Who counts when health counts? A case-study of multi-stakeholder initiative to promote value-creation in Swedish healthcare.

A European initiative to design a "medical information framework" conceptualised how multiple stakeholders join in collaborative networks to create innovations. It conveyed the ways in which value is created and captured by stakeholders. We applied those insights to analyse a multi-stakeholder initiative to promote improvement of Swedish healthcare. Our longitudinal case study covered totally fifty stakeholders involved in a national project, aiming at designing a system to support value-based evaluation and reimbursement. During the project the focus changed from reimbursement to benchmarking. Sophisticated case-mix adjusting algorithms were designed to make outcome comparisons valid and incorporated in a software platform enabling detailed analysis of eight patient groups across seven regional health authorities. Those were deliverables demonstrating value created. However, the project was unable to transfer the system into routine use in the regions, a failed value-capture. The initial success was promoted by collaborative processes in diagnosis-specific working groups of well-informed and engaged professionals. The change of focus away from reimbursement decreased the involvement among health authorities, leaving no centrally placed persons to push for implementation. It highlights the importance of health professionals as the key stakeholder, who has both the know-how instrumental to creating an innovation, and the local involvement guaranteeing its implementation.

As predicted by theory: choice and competition in a publicly funded and regulated regional health system yield improved access and cost control.

BACKGROUND: New Public Management (NPM) has been widely used to introduce competition into public healthcare. Results have been mixed, and there has been much controversy about the appropriateness of a private sector-mimicking governance model in a public service. One voice in the debate suggested that rather than discussing whether competition is "good" or "bad" the emphasis should be on exploring the conditions for a successful implementation. METHODS: We report a longitudinal case study of the introduction of patient choice and allowing private providers to enter a publicly funded market. Patients in need of hip or knee replacement surgery are allowed to choose provider, and those are paid a fixed reimbursement for the full care episode (bundled payment). Providers are financially accountable for complications. Data on number of patients, waiting lists and times, costs to the public purchaser, and complications were collected from public registries. Providers were interviewed at three points in time during a nine-year follow-up period. Time-series of the quantitative data were exhibited and the views of actors involved were explored in a thematic analysis of the interviews. RESULTS: The policy goals of improving access to care and care quality while controlling total costs were achieved in a sustained way. Six themes were identified among actors interviewed and those were consistent over time. The design of the patient choice model was accepted, although all providers were discontent with the level of reimbursement. Providers felt that quality, timeliness of service and staff satisfaction had improved. Public and private providers differed in terms of patient-mix and developed different strategies to adjust to the reimbursement system. Private providers were more active in marketing and improving operation room efficiency. All providers intensified cooperation with referring physicians. Close attention was paid to following the rules set by the purchaser. DISCUSSION AND CONCLUSIONS: The sustained cost control was an effect of bundled payment. What this study shows is that both public and private providers adhere long-term to regulations by a public purchaser that also controls entrance to the market. The compensation was fixed and led to competition on quality, as predicted by theory.

Time-driven activity-based costing for patients with multiple chronic conditions: a mixed-method study to cost care in a multidisciplinary and integrated care delivery centre at a university-affiliated tertiary teaching hospital in Stockholm, Sweden.

OBJECTIVE: This study can be applied to cost the complex non-standardised processes used to treat patients with multiple chronic conditions. DESIGN: A mixed-method approach to cost analysis, following a modified healthcare-specific version of the seven-step Time-Driven Activity-Based Costing (TDABC) approach. SETTING: A multidisciplinary integrated and person-centred care delivery centre at a university-affiliated tertiary teaching hospital in Stockholm, Sweden, designed to improve care coordination for patients with multiple chronic conditions, specifically diabetes, cardiovascular disease and kidney disease. PARTICIPANTS: 314 patients (248 men and 66 women) fit inclusion criteria. Average age was 80 years. RESULTS: This modified TDABC analysis costed outpatient care for patients with multiple chronic conditions. The approach accounted for the difficulty of conceptualising care cycles. The estimated total cost, stratified by resources, can be reviewed together with existing managerial accounting statements to inform management decisions regarding the multidisciplinary centre. CONCLUSIONS: This article demonstrates that the healthcare-specific seven-step approach to TDABC can be applied to cost care for patients with multiple chronic conditions, where pathways are not yet discernable. It became clear that there was a need for slight methodological adaptations for this particular patient group to make it possible to cost these pathways, stratified by activity and resource. The value of this approach can be discerned from the way management incorporated the results of this analysis into the development of their hospital strategy. In the absence of integrated data infrastructures that can link patients and resources across financial, clinical and process data sets, the scalability of this method will be difficult.

Ready for the Triple Aim? Perspectives on organizational readiness for implementing change from a Danish obstetrics and gynecology department.

BACKGROUND: As health care strives towards the Triple Aim of improved population health, patient experience, and reduced costs, an organization's readiness for change may be a key factor. The concept refers to the collective commitment of organizational members to a change and belief in their shared ability to make that change happen (efficacy). This study aims to assess the organizational readiness for implementing large-scale change at a clinical department in pursuit of the Triple Aim and to determine key associated factors. METHODS: A cross-sectional study at a Danish Obstetrics and Gynecology department faced with external pressure to become more efficient without compromising patient outcomes and experience. The Organisational Readiness for Implementing Change (ORIC) questionnaire was distributed to all employees (n = 403). Descriptive statistics was used to assess overall organizational readiness and single items. The between-group differences in subject characteristics were assessed with independent t-test and non-parametric test. Multiple linear regression was employed to control for potential confounders. RESULTS: Response rate was 72%. The level of agreement with the commitment statements was high, and low with the efficacy statements. We did not observe statistically significant differences in the overall score between organizational sections or in relation to gender, age, or profession. Managerial status (B = 3.2, 95% CI = .52, 5.9, P = .02) or interim employment(B = 2.7, 95% CI = .47, 4.9, P = .02) were significant predictors of a high change efficacy score after controlling for potential confounders. CONCLUSIONS: Changes related to pursuit of the Triple Aim were seen as something that "has to" be done, but left managers, and even more so staff, wondering what "to do" and "how to" do it. Change strategies should therefore address these uncertainties by translating political "have to's" proposals that resonate with staff, spark engagement, and clarify "how to" deal with the complexity of large-scale change.

Assessing the reliability and validity of the Danish version of Organizational Readiness for Implementing Change (ORIC).

BACKGROUND: Organizational change initiatives in health care frequently achieve only partial implementation success. Understanding an organizational readiness for change (ORC) may be a way to develop more effective and efficient change strategies. Denmark, like many countries, has begun a major system-wide structural reform which involves considerable changes in service delivery. Due to the lack of a validated Danish instrument, we aimed to translate and validate a Danish version of the Organizational Readiness for Implementing Change (ORIC) questionnaire. It measures if organizational members are confident in their collective commitment towards and ability (efficacy) to implement organizational change. ORIC is concise, grounded in theory, and designed, but not yet validated among employees in a real hospital setting. METHODS: The 12-item ORIC instrument was translated into Danish and back-translated to English. Employees (N = 284) at a hospital department facing a major organizational change in the Central Denmark Region completed the questionnaire. Face and content validity was ascertained. Exploratory factor analysis (EFA) and a confirmatory factor analysis (CFA) were used to assess construct validity. Reliability was assessed with Cronbach's alpha. Item response theory (Rasch analysis) was used to determine item and person reliability. RESULTS: Response rate was 72%. A two factor (commitment and efficacy), 11-item scale, of the Danish language ORIC was shown to be valid (CFI = .95, RMSEA = .067, and CMNI/DF = 2.32) and reliable (Cronbach's alpha 0.88) in a health care setting. Item response analysis confirmed acceptable person and item separation reliability. CONCLUSIONS: Our version of ORIC showed acceptable validity and reliability as an instrument for measuring readiness for implementing organizational change in a Danish-speaking health care population. For health care managers interested in evaluating their organizations and tailor change strategies, ORIC's brevity and theoretical underpinnings could make it an appealing and feasible tool to develop more successful change efforts.

Time-driven activity-based costing in health care: A systematic review of the literature.

Health care organizations around the world are investing heavily in value-based health care (VBHC), and time-driven activity-based costing (TDABC) has been suggested as the cost-component of VBHC capable of addressing costing challenges. The aim of this study is to explore why TDABC has been applied in health care, how its application reflects a seven-step method developed specifically for VBHC, and implications for the future use of TDABC. This is a systematic review following the PRISMA statement. Qualitative methods were employed to analyze data through content analyses. TDABC is applicable in health care and can help to efficiently cost processes, and thereby overcome a key challenge associated with current cost-accounting methods The method's ability to inform bundled payment reimbursement systems and to coordinate delivery across the care continuum remains to be demonstrated in the published literature, and the role of TDABC in this cost-accounting landscape is still developing. TDABC should be gradually incorporated into functional systems, while following and building upon the recommendations outlined in this review. In this way, TDABC will be better positioned to accurately capture the cost of care delivery for conditions and to control cost in the effort to create value in health care.

Money's (not) on my mind: a qualitative study of how staff and managers understand health care's triple Aim.

BACKGROUND: The "Triple Aim" - provision of a better care experience and improved population health at a lower cost - may be theoretically sound, but paradoxical in practice as it forces together the logics of management and medicine. The aim of this study was to explore how staff and managers understand the change imperative inherent to the Triple Aim and the mental models underlying their understanding. METHODS: This qualitative study builds on thirty semi-structured interviews conducted with managers, nurses, midwives, medical secretaries, and physicians at a department of Gynecology and Obstetrics in Denmark who successfully cut costs through staff and bed reductions and, from what we can ascertain, maintained care quality. Mental models were articulated from a content analysis of the interviews. RESULTS: Staff and managers identified with the different dimensions of the Triple Aim along classic professional divides, i.e. nurses and midwives focused on patient experience, physicians on health outcomes, and manager on all three. Underlying these, we found four mental models. The understanding of change was guided by a Professional ethos (inner drive to improve care) and a Socio-political discourse (external requirement to become more efficient) mental model. The understanding of economics was guided by a You-get-what-you-pay-for and by a More-bang-for-the-buck mental model. A complex interplay could be discerned between all four, which led staff to see the Triple Aim as a dilemma between quality and economics and a threat to clinical care and quality, whereas managers saw it as a paradox that invited improvement efforts. Despite these differences, managers chose a change strategy in line with staff mental models. CONCLUSIONS: The practical challenges inherent to the Triple Aim may be symptomatic of the interactions between the different mental models that guide staff and managers' understanding and choice of change strategies. Pursuit of quality improvement in the face of financial constraints (the essence of the Triple Aim) may be facilitated through conscious exploration of these empirically identified mental models. Managers might do well to translate the socio-political discourse into a change process that resonates with the mental models held by staff.

Pseudo-understanding: an analysis of the dilution of value in healthcare.

BACKGROUND: Management concepts cycle through healthcare in trends lasting 3-5 years. This may hinder policy-makers, healthcare managers, researchers and clinicians from grasping the intricacies of a management concept and prevent organisations from realising the potential of these concepts. We, therefore, sought to characterise how the newest management concept, value-based healthcare (VBHC), is used and understood in the scientific literature. METHODS: We developed a novel five-step approach: (1) identification of a trend-starting article, (2) identification of key conceptual aspects in the trend-starting article, (3) collection of citing articles and identification of citing text, (4) categorisation of citing text to evaluate which aspects were used and (5) categorisation of citing text according to the structure of observed learning outcomes (SOLO) taxonomy to evaluate understanding. RESULTS: We identified four aspects in the trend-starting article, 'What is value in healthcare', of which value and outcomes were the most cited. More than one-quarter of the citing texts demonstrated no understanding of the aspect referred to; most demonstrated a superficial understanding. Level of understanding was inversely related to journal impact factor (IF), and did not change significantly over time. A deeper understanding was demonstrated in those articles that repeatedly cited the trend-starting article. CONCLUSIONS: None of the four aspects were understood at a level required to develop the management concept of VBHC. VBHC may be undergoing a process of dilution rather than diffusion. To break the cycle of management trends, we encourage a deeper reflective process about the translation of management concepts in healthcare.

Identifying outcome-based indicators and developing a curriculum for a continuing medical education programme on rational prescribing using a modified Delphi process.

BACKGROUND: Continuing medical education (CME) is compulsory for physicians in Iran. Recent studies in Iran show that modifications of CME elements are necessary to improve the effectiveness of the educational programmes. Other studies point to an inappropriate, even irrational drug prescribing. Based on a needs assessment study regarding CME for general physicians in the East Azerbaijan province in Iran, rational prescribing practice was recognized as a high priority issue. Considering different educational methods, outcome-based education has been proposed as a suitable approach for CME. The purpose of the study was to obtain experts' consensus about appropriate educational outcomes of rational prescribing for general physicians in CME and developing curricular contents for this education. METHODS: The study consisted of two phases: The first phase was conducted using a two-round Delphi consensus process to identify the outcome-based educational indicators regarding rational prescribing for general physicians in primary care (GPs). In the second phase the agreed indicators were submitted to panels of experts for assessment and determination of content for a CME program in the field. RESULTS: Twenty one learning outcomes were identified through a modified Delphi process. The indicators were used by the panels of experts and six educational topics were determined for the CME programme and the curricular content of each was defined. The topics were 1) Principles of prescription writing, 2) Adverse drug reactions, 3) Drug interactions, 4) Injections, 5) Antibiotic therapy, and 6) Anti-inflammatory agents therapy. One of the topics was not directly related to any outcome, raising a question about the need for a discussion on constructive alignment. CONCLUSIONS: Consensus on learning outcomes was achieved and an educational guideline was designed. Before suggesting widespread use in the country the educational package should be tested in the CME context.