Abstract Case study: on the relational integration between emergency physicians and medical specialists of other departments and the influence on the patient flow at the ED.

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Case study: on the relational integration between emergency

physicians and medical specialists of other departments and the

influence on the patient flow at the ED.

Master Thesis Supply Chain Management

University of Groningen February 14, 2018 By: Susan Reiring Student number: S2195267

E-mail: susanreiring@gmail.com

Supervisors: Professor van der Vaart Rachel Gifford, MSc

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Co-assessor: Professor Ahaus

Abstract

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1. Introduction

The patient care at the emergency department (ED) is influenced by the patient flow (Van der Linden, De Beaufort, Meylaerts, Van den Brand, & Van der Linden, 2017). Patient flow can be defined as: “the speed at which patients are transferred from one step in the care process to the next” (Hopp & Spearman, 2001). Delays in this care process can result in adverse outcomes and less satisfied patients (Van Der Linden et al., 2017). Furthermore, the patient flow is closely linked to quality and costs of healthcare (Huang, Carmeli, & Mandelbaum, 2015). Therefore, improving the patient flow and examining what inhibits the patient flow is important to improve the ED operations.

In the Netherlands, there is a specialty dedicated to the ED, the emergency physicians (EPs). Since 2008, this is an official specialty in the Netherlands (Nederlandse Verening van Spoedeisende Hulp Artsen, 2014). In countries like Canada, Australia, the United States and Great Britain, EPs exist already for a longer time (ACEM, 2018). Before 2008 in the Netherlands, different medical specialists of other departments worked at the ED, next to the work at their own department. In order to lower the burden of medical specialists and to cope with the growing patient influx and growth of the EDs, the idea of dedicated physicians at the ED developed. A financial system and an educational program were established for EPs to improve the acute care that is given at the ED (Nederlandse Verening van Spoedeisende Hulp Artsen, 2014). The main idea behind this improvement is that there are dedicated physicians, who are specially trained for acute care at the ED. The training is a three-year program that can be followed after the initial six years of becoming a medical doctor. EPs are trained to stabilize, diagnose and treat the patients on the short-term, with general knowledge of many different diseases (Nederlandse Verening van Spoedeisende Hulp Artsen, 2014). The difference with medical specialists is that medical specialists are trained to treat a specific disease or a specific part of the human body on the long-term. Medical specialists are trained for at least six more years after the initial six years of becoming a medical doctor. Furthermore, they work at their own departments in the hospital. These departments are highly differentiated (Glouberman and Mintzberg, 2001) and the medical specialists have a high degree of autonomy (Smithson and Baker, 2007). Because of this, there is only limited integration between departments (Drupsteen, Van der Vaart & Van Donk, 2013).

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different specialities. When patients need to report to the medical specialists about a patient they have seen for their specialty, when patients need a more in-depth assessment, diagnosis or treatment, when patients need to be admitted to a department or when it is busy at the ED, medical specialists of other departments are called or asked to come to the ED for assistance. This means that often there is an interface between the EPs and medical specialists of other departments. During this interface, the medical specialists and EPs need to collaborate to help the patients in the most effective and efficient way, to make sure no delays in the patient flow occur. However, due to the different types of education, knowledge and the autonomous departments, problems arise during this interface. Therefore, the focus of this research is on this interface between medical specialists of different departments and EPs, what barriers exist to this interface and how this influences the patient flow. Since the focus is on this interface and collaboratively organising the best care for the patients at the ED, integration between the EPs and medical specialists of other departments is important. Integration can be defined as: “collaboratively manage intra- and inter-organizational processes” (Flynn, Huo & Zhao, 2010 p.59).

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How does the relational integration of EPs and medical specialists of other departments influence the patient flow at the ED?

This research will contribute to a better understanding of the relational integration between EPs and medical specialists and how this is perceived to influence the patient flow at the ED. It will be investigated how the relational integration works, at what moments relational integration occurs, what barriers inhibit the relational integration and if relational integration is perceived to influence the patient flow at the ED. This will be investigated by means of an exploratory case study at a large ED in the Netherlands. This research is also of practical relevance as such insights may help hospitals in improving patient flow by better understanding the barriers to, and the importance of, successful relational integration between EPs and medical specialists. The structure of this paper is as follows. In the next chapter of this paper the theoretical background on the ED, patient flow and relational integration will be explained. In the third chapter the methodology will be described. In the fourth chapter the findings of the research will be presented, discussing which barriers are found and how they are perceived to influence the patient flow. The fifth chapter will further discuss the findings. The sixth chapter will give a conclusion on the research and recommendations for further research.

2. Theoretical background

2.1 The emergency department

The emergency department (ED) is a hospital facility in which different medical specialists and physicians of different levels of seniority help acute patients, diagnose them and make decisions about necessary treatments (Asplin, Magid, Rhodes, Solberg, Lurie, & Camargo 2003). The ED is open 24 hours a day for acute patients (Cheung et al., 2010). The organization and staffing of EDs may vary by hospital and differs across countries. However, generally in the Netherlands, EPs and residents work at the ED. These residents are residents of different specialities, most often residents for cardiology, neurology, surgery, internal medicine, paediatrics, radiology and residents for the ED.

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Patients can come in at the ED through three different ways; they can be referred by the general practitioner, brought in by the emergency medical service or they can come in via self-referral. Upon entering the ED, a receptionist registers the patient. Once registered, a trained nurse will do a triage in order to decide how fast the patient needs treatment and what type of treatment. This triage is based on the Manchester Triage System (MTS), which makes use of five different levels. These levels give an indication of how fast a patient will be seen (Mackway-Jones et al. 2014). After the triage the patient will be diagnosed by an EP or resident, and when necessary a medical specialist will be asked to assist or supervise. During this diagnosis extra lab-test can be done to make a proper diagnosis. Thereafter, if necessary, a patient will be treated, again by an EP or resident and when necessary a medical specialist. After the treatment, the patient can be discharged, admitted to a department in the hospital or the patient can be moved to an external facility (Asplin et al., 2013).

To get clear insights on the relation integration between EPs and medical specialists of different departments, the relations and responsibilities of the medical specialists, EPs and residents who work at the ED should be clear. Generally, these relationships and responsibilities are the same in most hospitals in the Netherlands and are shown in figure 2.1. During the triage, patients are assigned to a specialty. This means that a medical specialist of this specialty is responsible for this patient, which in theory means that they should always be involved in the decision on the patients. Although medical specialist bear the end responsibility, medical specialists are often no on the ED, since residents of the different specialties diagnose and/or treat the patients for their specialty at the ED (Nederlandse Verening van Spoedeisende Hulp Artsen, 2014). These residents are supervised by a medical specialist. Supervision is: “the provision of monitoring, guidance and feedback on matters of personal, professional and educational development in the context of the resident’s care of patients” (Kilminster & Jolly, 2000, p.828). Part of the supervision is the authorization of performing tasks and responsibilities for the residents. This means that at the ED the residents are allowed to diagnose and treat the patients coming in for their specialty. However, resident need to report patients to and discuss them with the medical specialist. This can be face-to-face or by phone, in this way the supervision is given. However, since EPs also work on the ED and are therefore easier to reach than medical specialists on another departments, indirect supervision is often given by EPs as well. In these cases, residents ask EPs for help. However, the resident still needs to contact their medical specialist to report about the patient.

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of the responsibility, since the EP is a medical specialist as well (Nederlandse Verening van Spoedeisende Hulp Artsen, 2014). However, the medical specialist remains the person who is responsible for the patients assigned to their specialty. EPs can ask assistance of the medical specialist for certain patients, which can be helpful, since the EP has general knowledge on many different diseases and medical specialists have specialized knowledge on a specific diseases or body parts. This might be helpful for example, when a more in-depth assessment of a patient is necessary or when a patient should be admitted. In these cases, the EP can ask a medical specialist by phone or face-to-face for assistance.

Furthermore, there are residents specifically for the ED, who are supervised by the EPs and are also allowed to treat patients of different specialties. However, they should always report to the EP, who is their supervisor.

Figure 2.1 Chain of responsibility

2.2 Patient flow

The patient flow is an important factor in hospital performance that influences the patient satisfaction, the quality of care and the costs (Johnson & Capasso, 2010). The patient flow in the ED encompasses the whole process from the first moment the patient enters the ED till the moment the patient leaves the ED, either to go home or to be referred to another department.

The focus of this research is on the relationship between relational integration and patient flow, examining how problems in the relational integration between EPs and medical specialists may lead to delays in the patient flow. This research will use the perception of medical specialists and EPs, to investigate if, and how, patient flow is affected by the relational integration between the EPs and medical specialists.

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et al., 2016). Common causes for delays in the patient flow are delays in transfers (Tang, Chen, & Lee, 2015; Zhao et al., 2015), variability in arrival rates (Huang et al., 2015) and capacity problems in available beds and in available personnel (Asplin et al., 2003; Hoot & Aronsky, 2008). Most of these studies investigate the patient flow at a single step or department in the care process (Haraden and Resar, 2004). However, in this research, multiple departments need to be taken into account, as the focus is on the relational integration between EPs and medical specialists of different departments. The integration between multiple departments is not widely studied yet, because hospitals often are a collection of individual departments that are set-up around one specialty (Drupsteen et al., 2013), with a high degree of autonomy (Smithson & Baker, 2007) and the departments are often highly differentiated (Glouberman & Mintzberg, 2001), which causes limited integration (Drupsteen et al. 2013).

2.3 Integration and relational integration

Drupsteen et al. (2013) were one of the first to investigate the relation between integration and patient flow in a healthcare setting between different departments, concluding that integration has a positive influence on patient flow in an elective care setting. However, as their research is only on the orthopaedic care paths in the elective care (Drupsteen et al. 2013), further research on integration between different departments in the healthcare setting remains limited (Drupsteen et al., 2013). Therefore, prior research has to be drawn from fields outside healthcare.

Research on integration in manufacturing settings found that supply chain integration has a positive impact on performance (e.g. Drupsteen et al., 2013; Flynn et al., 2010; Leuschner et al., 2013; Turkulainen et al., 2017; Vijayasarathy, 2010). In a manufacturing setting the integration helps to understand each other’s processes and plans and therefore, produce goods on time and improve the performance (Flynn et al., 2010). Furthermore, integration can improve the operational performance, such as quality, flexibility, costs and innovation (Leuschner et al., 2013). Linked to healthcare this research suggests that more integration can help to understand the processes of the different departments and improve the operational performance.

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relational integration in manufacturing settings found that relational integration has a positive impact on performance (Leuschner et al., 2013; Vijayasarathy, 2010). Relational integration focuses on making strategic connections between firms and the main concepts are trust and commitment in long-term relations. Trust and commitment can increase the degree of integration (Leuschner et al., 2013) and show that the relationship is appreciated and that there is a wish to maintain the relationship (Vijayasarathy, 2010). Trust improves the stability, information sharing and performance and it creates commitment to long-term relationships (Vijayasarathy, 2010). Additionally, commitment strengthens the willingness to invest in resources, information sharing and integration of processes for advantages to all supply chain partners (Vijayasarathy, 2010). Commitment is based on the commitment of the other party, which means that both parties can influence each other positively or negatively by means of their own level of commitment (Prahinski & Benton, 2004). Furthermore, long-term relations can help to develop and sustain a high level of integration. Also, more durable performance wins can be obtained (Leuschner et al., 2013).

Although prior research found that relational integration has a positive effect on the performance in manufacturing settings and Drupsteen et al. (2013) found a positive effect between integration and patient flow, it is unclear if such findings can be translated to the acute healthcare setting.

3. Methodology

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3.1 Case description

The case study is conducted at a large ED in the Netherlands. EPs, residents of the ED and residents of cardiology, neurology, radiology, paediatrics, surgery and internal medicine work at the ED and they often collaborate with medical specialists to assess, diagnose and treat patients.

3.1.1 Tasks of the medical specialists, EPs and residents related to the ED

The medical specialists are responsible for all the patients that are seen for their specialty at the ED. In theory, this means that they should always be involved in the decisions about the patients. However, physically, they do not need to be at the ED, since the residents of their specialty and EPs diagnose and treat most of the patients. There is always one medical specialist per specialty on-call. This medical specialist is the contact person for the residents and the EPs at the ED. Depending on the specialty, there are different agreements on their on-call availability. During the night, when medical specialists are not at the hospital most medical specialists need to be able to be at the hospital within 30 minutes. Some other medical specialists, for example, the trauma surgeon and the vascular surgeon, need to be able to be at the hospital within fifteen minutes. Furthermore, when specialists are on-call during the day and working themselves, they have the same rules, which means that they need to be available for the ED within fifteen or 30 minutes for assistance and supervision. This means that they are still able and allowed to work at their own department during the day.

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they are in charge and need to give different residents or medical specialists a task, depending on the problem. Another important task in patient treatment is leading multidisciplinary patient presentations. In this case, a patient has complaints or injuries for multiple specialties and it is unclear to which specialty the patient needs to be assigned. The EP makes sure that residents or medical specialists of different specialties, depending on the earnestly of the problem, assess the patient, so it becomes clear to which specialty the patient should be assigned and what treatments are necessary.

The residents of the different specialties diagnose and treat the patients that are assigned to their specialty during triage. Formally, the residents need to discuss every single patient that the resident diagnosis and/or treats with their medical specialists for supervision. Furthermore, they can contact the medical specialist if they have questions, are unsure what to do or if they need supervision in general. Often, they ask the EP for indirect supervision as well, since the EP is on the ED and therefore, easier to reach. However, they still need to contact their supervisor to discuss the patient.

The residents of the ED are supervised by the EPs and therefore also treat patients of different specialties.

3.1.2 The process of the ED

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Figure 3.1. ED process

3.1.3 Intervention on the ED

This hospital acknowledged that improvements could be made at the ED. Therefore, they started an intervention. They want to improve the quality of care, reduce the length of stay (LOS), reduce the number of diagnostics and to reduce the admissions to the departments. The hospital expected that these improvements could be made by having medical specialists closer to the ED. To test this, a pilot study of eight weeks was done in 2016, which resulted in an improved patient flow (Van der Linden et al, 2017). The five main medical specialties, being: cardiology, neurology, internal medicine, radiology and surgery, needed to be in the hospital during their on-call shifts, instead of being on-call at their homes. These medical specialists have more knowledge than the residents of their specialty and by being closer to the ED it was expected that they can help the residents make faster decisions in an earlier stage of seeing the patient (Van der Linden et al., 2016). To gain better insights, a longer pilot version is redone from November 2017 till March 2018. Instead of only being on-call, one medical specialist for each of the five main specialities has to actually be at the ED from 12-8 PM.

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Figure 3.2 ED process during intervention

Although the focus of this research is not on this intervention, it will be used as an example in this research, showing how relational integration has changed. With regard to relational integration, the situation before and during the intervention will be compared, in order to find out what barriers existed and might be removed or improved, because of the intervention.

3.2 Data collection

In this hospital, nine doctors were interviewed, including six medical specialists of different departments and three EPs. Data was collected in December and January by means of semi-structured interviews. These interviews were either by phone or face-to-face in the hospital. The interview guide for these interviews can be found in Appendix A. The interviews took on average one hour and were audio-recorded and transcribed. The aim of the interviews was to gain the perspective of the EPs and the medical specialists about the relational integration. Topics discussed included what the relational integration between EPs and medical specialists is like, what the barriers are and if these are perceived to influence the patient flow.

3.3 Data analysis

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the ED. To increase validity, only dimensions that were named by at least two interviewees were used as barriers for the relational integration.

4. Findings

In this section, the findings of the interviews are described. This study investigates in what way relation integration between the EPs and medical specialists exists, what barriers there are to relational integration and if and how these are perceived to cause delays and therefore influence the patient flow. First, a general explanation will be given on the relational integration existing between EPs and medical specialists. Second, the identified barriers to relational integration will be explained and whether and how they are perceived to influence the patient flow. Last, the intervention at the hospital will be discussed to analyse changes in the relational integration.

4.1 Explanation on the relational integration

EPs and residents assess, diagnose and treat the patients at the ED. Furthermore, medical specialists are scheduled to be on-call. Formally, this means that the medical specialists need to give supervision to the residents of their specialty at the ED. Additionally, the medical specialist need to assist the EPs when they are asked. Most often, medical specialists are at their own department while being on-call. Therefore, the assistance for the EPs and supervision for the residents most often is via the phone. Only in a limited amount of cases a medical specialist goes to the ED, some medical specialists more than others. The internist and the surgeon are examples of specialties that are more often at the ED, since the internist has acute care as a focus and the surgeon often assesses a patient at the ED in order to decide if a patient needs surgery.

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to be admitted to a department. The EP calls the medical specialist on-call to let him/her know that the patient is coming. Some short information on the patient is shared and a treatment plan is described in the medical record of the patient, together with all the tests and diagnostics, which can be seen by the medical specialist. Third, when it is busy, medical specialists can be called to let them know that there are many patients for their specialty and that they should come to the ED, so the patients of that specialty can be assessed, diagnosed and treated faster to improve the patient flow. The fourth situation, in which relational integration should exists is when EPs and medical specialists have contact about patients assigned to a specialty. In theory, every patient should be discussed with the medical specialists, since they are responsible. However, the interviews revealed that the formal agreements on the responsibility and tasks of the medical specialists, EPs and residents are often unclear and that many patients treated by the EPs are not discussed with the medical specialists. EPs and medical specialists explained that they do not call for every patient, but that different agreements are made per specialty. For example, for internal medicine, the internist always needs to be contacted when a patient for internal medicine comes in. In other cases, when no clear agreements are made, the EP contacts the medical specialist if the EP thinks it is necessary or when they know that the medical specialist wants the EP to contact him/her, based on prior experience with that medical specialist. The residents also do not always contact the medical specialist for supervision. This depends on their experience and on the diagnosis and treatment of the patient. Often when the resident is just starting, the resident has to call the medical specialist for every patient. When the resident gets more experience, he/she discusses with the supervisor for which type of patient he/she still needs supervision and for which type of patients the resident does not.

There are two possible reasons why the formal agreements are not followed and other agreements are made. First, because the formal agreements are unclear, as the different interviewees all mentioned different agreements or explained that they did not know what the agreements were. The other reason for not following the formal agreements might be because of the lack of commitment to the ED, which is the first barrier to relational integration between EPs and medical specialists and will be explained in the following paragraphs.

4.2 Commitment

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They are working at their own department, which is their priority and the ED is something they do on the side:

MS4: “we would only be at the ED when called for, which means it is always an interruption of other work you are doing.”

Some medical specialists explained that the ED has to wait when they are busy doing something else, which suggests that they see their work at their own department as more important. Because of this lack in commitment to the ED problems arise. The first is the availability of medical specialists for the ED, which is closely linked to not following the agreements for being on-call. The second is the indirect way of communication and the third problem is the misalignment of goals. In the next paragraphs this will be explained, linked to relational integration and to the patient flow.

4.2.1 Availability

There are three ways in which the availability of the medical specialists influences the relational integration and the patient flow. First, medical specialists are often unavailable or unwilling to go to the ED or to discuss patients via their phone immediately. This is often, because the medical specialists are doing work at their own department. Additionally, not all medical specialists see the necessity to go to the ED immediately, because they might feel that the quality of the care they give, will not be less when they see a patient a little later:

MS6: “They [medical specialists] don’t see that they are necessary themselves. When you have a twist in your ankle, it doesn’t matter for them [medical specialists] to let the patient wait 20 minutes or 3 hours. Some doctors say you go to the ER and then you know you have to wait for 3 hours.”

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Second, sometimes medical specialists might not come at all. This can be due to different reasons: medical specialists might be busy with something else, they might not be in the hospital when they are on-call or they don’t think it is necessary for them to come. However, this is not in line with the agreements for being on-call:

EP1: “they [medical specialists] tend to take away the doctor who is actually scheduled for the ED during the day. If there is an outpatient clinic where there is no doctor, then they just say, we don’t go to the ED, we have to go to the outpatient clinic […] For them [medical specialists] it is just a few patients who are coming at the ED. Someone else can see their patients at the ED [EPs and residents], but there is not someone else who can see the patients at the outpatient clinic or the OR [operating theatre]. So, the first place where they can move someone to another place is from the ED.”

This means that the medical specialist who is on-call stays on-call, however, the medical specialist is not able to go to the ED when necessary. The medical specialist will not come to the ED when it is busy for his/her specialty and patients can only be discussed via the phone. Discussing the patient via the phone can also take extra time, since the medical specialist is in the operating theatre or outpatient clinic and therefore, is often unable to answer the phone immediately. This again restricts the relational integration, since the medical specialists pursue their own interests and therefore are less able to collaborate, which is perceived to inhibit the patient flow.

Third, it can take a while to find a medical specialist who has time to discuss a patient or go to the ED. This is often the case with surgeons on-call. The surgeons are allowed to perform surgeries when they are on-call. However, when surgeons are in the operating theatre, they usually do not have the time to discuss patients or leave the operating theatre to go the ED. Although, the surgeons are often operating with two surgeons and therefore, one of them can go to the ED, they often only do this when it is urgent. In other cases, EPs try to reach another surgeon to discuss a patient:

EP2: “I always find someone finally, but sometimes it takes me 30 minutes, which is not what it should be.”

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Finding a surgeon who is able to discuss a patient takes time and therefore this is perceived to delay the patient flow.

4.2.2 Indirect communication

Usually, the collaboration between medical specialists and EPs is via the phone, since medical specialists are at their own department or somewhere outside the hospital. Communication via the phone is a more indirect way than face-to-face and this influences how medical specialists and EPs treat each other:

EP2: “through the phone you can be a more unfriendly person then face-to-face.” MS6: “Through the phone they [medical specialists] say: “that is ridiculous what did he [EP or resident] do? Did he ask for this lab test?””

Often this unfriendliness is due to the busy schedule of the medical specialists or because EPs and medical specialists have different educational backgrounds and different knowledge. Because of these differences, incomprehension arises (Leonard, Graham, & Bonacum, 2004), which causes people to react more unfriendly. Furthermore, residents work at the ED for different specialties and therefore, the way EPs and medical specialists communicate is often via the resident. This means that for example, the EP asks the resident, to ask the medical specialist if a patient should be assigned to their specialty. The medical specialists will reply to the resident and the resident will tell the EP, which makes the communication between the EP and the medical specialist indirect. Because of this indirect way of communication, there is no effective relational integration. This is perceived to influence the patient flow. Which is explained by a medical specialist:

MS6: “a specialist is going back to the resident, the resident is going back to the EP and says: “no, you don’t need me [this specialty], you need another specialty.” Then the EP goes to another resident, so that takes hours.”

4.2.3 Misalignment in goals

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et al., 2015). Discussing what is best, takes time and therefore, is perceived to inhibit the patient flow.

Furthermore, multidisciplinary patient presentations occur. In these cases, a patient comes in with injuries or complaints for multiple specialties and therefore it is hard to assess which specialty the patient should be assigned to. The EP is in charge in these cases and makes sure the different specialties all assess the patient. In this way, it can be decided to which specialty the patient belongs and what the treatment plan should be. Often the patient is assessed by the different specialties in sequential order, because the medical specialists are often not available at the same moments. The patient has to explain the complaints multiple times to multiple medical specialists, which takes time. The goal of the EP is to have the patient seen by all the different specialties and if necessary, to have the patient admitted to a department as quickly as possible. However, often in these cases, medical specialists only want a patient to be admitted to their own department, when it is really clear that it is a patient for their specialty, even if it is clear that the patient cannot be discharged:

EP1: “if the same patient would be seen […] by three specialties, the specialties will point to each other and they are not willing to admit this patient.”

In this situation, which occurs often, the EP needs to discuss with all the different specialties to make sure that one of them finally admits the patients. There is limited relational integration, as the medical specialists and the EPs are not collaboratively striving for the same goal and the discussion on who needs to admit the patient takes a lot of extra time, which therefore is perceived to inhibit the patient flow.

Furthermore, there is a difference in providing care to patients. For the EP the patient is always the most important, no matter what patient. For the medical specialists this might differ. Hospitals and their employees always claim that the patient is the most important and that the patient is central. In patient-centred care, the patients’ participation and involvement, the relationship between the healthcare professional and the patient and the context in which the care is delivered are important (Kitson, Marshall, Bassett & Zeitz, 2013). However, different interviewees mentioned that the well-being of all patients is not always central for the medical specialists:

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MS2: “everybody [medical specialists] will certainly underline that the patient has the central position, but if it comes to action or to reality, then a lot of other things are first and then the patient. […] They [medical specialists] have their own goal and are not really interested in the patient. It sounds very strange, but the patient central is only in words.”

In the traditional care, the focus is on the disease, rather than on the person who has the disease (Bauman, Fardy and Harris, 2003). Patient-centred care gives the patient more responsibility and autonomy, in which the patient can decide for him/herself if a treatment plan will be followed and how. However, this can frustrate medical specialists, as the patient may decide that they do not want to follow the advice of the medical specialist (Bauman et al., 2003). Other reasons why medical specialists are not always patient-centred could not be clearly explained by the different interviewees. Possibly, because this can be a sensitive issue, since the main focus of physicians should always be on the patient.

4.3 Status and hierarchy

Most of the interviewees mentioned that the hierarchy in the hospital is limited. However, the interesting part is that status does seem to play a role in this hospital.

EP3: “we are a hospital with very little hierarchy.” MS4: “we are all equal, there is no hierarchy.”

The specialty of the EPs is developed to lower the burden of the medical specialists, who were supposed to work both at their own department and at the ED. However, now about ten years later, it appears that not all medical specialists are happy with the EPs:

EP3: “There are still some of the people, some of the specialists, who would say that the EP project is a failure. There are still specialists who think it is better to do it their own way.”

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Additionally, multiple specialists mentioned that the EPs are allowed to treat patients for the specialties, but that the different specialties are still more important, which is explained by multiple medical specialists:

MS6 talking about another medical specialist: “because they [medical specialists] have to do surgery or have really difficult other jobs, the EP is allowed to do that part, but in the end the medical specialist is the most important doctor there is.”

MS1: “we are specialists, so we are very good at a small part of the medicine and the emergency doctor sees a lot of different things and they will never know as much as the specialties that consult [be on-call] during the day.”

This suggests that some medical specialists do not see EPs as a specialty. There is not supposed to be a status differences between the EPs and medical specialists, since both of them are official specialties. However, two EPs also mentioned that they still feel that they have to prove themselves as a specialty. It seems as if the medical specialists doubt the ability of the EPs. To become an EP, a training of three more years after becoming a medical doctor is mandatory. To become a medical specialist for other specialties, at least six more years of training is mandatory after becoming a medical doctor. Because of this, some medical doctors feel that they have more knowledge, experience and are better at diagnosing and treating patients. Trust seems to be an issue here as well, as medical specialists feel that they are better at treating patients and therefore, do not trust the EPs in giving the same quality of care.

However, differences in status among healthcare professionals and trust issues are a strong barrier to shared decision making and restrains collaboration (Propp et al., 2010). Therefore, the status that still exists for some medical specialists might be the reason why a threshold for EPs to contact medical specialists still exists:

EP2: “when you phone someone you are not sure if it is really convenient at that moment, so you first make your package as a whole. You wait for the lab and wait for the X-ray etc.” […] –“Did it sometimes occur that you didn’t want to call a specialist because you thought that he or she might be busy, I should handle it myself? – O yes. Frequently.”

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influences the patient flow, since it takes more time before a patient is discussed and decisions can be made. However, none of the interviewees actually mentioned that status issues were perceived as a problem for the patient flow.

4.4 Findings related to the intervention

One medical specialist of every main specialty, cardiology, radiology, surgery, internal medicine and neurology, is obliged to be on the ED from 12-8 PM every day during this intervention. In this way, the medical specialists are also dedicated to the ED during those hours. This increases the relational integration, since the EPs and the medical specialists are collaboratively managing the processes on the ED, often with the same goal, diagnosing and treating patients as quickly as possible. Furthermore, medical specialists are more involved with the ED now, which helps to remove the barriers of the availability of the specialists and the indirect communication, since the medical specialists have to be at the ED and therefore the communication is most often face-to-face. Although the intervention is still continuing and not all data is available yet, the patient flow is already perceived as improved, as everyone on the ED thought there were less patients. However, there were actually more patients than other years.

Furthermore, the patient flow can be improved because the medical specialists have a better understanding of the ED and their role in this:

EP3: “when they [medical specialists] are on the ED, we can actually say to the medical specialists: “you see those three patients waiting for a bed on your ward? Right now, they are a problem to the patient flow at the ED and those three people in the waiting room, also of your specialty, can’t be seen because of that.””

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relational integration is improved, as the EPs and medical specialists can collaboratively focus on improving the patient flow.

Nonetheless, this solution is very expensive, since extra medical specialists need to be hired to do the work of the medical specialists that are now at the ED. Additionally, not all medical specialists are happy with this solution, since some of them feel that there are other things more important for them. A medical specialist explained:

MS1: “You have educated someone to be a consult trauma surgeon or an oncological surgeon to do something that nobody else can do, so I would think you would make them do that as much as possible and not take them back from that position and put them back to the ED, where they do things that other people can also do.”

Since more medical specialists had related opinions, it is unsure whether the intervention will continue and in what way this will be done. Data on the intervention will be important to see if improvements were actually made.

5. Discussion

This study aimed to investigate the relationship between relational integration and patient flow, examining how barriers to relational integration between EPs and medical specialists of different departments may lead to delays in the patient flow. The theory on relational integration states that commitment, trust and long-term relationships are important concepts that improve the performance (Vijayasarathy, 2010). In this study commitment, trust and long-term relations indeed showed to be related to the relational integration and the patient flow. In the following paragraphs, this will be discussed and linked to the barriers found to relational integration and patient flow.

The first barrier found was commitment, which causes three other problems that are perceived to inhibit the patient flow. First, the availability of medical specialists, which was closely related to the agreements for medical specialists on-call. Often medical specialists are unable or unwilling to go to the ED within 30 minutes. In this case, the agreements made for medical specialists on-call are not followed, which is a barrier to the relational integration.

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collaborative strategy lowers (Fawcett et al., 2015). Since residents of different specialties work at the ED, the communication between the EPs and medical specialists often goes via them, which does not motivate to collaborate.

Third, the misalignment of goals. A lack of integration causes a lack in shared goals in healthcare settings (Tang et al., 2015). Additionally, research in manufacturing settings found that shared goals improve the collaborative behaviour between different parties (Lavikka, Smeds, & Jaatinen, 2015). Even though, hospitals proclaim shared goals (e.g. patient-centeredness), the autonomy of the separate departments means they also pursue their own goals and these goals can compete (Tang et al., 2015). This was shown, for example, by medical specialists who are not willing to admit a patient to their departments when it is unclear if the patient belongs to their specialty, although it is clear that the patient cannot be discharged.

Furthermore, status and hierarchy show to be a problem for the relational integration. When individuals feel less respected then needed in their opinion, they are less likely to engage in cooperative behaviour and it is more difficult to motivate them to contribute to shared success (Kilduff, Willer, & Anderson, 2016) . Often medical specialists see themselves as more educated, more experienced and more knowledgeable. However, this view is not always shared, especially not by EPs and therefore status disagreements arise. Status disagreements cause differences in behaviour and this leads to ineffective performance (Kilduff et al., 2016) . This can work both ways, as medical specialists do not get the respect they want from the EPs and the EPs do not get the respect they want from the medical specialists.

Additionally, it seems that there is a lack of trust between the medical specialists and the EPs, since the medical specialists feel that they have more knowledge and are more experienced in diagnosing and treating patients than the EPs and therefore give better care. Based on the definition of Sako (1992), this can be linked to competence trust. Competence trust states that competence trust refers to the expectations with regard to the technical and managerial competences of the partner. Medical specialists feel that they have more knowledge and experience and therefore, their trust in the competences of the EPs is not very high, not to say they mistrust the EPs competences.

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There is a strong divide between medical specialists who see the value they can give to the ED by being present and medical specialists who do not and who see their own interests and work as more important than being present at the ED. Prior research found that medical specialists are often more highly regarded in their medical work than generalists (Abel & Thompson, 2011). Because of this, the work of the generalists therefore tends to be more marginalized (Abel & Thompson, 2011). This also shown by a group of medical specialists, since many of them do not see the value of the EPs. The status and the attitudes of the medical specialists towards the ED seem to be the foundation for the other barriers that are found or at least seem to reinforce them. The availability of the medical specialists can be explained by their attitudes towards the ED, in which they seem to pursue their own interests and not the interest of the patients at the ED and therefore are often not available for the ED. Furthermore, it seems that the medical specialists are not willing to make time for the EPs to discuss patients and therefore, the EP has to ask the resident to ask the medical specialist. The misalignment in goals can easily be linked to the attitudes of this group of medical specialists. These medical specialists seem to pursue their own interests, which clearly does not match with the goals of the EP. This causes EPs to feel a threshold to collaborate and a lack of goodwill trust can develop. Goodwill trust refers to the commitment of parties and is based on mutual expectations (Sako, 1992). It seems that this group of medical specialists is only pursuing their own interests and is not committed to others. Furthermore, because of the attitudes of this group of medical specialists, it might be possible that every intervention, however arranged, is doomed to fail, since medical specialists will try to pursue their own interests and are not willing to adjust.

Important to note is that further research is necessary to define the relation between the different barriers more in-depth and to distinguish the interests of the medical specialists.

6. Conclusion

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limited relational integration was found between EPs and medical specialists, because of two different barriers: commitment and status. Commitment includes the availability of medical specialists, indirect communication and misalignment in goals. The research shows that a lack in commitment causes that medical specialists are often unwilling or unable to be available for the ED. Furthermore, because of the lack of commitment, the communication between the EPs and medical specialists often goes via the residents. This takes a lot of extra time. Additionally, there are misalignments in the goals of medical specialists and EPs. Therefore, often discussion rises between EPs and medical specialists. Furthermore, status showed to be a barrier to relational integration. Status is important to some medical specialists and inhibits the relational integration, as EPs feel a threshold to call the medical specialists. The status and attitudes of medical specialists seem to be the underlying foundations for the barriers to commitment. However, since this study is the first in linking relational integration to patient flow, a more in-depth study on these barriers is suggested to give more insights on this. Further deductive research is also necessary to investigate the identified barriers more in-depth to find ways to remove these barriers. Additionally, to increase the generalizability, the research should be broadened to more hospitals and with more interviewees.

For managerial purposes an improved patient flow means that patients go through the ED faster. This ensures better quality of care, greater patient satisfaction and lower costs (Johnson & Capasso, 2010). The patient flow can be improved by improving or removing the identified barriers. Although, the intervention at this hospital might help in removing some barriers to relational integration, it is very expensive and not all the medical specialists are happy with this solution. Because these barriers are influenced by multiple factors and relational integration is between at least two parties, no simple answer to removing these barriers exist.

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Appendix A – Interview guide

Questionnaire

Demographics: Age: _____ Tenure: _____ Gender: _____ Hours: ___ 1. Can you tell me your role in the hospital?

2. What motivates you in your work? What is most important to you? 3. How did you end up at this particular hospital?

Intervention

1. How does the ED work here in terms of patients coming in? 2. Who is normally staffed here?

a. EPs/residents?

3. How is work divided between EPs/residents?

4. In what way do you work together with the ED/specialties? a. Information sharing/consults?

b. Handovers?

i. How do handovers work between the ED and wards? ii. Who is involved?

5. Why did this intervention start? 6. How does it work?

a. What are the roles of the EP’s and specialists? 7. Are there formal guidelines or is it trial and error? 8. How did the ED work before the intervention?

a. How did the specialists and EPs collaborate before? 9. Who wanted it?

a. Who didn’t? 10. Was there resistance to it?

a. Is there still resistance?

b. Do you think this might change? 11. How does the ED/specialists feel about it?

12. How is the collaboration going between the EPs/specialists? a. Do you like it?

13. Do the specialists have enough time for this?

14. Do the goals between the EPs and specialists always align? a. Why and why not?

15. Is there a hierarchy on the ED now? 16. What are barriers to the collaboration? 17. What is going well?

18. How did the first intervention (pilot) go? a. Did you like it?

19. What changed since the pilot? 20. What where barriers then?

a. Do you still notice these now?

21. What outcomes are hoped for in the intervention? 22. How are specialists being compensated for this? 23. How is the outcome measured?

a. What happens with the outcomes measures?

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25. Would you be happy if this would be the new way to work? 26. Does the intervention actually improve the patient flow?

a. How?

b. What does the specialist do, what the EPs couldn’t? 27. Does it also influence the other wards?

a. In what way?

Organizational structure:

1. Are you an employee of the hospital or self-employed? 2. Did you choose this payment? Why?

3. How is it organized/ distributed?

a. Tied to any performance/ activity? (e.g. Is your pay dependent on any output (so per DOT, DBC)

b. Does it influence how you work?

4. What would you say are the advantages and disadvantages of each model? 5. Are you colleagues (within specialty) all on same payment?

a. Other specialties?

6. Do you think it work to have more than one payment system for doctors? (In same hospital)

7. Do you think pay affects motivation? a. Can you give an example of this? b. Why does it make you feel that way?

8. Do you notice any difference in how specialists in different employment models work? a. What kind of differences, why do you think this happens?

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