“HANDLE WITH CARE”
Change process interventions and mechanisms of new 1.5
care organizations: a multi-stakeholder perspective
Evidence from a multiple case study
Master Thesis Msc BA – Change Management University of Groningen, Faculty of Economics and Business23-06-2014 Word Count: 13.992 T. Swanenberg S1778684 Van Speijkstraat 140-3 1057 HJ Amsterdam t.swanenberg@student.rug.nl
Under supervision of:
Dr. M.A.G. (Marjolein) Van Offenbeek Second Assessor University:
Dr. H. (Manda) Broekhuis
ACKNOWLEDGEMENTS
I am very grateful to all care professionals, managers and advisors for their participation in this study. Next, I am thankful to Marjolein van Offenbeek; as a supervisor, she gave me constructive feedback and motivated me to increase the quality of my thesis. Last, I want to thank my friends and family for
bringing an enormous amount of laughter and distraction during my thesis research. In particular I want to thank my fellow students Robert Westerhuis and Lisanne Jonkman for making my time as a
ABSTRACT
1
CONTENTS
1.INTRODUCTION………..………2
2.THEORETICAL BACKGROUND..………..………..4
2.1 Emergent network change……….4
2.2 Critical change success factors………5
2.2.1 Instability in the network……….……….5
2.2.2 Shared vision……….5
2.2.3 Trust and mutual respect………..………6
2.2.4 Open communication………..………6
2.2.5 Shared knowledge….………7
2.2.6 Commitment to collaborate…..……….7
2.3 Interrelatedness of success factors………..………8
2.4 Research questions and conceptual model……….……….9
3. METHOD………..10
3.1 Research design……..………...10
3.2 Case descriptions………..………10
3.3 Data collection………….……….………..10
3.4 Data coding & analysis……….……….……….12
4. RESULTS……….………..14 4.1 Within-case analyses………14 4.1.1 Case 1………14 4.1.2 Case 2………15 4.1.3 Case 3………16 4.1.4 Case 4………17 4.1.5 Case 5………17 4.1.6 Case 6………18 4.2 Cross-case analysis………19 4.2.1 Similarities………22 4.2.2 Differences………...25
5.CONCLUSION AND DISCUSSION……….………..27
5.1 Theoretical and practical implications………..28
5.2 Research validity and limitations………30
5.3 Future research………31
5.4 Conclusion………31
6. BIBLIOGRAPHY……….………33 APPENDICES
2
1. INTRODUCTION
The importance given to health care by individuals and governments and its growing costs makes health care a frequently researched area. Also in Dutch politics, health care has been an important policy area for decades: already in 1941, the Netherlands accepted the Sick Fund Law to increase the quality of health. The core principles of this law were evidence-based care, universal coverage and equity in accessibility (Van Weel, Schers & Timmermans, 2012). Ever since, all people have a General Practitioner (GP) that provides primary care and that functions as a gate keeper for access to secondary care. Currently, the organization, roles and responsibilities of primary care are changing. The Dutch minister of health care explains the reasons for this change in a recent letter to the parliament: “the quality of health care is excellent but its affordability is under pressure. If we want to ensure quality and accessibility, change in the organization of health care is needed (Ministry of VWZ, 2013)”. Therefore, recent governmental policies stimulate collaborative, multidisciplinary and demand-driven care. The aim of these policies is to ensure that people do not need multiple care professionals that are all responsible for a part of the care. The current fragmentation of care exists as care professionals work on a specific discipline and tend to neglect issues outside of their expertise area (Freeman & Hjortdahl, 1997; Haggerty, Reid, Freeman, Starfield, & McKendry, 2003; Rogers & Curtis, 1980). Next to the governmental pressures, insurance companies also exert power on the health care system. In 2006, Dutch health care changed to a market based system with competition between insurers. Consequently, insurers are now seen as an intermediary in providing the best care for the best price (van Weel et al., 2012). Consequently, insurers are keen to support health care innovations to increase cost efficiency and quality.
3 Currently, within 75% of the collaborative 1.5 care organizations, at least five different parties are involved (ZonMw, 2012), which requires intensive coordination and collaboration between all stakeholders of the organization. Furthermore, it is recognized that intense interdisciplinary collaboration represents a culture change for care practitioners as their professional autonomy suddenly needs to be shared (Nivel, 2009). Moreover, collaboration requires new ways of working and organizing. However, such an introduction of an innovation in health care is widely seen as a complex process (Fleuren, Wiefferink & Paulussen, 2004). The complex change process towards 1.5 care organizations seem to come with problems that mainly have to do with the change in roles and responsibilities (ZonMw, 2012). Moreover, problems arise because of the lack of focus on the development of the organization since care providers tend to focus more on the content (care) than on the organizational implications of the 1.5 care organization (ZonMw, 2012).
Although some first issues with the change towards 1.5 care organizations already surfaced, there are little empirical results that determine the factors that influence the development process of collaborative relationships between health professionals (Martin-Rodriguez, Beaulieu, D'Amour & Ferrada- Videla, 2005). Namely, general change management literature is not fully applicable to this health care change. Traditional change management literature mostly studies changes within one organization whereas 1.5 care organizations are collaborative initiatives which creates other change dynamics. In addition, the highly institutional context of health care organizations is a complex and unique environment (Cummings & Worley, 2005). Consequently, both health care practitioners and researchers will benefit from a more specific description of successful change processes for their industry (Kash, Spaulding, Johnson & Gamm, 2014). Moreover, a better insight in successful change processes is essential since strategic change competencies are becoming increasingly important as health care organizations are continuously repositioning themselves in the competitive market (Kash et al, 2014). Cawsey, Deszca and Ingols (2012) describe that the complex nature of change can be somewhat simplified by distinguishing that there are two different aspects to focus on in change management. Namely, change managers must focus on “WHAT” to change and “HOW” to change. In this respect, Greenhalgh, Robert, Macfarlane, Bate & Kyriakidou (2004) mention in their literature review on diffusion in health service innovations that future research should focus on two aspects. First, future research must be innovation process ("HOW") rather than innovation package ("WHAT") oriented. Second, researchers should study multiple cases instead of small isolated situations in order to study the influence of differences in context. The current change towards 1.5 care organizations is a perfect occasion to follow these recommendations. Moreover, the change in still in progress, which allows for real-time investigation of the change process.
In order to fill the theoretical and practical gaps, this research will focus on the “HOW” of change. More specifically, the following research question will be answered: How do change process mechanisms
and interventions influence the success of the change towards an 1.5 care organization? In short, this
research will draw on the management literature to improve the insight in the implementation of strategic multi-stakeholder change in the health care sector. In order to answer this explorative research question, six cases of 1.5 care organizations were analyzed by interviewing multiple stakeholders and analyzing secondary data.
4 study design and research methods. Subsequently, the results section describes the change process mechanisms and interventions and their effects per case. The last section answers the research question and discusses implications and limitations of this study.
2. THEORETICAL BACKGROUND
As mentioned in the introduction, the change towards 1.5 care organizations involves collaborative projects that include a (cultural) change towards new ways of working. Although CM literature gives valuable general insight in the critical change process factors for projects such as the 1.5 care projects, the CM field mainly focuses on change within organizations. As the 1.5 care projects are collaborations between different care organizations, a closer look will be taken at literature on strategic collaboration. In particular, two literature streams will be considered. First, attention will be given to PM literature that elaborates on critical success factors in projects with intense collaboration, like Public-Private partnerships. The PM and CM literature complement each other in their focus: PM literature has a strong focus on the management of tasks, but it frequently avoids the softer issues addressed in CM research. For example, it is a popular theme in CM to build awareness, readiness and desire for change, whilst implementing and coordinating the logistics require PM insight (Kotter & Cohen, 2002). Hence, the two fields should be treated as complementary. Second, research on joint ventures (JV) can also offer complementary insight in potential critical success factors for the change towards 1.5 care organizations. Like a 1.5 care organization, a JV is also a relationship between two or more parties with the strategic aim to fulfill a mutual business need while remaining independent businesses at the same time (Kumar, 2012). In order create a complete insight in the factors that possibly influence the creation of 1.5 care organizations, the literature review will focus on the complementary success criteria as defined in the CM, PM and JV literature.
Before I will elaborate on factors that potentially influence success of the 1.5 care projects, the type of change will be discussed as understanding of the dynamics within 1.5 care organizations is essential to understand the change process thoroughly.
2.1 EMERGENT NETWORK CHANGE
5 emergent change approach is more suitable in dynamic and uncertain contexts like the Dutch health care sector. Second, much of the planned change literature sees organizations as closed systems, whereas the emergent change approach recognizes organizations as open systems. Although the emergent change approach seems to be more relevant for this research, it must be acknowledged that the change towards 1.5 care seems to have some planned elements as well. For example, an evaluation of ZonMW (2013) describes the presence of project plans that describe project phases and steps. 2.2 CRITICAL CHANGE SUCCESS FACTORS
Even though the emergent change approach states that there is not one change process ("HOW") that guarantees success, complementary CM, PM and JV research findings shows that there are some factors that influence change success. These so-called critical success factors are instability, a shared vision, trust and mutual respect, shared knowledge, open communication and commitment to collaborate. An explanation for the importance of these factors will be given in the next sections.
2.2.1 Instability in the network
The first factor that is frequently found to contribute to change success is instability. Cummings & Worley (2005) describe that instability is essential to start a change in a network. They mention the strong relationship of this factor with the famous change management theory of Lewin (1951). Lewin described the issue of how to bring about change with a three-stage model, including an unfreeze, change and refreeze stage. This theory describes that before a change can occur, an unfreezing process must happen (Cawsey et al., 2007). This process includes dislodgement of beliefs and assumptions of the change participants whereby it creates openness for change. Cummings & Worley (2005) describe that instability in the network stimulates unfreezing. In order to create instability, members of a network must become aware of the required change in roles, responsibilities, goals, benefits and costs (Cummings & Worley, 2005). Cawsey et al. (2007) describe several ways to do this; for example by creating a crisis or by educating employees (e.g. showing benchmark data that support the change). As described in the introduction, governmental and insurance pressure create instability for care organizations. However, this research will explore whether additional change process interventions or mechanisms create instability in the network of the 1.5 care organizations as well.
2.2.2 Shared vision
6 more time-consuming and difficult (Cawsey et al., 2007).
Although empirical studies repeatedly stress the importance of a shared vision, in practice a vision is frequently lacking. Research found that a shared vision is often lacking between participants working in different functional areas (Gittell, 2006) whereby participants can show opportunistic behavior by pursuing their own functional goals (Luo, Shenkar & Nyaw, 2001). Since primary and secondary care providers both work in different functional areas, it is possible that a shared vision is lacking in the change towards 1.5 care organizations as well.
2.2.3. Trust and mutual respect
Research of Luo (2001) showed that a shared vision increases trust (Luo et al., 2001). This is interesting as many researchers state that trust is also one of the critical success factors for the development of a successful collaboration (D’Amour, Sicotte & Levy, 1999). Trust has to do with positive expectations people hold about each other’s behavior and fulfillment of obligations (Kumar, 2012). Trust is one of the most essential factors in managing network change since it increases willingness to change (Cummings & Worley, 2005). Although there are no ground rules of how to create trust, we know that trust is founded on behavioral predictability based on past experiences and mutual understanding of each other’s intentions (Lines, Selard, Espedal & Johansen, 2005). In addition, character traits like honesty, openness and integrity are consistently associated with trust (Cunningham & McGregor, 2000). Therefore, in order to create trust, practices that develop positive experiences between collaborators, mutual understanding of one’s intentions and honest, open and integer actions are helpful. However, just trust is not enough for successful collaboration; mutual respect is also found as an impactful factor on change and project performance. Respect adds to trust since it includes appreciation of the other’s work and acceptance of the value of the other (Martin-Rodriguez, Beaulieu, D’Amour & Ferrada-Videla, 2005). Again, there are no ground rules for how to create mutual respect. However, it requires knowledge and recognition of the contribution for the other team members and the recognition of its interdependence (Martin-Rodriguez et al., 2005).
Studies showed that care professionals attach much importance to trust and mutual respect; however, their professional autonomy can block respect and trust (D’Amour et al., 1999). More specific, a research of Belkadi (2006) on disease management in the USA found that care providers do not want to share their professional autonomy and experience with others. Furthermore, van Maanen & Barley (1984) show that occupational identity is a major source for pride, and professionals of different occupational communities reinforce their own status by showing disrespect for the work of people in another occupational community. Since primary and secondary care providers reside in different occupational communities, this can be a potential blocker for trust and mutual respect in 1.5 care organizations.
2.2.4. Open communication
7 communication. First, open communication supports understanding of how an individual’s work contributes to team objectives. Second, communication allows constructive negotiations and discussions. Third, communication is found to reinforce other important aspects in collaboration; for example mutual respect and trust (Henneman et al., 1995). All these findings stress the importance of open communication; however, how to facilitate open communication is a less frequently discussed topic. Change research shows that communication through a variety of communication channels is preferable (Cawsey et al., 2007). In addition, formal communication, like team meetings, is found as a critical aspect of communication.
Despite of the clear importance of open communication, a recent research of the ministry of health care found that collaboration between health care providers in 1.5 care organizations is not optimally fluent because of a lack of transparency and communication (Ministry of VWZ, 2013). Again, this can possibly be explained by the strong occupational identity and professional autonomy of care providers. More specific, it is possible that care providers do not communicate openly with professionals outside their occupational community in order to defend their occupational identity and to maintain their professional autonomy. Furthermore, open communication can be blocked by the fact that collaborating professionals in a 1.5 care organization are most of their time not working from the same location.
2.2.5. Shared knowledge
Trust and open communication are also the main drivers for sharing knowledge. This is essential since shared knowledge is found to increase the performance of a partnership (Jacobson & Choi, 2006). Weick & Robert’s (1994) theory on sense-making proposes that shared knowledge of the work process connects participants whereby it increases effective coordination. Therefore, the question arises of how to create effective knowledge sharing practices. Knowledge sharing practices are found to be effective when they focus on two aspects. First, effective practices focus on creating understanding among participants of how their individual tasks fit together with the tasks of other parties. This creates understanding of who needs to do what, and with what urgency (Gittell, 2008). Second, a recent study of Nivel (2013) showed that sharing content information is important too. More specifically, Nivel (2013) looked at the possibilities to substitute secondary care by primary care and the results show that the knowledge of the primary care provider must be sufficient to take over a part of the secondary care (Nivel, 2013). Several researchers indicated that there are some aspects that stimulate knowledge sharing; for example frequent face-to-face communication, a shared language, performance appraisal and IT systems that facilitate knowledge sharing (Cabrera & Cabrera, 2005).
Even though several research areas stress the importance of knowledge sharing, shared knowledge is frequently lacking in collaborative change project, projects and JVs. Dougherty (1992) gives a reason for a lack of shared knowledge by explaining that people with different functional backgrounds hold different ‘thought worlds’ because of their differences in training, expertise and socialization. Hence, it is possible that the lack of knowledge sharing exerts a negative influence on the performance of 1.5 care organizations as primary and secondary care providers come from different functional backgrounds (‘thought worlds').
2.2.6. Commitment to collaborate
8 core is voluntary (D’Amour et al., 1999). As a consequence, in order to start a collaborative practice, the professionals must be willing to collaborate and commit to a mutual process (Henneman et al., 1995). One essential aspect in creating willingness to collaborate is the establishment of ‘collaboration logic’, which basically means that both parties must see the collaboration as an effective way to reach certain objectives (Cummings &Worley, 2005). When the benefits for both parties are clear, commitment will be increased. Consequently, success of a change, project or JV is partly dependent on the strategic necessity (Luo, 2001). Greenhalgh et al., (2004) mention in their research on diffusion of health care innovations that innovations will be more easily adopted when the benefits are visible. Therefore, practices that make the benefits of the innovation visible and clear (e.g. demonstrations or sharing of positive outcomes) increase the likelihood of commitment to collaborate.
The commitment to collaborate potentially threatens success of the 1.5 care initiatives. Commitment can be low because the financial streams between primary and secondary care are still strictly separate (Nivel,2013). This separation of financial streams can cause that one of the participants receives more financial benefits from the collaboration than the other, which can hinder the willingness to collaborate.
2.3 INTERRELATEDNESS OF CRITICAL SUCCESS FACTORS
Even though the critical success factors individually exert a positive influence on a (change) project, they are also highly interrelated. For example, a shared vision increases trust as the collaborators get insight in each other’s motives (Henneman, et al., 1995). Moreover, a study on public-private partnerships found the interrelatedness of communication and trust (Jacobson & Choi, 2006). More specifically: effective communication mechanisms engender trust, and a high level of trust results in more open communication (Corrigan, Hambene, Hudnut, Levitt, Stainback, Ward & Witenstein, 2005). Furthermore, trust is one of the main determinants for knowledge sharing. Another relationship between the factors above can be found between a shared vision and commitment to collaborate. Namely, an appealing shared vision will emphasize the collaboration logic, which again is found to increase commitment (Cummings & Worley, 2005).
9
Figure 1. Communication and relationship ties of relational coordination.
2.4 RESEARCH QUESTIONS AND CONCEPTUAL MODEL
The literature review described six critical factors for change success. Hence, the relationship depicted by arrow A in figure 2 already received support in empirical research. Literature recommends some processes and interventions to simulate the development of these critical success factors (e.g. organize team meetings to foster open communication). However, the unique emergent change dynamics of 1.5 care organizations makes the influence of these mechanisms and interventions unpredictable. Although the emergent approach to change describes that there is not one process that guarantees success, influential change process mechanisms and interventions for 1.5 care projects will be researched in this study. In other words, I acknowledge the emergent aspects of the 1.5 care context; however, this research aims to involve a planned change perspective to expose change process mechanisms and interventions that impact the change towards 1.5 care organizations. Therefore, the following main research question will be answered: How do change process mechanisms and
interventions influence the success of the change towards a 1.5 care organization? As depicted in
the conceptual model, two relationships are proposed. First, the change process mechanisms and interventions can influence the critical change success criteria, whereby they indirectly influence change success. Second, change process mechanisms and interventions can influence the change success directly.
Figure 2. Conceptual model
Critical change success factors - Instability in the network
- Shared vision
10
3. METHOD
This section describes the multiple case study design employed in this study. First, I will elaborate on the research design and case context. Subsequently, the data collection and analysis procedures will be described.
3.1 RESEARCH DESIGN
A case study was expected to yield the most benefits for this research since it allows for understanding of a complex phenomenon within in a real-life setting by identifying how events take place (Yin, 2009). Moreover, Yin (2009) describes that case studies are best suited in research that answers a how or why question, where no control over the events is needed or feasible and where the focus is on contemporary events. Because this research on 1.5 care organizations fulfills these three criteria, a case study fits well. A multiple case study design was chosen because the results are more compelling and robust than results of single case studies (Yin, 2009) and the investigation of six cases complies with Eisenhardt's (1989) statement that 4 to 10 cases are convenient for most purposes. One of the selection criteria of the 1.5 care organizations was collaboration between a GP and a secondary care provider. To obtain a varied and realistic picture of the existing 1.5 care organizations, cases were selected that diverged in size, location and type of care. Moreover, both experimental cases (EC) defined by the ministry of healthcare and non-ECs were included. Additionally, cases were excluded if no stakeholder (which was directly involved in the change process) was available to have an one-hour interview with the researcher.
3.2 CASE DESCRIPTIONS
To give an appropriate answer on the research question, a clear overview of the 1.5 care projects is needed. In order to be able to determine the similarities and differences, a structured overview of the cases is presented in table I. The description follows the inclusion criteria provided earlier.
3.3 DATA COLLECTION
To get a deep understanding of the change process mechanisms and interventions in the cases, qualitative data were collected from 12 face-to-face semi-structured interviews with stakeholders of 1.5 care projects. Additionally, secondary data like written reports and articles were analyzed. Semi-structured interviews are appropriate as they provide an opportunity to explore interesting aspects that emerge during the interviews (Hill et al., 2005; Hill, Thompson, & Williams, 1997). An interview protocol (appendix 2) was developed deductively and provided an overall structure for the interviews. Prospective interviewees were contacted by telephone or e-mail, had the project explained to them and were sent an information sheet about the project by e-mail. All interviews took between 45 and 75 minutes and were recorded and fully transcribed; this resulted in 81 pages of interview transcripts.
Next to the interviewed stakeholders of the cases described in table I, two independent consultants were interviewed. The organization they work for supports primary care organizations by offering advice, project facilitation and project management. These interviewees both have experience with different types of 1.5 care projects. They were asked to contribute to this research as their experience and independent status can give a broad insight in the dynamics of 1.5 care projects.
11 Table I: Structured case descriptions
C ase Project Start / kick-off Location Experi- mental case of ministry
Collaborating parties & multidiscplinarity
Goals Project description Interviewed stake-holders
1 2011 West No Main collaborating parties
are a hospital and ten GPs. A pharmacy, dietetic care center, physiotherapists, addiction care providers are also involved
1) Increase care quality and patient satisfaction by offering health care close to the patients and by helping patients on the right place 2) Increase the hospital’s adherence
Opening of a health center that provides regional citizens with a broad spectrum of primary and secondary health care facilities, like GP practices (10), an X-ray department, several specialists’ consulting hours and a pharmacy
2 managers from the hospital
2 2013 East Yes Main collaborating parties
are an insurance company and a regional care group; but a hospital and a patient representative organization are also involved
Decrease costs and increase patient satisfaction by providing as much as possible care in primary care organizations
Two business cases were selected and set up. One aimed at patients with muscoskelatal problems by providing a 1.5 care consulting hour of a specialized GP in two municipalities. The other provides coordinated care for elderly patients after hospital dismissal 1 manager from the care group 1 general practitioner 3 2012 North-west
Yes A regional care group, five midwifery practices, a diagnostic center, regional GGZ, a hospital, and an insurance company
1) Provide care close to patients
2) Focus on prevention by offering integral care and by stimulating self-management
Six programs are part of the project: natal care, diagnosis, mental health care, chronic care, pharmacy and elderly care. Interventions will be designed until 2017. Different types of care providers work together to provide the care programs
1 project manager 1 program manager
4 2013 North No An elderly care organization (with nursing houses), GPs, dieticians, psychotherapists and elderly care specialists
Offer care close to the patients, preferably at home, by focusing on self-management, e-health and new ways of care organization and coordination
More demand-driven care was developed by designing modular (integral) care for elderly patients
1 indepen-dent facilitator
5 2013 South Yes Main collaborating parties are a regional care group, a patient representative organization, an insurance company and a hospital; but a university, regional GGZ and home care groups are also involved
Stimulate sustainable, affordable and high-quality care
Several sub-projects are included in a total regional project. One of the projects is called 1.5 care and contains a consult hour of specialists at a 1.5 care center, which functions as an extra gate keeper towards secondary care
1 manager of the care group 1 manager of the hospital 6 2014 Central No A hospital, a regional GP
group/organization, and an interdisciplinary care group
Stimulate interdisciplinary collaboration to be able to respond to future care demands by offering high-quality care
A trans mural center is opened were primary and secondary care services are provided. The hospital hosts policlinics here and several primary care providers and a GP post is hosted in the center
12
3.4 DATA CODING AND ANALYSIS
Data reduction and coding are important research activities in order to systematically interpret and analyze a large amount of messy qualitative data (Miles and Huberman, 1994). Therefore, a coding scheme was developed to support a systematic analysis of the qualitative data. The development of codes involved inductive as well as deductive strategies. The inductive coding allowed relevant specific concepts to come forward, even if they were not directly mentioned in the literature review (Hennink, Hutter & Bailey, 2011). Table II describes the main steps for the coding process in this research. The whole coding process is conducted in Atlas, a software package that facilitates an easy and structured coding process.
Table II: Coding process
During the third step, I marked relevant data into broad categories, like communication, knowledge sharing, and meetings. Later, these broad categories were split into smaller codes by pattern coding. The coding scheme describes all codes used by the researcher. Moreover, it gives some rules for each code in order to increase the accuracy of the coding process. A part of the coding scheme is depicted in table III, the whole scheme can be found in appendix 3.
Table III: Part of the coding scheme
After the coding process, a thorough analysis per case was made by doing two analyses. First, all positive and negative process mechanisms and interventions per case were summarized in a table. A part of this table is depicted in table IV, the full analyses of all cases can be found in appendix 4.
Step Description
1 Deductive codes were set up based on the literature review
2 Interview transcripts were read several times by the researcher for familiarization with the data
3 The researcher coded the transcripts deductively while at the same time data that are relevant but cannot be coded deductively were marked
4 Based on the marked data, inductive codes were developed by pattern coding
Code Description Code ID
(ATLAS)
Quote Symposia When regional symposia are
organized where different care providers meet, this code can be given
1-3:42 “ We organize days called ‘GP meets specialist’. Here, our specialists tell about an interesting topic or new insights within their expertise area. Afterwards, GPs and specialists meet each other during drinks in our restaurant..”
13
Table IV: Part of case analysis – case 2
Second, to get an even more valuable insight in the cases, a network of connections was made to see which connections between the change process interventions exist. One of the case networks is displayed in figure 3, and the full networks are shown in appendix 5. The arrows display whether there is a relationship between two concepts/interventions and the direction of the relationship. The criterion to place an arrow in the network is the presence of direct evidence in the data. For example, one interviewee describes the effects of knowledge sharing: “It helps, also because people get to know each other. Moreover, it creates commitment, and you can keep an eye one each other’s qualities.” Here, an arrow is depicted from ‘knowledge sharing’ to ‘commitment’ and ‘strong relationship.’ The plusses and minuses show whether a positive (+) or negative (-) relationship is found. Jointly, these two analyses gave a deep insight in each case.
Figure 3. Network analysis of case 6.
(+ positive relationship, - negative relationship)
Positive Negative
All GPs get €10 for each referral to the 1.5 care consult hour (financial incentive)
Convince the secondary care providers of a win-win situation, because they only get busier and they cannot see all patients anymore.
In the beginning, secondary care providers felt that the project harmed their income, whereby they were not enthusiastic to collaborate
14
4. RESULTS
This section presents the results of the analyses. First, change mechanisms and interventions found in each case will be discussed. Subsequently, an overview of the differences and similarities between the cases is given, as well as an overview of the interrelatedness of the change mechanisms and interventions.
4.1 WITHIN CASE ANALYSES
All cases have their own change story, with different interventions at different moments in the change process. I refer to appendices 5 and 6 for the complete case analyses, including a full overview of the change process interventions and mechanisms and the network of connections.
4.1.1 CASE 1
15 example joint training courses, a taster-day to understand each other’s work and a consult hour of secondary care providers for GPs to present patients. Moreover, an IT system allowed the involved care providers to review patient information even after referral to another care provider. These practices increased knowledge and recognition of each other’s work. Sharing of knowledge is mentioned as essential since primary and secondary care processes become interrelated within 1.5 care. Regarding communication, it is mentioned that a regular e-mail with updates supported the presence of up-to-date information, and the physical nearness of the primary and secondary care providers stimulates quick, real-time communication. In addition, the management organized periodic formal meetings to discuss relevant topics regarding the project.
Furthermore, some negative change process mechanisms and interventions surfaced. Firstly, even though the insurance company expressed that they were willing to contribute, they do not share knowledge about successful aspects of other 1.5 care projects. This makes it hard to determine potential successful interventions. Second, commitment of care providers decreases as insurance companies are not (yet) fully able to reward 1.5 care services. Nevertheless, the project is positively evaluated because patients and GPs appreciate 1.5 care services as they can be delivered quickly. Moreover, the hospital already increased its adherence area.
4.1.2 CASE 2
The second project is one of the experimental cases of the ministry of health. The project involves two 1.5 care services: the consult hours of a GP for patients with muscoskelatal problems and coordinated care for elderly people after hospital dismissal. Here, pressures to reduce costs and increase quality and patient satisfaction were reasons to start the project. In addition, the care group committed to the project as it increases their chances of multi-year contracts with the participating insurance company. Two GPs were selected to provide 1.5 care as they have the right experience and education. In addition, both GPs already started providing 1.5 care before the project started. The start-up phase of this project was facilitated by an external company: “It was helpful that this company was involved, just to make sure we made progress. In addition, they were able to give us a good insight in different project phases and they showed several possibilities. This helped us making good decisions.” Another interviewee described that the facilitating company increased commitment of all stakeholders as their services are costly and time was scarce. Furthermore, they made sure that decisions were made quickly by organizing an intense decision-making day. In addition, the GPs that provide 1.5 care services developed a desk scheme which shows the roles and responsibilities of regular GPs, 1.5 care GPs and specialists in the hospital.
16 publicly emphasized that the 1.5 care services will not impact the primary care budgets, one of the interviewees expected that the strictly separated financial streams between primary and secondary care can be a reason for their reluctance. Doubts about the financial implications also caused reluctance of specialists in the regional hospital as 1.5 care implicates a shift from care at the hospital to GPs. However, the pressure to lower costs and the fact that the GPs mentioned to refer to another hospital if they did not contribute made the specialists collaborate. Next, the steering committee was helpful to make major strategic decisions, whereas smaller working groups discussed minor topics like referral procedures. One of the interviewees describes a benefit of participation of the insurance company in the steering committee: “we can discuss anything for ever. People do not always want to contribute, even if it is beneficial for society as a whole. But if an insurance company says you have to do it, everybody does.” Last, although the project just started, some first results show that the majority of patients that use the 1.5 care services do not have to be referred to secondary care providers. 4.1.3 CASE 3
This project also is one of the experimental cases of the ministry of health. The project involves six programs were primary and secondary care providers collaborate. The project was set up to offer care close to patients and to focus on prevention. Moreover, governmental and social pressures created the need for 1.5 care in this region. Interviewees describe that this project is (partly) selected as an experimental case as the involved care group is relatively professionally organized and because of the good relationship between the care group and the hospital. Different types of care providers already knew each other because of all kinds of symposia and meetings in the region. These symposia are used as a platform to share knowledge and to build relationships. Furthermore, a shared IT-system is implemented to refer and track patients consistently. The interviewees described “The referral via a shared system is essential, if you do not have a good system to track and refer patients, you cannot do this.” Furthermore, stakeholder involvement is experienced as a positive aspect in the change process. The steering committee of the project consists of representatives of the care group, the hospital and an insurance company. This committee meets monthly and discusses issues that cross organizational borders. It is experienced as beneficial that the insurance company is involved as it creates the possibility to discuss compensation issues during the project. For example, it was decided that care providers would be rewarded based on savings in the region; however, this is hard to measure whereby the care providers are not rewarded fairly (which decreased commitment). Even though no solution is found yet for this issue, the interviewees mention that the insurance company is willing to discuss issues like this.
17 which impacts their incomes negatively. However, they do contribute to the project as they feel it as their responsibility to lower care costs. Moreover, they realize they cannot help all patients by themselves due to the aging population. Even though the project just started, first results show that the 1.5 care service is effective: the GPs that function as gatekeeper between primary and secondary care were able to keep 100% of the diabetic patients in primary care organizations.
4.1.4. CASE 4
The fourth case is a project that aimed to offer demand driven care by developing modular care for elderly patients. A task-force of approximately ten people from different disciplines was created to design the modules. Each care provider had a personal reason to contribute to the project: some contributed to ensure future referrals to their care services, others felt they had to contribute to increase quality of care. Two external facilitators lead the design of the modules during seven meetings with the task-force. These facilitators were chosen as they conducted a research about different types of elderly patients and their care demands. The presence of the facilitators was beneficial as “if you do not facilitate it, they do not stop discussing about care content.” Both the care providers and the facilitators experienced the multidisciplinary of the task-force as beneficial as they had to offer the modular care services jointly as well. Even though all care providers liked the multidisciplinary, some problems were experienced. Some care providers already worked together in a nursing home and they felt comfortable working together. However, care providers that did no knew each other felt that they were speaking another language, which hindered effective collaboration. Additionally, some of the care providers were used to think functionally and conceptually, whilst others had a greater difficulty with the design of the modules. Therefore, the facilitators organized extra meetings with some groups to concretize their plans. During the design process, the management of the nursing home was not actively involved “on the one hand, it was good that the management empowered the professionals, they were able to think freely and to come with creative ideas. On the other hand, the professionals missed the contact with the management team. Especially as it turned out that not all modules were strategically relevant for the management, and even could not be compensated by the insurance companies.” Consequently, not all modules are currently offered. This also has to do with difficulties with the insurance fees for these modules. Again, even though the insurance company expressed their willingness to support the modular care at the beginning of the project, some problems with financial compensation were experienced during implementation. Consequently, only 4 out of 14 designed modules are currently offered to patients.
4.1.5 CASE 5
18 providers – are responsible for the care facilities of next generations. It is another approach, but it works to get everybody on board.” In addition, an enthusiastic pioneer within the hospital is beneficial as he/she can advocate the benefits of the project within the hospital. Next to the appealing philosophy of this project, the 1.5 care idea landed well in this region as there is already a tradition of trans mural care. For example, already since the eighties, specialists and GPs have joint consult hour with the aim to deliver high-quality care, but also to build trust in each other’s ways of working and to strengthen the knowledge of GPs. Another factor that contributes to commitment of secondary care providers is the fact that specialists are employed by the hospital. Consequently, they do not have as much financial interests as specialists working in other 1.5 care projects “they are not money-driven, they just want to deliver high-quality and integer care.” Moreover, to stimulate the use of 1.5 care services, a financial benefit for patients is implemented “patients do not have to pay a contribution for the 1.5 care services they use; however, if they use secondary care services, they have to pay.” Next to the helpful effects of employed specialists, data also show another effective way to work with the care providers during the change: “Doctors do not accept commands, so top-down does not work here. We have to seduce them because they are well-educated professionals. However, it works perfectly if you ask them to think along or to come with ideas, that is where they are good at. Then they get enthusiastic and they come with a pocket full of ideas.”
The project is led by a steering committee consisting of representatives of the care group, the hospital and the insurance company. Whereas other projects experience some problems with the financial compensation of insurance companies, no problems are yet experienced here. More specifically, the steering committee is establishing a joint venture for this project; consequently, a special rate for the care services provided by the joint venture can be requested at the insurance companies. As the insurance company is directly involved in the project, no problems are expected here. Furthermore, the interviewees mention that the involvement of the university is helpful in evaluation of the project. The researches support the decision-making process since the results give indications for additions or changes of the project. Lastly, the project is successful so-far as 75% of patients using the 1.5 care services can be helped further by primary care providers, whereby costly use of secondary care can be avoided.
4.1.6. CASE 6
19 sharing practice “It helps, also because people get to know each other. Moreover, it creates commitment, and you can keep an eye one each other’s qualities.” Also a kick-off meeting in the new health center stimulated enthusiasm among the involved care providers. Furthermore, during this meeting, the care providers came up with a lot of ideas for future collaboration.
Next to these positive process factors, a few aspects were experienced as negative. First, the different IT systems of the involved care providers cannot be integrated, which makes that patient information cannot be shared easily. Consequently, it can be hard to track patients and it requires extra effort to share information and/or knowledge. Second, the lack of available labor force blocks progress “I see a lot of possibilities, but we simply of a lack of people to fix it. For example, we had a brilliant kick-off meeting were everybody came with good ideas; however, there is nobody that has time to put it into work and to organize a next meeting.” Lastly, although the care providers are all enthusiastic about the project, they are discouraged by the uncertainty of (future) financial compensation by the insurance companies. In addition, the high amount of changes in the healthcare sector causes an lot of extra work for health care providers, with the consequence that they can be too ‘tired’ to fully
commit to the project.
4.2 CROSS-CASE ANALYSIS
20 Table V. Overview of all change process mechanisms and interventions
( + Experienced as positive / - Experienced as negative ) Category
(Deductive or inductive)
Activity (All inductive)
Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Advisors
Create commitment to collaborate
- deductive category
Offer financial incentive for referral to 1.5 care - For the care provider
- For the patients
+ +
Give arguments for benefits of collaboration - show win-win
- show benefits
- mention to work with competitor if they not collaborate
+ +
Kick-off meeting + + + + +
Show philosophy of 1.5 care, abstract and visionary, that shows social importance
+
Jointly determine ideas for the care processes + + + + + + +
Respond to demands of care providers / work demand-driven
+
Enlarge already existing projects / relationships + + + + + + +
Show a successful example of a comparable project
+ + +
Specialist are employed by the hospital +
Representative from insurance company emphasizes that payments will be given to 1.5 care services
+
Oblige specialists to have a consult hour in the primary care organization
+ +
No guarantee of insurance companies that they compensate/pay for the 1.5 care services
- - - - - -
Instability in the network - Deductive
category
Pressures from society/government - Cost-efficiency
- Quality of care
- Chronic disease care protocols
+ + + + + + + Knowledge sharing practices - Deductive category
Consult hour of secondary care provider for primary care providers to ask questions
+ + +
Primary and secondary care providers work together in the other’s practice for a day ( ‘taster-day)
+ + +
Symposia within the region + + + + +
Show a successful example of a comparable project
21
Joint training courses + + + +
Shared IT-system for patient information + + + -
Training of primary care providers given by secondary care providers
+ + +
Insurance company works with several 1.5 care project but does not share information / best practices
- -
Vision creation - deductive
category
Create vision with stakeholder representatives + + + +
Create vision with all stakeholders + +
Vision creation process is led by external facilitator
+ +
Create vision with project task-force + + + +
Project Plan creation
- deductive category
Made by management and accepted by care professionals
+ +
Made by steering committee +
Trust creation - deductive
category
1.5 care provider already has a good reputation - due to teaching role in extracurricular training courses and role as club physician
+ +
Informal meetings + + + +
Take enough time before project start +
Being approachable + + +
Primary and secondary care providers work together in the other’s practice for a day
+ + +
Regular e-mail with updates + + +
Continuously changing care context - - -
Not only work based on cost-efficiency, but also on your vision to show goodwill
+ + +
No transparency about interests of different actors
- -
Enlarge already existing projects / relationships + + + + + +
No guarantee of insurance companies that they compensate/pay for the 1.5 care services
- - - - - - -
Professional autonomy - -
Helpful roles - inductive
category
Contact person of primary care and secondary care
+ +
Enthusiastic pioneer + + + + +
Project leader that keeps overview + + +
Process facilitator -Internal
- External & independent
+
+ + + + +
Decision making
Fix-it day organized by external facilitator to make essential decisions
22 4.2.1. Similarities
Table V shows several interventions that are present in the majority of cases. First, all stakeholders of the projects had their own reasons to commit, especially due to external pressures. Therefore, instability in the network was already present, and no additional actions were undertaken to convince the care providers of the need for an 1.5 care organizations. However, not all care providers fully commit to the 1.5 care project. A possible reason for their reluctance is the continuous changes in the - Inductive
category
External facilitator helps by make decision options transparent
+ +
Steering committee makes decisions + +
Evaluation studies results - + -
No transparency about interests of different actors
+ +
Clear roles and responsibilities - Inductive
category
Protocol of care process made by involved care providers
+ + + +
Regular e-mail with updates - on specialist’s consult hours - on project process
+ + +
Desk scheme with care processes +
No total clarity about roles and responsibilities + +
Invite representatives of stakeholder groups to determine future steps
+ Stakeholder involvement - Inductive category Steering committee + + + + +
Invite all care providers to a meeting with a specific theme
+ + +
Task force consist of different stakeholders + + + + +
Insurance company involved during or before the project
+ + + + +
Management not actively involved in development of project
- +
Kick-off meeting for different stakeholders + + + +
Communication - Deductive
category
Formal meetings of project team - set dates
- based on demand
+ +
+ + + +
Regular e-mail with updates + + +
Informal meetings -lunches
-symposia
+ + + + + +
No alignment between management and task force
-
Specialists have special service line to stay in touch
+ +
23 healthcare sector, and they already spent a lot of (extra) time to catch up with these changes. Furthermore, they are reluctant because of the separation of financial streams between primary and secondary care providers. Consequently, worries about compensation of 1.5 care services decrease commitment, especially of specialists that work in independent practices. Therefore, project leaders, and managers used different kinds of persuasion tactics to convince them. The whole range of persuasion tactics found in the cases is displayed in table VI.
Table VI: Persuasion tactics
Although the persuasion tactics range from mild to strong, all were experienced as successful. Furthermore, it was unexpected that worries about financial compensation exist as an insurance company is involved in every case. Data show that managers/project leaders in experimental cases of the ministry of health feel less worried about compensation. A possible explanation for this finding is that the insurance company is part of the steering committee so there is continuous and direct contact, which makes discussion about compensation methods possible.
Furthermore, all 1.5 care projects are an extension of an already existing relationship or project; which is beneficial as interviewees describe that trust, respect and open communication already exist among care providers. Nevertheless, all cases used interventions to further reinforce relationships (e.g. trust/mutual respect); in this respect, informal meetings are frequently mentioned as an effective intervention. Furthermore, periodic e-mails with updates about the project status increase trust and commitment.
Additionally, interviewees repeatedly described that knowledge sharing practices strengthen the relationship between care providers. When looking at all the knowledge sharing practices that are used in the cases, a differentiation can be made. Some practices already existed before the project started, others are executed within the project. This finding might indicate that knowledge sharing is always essential, not only in the context of a 1.5 care project. An overview of all practices is depicted in table VII. As shown in the table, a consult hour of secondary care providers for primary care providers is found both within and outside the time-frame of the project. A possible explanation for this finding is that sharing expertise knowledge of the secondary care provider is not only essential in 1.5 care projects, buts also in other care organizations. However, the need to share expertise knowledge can become more urgent in a 1.5 care setting as care shifts from secondary care to primary care.
Mild Strong Persuasion tactic Insurance company publicly states that compensation will be fair Emphasize social philosophy/aim of the project Persuade practice leader with benefits/arguments of the project Mention to work with another hospital/pract ice if they do not commit Hospital obliges specialists to take action in the 1.5 care project Actor Insurance company
Care group leader Manager of the hospital
GP and care group leader
24
Table VII – Knowledge sharing practices
More specific, regional symposia are frequently organized to share knowledge. Care providers from different organizations meet each other here, especially during the lunches/drinks. These symposia were already organized in the years before the 1.5 care project, whereby it supports the (current) strong relationship between care providers. Moreover, all interviewees emphasized the need for knowledge sharing as 1.5 care includes a shift of work from secondary to primary care. The effects of knowledge sharing practices are threefold: it increases a shared knowledge base, trust and mutual respect, but they also give insight in one’s roles and responsibilities. Again, this effect is evaluated as very important as roles and responsibilities suddenly needs to be shared between different care providers. In order to make sure that the roles and responsibilities are clear, in all cases, the care process of the 1.5 care services was designed jointly with involved care providers. This also stimulates commitment of the professionals. Mostly, this process involves a detailed explication and evaluation of every step in the care process, where after one’s roles and responsibilities, as well as the referral process could be determined. Some cases explicated the outcomes of this process in a desk scheme or document that depicts the new roles and responsibilities, as well as the new referral process.
In addition, all cases show that a facilitator (internal or external) contributes to project success as he/she helps concretizing ideas and stimulates effective decision making. Interviewees mention different reasons for these benefits. First, care professionals mainly look at care instead of the overall process; a facilitator keeps the eyes on the process. Second, the presence of an external facilitator is beneficial as he/she is independent and will not benefit one of the parties. Third, a facilitator can increase commitment of all stakeholder as the facilitator’s time is scarce and costly. Last, the independent consultants describe: “We can be a success factor ourselves as we do not have any financial interests in the project. Often, this supports the process as we can illuminate what we see without belonging to one of the parties.”
Furthermore, all cases created the vision with stakeholders; some created a task-force, while others organized a meeting for stakeholder representatives. All types were experienced as positive interventions. Additionally, all cases involve different kinds of stakeholders in the project team or steering committee. However, in case 4, the management of the nursing house was not fully involved in the design of the project’s care content. During the evaluation, the task-force expressed that they missed contact with the management; especially as it turned out that the management had other ideas about the care content. As a consequence, not all the designed care modules were implemented. Last, all cases have their own evaluation of their project’s success so far. Some mention that the project is successful as patients are satisfied, others mention cost savings or referral rates as success measures. Although I do not have data to assess the success of the 1.5 care projects against each other, the fact
Outside the 1.5 care project Within the 1.5 care project
- Regional symposia - (joint) Training courses
- Joint consult hours - Taster day
- Consult hours of secondary care providers for primary care providers to ask questions / present cases
- IT systems
25 that every case offers 1.5 care services now can be seen as successful as well.
4.2.2. Differences
There are also differences in the change process interventions and mechanisms of the cases. As described in the former section, all interviewees describe that commitment is caused by several (external) pressures, and different persuasion tactics are used to convince reluctant care providers. However, two cases use a financial incentive to increase commitment. More specifically, case 2 uses a financial incentive for GPs if they refer a patient to the 1.5 care service. Next, case 5 increases use of 1.5 care by offering patients a financial incentive: a patient does not have to pay a contribution for using a 1.5 care service, whereas they have to pay for secondary care.
Furthermore, case 5 seems to have some unique characteristics that influence commitment. First, the specialists are employed by the hospital; consequently, they do not have as much financial interests as other independent specialists have. Moreover, there is already a strong trans mural tradition in this region for decades, which makes it natural for primary and secondary care providers to collaborate. Further, the project has a strong societal philosophy which increases commitment of all stakeholders. Last, some interviewees describe that the lack of transparency (especially about one’s interests) blocks trust, but case 5 shows that their interests were shared transparently. More specifically, the GPs explicitly mentioned that they did not refer patients to the 1.5 care service as it was located in another GP’s practice. The interviewees mention that this transparency is beneficial. Namely, based on the feedback of the GPs the decision was made to locate the 1.5 care services in an independent location instead of a GPs practice.
Last, measurement of the project’s effects seems to be an important aspect of the change process. More specifically, insurance companies will compensate 1.5 care services if there are positive effects. Moreover, measurements can direct decision making. However, it is found hard to measure the effects due to unlinked IT systems and the difficulty to measure benefits in a whole region. So far, no solutions for this problem were found. However, data about case 5 mention effective measurements and evaluations due to the involvement of the university.
26
Figure 4. Network of connections
27
5. DISCUSSION & CONCLUSION
This chapter discusses the answer on the research question and theoretical and practical implications. Subsequently, the strengths and limitations of this research will be described, ending with recommendations for future research.
This study endeavored to explore how change process mechanisms and interventions influence success of change towards a 1.5 care organization. A wide variety of change process interventions is used in the cases and they can be broken down into several categories, which are depicted in table VIII.
Table VIII: Categories of change process interventions
Although all cases developed interventions in each category, the exact ways to do this differs from case to case. For example, results show that different types of persuasion tactics are used to increase commitment (table VI). I refer to table V for an overview of all change process interventions employed. The categories indicate that the interventions influence the critical change success factors (instability in the network, trust and mutual respect, open communication, shared knowledge, shared vision, commitment to collaborate). However, no activities to create instability in the network were found; possibly as instability is already felt due to external pressures. Furthermore, table VIII shows that three inductive categories came forward. They three come with some interesting results.
First, clear roles and responsibilities is considered as an extra critical success factor for change toward 1.5 care organizations. Clear roles and responsibilities are essential in 1.5 care projects as the care process between primary and secondary care providers becomes interrelated. In addition, roles are changing as more care is shifted to primary care providers. All cases develop(ed) interventions to determine the roles and responsibilities of care providers; some by making a desk scheme that displays roles, others by joint determination of care content. The importance of clear roles and responsibilities is already recognized in literature; for example by Jacobson & Choi (2005) in their work on public-private partnerships. This critical success factor is also interrelated with the other critical success factors: trust and respect can be increased when participants understand each other’s roles (Jacobson & Choi, 2005).
Second, the inductive category ‘helpful roles’ came forward when analyzing the data. Data repeatedly show that facilitators, independent project managers and enthusiastic pioneers benefit the change process. Interviewees mention different reasons for these benefits. First, care professionals mainly look at care instead of the overall process; a facilitator keeps the eyes on the process. Second, the presence of an external facilitator is beneficial as he/she is independent and will not benefit one of the parties; this creates trust. Third, a facilitator can increase commitment of all stakeholder as the facilitator’s time is scarce and costly. These findings are in line with the three benefits of external consultants described by Cawsey et al. (2007). They describe that an external consultant can provide subject-matter expertise, as well as team-process skills that bring change teams through the problem. Second, they provide independent, trustworthy support. Finally, the external validation of the change process can create higher levels of support for the change (Cawsey et al., 2007).
Create commitment to collaborate Knowledge sharing practices Create a vision & project plan
