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It takes two to tango; how health care providers facilitate and influence patients to co-create value in health care

supply chains

by

Jasper Zachariasse

Rijksuniversiteit Groningen Faculty of Economics and Business

Msc Supply Chain Management

Supervisor: Dr. S.A. de Blok

Co-assessor: Prof. Dr. Ir. C.T.B. Ahaus

Van Brakelplein 38 9726 HG Groningen j.a.zachariasse@gmail.com Student number: S2053659

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Abstract

This research focuses on what health care practitioners do during value co-creation. In addition to this the supporting role of health care supply chains in value co-creation is addressed. A case study focusing on the practitioners in three health care supply chains was done. This study contributes by proposing to extend the value sphere’s model of Grönroos & Voima (2013). This by adding a service induced sphere, so co- creation activities that are aimed at patient self-management can be evaluated. As a result of this study, practitioner activities that facilitate and influence value co- creation are identified, as is the distribution of these activities among health care practitioners. Furthermore underlying factors that support practitioners in value co- creation within health care supply chains are identified.

Key words: value co-creation, health care, practitioners, supply chain, network, facilitation, influencing, support

Table of Contents

Abstract ... 2

Introduction ... 4

Theory ... 6

Value Co-creation in Services ... 6

Patient Value Co-Creation in health care ... 6

Practitioner role in co-creation of value ... 8

Health care ‘supply chains’ ... 9

Model development ... 11

Methodology ... 12

Research Method ... 12

Case Setting & Description ... 12

Data Collection ... 14

Data Coding and Analyzing ... 14

Results ... 16

Value co-creation activities ... 16

Distribution of activities ... 17

Network support of value co-creation ... 18

Discussion & Conclusion ... 21

Discussion ... 21

Limitations ... 23

Conclusion ... 23

Implications for theory ... 24

Implications for practice ... 24

Directions for further research ... 24

References ... 26

Appendix A: Questionnaire ... 30

Appendix B: Inductive Codes ... 31

Practitioner activities ... 31

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Network support ... 31

Appendix C: Coding tree ... 32

Practitioner activities ... 32

Network factors ... 32

Appendix D: Within case analysis ... 33

Within case analysis Maxillofacial Oncology ... 33

Network analysis ... 35

Within case analysis Chronic Care ... 35

Network analysis ... 37

Within case analysis Health center ... 38

Network analysis ... 38

Appendix E: Original Quotes ... 39

Maxillofacial oncology case ... 39

Network quotes ... 40

Chronic Care Case ... 42

Network quotes ... 44

Documents ... 45

Health center ... 46

Network quotes ... 46

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Introduction

The western world faces multiple challenges concerning health care due to aging populations and the increase of chronic conditions like diabetes type 2. It is recognized that these chronic non-communicable diseases are an important focus for the future. Especially as they are in some countries estimated to account for 80% of interactions with the health care system (Nuño et al. 2012). As the treatment of these illnesses can involve multiple practitioners, this requires an integrated multi- disciplinary design that is well coordinated, with patients who contribute to their health with active participation (Tsiachristas et al. 2011). However in realizing this there are many challenges. Health care providers are traditionally functionally organized, which can be a barrier to integrating services and the delivery of patient centered care (Meijboom et al. 2011). Next to this the role of the patient seems to be changing with new definitions of health as Huber et al. (2011) defines health as the ability to adapt and self-manage. By applying the business concept of co-creation on patient-provider interaction and health care supply chains as a whole, this research aims to address what drives the value co-creation in health care.

The delivery of health services involve what Sampson, Schmidt, and Gardner (2015) define as service supply chains, in this patients present their condition and the providers deliver health care services. In a service supply chain customers are acting as suppliers of input, leading to a bi-directional flow of process inputs in the provision of services (Sampson & Froehle 2006). This is closely related to the concept of value co-creation in which customers are seen as the creators of their own value during the service delivery process (Vargo & Lusch 2004; Vargo & Lusch 2008). McColl- Kennedy et al. (2012) recognize that during the delivery of health services, customers can have various roles like passive compliers or team managers. In performing these roles customers showed a variety of value creating activities ranging from accepting information from the practitioner, to rearranging the practitioners involved in treatment. The importance of this lays in the fact that the customers who portrayed a proactive role and associated activities reported better health. Sweeney, Danaher, and McColl-Kennedy (2015) added to this that the effort customers put into these co- creation activities is linked positively to the quality of life perception, satisfaction and behavioral intentions. Patients more frequently portrayed co-creation activities that required less effort, like sharing information, compared to more difficult activities like actively changing lifestyle.

The studies mentioned above have reviewed the co-creation of value from a patient point of view but not taken into account the interaction with the health care provider.

From a business perspective Grönroos (2008) argues service providers facilitate and can influence how customers co-create value. However in the context of health care it is not clear how practitioners facilitate and influence patient value co-creation. While this might be of the essence to activate a patient to self-manage and co-create value, especially with new definitions of health like that of Huber et al. (2011). By viewing co-creation in health care from a practitioner perspective this research aims to assess the practitioners role in facilitating and influencing patients to co-create value.

Ultimately, this can help view the whole interaction process between patient en practitioner in value co-creation and not just one side of the equation. In addition to this, during treatment of a disease the patient often sees multiple health care

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practitioners who perform their own specialized treatment. As a result of this patients co-create value not only through interaction with one practitioner but also through others in the patients network (McColl-Kennedy et al. 2012). New developed concepts of disease management for chronic diseases show that supply chains get longer with combinations of different care providers in which the patient himself often is in the lead (de Vries & Huijsman 2011; Johansson et al. 2010). But as these chains get longer they get more vulnerable, as the weakest spot in the health care systems is when patients flow from one provider to the next (Meijboom et al. 2011).

This stresses the relevance to assess how health care supply chains as a whole support practitioners in the process of value co-creation. In doing so this research addresses the direction of Sweeney et al. (2015) for further research by taking a multiparty view of actors with whom the patient interacts to co-create value.

This research aims to address the aforementioned gaps in literature by first addressing the facilitating and influencing role of health care providers. This brings forward the first research question. RQ1: Which type of patient value co-creation activities do health care providers facilitate and influence? This will be extended by the second research question that evaluates the practitioner role when multiple practitioners are involved in treatment. RQ2: How is the facilitation and influencing of patient value co-creation activities distributed among multiple health care providers in a health care supply chain? The third and final research question addresses the influence of the supply chain as a whole on the patient value co-creation. RQ3: How does a health care supply chain as a whole support the role of health care practitioners in patient value co-creation? To answer these research questions a case study with semi- structured interviews focusing on care providers operating in health care supply chains will be done. By answering these questions the knowledge on the service providers role in value co-creation will be extended, especially within a health care context. Furthermore it adds a multi-party perspective to co-creation literature. This could help health care practitioners to evaluate their service offerings to increase their ability to facilitate and influence patient value co-creation, which could potentially increase a patient’s ability to adapt and self-manage its own health.

The remainder of this paper is organized as follows. First the theoretical background will be further developed based on the service dominant logic, customer value co- creation in health care and the health care practitioners role in value co-creation. In addition to this the implications of a service supply chain in health care are presented.

In the second section the method of data collection will be discussed followed by the results found in this research. The final section will consist of a discussion on the results and the limitations of this study will be presented. Conclusions will be drawn, implications for theory and practice presented and suggestions for further research will be made.

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Theory

Value Co-creation in Services

The past decade has brought a shift in how firms see their customers. Instead of only consuming a service, today customers are considered co-producers or co-creators of value in the delivery of value (Eichentopf et al. 2011). In their seminal work on the service dominant logic (SDL) Vargo and Lusch (2004) focus on this customer role and state that the customer is a co-producer of service and customers are active participants in relational exchanges and co-production of value. As a comment on the service dominant logic’s view that customers are always seen as value co-creators Grönroos & Ravald (2011) and Grönroos & Voima (2013) argue that current approaches are not suitable to clarify the relative importance of service provider and customer interaction. This as they leave the role of the customer and service provider unspecified. To further analyze this, Grönroos & Voima (2013) identified three spheres in which value can be created, as shown in Figure 1. In the provider sphere the service provider is responsible for the production of resources that potentially create value for the customer. In the customer sphere the customer creates value independent of the service provider, so without interaction. However, when the two spheres meet they form the joint sphere. In this sphere there is a bi-directional flow of input through which both customer and service provider can interact to co-create value. Furthermore Grönroos & Voima (2013) argue that the spheres should be seen as dynamic, as the provider may invite the customer to join as a co-producer at different points in the production process, which broadens the joint sphere and enables the co-creation of value. This can for example be observed in the tailoring of customized suit, as a customer is first measured while after production of the suit it further tailored in the presence of the customer to meet requirements. In this research services will be analyzed by using this lens on value co-creation as this enables to identify how value-creating activities are spread between service provider and customer in the process.

FIGURE 1

Simplified model of Grönroos & Voima (2013)

Patient Value Co-Creation in health care

Compared to regular services, service delivery in health care has some unique characteristics that have to be taken in to account. Health care is a service that people need but not necessarily want, furthermore, it is one of the most personal and important services a consumer consumes (Berry & Bendapudi 2007). This is reflected by an often vulnerable ‘customer’ as they might suffer from physical, mental or social conditions that affect their well-being, because of this they are referred to as patients. As a result, health care services are different from regular services this can affect a patients willingness and ability to co-create value. Bendapudi and Leone

Provider Sphere

Potential Value

Joint Sphere

Value creation in interaction

Customer Sphere

Independent value creation

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(2003) stress that as patient might be reluctant to participate in the delivery of health services as they view health care as a ‘need’ service rather than a ‘want’ service for which they have chosen. However Gill et al. (2014) stress that the participation of a patient is important in the support of their health service e.g. provide accurate information, exercise, eat the right food self-monitor. If patients refuse or are unable to participate, it can become difficult to reach the desired treatment outcome.

McColl-Kennedy et al. (2012) identify eight types of activities a patient can perform to co-create value in the treatment of cancer. This varied from compliance with the basic treatment to patients who compose their own team of health care specialists.

Patients who performed proactive activities are associated with high quality of life, whereas patient who participated in a passive way are connected to a low quality of life. Sweeney et al. (2015) extended this by proposing three categories based on where and how value-creating activities are performed, being; within firm based activities, outside firm activities and self-generated activities. The activities identified by Sweeney et al. (2015) are used to give an overview of patient value co-creating activities in chronic health care as shown in table 1.

TABLE 1

Patient Value Co-creation Activities (Sweeny et al. 2015)

The activities can be applied to the spheres model of Grönroos and Voima (2013) in which a customer is able to co-produce value in the joint sphere with the service provider (within firm activities) but also value creation in their own, customer, sphere (outside firm activities & self-generated activities). The ‘outside firm activities’ can create value by using personal and market based sources (Sweeney et al. 2015).

However these activities could be induced by a care provider who stimulates a patient to do these activities or as part of treatment e.g. dietician. This research proposes to adapt the model of Grönroos & Voima (2013) by adding the ‘service induced sphere’

for ‘beyond focal firm activities’. The adapted model can be seen in figure 2. Through the addition of this sphere it becomes clear where actual value of the service is created.

Where value is created How value is created Within firm activities Actively sharing information

Compliance with basic requirements

Proactive involvement in decision making

Interactions with clinic staff

Outside firm activities Relationships with family and friends

Connecting with others with illness

Diversionary activities

Healthy diet

Managing the practicalities of life

Seeking information

Self-generated activities Positive thinking

Emotional regulation

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FIGURE 2

Adapted model of Grönroos & Voima (2013); Sweeney et al. (2015)

In health care the value proposition of each practitioner can show a high degree of heterogeneity in treatment focus, especially because of the functional organization in health care. This is reflected by where the actual value is created. A physiotherapist might interact with the patient in direct treatment, mainly physically executed by the provider on the patient. In doing so mainly delivering a value proposition in the joint sphere. But in case of a dietician the provider does not offer a direct treatment in which the patient itself is being processed but offers information and advice on how a patient can self-manage its diet. By applying this information the patient can create value in the value induced sphere. This shows that in the provision of health care, treatment can be directed to the value creation outside the firm, stimulating the patient co create value in the service-induced sphere. The adapted spheres model can help to position practitioner activities to where they aim to add value in the process of value co-creation

Practitioner role in co-creation of value

The customer value co creation activities and the distribution of these activities to where value is created offer an insight from a patient perspective (McColl-Kennedy et al. 2012; Sweeney et al. 2015). The activities in the joint, service induced and customer sphere show what a patient does when participating in value co-creation.

However it does not give insight into the type of interaction between health provider and patient. Grönroos (2008) specifies an important role of the service provider as facilitator of value, by providing customers with the necessary resources for value creation. Service providers are not restricted to act as value facilitator only, they can take up an active role in the customers’ value generation process and directly influence this (Grönroos 2008). This shows that service providers do not only offer value during interaction in the joint sphere. By taking on an active role practitioners can influence a customer to generate value in the service induced sphere. Applied to health care, the practitioner can be seen as offering potential value to a patient by performing treatment. This can lead to value creation on the spot or by activating the patient, which can lead to induced value creation in a later stage by the patient.

Within health care literature there are different activities identified that a practitioner can perform. In the delivery of chronic care Katon et al. (2001) identified activities for care providers like primary care physicians, nurses and allied professionals. Table 2 shows a simplified overview of these practitioner activities. What can be observed is that the primary care physician is concerned with activities like screening, diagnosis and patient education. The nurse and allied professionals seem to occupy a role that is directed towards support of self-management activities and monitoring. The nature of these activities give some indication of how health care practitioners might facilitate

Provider Sphere

Potential Value

Joint Sphere

Value creation in interaction

Customer Sphere

Independent value creation

Service induced

Sphere

Value creation induced by interaction

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and influence value creation. Screening and diagnosis for example seem to facilitate value to the patient through direct interaction taking place in the joint sphere. While patient education and support for self-management activities might be aimed at value creation by the patient in a later stage, relating it to the service induced sphere.

TABLE 2

Health care provider activities in chronic care, simplified from Katon (2001)

From a service perspective Grönroos (2008) argues that service providers can actively influence how the value propositions that are made are fulfilled through the customers’ value creation. However it is the customer who ultimately creates value through interaction or as result of interaction. Hibbard & Mahoney (2010) argue health care providers have an important role as patient activation is about a patients self-concept; health care providers should create opportunities for patients to learn step by step and experience success to develop a more positive self-concept as manager of their health. Effectively meaning that health care providers are responsible for developing the patient as value creator in the value induced sphere.

Although no specific value facilitating and influencing activities are identified from a co-creation perspective, in this research the following definitions are applied. Value facilitating activities are activities that on their own do not provide direct value for a patient and require a rather passive compliance from the patient. Value influencing activities are activities that a patient can use for current or future value creation and often need the patient to be actively involved.

Health care ‘supply chains’

The delivery of services can be very different, where one service might only need a simple single interaction, e.g. buying a cup of coffee, other services might be more complex and consumed over time, e.g. treatment of chronic disease. In relation to this Strandvik, Holmlund, and Edvardsson (2012) show customers might not assess services separately but instead consider how well they fit with other current or planned services, and what the matching implies for the customer themselves.

Therefore in assessing service delivery it is important to realize that services can be interrelated and are not always possible to assess when viewed independently.

However service research on co-creation has mainly focused on the customer-service provider interaction. Sweeney et al. (2015) stresses that a next step in assessing the value co-creation activities is to take a multi-party view to examine the range of activities undertaken by others in the patients’ service network. Barlow et al. (2002) shows that a multitude of practitioners can be involved in treatment and self- management interventions ranging from nurses to physiotherapists and psychologists.

This indicates that in the value co-creation process, multiple health care providers can be involved, each health care provider addressing a specific part of treatment and a Primary care physician Nurses & Allied professionals

Screening Increasing frequency of contact

Diagnosis Monitoring symptoms and Side-effects

Preventive services Support for self-management activities Patient education Referral back to primary care physician

Monitoring outcome

Prescription of medication Recommendation of lifestyle

changes

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patients’ ability to self-manage. However from a co-creation perspective this has not been done, to address this it is necessary to identify how the multiple parties cooperate and how this contributes to value co-creation.

In the service delivery there is collaboration between the service provider, suppliers of the service providers e.g. (lab for blood testing) and the customer to co-produce value in complex chains or networks (Giannakis 2011). In the delivery of health care services there is increasing awareness to work towards integrated, multidisciplinary and well-coordinated care with empowering patient to participate actively in their provision of health care (Tsiachristas et al. 2011). This is reflected in provision of chronic care as there are now multiple practitioners working together on the areas like e.g. diabetes and COPD in so called health care supply chains or from a medical jargon integrated care models. However the description of a ‘health care supply chain’

can give a confusing signal as there is often no linear flow as seen in traditional goods or manufacturing supply chains. What is often observed within health care is a multi- actor delivery process in which a patient flows back and forth between different providers who operate in a network (Sampson et al. 2015). This shows similarities to what Maull et al. (2012) describes as the service customer perspective on networks, with the customer at the center, facing multiple providers. Opposed to this is the service provider perspective where one service provider faces multiple customers, as can be seen in figure 3. For this research the ‘service customer perspective’ on networks is taken as this places the customer in the center of a service providers network, that jointly fulfills the customers’ needs (Sampson & Spring 2011). This is also compatible with the organization of health care as within, for example, chronic care there have been extensive efforts to organize chronic care in an integrated manner around the patients (Tsiachristas et al. 2011).

FIGURE 3

Service Network Perspective (Maull et al. 2012)

In this network the customer interacts with each service provider, who may interact with other service providers and deliver complementary sections of the whole service to the customer (Tax et al. 2013) In this multi-party view it is important to evaluate the distribution of facilitating and influencing practitioner activities aimed at patient value co-creating. By doing so this helps to constructs an inclusive view on value co- creation when multiple health care providers within a network deliver parts of a health care service and how supply chains support practitioners in value co-creation.

Service provider

Customer

Customer

Customer

Service provider

Service provider Service provider

Customer

Service Provider Perspective Service Customer Perspective

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Model development

The development of the theoretical section provides a basis to place the research questions within a conceptual model. In this model the three research questions are situated as can be seen in figure 4. With the first research question (RQ1) being:

Which type of patient value co-creation activities do health care providers facilitate and influence? This question focuses on the individual interaction between patient and health care provider. With the aim to develop an in depth view on how health care providers facilitate and influence a patient in the co-creation of value. The second research question (RQ2) ‘How is the facilitation and influencing of patient value co- creation activities distributed among multiple health care providers in a health care supply chain?’ elaborates on the first question. This is done by evaluating how facilitating and influencing activities are distributed among multiple health care providers who deliver complementary parts of a service. Because of the high heterogeneity in health care services it might be expected that they facilitate and influence different patient co-creating activities. The third research question (RQ3)

‘How does a health care supply chain as a whole support the role of health care practitioners in patient value co-creation?’ addresses the role of a supply chain as a whole on patient value co-creation. This could shed light on how the network as a whole supports the value facilitated and influencing activities that is offered to the patient when multiple health care providers coordinate/integrate their services.

FIGURE 4 Conceptual model

Joint Sphere

Value creation in interaction

Customer Sphere

Independent value creation

Service induced Sphere

Value creation induced by interaction

Provider Sphere

Potential Value

Provider Sphere

Potential Value

Provider Sphere

Potential Value

Provider Sphere

Potential Value

Health care supply chain Network Sphere

Potential Value

RQ 1 RQ 3

RQ 2

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Methodology Research Method

In this research a case study is done to answer the research questions. As a case study is suitable for the answering of why, what and how questions, with understanding of the context (Voss et al. 2002). This matches the questions in this study, furthermore health care poses a specific context with special characteristics compared to other services (Berry & Bendapudi 2007). In addition to this Yin (1990) specifies that within health care the need for case studies is driven by developments in managed care systems with multiple components that are linked and result in great complexity.

Which is represented in this study by taking a network perspective to the delivery of health care. Next to this, the nature of research with the aim to extend the theory of value co-creation shows a close fit for a case study. This as Voss et al. (2002) point out a case is suitable for building or extending theory. Most importantly the choice for a case study is motivated by the possibility to capture the dynamics that are present in specific settings (Eisenhardt 1989). The dynamic nature of this study is found in value co-creation, as this is an interactive process in which customer and service provider interact to create value. Overall this case study can be seen as an explorative research, as the role of the health care provider in value creation has received little attention and there is no clear single set of outcomes (Yin 2009)

To set up a case study Miles and Huberman (1984) stress the value of a conceptual model and the development of specific research questions as this aids to create focus and defines a research explicitly wants to know. This is supported by Eisenhardt (1989) as without a clear research focus the volume of data in a case study can be overwhelming. Both a conceptual model and research questions have been developed in the previous sections to give a clear direction to this study. With the research questions addressing both individual health care providers and health care supply chains it is important to reflect this in the case selection. This as the unit of analysis is represented by the selected cases in case study research (Voss et al. 2002). For this research a health care supply chain as a whole is seen as the unit of analysis. By doing so the within case analysis can provide insights on the individual interaction and the cases as a whole on the role of the supply chain.

Case Setting & Description

In selecting the cases it is important the characteristics that are identified in the theoretical propositions and conceptual framework are reflected (Yin 2009). For this research three health care supply chains are selected in which the individual practitioners have direct contact with the patient. This reflects the conceptual framework and allows the theoretical propositions to be studied. The three cases represent both the cure and care part of health care and reflect a different type of health care supply chain. This makes it suitable to evaluate how the role of the health care providers and health care supply chains might differ, constructing a more general view on the practitioner role in patient value co-creation. This as the contrasting settings allows to understand the similarities and differences between the cases (Baxter & Jack 2008).

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The first case is based on a maxillofacial oncology network within a large academic hospital in The Netherlands and has a clear aim to cure. Each year around 500 patients with this disease are treated in the hospital. The practitioners in the case reflect the professions that are most likely to be involved in treatment. The included practitioners cooperate on a daily basis. As these practitioners both interact on a patient and network level this makes a suitable case for this research. The second case represents multiple health care practitioners involved in the treatment of chronic conditions like Diabetes type2, Chronic Obstructive Pulmonary Disease (COPD) and cardiovascular risk management (CVRM). There have been lots of efforts in structuring these health care supply chains throughout the years leading to a clear defined pathway for patients on a national level in The Netherlands. The practitioners are involved in the treatment of the same diseases, exception being the COPD service that only focuses on COPD. Furthermore they are all linked to the same cooperation of primary care practitioners that is responsible for the general organization of primary care within a province of the Netherlands. As the practitioners are directly involved in the treatment of the same diseases and are linked by the regional cooperation this makes a suitable case for this research. The third case is only applicable for the third research question as the individual interviewed was not directly involved in treatment. This was a manager of primary care health center serving around 14.000 patients in a neighborhood of a large city in The Netherlands.

This center is in the same geographical area as the other chronic case, only the practitioners of the health center are not linked to the cooperation. Instead the involved practitioners manage the primary care within the neighborhood themselves.

TABLE 3 Case description

The maxillofacial oncology case consists of the three most common practitioners who have a close cooperation in the treatment of this disease, as can be seen in table 3. The maxillofacial surgeon is the practitioner that carries the executive responsibility. The disease itself is treated in two ways, either surgery or radiotherapy in treatment, in the latter case the radiologist is partly responsible in treatment. The advanced nurse practitioner fulfills complementary tasks to the other two practitioners, mainly with a

Case Practitioner Disease Specifics

Cure case A. Maxillofacial surgeon Maxillofacial oncology

B. Radiologist Maxillofacial oncology Only involved in case of radiotherapy C. Advanced nurse

Practitioner

Maxillofacial oncology Chronic

care case

D. GP Diabetes type 2, COPD, CVRM

E. GP Assistant Diabetes type 2, COPD, CVRM

F. COPD Service COPD Serves multiple GP

practices G. Dietician Diabetes type 2, COPD, CVRM Independent

practitioner Health

center case

H. Manager Health center Only for network

analysis

Documents Disease

Chronic care case

I. Care guideline Diabetes Type 2

J. Care guideline COPD

K. Care guideline CVRM

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care focus. All three practitioners situated in the same academic hospital. This network did not show a high degree of standardization as the practitioners noted that there is a high heterogeneity of patients, resulting in customized treatment plans. The chronic case consists of four practitioners involved in the treatment of Diabetes type 2, COPD, CVRM and in the case of the COPD service only COPD, as can be seen in table 3. The General Practitioner carries the executive responsibility for his patients, although the GP assistant is responsible of every day operations concerning the patients with those diseases. Both the GP and the GP assistant worked in the same practice that is situated in a health center. The dietician is freely accessible for every patient and covers all three patient groups. The COPD service is an organization that a GP can opt for to handle specific issues regarding COPD and it serves multiple GP practices. This case also includes formal care guidelines for each chronic disease.

Data Collection

Two data collection methods are used in this case study, semi structured interviews, and document research. The researcher was present during a multi-disciplinary meeting of the Maxillofacial oncology case, however this yielded no specific data that is included. By using multiple methods the aim is to triangulate data to increase validity and strengthen the substantiation of constructs and hypothesis (Eisenhardt 1989; Yin 2013). Semi structured interviews were used to capture the complexity of the interaction between provider-customer and firm-supply chain. This as interviewing enables to gather data that is targeted on the topic (Yin 1999). By semi structuring the interviews it allows a degree of freedom during the interview within predetermined boundaries. The questions used during the interview can be found in Appendix A. The first set of questions where aimed at the practitioners individual interaction with the patient. Whereas the second set of questions is aimed at the interaction between practitioners. In the development of these questions the value creation spheres are taken into account as this enables to ask more focused question on the role of the health care provider. Following de Blok et al. (2010), all interviews are conducted by the same researcher as this ensures similarity in style and form. The interviews were audiotaped and transcription is done by the same researcher who conducted the interviews. To increase the validity of the collected data, the interview transcripts were send back to the interviewees to check the content (Voss et al. 2002;

de Blok et al. 2010). The studying of documents gives the advantage to access a data source that is not created as a result of the case study (Yin 1999). For this research documents concerning the formal guidelines of the chronic care network were studied. This can give a view on how the networks formally see the patient and practitioner in respect to co-creation of value and how this is taken in to account during the cooperation.

Data Coding and Analyzing

After data collection and verification of the interview transcripts, data was reduced by the use of coding. This as it is important to organize data in to categories that help to uncover and document links between concepts and experiences (Bradley et al. 2007).

Furthermore by coding data can be condensed so it can be used for data display, conclusion drawing and verification (Miles & Huberman 1984). The same researcher that was responsible for the data collection also coded the data. The data coding was done with the use of Microsoft Excel by applying an integrated approach of inductive and deductive nature, a full coding tree can be found in Appendix C.

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The descriptive codes used in the within case analysis were based on the concepts derived from theoretical section and included the value creation spheres as first order themes. An overview and description of the deductive codes can be seen in table 4.

TABLE 4

Deductive coding value spheres

Topic Deductive code Description

Value creation Provider sphere Activities with presence of patient

Joint sphere Activities performed in presence of patient, aimed at value creation in encounter

Service induced sphere Activities performed in presence of patient, aimed at value creation by the patient at a later stage

However the main basis for coding has been of inductive nature as this provides the opportunity to develop codes based on the data itself (Bradley et al. 2007). The advantage of this is that new insights can be developed and analyzed. From each interview, quotes are selected that fit the description of the deductive code, a careful analysis of the content was done to identify commonalities and differences. The quotes were grouped and inductive coding was used to assign 3rd order codes reflecting the interviewed practitioner activities. A full list of these inductive codes can be found in the coding trees of Appendix C. After listing the activities per deductive code, activities were sorted based on the practitioner to show the distribution of activities. The transcript parts that address the supply chain as a whole were coded by assigning inductive codes to quotes. These inductive codes where analyzed and grouped per case, a full list of the inductive codes can be seen in Appendix B. The within case analysis helped to specify the unique characteristics of each case and to give depth to the analysis. Furthermore a within case analysis offers insights as it is a way to become more familiar with data and helps to reduce the amount of data (Eisenhardt 1989).

A cross-case analysis was done based on the within case analysis. This is done by following Eisenhardt (1989) as the categories that were identified in each case were carefully compared to find intergroup differences and similarities. Furthermore as the theory section mentioned the concept of the service provider as value facilitator and influencer of value co-creation this has been used as a deductive aggregate dimensions for the practitioner activities. A description of the deductive aggregated dimensions can be seen in table 5.

TABLE 5

Deductive coding practitioner role

Topic Deductive code Description

Practitioner role Facilitator Activities that on their own do not provide direct value for a patient

Influence Activities that a patient can use for current or future value creation

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Results

In this section the results of the cross case analysis are presented. An overview of the within case analysis this can be found in Appendix D. The results are presented in three sections. The first section focuses on the practitioners facilitating and influencing activities of the maxillofacial and chronic care case. The second section compares the distribution among the practitioners of the two cases. Finally the third section compares how the supply chain as a whole supports practitioners in their value co-creation activities

Value co-creation activities

The compiled practitioner activities of both cases are visible in in table 6. In addition to this the table also shows if the activity facilitates or influences value co-creation.

TABLE 6 Practitioner activities

Provider sphere Example Source Category Case

1. Consulting colleagues

Consult expertise of colleague(s) (e.g. “The advantage of such a multi- disciplinary meeting is that there are all different specialists and you go through the treatment plan.”)

A Facilitating A,B

2. Administration Keeping track of treatment (e.g. “We always write everything down in the medical file.”)

C Facilitating A,B 3. Medication Prescription of medication (e.g. “A GP assistant is not allowed to

prescribe medication on her own, but in my practice she is often allowed to continue medication.”)

D Facilitating B

4. Management Managing supportive tasks (e.g. “Managing the GP practice, making sure the GP assistants are there and that they are qualified and take work related classes.”)

D Facilitating B

5. Referral Referral of supportive tasks (e.g. “So I often refer to the nurse practitioner who can address some psychosocial issues, sexuality and related issues.”)

A Facilitating A Joint sphere

6. Diagnosis Diagnose the illness (e.g. “The first encounter with the patient is often, that you have to make a reasonable diagnosis.”)

A Facilitating A,B 7. Check-up Routine checks during or after treatment (e.g. “It is often a technical

check-up, if wounds are closed and if there are no infections.”)

A Facilitating A,B 8. Measurements Gathering information by measurements (e.g. “Measuring blood pressure,

counting a patients pulse. We also have a MyDiagnostic with which we can see whether or not a patient has atrial fibrillation”)

E Facilitating A,B

9. Shared decision making

Decisions on treatment (e.g. “It is often making decisions in consultation with the patient”)

A Influencing A,B 10. Informing Basic information on treatment (e.g. “You sometimes come across

patients who have a certain anxiety for the treatment. So I all ways check if this is grounded on the right knowledge, if not I start a conversation with the patient to inform him right.)

B Influencing A,B

11. Referral Referral to different specialism (e.g. “When a patient wants more in depth knowledge on food, I often in consultation with the patient I refer them to a dietician.”)

A Influencing A,B

Service induced sphere

12. Informing Information for future use (e.g. “Sometimes I give patients a small brochure with information”)

E Influencing B 13. Referral Referral for self-management issues (e.g. “We also advice the GP, as he

often has these quit smoking programs, that is sometimes also a safer environment for the patient.”)

B Influencing A,B

14. Education Education on self-management (e.g. “If a diabetes patient has to use insulin for the first time, we have to teach them how to do that, a patient also has to learn how to check has blood sugar level.”)

E Influencing A,B

15. Coaching Motivating patients for self-management (e.g. “We often try to motivate C Influencing A,B

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patients before the treatment to quit smoking.”) 16. Giving

assignments

Assignment of self-management tasks (e.g. “Is often ask a patient to write down what they eat for a couple of days”)

G Influencing B 17. Formulating

goals

Formulation of self-management goals (e.g. “We try to stet goals with the patient where they want to be when we have the next meeting.”)

G Influencing B

The table shows an overall concentration of value facilitating activities in the provider sphere. In both cases consulting with colleagues and administration are observed as value facilitating activities. However management tasks and medication prescription was only observed in the chronic case. The referral of supportive tasks was only found in the cure case. The joint sphere shows a mixed picture of both value facilitating and value influencing activities. These activities were found in both cases, indicating similar processes that involve direct interaction with the patient. During the treatment process a check-up can for example be seen as a necessary and routine activity in both cases. The check-up on it’s own can be seen as a value facilitating activity as it does not provide direct value for the patient. The serviced induced sphere showed a homogenous nature of influencing activities. Activities like referral for self- management, education on self-management and motivating patient for self- management were observed in both cases. A difference is visible in activities like;

giving information for future use, assignment of self-management tasks and the formulation of self-management goals. These activities were only observed in the chronic care case and can be seen as influencing activities as they are aimed at future value creation by the patient.

Distribution of activities

The activities described above are distributed among different providers. Table 7 below shows how the facilitating and influencing activities are distributed among the different practitioners.

TABLE 7

Distribution of practitioner activities

Practitioner Facilitating activity Influencing activity Case Maxillofacial surgeon Consulting colleagues

Administration Diagnosis Check-up Referral

Shared decision making A

Radiologist Consulting colleagues Administration Diagnosis Check-up

Shared decision making Informing

Referral

A

Advanced nurse practitioner

Consulting colleagues Administration Diagnosis Check-up

Informing Education Coaching

A

GP Consulting colleagues

Medication Management Diagnosis

Shared decision making B

GP assistant Consulting colleagues Administration Diagnosis Check-up Measurements

Shared decision making Referral

Informing Education Giving tasks

B

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COPD service Administration Measurements

Education B

Dietician Consulting colleagues Administration Measurements

Informing Education Formulating goals Giving tasks

B

As can be seen the distribution of facilitating and influencing activities is skewed in both cases. The maxillofacial surgeon and radiologist show a high number of value facilitating activities and seem to refer in case value influencing activities need to be addressed. The nurse practitioner shows a more even distribution of both facilitating and influencing activities. This is also the only practitioner in this network who deploys educating and coaching activities. Compared to the chronic case a similarity is visible between the GP and Maxillofacial surgeon as both mainly deploy value- facilitating activities. Whereas the GP assistant and Dietician show a more distributed range of activities. A difference is observed when looking at the range of influencing activities, which are much more diverse is case of the GP assistant. Furthermore the chronic care case also shows the dietician who is actively involved in influencing activities by formulating self-management goals and the assignment of self- management tasks. Overall, value influencing activities seem to be performed more downstream. In contrast to this the cure case shows three referral types of which referral of supportive tasks and referral for self-management issues are not observed in the chronic case. Another difference can be seen in the frequency of diagnosis as a recurring activity, which is visible at the three practitioners of the cure case but only visible at the GP and GP assistant in the chronic case. Overall it is visible that practitioners in the chronic care case perform more value influencing activities.

Especially the dietician is a specific case in which the influencing activities are prominently visible. While in the maxillofacial oncology case, this is mostly done by the nurse practitioner.

Network support of value co-creation

When viewing the networks two categories can be identified that support practitioners in value co-creation activities, being organization and communication. Furthermore, physical proximity, practitioner heterogeneity and knowing colleagues can be seen as enablers and blockers. A complete overview can be found in table 8.

TABLE 8 Network factors

Category Network factors Example Case

Organization Formal organization

Division of tasks and responsibilities (e.g. “It is clear where patients go and how treatment is done, when boundaries are crossed and things go wrong the alarm bells will ring”)

A,B,C

Formal guidelines

Standardized documents on care procedures (e.g. Care guidelines on Diabetes type2, CVRM, COPD. “The formal guidelines are basically the foundation on which you build care programs.”)

B,C

Formal network meeting

Planned meetings on network policy (e.g. “The specific professions have their own mono disciplinary meetings. But we also have multi-disciplinary meetings for each individual chain.

In these meetings we evaluate the overall chain results.”)

C

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All networks showed a high degree of formal organization as each practitioner has a clear role in the treatment process. Within the chronic care case and the health center there are standardized guidelines about how care should be delivered throughout the network. Both issues can be seen to support practitioners in value co-creation as it contributes to general processes within the network. The formal policy meetings of the health center focusing on the network as a whole as it does not explicitly influence one specific patient and can be seen to support more general value. The formal meetings on treatment, as observed in the maxillofacial oncology case seem to directly support the shared decision process. This as the formal meetings affect the treatment plan that returns in the shared decision making process. The use of ICT for the information transfer is seen in case of the maxillofacial oncology and health center who both have an information system which links all practitioners within the network.

In the chronic care case the ICT system is only partially linked and includes only practitioners who operate within the GP’s practice. In addition to the use of an electronic patient file, all networks still show that the formal letter is still an important way of communication on treatment. Next to this three enablers and blockers are observed being, physical closeness, practitioner heterogeneity and knowing colleagues. In case of the maxillofacial oncology and health center physical proximity is high, as all main practitioners are located in the same building. For the chronic care case this partially true as it only includes the practitioners located in or close to the GP’s health center, for patients it is for example possible to select their own dietician.

Physical closeness enables the practitioners to make use of formal and informal meetings. However physical closeness could also support value for the patient as the location is familiar and travel distances are minimized. A practitioner’s way of working can act as enabler or blocker of the value co-creation process. This can be observed in for example the decision to refer patients or the shared decision making process due to practitioner preferences. The familiarity with colleagues can be seen as an enabler or blocker as it can affect referrals but also the communication among

Communication Information transfer via electronic patient file

Use of electronic patient file in network (e.g. “I can read everything in the electronic patient file, as all the patients are treated within the hospital.”)

A,C

Information transfer via formal letter

Use of formal letter with treatment description (e.g. “We often receive information via a patient letter.”)

A,B,C

Formal treatment meeting

Planned meetings on treatment decisions (e.g. “We see the multi-disciplinary meetings as supporting tool, we also communicate the decisions to others who are involved.”)

A

Informal meeting Unplanned meetings with no formal agenda (e.g. “During an informal meeting I for example tell the dietician, the patient and I agree to this and that. In those occasions we both know what happened and we can build upon that.”)

A,B,C

Enablers &

Blockers

Physical proximity

Concentration of network in a geographical location (e.g. “In health care centers, no matter what size, but if all the involved practitioners are located together the communication is much easier.”

A,C

Practitioner heterogeneity

Practitioner way of working (e.g. “There is a difference between practices how often they refer to may as a dietician. On might refer every patient with a question to me, while another practice will only do it in complex cases.”)

A,B

Knowing colleagues

Familiarity with colleagues (e.g. “This morning it went by a GP assistant whom I had never seen before to get to know each other and explain what I do and when she could refer to me.”)

A,B,C

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