Getting our hopes up: How actors perceive network effectiveness and why it matters.

Health care's grand challenges, such as continuously increasing costs, challenge the sustainability of health systems. Purpose-oriented networks are considered a favorable mode of organization to address these grand challenges. Therefore, it is crucial that they are effective. While network effectiveness is a heavily theorized, multi-dimensional concept that is often measured as a perception of actors, little is known about how network actors perceive effectiveness in practice and how this influences their behavior. In this study, we explored how network actors perceive network effectiveness using 32 interviews with representatives from network member organizations and regulatory agencies actor, 28 h of network meeting observations, and 1.272 pages of documents such as meeting minutes and media outlets. Our results show that actors primarily see hard outcomes (e.g. changes in cost or quality of care) as effectiveness but given the temporal nature of these goals and difficulties quantifying them, they resort to the collaborative process as a proxy to assess effectiveness. Actors engage in networks to solve grand challenges. However, conforming to expectations and environmental pressures also play a substantial role for actors to (continue to) participate in networks. In the absence of hard outcomes, actors legitimize their continued participation in networks using the collaborative process of networks. Actors therefore take purpose-oriented networks for granted as a legitimate way of organizing. Besides attempting to solve grand challenges, networks thus also seem to be adopted because of powerful institutional rules that function as rationalized myths, to gain legitimacy. Future research should be aware of and further unravel the institutional pressures in networks.

So Happy Together: A Review of the Literature on the Determinants of Effectiveness of Purpose-Oriented Networks in Health Care.

While purpose-oriented networks are widely recognized as organizational forms to address wicked problems in health care such as increasing demands and expenditure, the associated literature is fragmented. We therefore reviewed empirical studies to identify the determinants of the effectiveness of these networks. Our search yielded 3,657 unique articles, of which 19 met our eligibility criteria. After backward snowballing and expert consultation, 33 articles were included. Results reveal no less than 283 determinants of effective health care networks. The majority of these determinants are processual and involving professionals from the operational level is particularly salient. In addition, most studies relate determinants to process outcomes (e.g., improved collaboration or sustainability of the network) and only a few to members' perception of whether the network attains its goals. We urge future research to adopt configurational approaches to identify which sets of determinants are associated with networks' ability to attain their goal of addressing wicked problems.

Can Organisational Culture of Teams Be a Lever for Integrating Care? An Exploratory Study.

INTRODUCTION: Organisational culture is believed to be an important facilitator for better integrated care, yet how organisational culture impacts integrated care remains underspecified. In an exploratory study, we assessed the relationship between organisational culture in primary care centres as perceived by primary care teams and patient-perceived levels of integrated care. THEORY AND METHODS: We analysed a sample of 2,911 patient responses and 17 healthcare teams in four primary care centres. We used three-level ordered logistic regression models to account for the nesting of patients within health care teams within primary care centres. RESULTS: Our results suggest a non-linear relationship between organisational culture at the team level and integrated care. A combination of different culture types-including moderate levels of production-oriented, hierarchical and team-oriented cultures and low or high levels of adhocracy cultures-related to higher patient-perceived levels of integrated care. CONCLUSIONS AND DISCUSSION: Organisational culture at the level of healthcare teams has significant associations with patient-perceived integrated care. Our results may be valuable for primary care organisations in their efforts to compose healthcare teams that are predisposed to providing better integrated care.

Cross-Cultural Validation of the Patient Perception of Integrated Care Survey.

OBJECTIVE: To test the cross-cultural validity of the U.S. Patient Perception of Integrated Care (PPIC) Survey in a Dutch sample using a standardized procedure. DATA SOURCES: Primary data collected from patients of five primary care centers in the south of the Netherlands, through survey research from 2014 to 2015. STUDY DESIGN: Cross-sectional data collected from patients who saw multiple health care providers during 6 months preceding data collection. DATA COLLECTION: The PPIC survey includes 59 questions that measure patient perceived care integration across providers, settings, and time. Data analysis followed a standardized procedure guiding data preparation, psychometric analysis, and included invariance testing with the U.S. dataset. PRINCIPAL FINDINGS: Latent scale structures of the Dutch and U.S. survey were highly comparable. Factor "Integration with specialist" had lower reliability scores and noninvariance. For the remaining factors, internal consistency and invariance estimates were strong. CONCLUSIONS: The standardized cross-cultural validation procedure produced strong support for comparable psychometric characteristics of the Dutch and U.S. surveys. Future research should examine the usability of the proposed procedure for contexts with greater cultural differences.

The impact of redesigning care processes on quality of care: a systematic review.

BACKGROUND: This literature review evaluates the current state of knowledge about the impact of process redesign on the quality of healthcare. METHODS: Pubmed, CINAHL, Web of Science and Business Premier Source were searched for relevant studies published in the last ten years [2004-2014]. To be included, studies had to be original research, published in English with a before-and-after study design, and be focused on changes in healthcare processes and quality of care. Studies that met the inclusion criteria were independently assessed for excellence in reporting by three reviewers using the SQUIRE checklist. Data was extracted using a framework developed for this review. RESULTS: Reporting adequacy varied across the studies. Process redesign interventions were diverse, and none of the studies described their effects on all dimensions of quality defined by the Institute of Medicine. CONCLUSIONS: The results of this systematic literature review suggests that process redesign interventions have positive effects on certain aspects of quality. However, the full impact cannot be determined on the basis of the literature. A wide range of outcome measures were used, and research methods were limited. This review demonstrates the need for further investigation of the impact of redesign interventions on the quality of healthcare.

Experiences and preferences of patients visiting an otorhinolaryngology outpatient clinic: a qualitative study.

BACKGROUND: Patient-centred care has received considerable attention in the last few decades, but the patients' perspective remains underexposed. This study reports on an in-depth evaluation of patients' experiences and preferences at an otorhinolaryngology outpatient department. METHODS: Qualitative research was conducted on patients' experiences and preferences at an otorhinolaryngology outpatient department in an academic hospital. The study comprised two phases. First, semi-structured interviews were held with 22 patients. Second, results from the interviews were verified and deepened in a focus group (N = 7). RESULTS: Overall, experience with patient-centred care was positive at the outpatient department. Three of the six dimensions of patient-centred care predominated in the interviews and the focus group: information, communication and education; coordination and integration of care; and respect for patients' values, preferences and expressed needs. The negative experiences were mostly in these dimensions. The dimensions physical comfort and involvement of family and friends were of lesser significance. Opinion on emotional support--relieving fear and anxiety differed as to whether this was the responsibility of the doctor or the patient. CONCLUSION: Qualitative research provided a deeper understanding of patients' experiences and preferences at an otorhinolaryngology outpatient department. Such an in-depth evaluation can be useful in the transition towards patient-centred care.

Using Lean Thinking at an otorhinolaryngology outpatient clinic to improve quality of care.

OBJECTIVES/HYPOTHESIS: Although Lean Thinking has led to considerable improvement in a variety of healthcare settings, its effects on otorhinolaryngology remain underexposed. This study reports on how the implementation of Lean Thinking at an otorhinolaryngology outpatient clinic has affected patient and provider satisfaction, waste reduction, and organizational culture. STUDY DESIGN: Prospective before-and-after design. METHODS: The 18-month prospective before-and-after design used mixed methods for data collection and analysis. A survey was conducted to measure satisfaction among patients and providers. Semistructured interviews were conducted to evaluate the effect of Lean Thinking on waste and organizational culture. RESULTS: During the project, 69 issues were posted on the Lean board. Improvements were made on 36 inefficiency issues, not all concerning a specific type of waste. Employees reported considerable improvement in transportation, motion, and waiting. Patient satisfaction was high both at baseline and follow-up and did not change significantly. The effects on provider satisfaction were slight; satisfaction with autonomy and participation decreased significantly, but satisfaction with communication increased significantly. CONCLUSIONS: The implementation of Lean Thinking at an otorhinolaryngology outpatient clinic reduced waste and increased provider satisfaction with communication. Although patient satisfaction did not change significantly, it cannot be concluded that the intervention had no effect on perceived quality of care. Other approaches to measure patients' perceptions should be considered. LEVEL OF EVIDENCE: NA.

Translating the Patient Perception of Integrated Care Survey to Measure Integrated Care in the Netherlands: Combining Equivalence and Contextualization Approaches for Optimal Results.

INTRODUCTION: An increase in initiatives to improve integration of care provides the need for instruments that assess the degree of integrated care as perceived by patients across cultural contexts. This article aims to explain the relevance of equivalence and contextualization approaches in translating and adapting the Patient Perception of Integrated Care Survey developed in the US for use in the Netherlands. THEORY AND METHODS: The World Health Organization guidelines guided the translation and adaptation, including a forward-backward translation and patient-feedback through informal contacts (N4) and cognitive interviews (N14). RESULTS: The forward-backward translation produced a Dutch version of the Patient Perception of Integrated Care Survey with minor adaptations. Patients evaluated the survey as very relevant. Alterations resulted from structural and cultural differences and specificities of patients with chronic conditions. CONCLUSIONS AND DISCUSSION: A context-sensitive translation process is key to developing instruments for cross-cultural health research. Our results show that equivalence- and contextualization methods provide equally relevant, yet substantially different contributions to the translation outcome and should both be incorporated when translating instruments for different cultural contexts. The results support the applicability of the Patient Perception of Integrated Care Survey in the Netherlands and are promising for its adoption in other cultural contexts.

Interprofessional communication failures in acute care chains: How can we identify the causes?

Although communication failures between professionals in acute care delivery occur, explanations for these failures remain unclear. We aim to gain a deeper understanding of interprofessional communication failures by assessing two different explanations for them. A multiple case study containing six cases (i.e. acute care chains) was carried out in which semi-structured interviews, physical artifacts and archival records were used for data collection. Data were entered into matrices and the pattern-matching technique was used to examine the two complementary propositions. Based on the level of standardization and integration present in the acute care chains, the six acute care chains could be divided into two categories of care processes, with the care chains equally distributed among the categories. Failures in communication occurred in both groups. Communication routines were embedded within organizations and descriptions of communication routines in the entire acute care chain could not be found. Based on the results, failures in communication could not exclusively be explained by literature on process typology. Literature on organizational routines was useful to explain the occurrence of communication failures in the acute care chains. Organizational routines can be seen as repetitive action patterns and play an important role in organizations, as most processes are carried out by means of routines. The results of this study imply that it is useful to further explore the role of organizational routines on interprofessional communication in acute care chains to develop a solution for failures in handover practices.

Barriers to implementation of a redesign of information transfer and feedback in acute care: results from a multiple case study.

BACKGROUND: Accurate information transfer is an important element of continuity of care and patient safety. Despite the demonstrated urge for improvement of communication in acute care, there is a lack of data on improvements of communication. This study aims to describe the barriers to implementation of a redesign of the existing model for information transfer and feedback. METHODS: A case study with six cases (i.e. acute care chains), using mixed methods was carried out in the Netherlands. The redesign was implemented in one acute care chain while the five other acute care chains served as control groups. Focus group interviews were held with members of the acute care chains and questionnaires were sent to care providers working in the acute care chains. RESULTS: Respondents reported three sets of barriers for implementation of the model: (a) existing routines for information transfer and feedback in organizations within the acute care chain; (b) barriers related to the implementation method and time period; and (c) the absence of a high 'sense of urgency' amongst providers in the acute care chain which would aid in improving the communication process. CONCLUSIONS: This study shows that organizational factors play an important role in the success or failure of redesigning a communication process. Organizational routines can hamper implementation of a redesign if it differs too much from the routines of care providers involved. Besides focussing on provider characteristics in the implementation of a redesigned process, specific attention should be paid to unlearning existing organizational routines.

Can we make sense of multidisciplinary co-operation in primary care by considering routines and rules?

Although it is widely acknowledged that the complex health problems of chronically ill and elderly persons require care provision across organisational and professional boundaries, achieving widespread multidisciplinary co-operation in primary care has proven problematic. We developed an explanation for this on the basis of the concepts of routines (patterns of behaviour) and rules, which form a relatively new yet promising perspective for studying co-operation in health-care. We used data about primary care providers situated in the Dutch region of Limburg, a region that, despite high numbers of chronically and elderly persons, has traditionally few healthcare centres and where multidisciplinary co-operation is limited. A qualitative study design was used, in which interviews and documents were the main data sources. Semi-structured interviews were conducted with providers from six primary care professions in the Dutch region of Limburg; relevant documents included co-operation agreements, annual reports and internal memos. To analyse the evidence, several data matrices were developed and all data were structured according to the main concepts under study, i.e. routines and rules. Although more research is needed, our study suggests that the emergence of more extensive multidisciplinary co-operation in primary care is hampered by the organisational rules and regulations prevailing in the sector. By emphasising individual care delivery rather than co-operation, these rules stimulate the perseverance of diversity between the routines by which providers perform their solo care delivery activities, rather than the creation of the amount of compatibility between those routines that is necessary for the current, rather limited shape of multidisciplinary co-operation to expand. Further research should attempt to validate this explanation by utilising a larger research population and systematically operationalising the rules existing in the legal and--more importantly--organisational environment of primary care.

Is integrated nursing home care cheaper than traditional care? A cost comparison.

BACKGROUND: It is generally assumed that integrated care has a cost-saving potential in comparison with traditional care. However, there is little evidence on this potential with respect to integrated nursing home care. AIMS AND OBJECTIVES: DESIGN/METHODS/SETTINGS/PARTICIPANTS: Between 1999 and 2003, formal and informal caregivers of different nursing homes in the Netherlands recorded activities performed for residents with somatic or psycho-social problems. In total, 23,380 lists were analysed to determine the average costs of formal and informal care per activity, per type of resident and per nursing home care type. For formal care activities, the total personnel costs per minute (in Euro) were calculated. For informal care costs, two shadow prices were used. RESULTS: Compared to traditional care, integrated care had lower informal direct care costs per resident and per activity and lower average costs per direct activity (for a set of activities performed by formal caregivers). The total average costs per resident per day and the costs of formal direct care per resident, however, were higher as were the costs of delivering a set of indirect activities to residents with somatic problems. CONCLUSIONS: The general assumption that integrated care has a cost-saving potential (per resident or per individual activity) was only partially supported by our research. Our study also raised issues which should be investigated in future research on integrated nursing home care.

The impact of integrated care on direct nursing home care.

BACKGROUND/AIM: The introduction of integrated nursing home care is an important policy goal in many countries and is expected to affect the type, frequency and duration of activities delivered to nursing home residents. The exact impact however is unknown. The aim of this paper is to reduce this information gap in order to provide decision supporting information to policy makers and managers. DESIGN/METHODS/ETHICAL ISSUES: At three measurement points between 1999 and 2003, caregivers belonging to 18 functions registered activities delivered to somatic and psycho-geriatric nursing home residents in The Netherlands. Residents either received traditional care, integrated care or care that contained elements of traditional and integrated care (hybrid care). Thirty-six thousand and seventy-one registration lists were used for data analysis. Data analysis included determining, comparing and linking the (total) average frequency and duration of each activity per care type, measurement point and type of resident. RESULTS: The (total) average frequency and total duration of most activities were higher for integrated care than for traditional and hybrid care. The average duration per activity was generally higher for traditional care. The (total) average frequency of most direct care activities at most measurement points and the total average duration per resident per day were higher for somatic care than for psycho-geriatric care. CONCLUSIONS: The introduction of integrated nursing home care affects the total average duration and frequency of direct care activities. However, there is no noticeable impact on individual activities or on differences in activities received by somatic and psycho-geriatric residents and the degree to which the occurrence of an activity is related to the duration of that activity. This is because a large proportion of care delivery represents patterned behaviour (routines). Because existing routines are difficult to get rid of, we should not have too high expectations about the effect of integrated care on service delivery.

Nursing home care: whodunit?

AIMS AND OBJECTIVES: (1) To analyse and compare (changes and differences in) activity profiles of various types of nursing home care. (2) To assess the impact of integrated care on these activity profiles. BACKGROUND: Because of an ongoing introduction of integrated nursing home care, caregivers increasingly have to co-ordinate their activities, engage into interprofessional relationships and take over each other's tasks. Consequently, activity profiles [i.e. combinations of (contributions to) care activities and the roles that perform them] are expected to change. DESIGN/METHODS: At three measurement points in the period 1999-2003, caregivers (in 18 different roles) recorded and listed direct and indirect care activities. A total of 41,335 lists were analysed to derive activity profiles of traditional, transitional and integrated nursing home care in the Netherlands. RESULTS: Traditional, transitional and integrated care shared some comparable activity profiles. Integrated care differed from the other types with respect to the contribution of the geriatric nurse, recreational activities supervisor, nutrition assistant, household assistant and nursing assistant to activities such as extra care, handling food and club activities. Contrary to the other roles, the licensed practical nurse contributed to (almost) all activities in all types of care. CONCLUSIONS: Nursing home care has several recurring activity profiles. These profiles are the same in all types of nursing home care. The introduction of integrated care implies that particular profiles have to be added to these profiles. As a generalist, the licensed practical nurse seems to play a key role in all activity profiles. RELEVANCE TO CLINICAL PRACTICE: Because of demographic and financial pressures, integrated care for older people becomes increasingly important. By addressing the impact of integrated care on activity profiles, this paper provides information on how new types of care can be delivered in the most effective manner.