Within the department, the hospital

physician is adopted into a surgical ward.

Reason for adopting the hospital physician. The reason for adding a hospital physician to the

skill mix was not very clear to everyone in the department. As the hospital physician mentioned ‘I was

hired by the hospital, for the surgeons. But hey were not clearly involved in that decision’ (HP-D). The

medical specialist explains why these surgeons were in need of a hospital physician: ‘Especially

surgeons need a hospital physician. Because they are only cutting and don’t think about the rest of the patient’ (MS-D). This super specialization is again stressed by the hospital physician, who mentions

that ‘The medical specialists do not see a lot of what is happening on the floor’ (HP-D). When asked, the nurse could see how the hospital physician could be beneficial to the department: ‘I think when a

hospital physician is at the department for a while, he will be able to increase continuity much more’ (NS-D).

Effect on structure. Super specialization was one of the reasons why the hospital physician

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Substitution and distribution of tasks. In hospital D, the results of the surveys indicate that the majority of the current tasks of the hospital physician were previously done by the assistant not in training (59%) and the medical specialist (27%). When asked, the medical specialist does not see much change in the vertical structure at the medical ward: ‘The hospital physician does the work that

an attending would usually do’ (MS-D). The nurses on the other hand do see that the hospital physician

has a distinct role from that of the attending: It [hospital physician or attending] is not exactly the

same role. The attending really is.. he follows an educational program in a specific specialism, to specialize in that area and then leaves’ (NS-D). With this, they note that the hospital physician does

not simply replace the assistants or attending but has more to offer.

Vertical differentiation. Based on the first reactions during the interviews, there have been no visible changes in the vertical structure of the department. However, the nurses at hospital D note that it may be the case that the hospital physician substitutes for more than one person in the department. They state: ‘On the other hand, when the hospital physician replaces the attendings, then

3 puppets leave for only one hospital physician’ (NS-D). While there is no evidence for this yet, if this

is the case the adoption of the hospital physician would lead to vertical integration rather than differentiation.

Horizontal integration. In hospital D, both information processing capacity and information processing capability have been evaluated as increased. However, like in hospital C, most of the changes were seen in the information processing capacity of the department.

Information processing capability. In the interviews, information processing capability has

been mentioned as an increase in coordination between departments and an increase in quality of handover of care. Attention for increasing quality of the handover of care is explained by the hospital physician himself. He states that ‘More and more care has shifted towards the general practitioner. I

think, if we choose to do so, care has to be transferred directly, at least through a phone call’ (HP-D). Information processing capacity. As mentioned before, the majority of the current tasks of

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their superiority over lower skilled workers. The fact that this hospital physician does not do that is perceived as very positive. According to the nurses, this increases the integration within the department and makes it easier to communicate. This in turn improves the cooperation in the department. This also becomes visible in the results of the survey, as 50% of the respondents rate the cooperation between hospital physician and nurses as positive.

Effect on quality. During the interviews, the quality aspects broad view, effectiveness and

coordination were mentioned often. The broad view is described by both having a clear overview of the situation and being the generalist to cope with these situations. As the medical specialist says:

‘The added value during the week, that would be the specific role of the hospital physician. Like you said, that is probably the generalist part, that he can manage that easily’ (MS-D). Also, the hospital

physician says about the generalist view that he considers the whole patient from the beginning: ‘I

learned to consider right at the point of admission, can a patient go back home after his hospital stay or does he have to rehabilitate? What can we organize or initiate now, so that we don’t have to wait for that later?’ (HP-D). Also, he stresses the difference between the medical specialists and his new

profession: ‘Internists what to unravel everything in detail and I think I learned a lot at the geriatric

department in this case. There they look a lot at functionality. What is the added value and why would you do additional research, except for yourself to see where that one liver value is coming from?’ (HP-D). Not only does this shift the focus towards the patient as a whole, it also increases the speed of

care and improves transfer of care. The speed of care is mentioned by the medical specialist in relation to the experience that the hospital physician has: ‘You can see that he is really fast at creating an

overview and picking up on things fast. I think that is experience and the fact that he has finished his studies. This way he distinguishes himself from (name) who is still in her studies’ (MS-D). Also, the

hospital physician notes that a good handover is important to patient satisfaction: ‘Patient satisfaction

is a very important factor. Is the patient discharged well? In the sense that, does the patient understand what he has been through, what happened and when he should alarm us?’ (HP-D). This illustrates the

overall consensus that the hospital physician pays more attention to continuity and quality of care, as the nurses literally say: ‘They pay more attention to continuity and quality’ (NS-D).

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