Redesigning value-based hospital structures: a qualitative study on value-based health care in the Netherlands

Reworking Nursing Expertise: Directors of Nursing's Tactics to (Re)Connect Knowledge and Power in Hospital Governance

Shared governance in hospitals promotes the inclusion of nurses' expertise, knowledge and skills in organisational processes, and nurses increasingly fulfil positions in organisational hierarchies. However, incorporating nursing expertise in strategic governance structures might be complicated, as these structures are primarily linked to managerial and biomedical expertise. Drawing on a Foucauldian perspective on knowledge and power, intertwined and embedded in everyday (inter)actions, we study how newly appointed directors of nursing challenge these dominant 'modes of knowing'. By focusing on a (Dutch) healthcare organisation, a large academic medical centre, we gained insight into how the history of director of nursing roles relates to how nursing expertise is valued. We gathered qualitative data (from multiple sources) to get close to the daily practices of these directors. In this way, we were able to highlight three tactics that enable directors to relate to new 'knowledge-power knots': (1) positioning, by creating more unity; (2) profiling, by showing significance and (3) powering, by being alert and intervening. With these tactics, the directors of nursing try to embed themselves and their expertise in hospital governance. This study contributes to an everyday understanding of power and the tactics that directors of nursing employ as an ongoing practice. This provides practical starting points for embedding nursing in governance and decision-making.

Value-based healthcare for social insurance medicine: key enablers for adoption in practice

BACKGROUND

Driven by rising retirement age and increasing prevalence of chronic diseases impacting work participation, there is an increasing need for quality and efficiency improvement in social insurance medicine (SIM). SIM provides guidance to individuals facing long-term work disability, assess their functional abilities and eligibility for long-term disability benefits. Value-based healthcare (VBHC) targets quality and efficiency improvements in healthcare by placing a priority on improving patient value. So far, VBHC has been introduced with fundamental principles and essential components for its adoption in curative care. Hence, there is room for debate on what are key enablers for the adoption of value-based SIM.

PURPOSE

The study aims to explore key enablers for the adoption of VBHC in the practice of SIM.

METHODS

In this exploratory qualitative study, participants consisted of 15 professionals with expertise either in SIM (n=10) or with expertise in the adoption of VBHC in the curative care sector (n=5). Each participant took part in both a semistructured individual interview and a focus group interview. Thematic coding was employed to analyse the data.

RESULTS

Seven key enablers were identified: (1) investigate the meaning and implementation constraints of value in SIM, (2) integrate SIM into work-focused care networks, (3) explore the need and feasibility for specialisation based on functional problems, (4) identify the most important work outcomes for the patient, (5) identify proxy indicators for cost drivers, (6) identify value-driven financial incentives and (7) develop an information technology system to exchange data.

CONCLUSIONS

This paper provides understanding of what is needed to adopt value-based SIM. Future research should delve deeper into these seven key enablers to facilitate the adoption of VBHC, and thereby promote value creation in the practice of SIM.

Moving from Principles to Practice: A Scoping Review of Value-Based Healthcare (VBHC) Implementation Strategies

BACKGROUND/OBJECTIVES

The principles of value-based healthcare (VBHC) have received widespread endorsement, leading healthcare organizations worldwide to shift their strategies towards them. However, despite growing recognition and acceptance, the actual implementation of value-based approaches varies widely. This research aims to identify studies that address the implementation of VBHC at different levels (healthcare policymakers, hospital administrators, and healthcare providers), focusing on each level's relative strategies.

METHODS

To this end, a scoping review was conducted in accordance with the PRISMA extension for the scoping reviews checklist. The electronic databases of Web of Science, PubMed, MEDLINE, and Scopus were searched to identify relevant publications in English from January 2006 to 31 July 2023.

RESULTS

We identified 30 eligible studies. Findings are organized into four main macro strategic levels, each comprising specific dimensions and operational approaches. Fourteen articles analyzed the role of government commitment in VBHC implementation, while six articles focused on regional integrated care systems. The role of hospitals was described in sixteen records.

CONCLUSIONS

Our study suggests that a comprehensive approach is necessary for the successful implementation of VBHC. Hospitals emerge as pivotal in this shift, requiring organizational and attitudinal changes among healthcare professionals. However, a complete transition towards VBHC that ensures seamless patient management throughout the entire care delivery value chain necessitates government involvement in terms of state legislation, reimbursement methods, and hospital networking.

A decade of change towards Value-Based Health Care at a Dutch University Hospital: a complexity-informed process study

BACKGROUND

While healthcare organizations in several countries are embracing Value-Based Health Care (VBHC), there are limited insights into how to achieve this paradigm shift. This study examines the decade-long (2012-2023) change towards VBHC in a pioneering Dutch university hospital.

METHOD

Through retrospective, complexity-informed process research, we study how a Dutch university hospital's strategy to implement VBHC evolved, how implementation outcomes unfolded, and the underlying logic behind these developments. Data include the hospital's internal documents (n = 10,536), implementation outcome indicators (n = 4), a survey among clinicians (n = 47), and interviews with individuals contributing to VBHC at the hospital level (n = 20).

RESULTS

The change towards VBHC is characterized by three sequential strategies. Initially, the focus was on deep change through local, tailored implementation of multiple VBHC elements. The strategy then transitioned to a hospital-wide program aimed at evolutionary change on a large scale, emphasizing the integration of VBHC into mainstream IT and policies. Recognizing the advantages and limitations of both strategies, the hospital currently adopts a "hybrid" strategy. This strategy delicately combines deep and broad change efforts. The strategy evolved based on accumulated insights, contextual developments and shifts in decision-makers. The complexity of change was downplayed in plans and stakeholder communication. By the end of 2023, 68 (sub)departments engaged in VBHC, enabled to discuss patients' responses to Patient Reported Outcomes Measures (PROMs) during outpatient care. However, clinicians' use of PROMs data showed limitations. While pioneers delved deeper into VBHC, laggards have yet to initiate it.

CONCLUSIONS

VBHC does not lend itself to linear planning and is not easily scalable. While there appears to be no golden standard for implementation, blending local and larger-scale actions appears advantageous. Local, deep yet harmonized and system-integrated changes culminate in large scale transformation. Embracing complexity and focusing on the ultimate aims of (re)institutionalization and (re)professionalization are crucial.

Multidisciplinary Collaboration in Hospitals via Patient- and Process-Oriented Units: A Longitudinal Study

Introduction

The complexity of healthcare is increasing, mainly due to the prevalence of multimorbidity in an ageing population. Complex care for patients with multimorbidity requires a multidisciplinary approach. Traditional physician-centered hospital structures do not facilitate the necessary multidisciplinary collaboration. European hospitals are implementing process-based hospital designs with patient- and process-oriented units to stimulate multidisciplinary collaboration. Patient-oriented units are formed based on shared patient groups and focus on care trajectories, while process-oriented units are formed based on having similar processes and focus on efficiency.

Purpose

This study has two aims. First, to study the effect of introduction of these units on multidisciplinary collaboration and perceived impact (efficiency, innovation, and effectiveness). Second, to study whether there are differences between patient- and process-oriented units.

Methods

A survey-based longitudinal evaluation study was conducted in 2020 and 2022 among physicians in a Dutch hospital to measure multidisciplinary collaboration (relational coordination) and perceived impact (efficiency, innovation, and effectiveness). In addition, open questions were used to enrich the data.

Results

Quantitative and qualitative data together suggest that physicians in patient-oriented units notice benefits from the redesign to multidisciplinary units, they perceive higher impact over time. Physicians in process-oriented units achieve a better relationship with the physicians in their unit over time, but they do not perceive impact as high as physicians in patient-oriented units.

Conclusion

A process-based design with patient- and process-oriented units is supportive of multidisciplinary collaboration and perceived impact, especially for physicians in patient-oriented units. Physicians in patient-oriented units are positive about the introduction of these units as they feel it contributes to better multidisciplinary patient care. As the results for physicians in process-oriented units may be less directly visible in terms of quality of care, they are less likely to see positive effects, even though their relationships are improving.

Value-based healthcare implementation in the Netherlands: a quantitative analysis of multidisciplinary team performance

BACKGROUND

Many hospitals worldwide have set up multidisciplinary Value Improvement (VI) teams that use the Value-Based Health Care (VBHC) theory to improve patient value. However, it remains unclear what the level of VBHC implementation is within these teams. We therefore studied the current level of VBHC implementation in VI teams.

METHODS

A questionnaire was developed based on the strategic agenda for value transformation and real-world experiences with VBHC implementation. The questionnaire consisted of 21 questions, mapped to seven domains, and was sent out to 25 multidisciplinary VI teams. Median scores for individual questions (scale = 1-5) and average scores per domain were calculated.

RESULTS

One hundred forty VI team members completed the questionnaire. The overall average score is 3.49. The 'culture and responsibility' domain obtained the highest average score (µ = 4.11). The domain 'measure and improve outcomes' and the domain 'multidisciplinary team' obtained average scores that are slightly higher than the overall average (µ = 3.78 and µ = 3.76 respectively), and the domains 'strategy and organizational policy,' 'collaboration and sharing,' and 'IT and data' scored a little below the overall average (µ = 3.41, µ = 3.32, and µ = 3.29 respectively). The domain 'costs and reimbursement' obtained the lowest average score (µ = 2.42) of all domains, indicating that the implementation of this particular aspect of VBHC remains lagging behind.

CONCLUSIONS

Our results indicate activity in each of the questionnaire domains. To bring VBHC implementation to the next level, more attention should be given to the financial aspects. Our questionnaire can be used in future studies to identify improvements or differences within VI teams.

Evaluating patient participation in value-based healthcare: Current state and lessons learned

INTRODUCTION

Value-based healthcare (VBHC) focusses on increasing value for patients. Hospitals aim to implement VBHC via value improvement (VI) teams for medical conditions. To determine the patient's perspective on value, collective patient participation is important in these teams. We therefore evaluated the current state of patient participation in VI teams and share lessons learned.

METHODS

This mixed-methods study was conducted at seven collaborating hospitals in the Netherlands. A questionnaire (the public and patient engagement evaluation tool) was tailored to the study's context, completed by VI team members (n = 147 from 76 different VI teams) and analysed with descriptive statistics. In addition, 30 semistructured interviews were held with VI team members and analysed through thematic analysis. Data were collected between February 2022 and January 2023 and were triangulated by mapping the quantitative results to the interview themes.

RESULTS

Thirty-eight of the 76 included VI teams reported using a form of patient participation. Many respondents (71%) indicated a lack of a clear strategy and goal for patient participation. Multiple VI team members believed that specific knowledge and skills are required for patients to participate in a VI team, but this led to concerns regarding the representativeness of participating patients. Furthermore, while patients indicated that they experienced some level of hierarchy, they also stated that they did not feel restricted hereby. Lastly, patients were satisfied with their participation and felt like equal VI team members (100%), but they did mention a lack of feedback from the VI team on their input.

CONCLUSION

The results imply the lack of full implementation of patient participation within VI teams. Guidelines should be developed that provide information on how to include a representative group of patients, which methods to use, how to evaluate the impact of patient participation, and how to give feedback to participating patients.

PATIENT AND PUBLIC CONTRIBUTION

Two patient advisors were part of the research team and attended the research team meetings. They were involved as research partners in all phases of the study, including drafting the protocol (e.g., drafting interview guides and selecting the measurement instrument), interpreting the results and writing this article.

Value-Based Healthcare Delivery: A Scoping Review

Healthcare systems are transforming from the traditional volume-based model of healthcare to a value-based model of healthcare. Value generation in healthcare is about emphasising the health outcomes achieved by patients and organisations while maintaining an optimal relationship with costs. This scoping review aimed to identify the key elements and outcomes of implementing value-based healthcare (VBHC). The review process included studies published from 2013 to 2023 in four different databases (SpringerLink, PubMed, ProQuest and Scopus). Of the 2801 articles retrieved from the searches, 12 met the study's inclusion criteria. A total of 11 studies referred to value as the relationship between the outcomes achieved by patients and the costs of achieving those outcomes. Most of the studies highlighted the presence of leadership, the organisation of care into integrated care units, the identification and standardisation of outcome measures that generate value for the patient, and the inclusion of the patient perspective as the most prominent key elements for optimal VBHC implementation. Furthermore, some benefits were identified from VBHC implementation, which could shed light for future implementation actions. Therefore, the VBHC model is a promising approach that may contribute to an improvement in the efficiency and sustainability of healthcare.