The influence of different leadership roles on the
functioning of value based healthcare teams
Master thesis
MSc Business Administration - Change Management
Student: Florine Enzing (S2522063)
Supervisor: Dr. Oskar Roemeling
Co-assessor: Dr. Albert Boonstra
Word count: 17.082
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0. Abstract
Background: Value based healthcare is a relatively new method of continuous improvement,
specifically aimed at the healthcare sector. Although the approach seems promising, little is known about the dynamics of different leadership roles in VBHC teams, and factors that aid or hinder the functioning of these teams. Therefore, the aim of this study is to investigate how different leadership roles influence VBHC teams, and gain more insight in the functioning of these teams.
Method: An explorative case study was conducted in a peripheral Dutch hospital. Fifteen
semi-structured interviews were held with team members of two VBHC teams to create an understanding of the functioning of VBHC teams and the different leadership roles in these teams. Furthermore, two observations were held, and internal company documents were studied to gain insight in the way VBHC is executed in the VBHC teams.
Findings: The results show that different leadership roles are needed in VBHC teams, which are now
mainly fulfilled by the project leader, complemented by the medical leaders and unit head. Ideally, the roles and tasks of the project leader should shift to the medical leaders (strategic and tactical tasks) and unit head (operational tasks). This will foster the functioning of VBHC teams and the
institutionalization of VBHC principles. Based on this proposition, a conceptual model is created. Furthermore, we identified characteristics of successful VBHC teams on the individual, team, and project level.
Conclusion: This study contributes to the practical knowledge on VBHC by indicating different
leadership roles that are needed in VBHC teams, and proposing an ideal division of these leadership roles. Furthermore, this research provides an overview of factors that positively support VBHC teams. These include creating a shared vision and a positive team climate for change, forming
multidisciplinary teams, and creating ownership of the VBHC project by team members. Besides, VBHC teams should receive support in the form of a project leader and data analyst, the right data systems, and time for medical specialists to work on the VBHC project.
Keywords: value based healthcare (VBHC), leadership in VBHC, continuous improvement teams,
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1. Introduction
In this study, we are interested in the role of leadership in value based healthcare teams. Specifically, we will look at the different leadership roles in VBHC teams. Next to the role of leadership, we provide an overview of characteristics that typify successful VBHC teams.
Today, there is a strong pressure for healthcare organizations to improve. Reasons for this are rising financial pressures, the ageing society, and the occurrence of incidents and problems (Joosten, Bongers, & Janssen, 2009; Kim, Spahlinger, Kin, & Billi, 2006). There is a need to decrease costs and to improve safety, quality, and efficiency of healthcare (Sloan et al., 2014). Due to this pressure, an increasing amount of healthcare institutions are implementing a continuous improvement program to achieve lower costs while maintaining high quality (Radnor & Boaden, 2008). Some well-known examples of continuous improvement programs are Lean thinking, Six Sigma, and Total Quality Management (Bhuiyan & Baghel, 2005). Continuous improvement programs have been around for quite some time. Although they were first primarily aimed at manufacturing and production
companies, in the last few decades they have been increasingly applied/introduced in service settings too, such as health care.
A relatively new method of continuous improvement, which is specifically aimed at the health care environment, is value based healthcare (VBHC). Porter (2008) was the first to introduce the concept, and explains that the main problem of today is the way in which healthcare is organized. The author argues that healthcare systems are fragmented, inefficient, and lack transparency for patients to make informed choices about their care. Porter emphasizes the need to change the structure of the current healthcare system to a more suitable healthcare system to meet current demands. The core of VBHC is the focus on delivering value for the patient in relation to the costs of delivering care.
Although the ideas of Porter have spread to many countries, and have been applied in a number of health industries (Andersson et al., 2015; Nilsson et al., 2016; Tseng & Hicks, 2016), research on VBHC remains scarce. Since VBHC is a relatively new method, literature has mainly focused on conceptualizing and understanding VBHC. Empirical research on the practical implementation of VBHC remains limited, and little is known about factors that aid or hinder the efficiency of VBHC implementation.
For any continuous improvement project to succeed, it is necessary to create a culture of continuous improvement (Holtskog, 2013; Singh & Singh, 2015). Augsdorfer and Harding (1995) agree that creating an improvement culture in the organization will foster CI initiatives. Since VBHC aims at continuous improvement, we argue that for VBHC to be successful, it is necessary to create an improvement culture. A key factor in creating and changing organizational culture is leadership (Schein, 2010). Poksinska (2010) states that support from managers at every level is needed to implement a continuous improvement culture. Therefore, the role leadership adopts during a VBHC project seems likely to influence the success of the overall VBHC project.
Physician engagement is a key factor when implementing VBHC, since physicians have the authority to change care practices to practices that create value for patients (Porter & Teisberg, 2006). Physicians have considerable power in processes and practices of healthcare development (Lindgren et al., 2013). To cope with the high demands on quality and costs, physician involvement in
healthcare improvement efforts is needed (Berwick & Nolan, 1998).
Commonly, CI programs have a traditional project leader that guides the CI program. This project leader has a managerial background and is educated to manage, guide, and support employees to work with the CI program. Nevertheless, healthcare is a completely different sector than the
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silos, where physicians have considerable power. We do not know how healthcare departments and physicians will react to the introduction of a project leader. Therefore, we are interested in the different leadership roles in VBHC teams.
Little is known about the way in which VBHC teams are managed and supported. This means that this topic requires further exploration, since concepts and relationships are not fully understood yet. Specifically, it has not been investigated how different leadership roles influence the functioning of VBHC teams in the healthcare sector. Therefore, the research question of this paper will be:
“How do different leadership roles influence VBHC teams?”
To understand the dynamics of leadership, it is necessary to know what VBHC teams looks like, and how they function. Since literature on VBHC is still scarce, little known about the
characteristics and functioning of VBHC teams. We do know that for a continuous improvement initiative to be successful, a learning environment should be created. Crossan et al. (1999) argue that individual, group, and organizational levels need to be linked together to reach organizational learning. Therefore, we are interested in the characteristics of VBHC teams on the team member, team, and project level. To gain more understanding in the functioning and dynamics of VBHC teams, we want to identify the specific characteristics that VBHC teams should have to be successful.
Consequently, a sub question to the research question is:
“What are characteristics of successful VBHC teams?”
In order to answer the research questions, a case study is conducted in a hospital environment. Data are retrieved from semi-structured interviews, observations, and company documents. The results of this study contribute to the existing literature on VBHC in several ways. First, by
researching the different leadership roles that are present in VBHC teams, and their influence on the functioning of the team. And second, by providing more insight in the characteristics of VBHC teams. We will give some practical implications for managers that will help them to support VBHC teams. This is done by indicating failure or success factors for VBHC teams, and presenting the different roles of leadership.
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2. Literature review
2.1 Continuous improvement programs in healthcare
Continuous improvement (CI) is a method for identifying opportunities for streamlining work and reducing waste (Reid et al., 1999). A CI program can be described as a culture of sustained improvement targeted at the elimination of waste in all systems and processes of an organization (Singh & Singh, 2015; Womack & Jones, 1996). Different tools and techniques are used to search for sources of problems, waste, and variation, and find ways to minimize them (Deming, 1950; Reid et al., 1999). The most frequently used methods of continuous improvement are Six Sigma, Lean, Total Quality Management, and Lean Six Sigma (Bhuiyan & Baghel, 2005). These methods emphasize employee involvement and teamwork; measuring and systematizing processes; and reducing variation, defects, and cycle times. Continuous improvement programs were first primarily aimed at production companies. However, in the last few decades, many service companies began to
implement CI programs too. Due to the need to improve and become more efficient, the healthcare industry also embraced continuous improvement programs.
The healthcare industry experiences an increasing need to change and improve their
functioning. The Institute of Medicine (2001) stated that the healthcare system functions at far lower levels than it should, and healthcare leaders should evaluate how continuous improvement principles can be implemented to address the rising challenges of safety, quality, and efficiency. Poksinska (2010) sees the need for change as well, and states that current healthcare systems require a shift in how the flow of patient care delivery is organized. Kim et al. (2006) describe how the application of CI principles can help hospitals to achieve a better performing healthcare system.
Although continuous improvement programs have great potential in improving healthcare settings, the implementation of these programs faces several problems. Healthcare is a highly political and complex organizational setting, characterized by powerful professional groups and regulatory systems (Bååthe & Norbäck, 2013; Radnor et al., 2012). This makes it hard to transfer the principles of continuous improvement - which are developed in the automotive and manufacturing sector - to the healthcare sector. It appears to be hard to move beyond the simple application of CI tools and
techniques to a more system-wide approach (Poksinska et al., 2013; Radnor & Boaden, 2008; Radnor et al., 2009). Several authors express their concern about the one-sided focus on process improvement in continuous improvement programs (Al-Balushi et al., 2014; Poksinska, 2010). It seems hard to move to a more system-wide approach, mainly because of the large differences between the healthcare and the manufacturing sector (Poksinska, 2010; Radnor et al., 2012).
Healthcare is often fragmented into individually functioning units that operate as autonomous “silos”. Traditional CI efforts are often focused on small-scale activities at the department or ward level, aimed at optimizing the performance of an individual area (De Souza, 2009; Radnor et al., 2012). But for CI programs to be successful, a systematic, holistic view of process improvement should be taken (Joosten et al., 2009). The focus should be on improving the entire process flow, which requires cooperation of multiple operating units (De Souza & Pidd, 2011; Kim et al., 2006).
2.2 Value based healthcare
To meet the specific demands of the healthcare industry and overcome the difficulties in
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improving performance in healthcare is defining value, which is the patient health outcomes achieved plus the efficiency of the delivery of services as accounted for by costs.
Berwick and Nolan (1998) state that in healthcare, improvement was always sought by trying to perfect the elements of care. Traditional CI programs often create “pockets of best practice”: local units are optimized, but the whole pathway does not become more efficient (Joosten et al., 2009; Poksinska et al., 2013). Real efficiency depends on the interactions between different units, not the optimization of one single unit, so changing the patterns of interaction and redesigning work flows will lead to much greater improvements.
The core of VBHC is the focus on delivering value for the patient in relation to the costs of delivering care (Andersson et al., 2015). Porter (2008) defines VBHC by the next principles. The first principle is that improving value should be the goal. This implies improving the outcomes of care for patients, while maintaining or decreasing the costs of care. For example, when surgeries are improved and a hospital can perform five surgeries per day, instead of two, this means that the waiting time for patients decreases, while the costs for the hospital also decrease, meaning that value increases.
The second principle is that care should be organized around the way value is created. Care for a medical condition involves multiple specialties and interventions (Porter, 2010). Today, the system is organized around specialties, departments, and interventions, although value is created by efforts over the full cycle of care of a patient’s condition. Care for a medical condition should be organized into integrated practice units (IPUs) which include all the necessary skills and specialties, including those needed for complications (Cormier et al., 2012). Care should be organized around each medical condition, and accountability for value should be shared among the staff involved.
The third principle is the need to measure value. Outcomes should be measured for the medical condition over the full cycle of care, not for the specialty or intervention. There is a hierarchy of outcomes. The first tier of outcomes has to do with the health status achieved for a patient. The second tier captures outcomes relating to the care itself, and measures the process of recovery. A third tier of outcomes involves the sustainability of health. Value for patients is often revealed over time and is shown in long-term outcomes like sustainable recovery, need for ongoing interventions, or occurrence of complications. The right way to measure value is to track patient outcomes and costs over the long term (Porter, 2010).
The fourth and final principle is to align reimbursement with value creation. Now,
reimbursement takes place for discrete services, not for care cycles (Cormier et al., 2012). Costs, like outcomes, should be measured around the patient. We must start paying for care cycles, not for discrete interventions. Finally, information technology is needed to integrate care with IPUs and measure results. Data should be organized around the patient, not the department.
Ultimately, VBHC can be considered as a new paradigm for healthcare. Here, a shift from capacity or production focused healthcare delivery towards value based delivery is proposed. In turn, the focus on value is expected to provide more value for the patient, and produce efficiency gains for healthcare organizations. However, there are some criticisms on the approach. To begin with, it remains hard to quantify value. Although the aim is higher quality against lower costs, it seems difficult to define and measure these performance numbers. Next to that, little is known about factors that enable or restrict VBHC projects. Therefore, the practical application of VBHC remains unclear.
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Batalden and Davidoff (2007) emphasize the complexity of the healthcare environment, and argue that simply implementing a structure for measurement is not enough to reach real improvement. VBHC should take the characteristics of the complex environment into account. Furthermore, the approach is similar to Lean, since both approaches focus on process improvement and higher quality. It is hard to indicate real differences between the two approaches, and some argue that the only difference is the use of different words and definitions.
2.3 Leadership in continuous improvement programs
The implementation of CI programs requires a change in the way a leader acts, interacts, and communicates with employees, and makes decisions (Liker & Convis, 2012; Mann, 2005). Most continuous improvement focused leadership studies (Dumbrowski & Mielke, 2014; Morrow et al., 2014; Poksinska et al., 2013; Soliman & Saurin, 2017) directed their attention to Lean, and hence Lean leadership is a term used to describe a specific leadership style. In this study, we argue that both Lean and VBHC are typified by a focus on continuous process improvement. In addition, both systems ultimately strive for a culture of improvement, where actors continuously evaluate and improve processes. Hence, we argue that Lean leadership should be considered as simply CI leadership, which implies that earlier Lean related lessons are of importance for VBHC as well.
Several authors argue that an improvement culture should be created to become a successful learning organization. CI leadership is needed to create such a culture (Dumbrowski & Mielke, 2014; Soliman & Saurin, 2017). Cormier et al. (2012) state that leadership is essential in organizations that experience change, which is inherent to implementing a CI program. Without continuous effort from leaders, the implementation of a CI initiative will not be sustained over the long term (Aij et al., 2015; Poksinska et al., 2013). Mann (2005) agrees and states that the main reason for the failure of many continuous improvement initiatives might be the inability to change leadership practices.
CI leadership requires a shift from managing processes to managing people (Morrow et al., 2014; Poksinska et al., 2013; Van Dun & Wilderom, 2016). Leaders implementing CI programs need to cultivate a strong culture of engagement for patients and staff. Behaviors of CI leaders should be directed at continuous improvement, root-cause analysis, and respect for people (Mann, 2005; Van Dun & Wilderom, 2016). Aij et al. (2015) found that the most important factor for CI leaders in healthcare is to be present on the work floor and experience practice to understand the processes and see where value is created. Two other important characteristics of successful CI leaders are engaging in employee empowerment and trust, and showing modesty and openness (Aij et al., 2015).
Poksinska et al. (2013) describe motivating and empowering employees, participation in goal achievement, and focus on learning and personal responsibility as important components of CI leadership. Furthermore, CI leaders should motivate team members, search for solutions to problems rather than blaming others, ensure that the team consists of all the involved disciplines, and invite all team members to share their opinion (Aij et al., 2013). CI leaders have to be more forward than backward looking (Van Dun & Wilderom, 2016). CI leadership behaviors can be described as transformational leadership behaviours (Poksinska et al., 2013). Since VBHC is aimed at continuous improvement, we expect that CI leadership behaviors are also important in VBHC teams.
2.4 Medical leadership
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The healthcare sector is often described as difficult to manage and control, since the organization of healthcare institutions is so complex. The worlds of cure (physicians) and control (managers) are two different worlds, which are often hard to integrate (Bååthe & Norbäck, 2013). This can be seen as a conflict between between managerialism (business logics) and professionalism (professional logics) (Lindgren et al., 2013). Historically, healthcare institutions like hospitals are seen as professional bureaucracies, which are mostly resistant to change (Baker & Denis, 2013).
A strategy to overcome the inertia of professional bureaucracies and to bridge the gap between managers and physicians is to put physicians in formal leading positions (Andersson, 2015; Baker & Denis, 2013). An argument for this is that physician as managers can inhibit the medical world, while managers without a medical background can hardly inhabit this world, since it is so complex. Medical leaders have the opportunity to integrate the worlds of cure and control, and thus have the potential to transform healthcare.
Edmonstone (2017) agrees and argues that leadership in healthcare and other sectors is dominated by the ideology of managerialism. Managerialism places an emphasis on healthcare leaders and managers, and see them as the most essential element for governing healthcare organizations. Healthcare organizations are seen as top-down hierarchies, where rational assessment of problems will lead to organizational success. Healthcare is treated in exactly the same way as other
organizations. However, healthcare organizations are fundamentally different. Therefore, Edmonstone (2017) advocates a different approach to leadership in healthcare.
Berwick and Nolan (1998) state that physicians need to start using their considerable power and influence to change the healthcare sector and face the rising financial and societal pressures. Physicians started to move from purely medical roles to part-time advisory roles into full-time management roles in the 1990s (Clay-Williams et al., 2017). Reasons for this were the need for medical contribution in managing healthcare organizations, and greater control of physicians over resource allocation. Today, many physicians are also functioning as a manager.
The majority of medical executives today act as ‘hybrid managers’, who continue to manage a clinical workload alongside their management responsibilities (Clay-Williams et al., 2017). In the UK National Health Service (NHS), enhancing medical engagement in leadership is seen as a factor that may contribute to improved organizational performance. Physicians are successful in addressing patient outcomes, and quality and safety issues. Other benefits to employing physicians in management roles include bottom-up leadership, greater political influence and improved
communications between physicians and senior management. Furthermore, physicians prefer to be led by physicians instead of traditional managers (Clay-Williams et al., 2017).
However, physicians are not trained to be managers. Physicians are educated to become the best they can as individual professionals by advancing their skills and knowledge (Berwick & Nolan, 1998). Nevertheless, being a better physician within the system and changing the system to improve it are two different things, and physicians may find it hard to change roles (McAlearney et al., 2005). Other downsides to medical leadership are physicians’ over identification with their professional clinical role, their tendency to be individualists rather than team players, and their lack of knowledge of financial management and organizational strategy. Several researchers found that hybrid managers are less likely to be effective in their non-clinical leadership role (Kippist & Fitzgerald, 2009; Quinn & Perelli, 2016). Reason for this is that they prioritize clinical work over management.
Spehar et al. (2014) conducted a study on hybrid leaders in Norway, and found that
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other medical managers, they saw each other as competitors who represent their own professional group. To sum up, although hybrid managers offer great potential in improving healthcare, this potential is often not realized, as physicians remain foremost physicians.
Andersson (2015) also recognizes this problem, and found that physicians that moved to manager roles showed limited identity change. Hybrid managers did not act as real managers, but continued to be physicians, only in a new position. Becoming a medical leader poses an identity challenge to physicians. The cultures physicians and managers belong to are very different from each other (Bååthe & Norbäck, 2013). Physicians might find it difficult to integrate the many different, and sometimes, conflicting demands of the two professions. The physician identity is a lot about autonomy, whereas the managerial identity is not at all about autonomy (Baker & Denis, 2013). Therefore, becoming a manager can be seen as a threat to a physician’s identity, since it is seen as a loss of autonomy. Being a manager is almost an anti-identity for physicians. A solution to overcome this identity conflict could be that a physician collaborates closely with a non-physician manager.
Concerning improvement programs, managers and researches argue that engaging physicians is essential in efforts to improve healthcare processes (Bååthe & Norbäck, 2013). Although this statement is shared among healthcare practitioners, physician participation in organizational
improvement work remains limited. When placing physicians in leadership positions, it is important to not only make a structural change by creating formal leadership positions, but to couple this with a more active strategy to get physicians involved in improvement work (Baker & Denis, 2011).
To summarize, it seems that there is great potential in improving organizational performance by putting medical specialists in leader positions. However, in real life, several difficulties need to be overcome if medical leaders are to be real managers. Andersson (2015) states that it is clear that physicians should be involved in the organization of hospitals. However, this physician participation could also take place through cooperative relationships with non-physician managers (e.g. nurses), who tend to switch easier to a managerial career. This is because a nurse identity is more compatible with a manager identity (Andersson, 2015).
To conclude, we expect that CI leadership behaviors are needed in managing VBHC teams, since the aim of VBHC is continuous improvement. We expect that a leader showing CI leadership behaviors will have a positive influence on the functioning of VBHC teams. Nevertheless, VBHC is a CI effort specifically designed for the healthcare sector. The healthcare sector is characterized by a complex organizational structure, where physicians have considerable power and are sometimes operating in leadership roles. Therefore, we expect that physicians that are medical leaders will have considerable influence on the functioning of VBHC teams. We do not know yet what the role of medical leaders and other leaders in VBHC teams entails, and what kind of behaviors they perform.
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3. Methodology
This section will provide an overview of the method in which this study is conducted. First, the chosen research approach will be discussed. Second, the case site will be presented. Consequently, the data collection method will be elaborated on and issues of controllability, reliability, and validity are discussed. Finally, the method of data analysis will be presented.
3.1 Research approach
A theory development approach is chosen, since the topic of value based healthcare is still ill explored in the literature. There is no existing literature on medical leadership in value based healthcare
settings. This topic requires further exploration since concepts and relationships are not fully understood yet. Specifically, it has not been investigated sufficiently how different leadership behaviors influence the effectiveness of VBHC projects in the healthcare sector. Therefore, this research is an exploratory research, since this research will enter a relatively new field of literature on leadership in value based healthcare (Eisenhardt, 1989; Yin, 2013).
This study aims to provide more insights and information to theorists and practitioners of value based healthcare. This research adopts a qualitative method since this has the ability to capture complexity, potential relevant contextual factors, the chronological flow of events, and rich details (Yin, 2013). This research employs a single-site case study, which enables the analysis of complex social phenomena, processes and contemporary real-life contexts. Quality criteria for qualitative research are controllability, validity, and reliability (van Aken et al., 2012). Measures for these are used and are explained in the next paragraphs.
3.2 Case criteria and case description
The criteria for selecting a research site were: (1) The healthcare organization needed to practice continuous improvement activities that are based on the philosophy of value based healthcare; (2) The healthcare organization needed to have multiple teams whose primary aim is to continuously improve the healthcare process by practicing value based healthcare; (3) These teams needed to include a form of leadership in order to research the dynamics of leadership.
The case site that was selected based on these criteria is a large peripheral hospital in the the Netherlands. This hospital consists of 3.000 employees and almost 900 beds. The hospital can be considered as a high quality (production) hospital. The hospital belongs to an overarching organization, which we will call Medigroup. Medigroup consists of seven large hospitals in the Netherlands who work together in implementing value based healthcare.
This hospital implemented a value based healthcare program three years ago. At this moment, there are eleven VBHC projects running in the hospital. Three project leaders and four data analysts are working full-time to support the VBHC projects. Every particular VBHC team of each of the seven hospitals have a two-monthly meeting together to discuss the project. In these meetings, data of the hospitals are compared with each other. Problems and possible solutions to problems are discussed and best practices of the ‘leading’ hospital are shared among each other.
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Both teams have 11 members, and are supported by the same project leader and a different data analyst. The project leader has a managerial background. Next to that, teams include two or more physicians that are seen as owners of the care path. These physicians are called medical leaders and are appointed based on their specialized knowledge of a medical condition. The hip arthrosis team includes three medical leaders, who are all orthopedists. Further, the team consists of several other medical specialists, a nurse, a unit head, a health coordinator, and supporting staff for VBHC. The breast cancer team has two medical leaders, one is a surgeon and one is a medical oncologist. Other team members are several other medical specialists, a nurse, coordinating staff, and supporting staff for executing VBHC. Hereafter, we will use the term “she” to denote each team member.
3.3 Data collection
For this research a case study approach is chosen. Since two teams are being researched, and the research involves multiple units of analysis, we can talk of an embedded multiple case study (Yin, 2013). To ensure the controllability of a research, it is necessary to show how the research is executed (van Aken et al., 2012). In this research, memos are written with detailed descriptions of all ideas, decisions and documents that were developed throughout the research process. This allows other researchers to replicate the study and evaluate it in terms of further quality criteria.
The research must also be reliable, which means that the data is independent of the particular characteristics of the study and similar data can be collected in other settings (Yin, 2013; van Aken et al., 2012). This includes controlling for several biases. To ensure reliability of the instruments, triangulation is used by combining multiple sources of evidence (Eisenhardt, 1989; Yin, 2013). Primary data are collected through semi-structured interviews. Semi-structured interviews can target towards the particular subject the researcher is interested in and can give insights in the perceived explanations, causes and inferences of phenomena (Yin, 2013).
The data at this hospital are collected by two researchers, who collect the data together, but both have a different research topic. To reach the members of the two teams, an introductory email was sent to the medical leaders of both teams. This email explains the purpose of the research and introduces the two researchers of this study. After the medical leaders agreed on participating in this research, this email was sent to all the team members of the two teams to invite them for an interview.
A total of 15 interviews was conducted, ranging from 14 to 60 minutes, with an average of 44 minutes. From the hip arthrosis team (case A), 7 of the 11 team members were interviewed, and from the breast cancer team (case B) 8 of the 11 team members were interviewed. Interviews were held with different functions of the teams, consisting of a medical leader, medical specialists, a physician, nurses, unit heads, health coordinators, data analysts, and a project leader. Since both teams are provided with the same project leader, the project leader was interviewed twice to provide information on both cases. The aim was to interview all medical leaders, however four of the five medical leaders were unfortunately too busy to participate in an interview. An overview of the interviewees can be found in Table 1.
Interviewee and abbreviation Male/ Female Age
Case A – Hip arthrosis team
Unit head (UH_A1) F 42
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Nurse (N_A1) M 40
Project leader (SS_A1) F 39
Data analyst (SS_A2) M 34
Total n = 7 56% F / 44% M 45 average
Case B – Breast cancer team
Medical leader (ML_B1) M Unknown
Unithead (UH_B1) F 52
Medical specialist (MS_B1) F 52 Medical specialist (MS_B2) M Unknown
Physician (P_B1) F 30
Nurse (N_B1) F 43
Project leader (SS_B1) F 39
Data analyst (SS_B2) F 29
Total n = 8 75% F / 25% M 41 average Table 1: Overview of interviewees per case
Other primary data are through observations in the different departments involved in the VBHC project, attending a multi-disciplinary consultation of the breast cancer team, and attending an operation where a hip arthrosis patient got a new hip. Secondary data are retrieved by studying several company documents.
The use of semi-structured interviews reduces researcher bias, by making sure that all interviews have a similar base situation and quality, while also allowing the researcher to ask follow-up questions. These are needed to make sure that individual aspects can be considered as well, and the interviewees have the chance to bring up their ideas, concerns and attitudes towards the questions asked. All interviews are conducted by the same two researchers. The interviews are recorded so that they can be re-listened and the researcher can pay special attention to issues that appear to be of special importance throughout the research. To minimize respondents’ bias, two groups of employees from two different VBHC teams are interviewed. Conducting the interviews at two different teams also helps to reduce circumstance bias. Furthermore, both the supporting staff that facilitates the VBHC initiative as well as the different employees that need to work with the VBHC principles will be interviewed. This gives insights from two different perspectives.
The purpose of the interview was first clearly explained to interviewees, and interviewees were asked to give permission for recording the interview. After the interview, the interviewee was asked if he/she wanted to receive the transcripts to verify what has been said. This is called a member check, and ensures that data are interpreted in the right way (Van Aken et al., 2012). The interview protocol can be found in Appendix 3.
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3.4 Data analysis
The interviews will first be transcribed, after which inductive coding will take place. An overview of the data used in the coding process can be found in Table 3. The data will be analyzed according to the method of Eisenhardt (1989). First, the transcripts of each interview will be observed and provided with preliminary codes. These codes are mapped in a code book with additional quotes from the interviews. Then, second-order coding will take place, where core categories will be established, which enables classification of the data. A within-case analysis will be done for each of the two cases. Secondly, the cases will be compared in a cross-case analysis, to search for cross-case patterns. Mechanisms will be identified to explain how different leadership roles and the functioning of VBHC teams are related. An example of the concept of project characteristics and how this concept is constructed from first-order to second-order coding can be found in Figure 1.
Finally, when conclusions are made from the cross-case analysis, the raw data of the
individual interviews will be read again to check whether the researchers’ interpretations are correct. The data collection and analysis will result in the main findings which are presented in the results and discussion section.
Sources of data analysis
4 orientation talks with two VBHC project leaders and a VBHC data analyst 15 interviews, 170 pages of transcripts and 612 minutes recorded interviews One observation during a medical procedure of Case A
One observation during a multidisciplinary meeting of Case B
One site visit at department of Case A, one site visit at department of Case B
Internal documents: PowerPoint presentation of introductory VBHC meeting Case A and B Internal documents: Reports of results VBHC projects Case A and B
Internal documents: Report of Medigroup structure Table 2: Different sources of data analysis
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4. Results
First, a within-case analysis is conducted to find the main themes for both cases. To start with, the findings concerning leadership are discussed for both cases. The role of the medical leader, the project leader, and the unit head will be examined. Consequently, the general findings are discussed. These are divided into three different levels. The first level is the individual level and describes which characteristics team members of a VBHC team should possess. The second level is the team level, which describes the conditions that should be present in the team climate. The third is the project level, and describes the characteristics the project should have to facilitate successful outcomes of the VBHC initiative. Afterwards, a cross-case analysis is conducted to search for similarities and
dissimilarities across the two cases.
4.1 Results case A (hip arthrosis team)
4.1.1 Leadership
Medical leadership
In this team there are three medical leaders, who are all surgical specialists. Team members find that the medical leaders are enthusiastic, which motivates them to join the meetings and work on the project. However, team members see medical leaders more as members of the team than as actual leaders. Medical leaders do not always have a proactive role, which is mostly the consequence of their busy schedule. Some team members think that the medical leaders look at the process mostly from the perspective of their own discipline, while it is important that they look holistically at the process. Their main input is their specialized knowledge of the condition. Ideally, the medical leaders jointly make decisions. However, each of them has their own opinion, and sometimes they disagree with each other on topics discussed. This causes ambiguity and makes that decisions are postponed and some things drag on.
One of the medical leaders (ML_A1) is seen as very enthusiastic and motivated. This makes that team members feel motivated to work together on improvements. This medical leader is seen as a visionary, someone who also looks at other departments like ICT to find points for improvement. This medical leader has been more involved from the start, and also gives presentations about VBHC. The other two medical leaders are also ambitious and willing to work on VBHC. This is supported by the fact that we were allowed to attend a surgery, which was performed by one of the medical leaders of this team. This medical leader (ML_A2) was willing to show us what the treatment of this condition looks like, and to give us a better understanding of the care path. Team members view these medical leaders also positively. However, they are not as involved as the other medical leader.
The supporting staff of the VBHC teams has very high expectations of medical leaders. They expect them to be very good at their discipline, have insight in the whole care path, and that they motivate and enthusiasm team members to contribute to the project. However, medical leader are taught how to be a qualified physician, and not how to be a good leader. As SS_A1 says: “We have
quite some expectations of a medical leader. What I question myself is if they are sufficiently equipped for this job, because they still remain just physicians.” It seems that medical leaders do not see
themselves as actual leaders of the VBHC project. SS_A1 states: “I talked to her before about how
she sees her role. She sees herself indeed mostly as orthopedist and not as a medical leader.” If
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Project leader
Team members are very positive about the project leader. They say that she is focused, has a
helicopter view, and has a good background for supporting this project. Team members see it as a pro that she is not involved in the project from a certain discipline. As MS_A2 mentions: “She is the
leader if I look at the meetings. She steers the whole thing and that is totally fine. She is not involved from a discipline. Hospitals are still organized in disciplines and they all have different interests, so I think it is very clever to let her hold the steering wheel. She is also very good in indicating if
something is not understood or if the topic should be discussed again in the next meeting. She is an independent supervisor.”
Unit head
The unit head knows all the processes of the care path, and is responsible for the organization of the nursing ward and the policlinic. The unit head of this department is very lean-minded, so she is motivated to work on continuous improvement. In this team, the project leader cooperates more with the health coordinator than with the unit head. The health coordinator can be seen as the right hand of the project leader in the VBHC project, and helps her with planning and preparing the meetings. Team members see this as a great advantage, since both the unit head and the health coordinator contribute in rolling out improvements in the department.
Position Main lessons
Medical leader - Medical leaders in this team are surgical specialists
- A team needs (at least) one medical leader that is in the lead. This medical leader should be ambitious, motivate and connect other team members, and involve other departments
- who are all orthopedics
- Medical leaders should look at the process holistically, they now look mostly at the project from their own discipline
- Including a diagnostic specialist as medical leader in this team might be a solution to the above mentioned problem
Project leader - The project leader leads the meetings, guards the agenda and follows up on appointments made
- The project leader should positively support the project, have a good (managerial) background and should be able to keep overview
- The project leader should ask critical questions to team members to make sure the project evolves
Unit head - Unit head is responsible for the organization of the department
- The unit head (or health coordinator) should encourage the VBHC project - The unit head (or health coordinator) should help the project leader with
preparing the meetings and making appointments with medical staff Table 3: Main lessons concerning leadership case A
4.1.2 Team member characteristics
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Second, members of this team are enthusiastic. Interviewees mention that especially one of the medical leaders is really enthusiastic, which motivates other team members to come to meetings and to actively participate in discussions. It is also important that team members take ownership of topics that are discussed during the VBHC meetings. Lastly, team members should be ambitious. It is important that all team members have the same goal in mind. The quality of care and the quality for patients should be the central theme, and the aim should be to strive for continuous improvement.
Team member characteristic Ground -edness Quotes Being critical 17 quotes
SS_A3: “The goal is improvement of care. So if you are not critical
and if you are satisfied with a medium result, you will not come further. (…) If we are all critical, and have ambitious goals concerning quality, than we will also achieve a lot”
Enthusiasm 12 quotes
SS_A2: “This team is a really enthusiastic team. If we are present at
a meeting, where everyone comes together, from the physiotherapist till the orthopedist, there is a lot of input. Everyone thinks about the topics that are discussed, and smaller teams are formed to
investigate certain things for example.”
Taking ownership
12 quotes
N_A1: “It is actually a prerequisite to have someone from each
department in the team, someone who takes ownership and that has the support from its department.”
Ambition 9 quotes UH_A1: “The ambition is very high, there is always a lot on the
agenda. And every team member also wants to discuss their own focus area and tasks in the meetings.”
Table 4: Overview of team member characteristics case A
4.1.3 Team characteristics
Cooperation
An important element of value based healthcare is that improvements are initiated and executed by
multidisciplinary teams. Team members of this team find this valuable, because they learn from
each other and gain more insight in all parts of the patients’ care path. It is important to look holistically at the process to initiate real improvements together. For successful cooperation in a multidisciplinary setting, input from all team members is necessary. In a kick-off meeting of VBHC, there were some factors listed that contribute to a successful team, and one of them was:
“Everyone contributes to the discussion at an equal amount.” Nevertheless, it happens regularly that
topics are discussed where some team members do not know anything about and do not have any input on. These team members just sit there and listen, and lose their attention.
Furthermore, cooperation between team members is needed. Topics that are discussed during the VBHC meeting often need further research, which is done in smaller subgroups. These subgroups come together and work out certain issues, which are taken back to the next VBHC meeting. Then the results are discussed and further steps are decided upon.
Team climate
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individuals at the beginning, it is become more and more a real team. However, team members say that it is hard to speak of a real team feeling since the team meets only once per month.
Team cha-racteristic Ground -edness Quotes Cooperation Cooperation between team members 22 quotes
SS_A3: “So we have subgroups that come together, because certain
topics are not of interest for the whole group. And then there is feedback in the whole group, so everyone is informed about all the things that are going on at the moment. So in the VBHC team we discuss that larger goals, that are divided into smaller subjects. To keep it manageable.”
Multidisci-plinary team
20 quotes
SS_A2: “An advantage of multidisciplinary team is that everyone can
share their opinion, so there is input on all levels and parts of the care process. All people involved in the care path a patient walks through come together.” Input from all team members 32 quotes
SS_A2: “I think it is really important that everyone in the team, and this
is also a prerequisite for VBHC, that everyone is equal. That everyone feels free to say what they think. That there is no hierarchy. And I think that atmosphere is present in this hospital.”
Team climate
Safety 3 quotes N_A1: “I really appreciate that we want to measure ourselves against
others, and that we show our vulnerability. (…) If you want to improve, you have got to have the room to make mistakes, or imperfections. But luckily the Board of Directors is very supportive in that sense, they clearly articulated that vision.”
Clarity 21 quotes
MS_A2: “We are looking together at the bigger image. People have an
opinion, so the atmosphere isn’t always pleasant. People are loud and clear. But it is more about making one’s opinion clear to others, since people’s interests are not always the same.”
Hospital flyer about VBHC: “We do this because we believe
transparency is essential in health care. By being open about our operations, we can learn from each other and from others. And others can hopefully learn from us. We hope that others follow our example”
Team feeling 2 quotes SS_A2: “According to me, it has become more a real team. Of course
they come together from the viewpoint of their own discipline, but it feels as if they are really working together on the project. Not only the medical specialists are giving their input, but also the other team members feel free to share their opinion.”
Table 5: Overview of team characteristics case A
4.1.4 Project characteristics
VBHC characteristics
According to team members, practicing VBHC gives more insight in the care path in the first place. Team members from every discipline are now more conscious about all parts of the process a patient goes through. Furthermore, VBHC means that the teams systematically look at the care processes in cycles of six months. The hospital compares itself Medigroup wide on performance measures, which was new for team members.
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and they can leave the hospital after two days. Thus they are a lot more mobile than before, when they had to stay in bed for five days after the operation. VBHC was introduced in this team three years ago, the team has now been through six cycles of six months. First, a lot of notable improvement were made but after a while, improvements are running out. This leads to weakened progress. As MS_A2 says: “Things are already running for some time and then the progress slows down a bit. We are
more monitoring at the moment.” VBHC meetings
Since the team meets only once per month for 45 minutes during the lunch break, planning the
agenda of the meeting is very important. The project leader leads the meetings, supported by the
health coordinator of the department. The biggest obstacle is the large number of topics that are on the agenda each meeting, which makes that a number of topics cannot be discussed and have to be passed on to the next meeting. This asks for prioritizing. As SS_A2 explains: “What we can improve as a
team is that a lot is being done at the same time. This Monday we had a meeting and there are so many things running at the moment. It is a lot more effective if we would say: we will first handle one thing before we move on to the other, because some people are now doing three different projects at the same time. That is just not that effective. Then it is better to say that we will first complete one project before we move on, otherwise it drags on and it does not get completed.”
Further, it is necessary that the tasks assigned to or information needed from medical staff is delivered to them in manageable pieces, so they are able to perform them in a short time. Outcomes of the VBHC meetings should be communicated to all medical staff of the involved departments.
Feedback of the results of the VBHC meetings to the different departments is essential. It happens
that medical leaders do not communicate sufficiently with each other, or do not communicate with the same team members, which causes ambiguity. As SS_A1 tells: “For example on the physiotherapy
trajectory, I notice that the medical leaders are not always on the same page. They do not
communicate with the same physiotherapists for example. One medical leader designs a plan with a physiotherapist. Then the plan is presented in the meeting, and there is confusion in the VBHC team, like: why is this? Because the other medical leaders and physiotherapist did not know about the plan. The medical leaders do not agree with each other on the topic and this causes confusion, which makes that the topic is skipped more easily.”
Data
Members of this team find collecting data and analyzing them valuable. However, several difficulties arise in working with data. First, it is hard to derive the needed data from the systems in which employees put data. The members of this team proposed a self-invented register five years ago, in which they can collect and find anything they want to know. But the ICT department did not grant their request till now.
Second, the data that VBHC uses are often too broad to give valuable insights to medical staff. Data that are used in VBHC are relatively broad parameters, like length of stay, survival, and costs. Medical staff wants more detailed information, as N_A1 explains: “If we want to know why an
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need more detailed information.” Lastly, it is very important that the VBHC team uses the same data
as other hospitals for their comparisons.
Facilitating factors
For VBHC to be successful, support from the hospital is needed in the form of a project leader and a data analyst. Furthermore, the hospital should facilitate the project by providing more time.
Everything related to VBHC has to happen besides team members’ normal work activities, which means progress can be slow. Medical specialists say that they find the project important, but they do not want to treat less patients to spend more time on the project. ML_A1 mentions: “As been said, we
do this VBHC project next to the normal patient care. I think that the real added value is reached when more time is provided for practicing VBHC, but given the capacity problems in the hospital we have at the moment this will be very difficult.”
The main lessons on the project level are combined with the general findings of case A in the table below.
Topic Main lessons
Leadership Medical leaders’ main contribution is their specialized knowledge about the condition. Medical leaders mostly look at the process from their own discipline. This team needs a surgical specialist, but also a diagnostic specialist (to look holistically). At least one medical leader should be in the lead. This medical leader should enthusiasm and motivate other team members.
The project leader should be supportive, keep the overview and guard the development of the project. Now, the project leader executes mostly operational tasks instead of strategic tasks.
The unit head is less involved in this team. The health coordinator helps the project leader with planning appointments and preparing meetings.
Team member characteristics
- Team members have to come with good arguments to back up their opinion. - Members of this team are critical, enthusiastic, and ambitious. They take ownership of their actions and the VBHC project.
Team
characteristics
- The team is multidisciplinary, and input from everyone is desired. Now, often topics are discussed where some team members do not have any idea about. - Subgroups are formed to work out certain topics.
- A positive team climate is needed. Team members should feel safe to say what they want. Further, it should be clear and transparent how the hospital performs. - It is hard to speak of a real team, since the team meets only once per month. Project
characteristics
VBHC characteristics: team members find the collection and comparison of data
valuable. Progress (improvements) is slowing down as the project endures.
VBHC meetings: often too many points on the agenda, this asks for prioritizing.
It is important that VBHC outcomes are communicated to the departments. This does not always happen sufficiently, according to team members.
Data: team members are unsatisfied with the ICT system. There is a mismatch
between the data Medigroup wants, and the data this team wants.
Facilitating factors: the medical specialists in this team are always over planned,
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4.2 Results case B (breast cancer team)
4.2.1 Leadership
Medical leadership
In this team there is shared leadership of two medical leaders. One is a surgeon and one is an internist-oncologist. In other hospitals from the Medigroup, the medical leader is a surgeon, but here they choose to incorporate the internist-oncologist as well, because she has a holistic view of the whole process. Both medical leaders take their responsibilities and work together in a good way. They are motivated and ambitious, which spreads to other team members. The internist-oncologist is more in the lead than the surgeon, but the surgeon comes in very quickly. The surgeon is also
knowledgeable and motivated, but she is a less present. The surgical department is currently understaffed, which makes that their time is very scarce and treating patients gets the priority.
The internist-oncologist is very powerful and convincing. She is very knowledgeable about the condition and the care path. The internist-oncologist is very critical and is not afraid to confront people and engage in discussions, which keeps other team members focused and alert. Sometimes, she looks at topics too much from her own discipline. Because the internist-oncologist can be very
steering, some team members do not dare to give their input, which is harmful for the safety in the team. This was confirmed by the multidisciplinary meeting we attended, this medical leader was very clear about her opinion and did not leave much room for others’ opinions. As SS_B2 argues:
“According to me, she sometimes cuts down the conversation, and a certain curiosity. Because she is really convinced about her own opinion, there is less room for others to bring in their ideas or to say that they would like to investigate a certain issue.”
Project leader
Team members find the project leader a powerful leader who positively supports the team. Her role is quite operational, like planning meetings and making phone calls. That support is needed, but the strategic and tactical role are also important. Supporting staff of this team stated that there is too much emphasis on the operational tasks she executes, while she is educated to be a strategic leader.
Unit head
In this team, the unit head has a more notable role. The unit head cooperates with the project leader in preparing and planning VBHC meetings. Outcomes of the VBHC meetings are implemented in the department by the unit head. She is responsible for the logistic side of the actions implemented. The unit head in this team is motivated, clear, and ambitious, which is positive for the VBHC project.
Position Main lessons
Medical leader - Medical leaders in this team should include a surgical specialist (looks at a specific part) and a diagnostic specialist (looks at the whole process) - The team needs a medical leader that enthusiasms other team members - Medical leaders should create a safe and supportive team environment. - Now, the diagnostic specialist in this team is directive and convincing,
which may harm the safety in the team
Project leader - Project leader should spread the VBHC vision, support the team, lead the meetings and guard the process
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- Unit head should cooperate with project leader in planning and preparing the meetings
- Unit head should arrange the practical matters, and makes sure that improvements are implemented in the department
Table 7: Main lessons concerning leadership case B
4.2.2 Team member characteristics
This team can be characterized as a very ambitious team. Their goal is to be the best performing department of this particular condition of the Netherlands. Team members are very enthusiastic and want to do a lot of things at the same time, which makes that they sometimes lose focus.
In order to improve, team members should be critical on the processes and performance. Team members are starting to ask others about their tasks. They did not do this often in the beginning, but they are getting more confident in questioning others. The project is more successful if team members take ownership of the project and the care they deliver. Every team member should feel responsible for the VBHC project, and for actions that follow from the meetings. This is sometimes still lacking, as team members only look at their own part of the care process.
Team member characteristic Ground -edness Quotes Being critical 53 quotes
P_B1: “I think that our team is a very critical team. I think that the
most important is that we critically look at what we are actually doing and what we want to improve.”
SS_B1: “I feel like they are starting to question each other more
critically. Like: why do you take that decision, can we do it differently, and have you already done your tasks.”
Taking ownership
50 quotes
SS_B1: “A lot of people only have input from the view of their own
discipline. They are just thinking: “What do I have to do?” Not: what can I do, or what can we do with each other, but only: what’s in it for me? They only look at their own part of the care process. Then I think: go and look with each other what that means for the patient.”
Ambition 12 quotes
P_B1: “I think that everyone is very motivated to realize the best
care for patients. I think our first priority is to deliver the best care.”
Enthusiasm 9 quotes N_B1: “You need some persons that steer the whole thing. In my
opinion, those two (the medical leaders) are doing that very well. That enthusiasms other team members as well. If there is an enthusiastic person who can talk about the project enthusiastically, that makes that you get enthusiastic as well.”
Table 8: Overview of team member characteristics case B
4.2.3 Team characteristics
Cooperation
Since the care path of this case is complex and involves several departments, a multidisciplinary
team is essential. Medical employees agree that for such a multidisciplinary care process, input from all team members is needed to make sure all parts of the process are represented. Medical staff say
they feel free to share their opinion, but they do mention that one has to come with good arguments to back up their opinion. Some team members find that one of the medical leaders is really
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Medical staff thinks that the cooperation between team members goes well. All team members deliver their input in the meetings and come to an outcome together. Given the limited time and capacity, they are making the most out of it by attending the meetings and giving their input. However, according to the supporting staff, the feeling of togetherness is not always present in this team. A reason for this could be that the patient care of this team is a lot more complex and involves more different disciplines than in case A.
Team climate
There should be clarity about where the team is heading, what the collective goal is, and what is expected from team members. Now, the overarching goal is clear to team members, but the practical implications and concrete steps for improvement are not always clear. It would be helpful if the team would formulate these, for example in the form of a multi-annual plan or an objective for this year. Next to that, team members should feel safe to share their opinion and to ask others critical questions.
Team characteristic Ground-edness Quotes Cooperation Cooperation between team members
36 quotes SS_B1: “According to me, everyone takes place in the team from the
view of its own discipline. There is not much cooperation. This is characteristic of that team, it is more a group of individuals.”
Multidiscipli-nary team
36 quotes P_B1: “There is one care path, and everyone of the team is involved
in that care path. The big advantage is that all these people attend the meetings, because everyone can then contribute and give their input. The pathologist looks at the process very differently than a surgeon. If you do not have a multidisciplinary team in a
multidisciplinary care path, you will not reach anything.”
Input from all team members
33 quotes MS_B2: “You need each other’s input, because that is needed in
such a multidisciplinary center. All those disciplines work together in there.”
Team climate
Safety 8 quotes UH_B1: “Well, if you do not feel safe, you will not dare to point out
things in the process that are not working well. If you see something that is not going well and you think people will get mad at you when you tell them, you will think twice before you will tell it. And that is harmful. That is not possible if we want improvement.”
Clarity 50 quotes SS_B2: “I think there is an open ambiance. There is the freedom for
everyone to make his/her voice heard.”
UH_B1: “It is about being clear, setting up a structure, stick to the
appointments made. That applies to everyone, everywhere.”
Table 9: Overview of team characteristics case B
4.2.4 Project characteristics
VBHC characteristics
It was new for this team to structurally measure data, deliver a scorecard, and compare data to that of other hospitals. It takes a long time to get used to VBHC, as SS_B1 explains: “We are actually still
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Team members find it valuable to measure itself to the rest of the Medigroup. Information can be exchanged between hospitals, hospitals learn a lot from each other and improve together. As SS_B2 says: “Because we are doing the same thing at the same pace in seven hospitals, we are
learning a lot quicker together, since we are actually doing the same thing.” At first, the most
important outcome of VBHC is that the team gains insight in the care path. In the first two years, many important improvements were made. However, at the moment team members feel like the
progress is slowing down. As MS_B1 tells: “I have the feeling that in the beginning, there were
really clear things that we could improve, and that we are now mostly fine-tuning. At a certain time, we are running out of things that can be improved.”
VBHC meetings
What characterizes the meetings is that a lot of things have to be discussed in a small amount of time. Therefore, carefully planning the agenda is important. Guarding the agenda, giving the floor to all team members, skipping things that are extensively discussed, summing up decisions made, and following up on appointments are important tasks of the project leader. The supporting staff is busy learning how to make the meetings more efficient. The project leader tries to prioritize and only discuss the most important topics. As SS_B1 tells, it can be hard to define priorities: “I tried to do
that before by first making clear what is running at the moment. Than we try to prioritize, but then they actually find everything important. And now we are looking, together with the unit head, at what are actually our long term goals, and what are goals for this year, and how do the actions that we are doing now in the team fit with those goals?”
When input from medical specialists is desired, information or requests should be delivered to them in manageable pieces. Feedback of the results of VBHC meetings to the involved departments is essential. For team members it is not always clear whether the outcomes actually reach everyone that is working in the involved departments.
Data
This team was already used to looking at performance based on numbers. However, structurally
collecting data and measuring the score card with that of other hospitals was something new.
Logically, team members had to get used to this. The background of looking at numbers helped the team to quickly integrate this way of working. As SS_B2 says: “What I view really positively is that
this team was already very mature at the moment we started with VBHC. And with mature I mean that in the area of this disease, there are already a lot of registrations that we can use as a starting point.”
While analyzing the data and comparing them to other hospitals, teams have to make sure they are looking at the same data.
Facilitating factors
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Topic Main lessons
Leadership Medical leaders: this team needs a surgical specialist and a diagnostic specialist. The diagnostic specialist is very clear and directive, which motivates employees, but also leads them to withdraw from sharing their opinion, which harms safety. The project leader supports the team mostly with operational tasks.
The unit head cooperates with project leader in planning and leading meetings, and arranges the practical matters when implementing decisions in the department. Teammember
characteristics
Members of this VBHC team are critical, enthusiastic, ambitious, and take ownership of the project. Team members lack ownership of data.
Team
characteristics
- This team consists of a lot of different discipline, since the care path is complex. - Team members form smaller subgroups to work out certain subjects.
- All team members should give their input in meetings. However, one medical leader is so directive, that some team members hesitate to share their opinion. - There should be a team climate in which employees feel safe to share their opinion; this is not always the case here.
- Further, it should be clear what the goals are and what is expected from team members. This team has a clear image of what they want to be (the best specialized center in the Netherlands).
- Lastly, there should be a team feeling. Since this team involves many different specialisms, it is hard to speak about a real team feeling. It is more a club of individuals.
Project characteristics
VBHC characteristics: it takes a long time to get the base right.
VBHC meetings: there are often too many points on the agenda. The agenda
should be guarded more strictly.
Data: it is valuable to collect and compare data, but it is often hard to retrieve the
right data from the systems.
Supporting factors: medical specialists need more time to work on VBHC.
Table 10: Main lessons case B
4.3 Cross-case analysis
4.3.1 Leadership
Medical leadership
Both teams agree that a medical leader should be passionate, enthusiastic, knowledgeable, and persevering. The medical leader should be able to look holistically at the process and invite all team members to share their ideas. Medical leaders attend the Medigroup meetings to exchange
information with other hospitals, and take this back to the own hospital. Medical leaders do not necessarily lead the project, they are only the ones that make decisions on medical topics. They are seen as owners of the care path and the patient streams. Medical leaders are not really active in involving each team member and asking their input.
