Toward a Theory of Organizational DNA: Routines, Principles, and Beliefs (RPBs) for Successful and Sustainable Organizational Change.

Organizational change is a key mechanism to ensure the sustainability of healthcare systems. However, healthcare organizations are persistently difficult to change, and literature is riddled with examples of failed change endeavors. In this chapter, we attempt to unravel the underlying causes for failed organizational change. We distinguish three types of change with different levels of depth that require different change approaches. Transformations are the deepest forms of change where beliefs and principles need to be modified to successfully influence routines. Renewals are deep forms of change where principles need to be modified to successfully influence routines. Improvements are shallow forms of change where only modifications at the level of routines are needed. Using deoxyribonucleic acid (DNA) as our metaphor, we propose a theory of "organizational DNA" to understand organizations and these three types of organizational changes. We posit that organizations are made up of a double helix consisting of a so-called "social string," which contains the "soft" interaction or communication among the organization's members, and a so-called "technical string," which contains "hard" organizational aspects such as structure and technology. Ladders of organizational nucleotides (i.e., Routines, Principles, and Beliefs) connect this double helix in various combinations. Together, the double helix and accompanying nucleotides make up the DNA of an organization. Without knowledge of the architecture of organizational DNA and whether a change addresses beliefs, principles, and/or routines, we believe that organizational change is constrained and based on luck rather than change management expertise. Following this metaphor, we show that organizational change fails when it attempts to change one part of the DNA (e.g., routines) in a way that renders it incompatible with the connecting components (e.g., principles and beliefs). We discuss how the theory can be applied in practice using an exemplar case.

Buffer management to solve bed-blocking in the Netherlands 2000-2010. Cooperation from an integrated care chain perspective as a key success factor for managing patient flows.

INTRODUCTION: Bed-blocking problems in hospitals reflect how difficult and complex it is to move patients smoothly through the chain of care. In the Netherlands, during the first decade of the 21st century, some hospitals attempted to tackle this problem by using an Intermediate Care Department (ICD) as a buffer for bed-blockers. However, research has shown that ICDs do not sufficiently solve the bed-blocking problem and that bed-blocking is often caused by a lack of buffer management. TOOL: Buffer management (BM) is a tool that endeavors to balance patient flow in the hospital to nursing home chain of care. RESULTS: Additional research has indicated that the absence of BM is not the result of providers' thinking that BM is unnecessary, unethical or impossible because of unpredictable patient flows. Instead, BM is hampered by a lack of cooperation between care providers. CONCLUSION: Although stakeholders recognize that cooperation is imperative, they often fail to take the actions necessary to realize cooperation. Our assumption is that this lack of willingness and ability to cooperate is the result of several impeding conditions as well as stakeholders' perceptions of these conditions and the persistence of their current routines, principles and beliefs (RPBs). DISCUSSION: We recommend simultaneously working on improving the conditions and changing stakeholders' perceptions and RPBs.

Diagnosis of sustainable collaboration in health promotion - a case study.

BACKGROUND: Collaborations are important to health promotion in addressing multi-party problems. Interest in collaborative processes in health promotion is rising, but still lacks monitoring instruments. The authors developed the DIagnosis of Sustainable Collaboration (DISC) model to enable comprehensive monitoring of public health collaboratives. The model focuses on opportunities and impediments for collaborative change, based on evidence from interorganizational collaboration, organizational behavior and planned organizational change. To illustrate and assess the DISC-model, the 2003/2004 application of the model to the Dutch whole-school health promotion collaboration is described. METHODS: The study combined quantitative research, using a cross-sectional survey, with qualitative research using the personal interview methodology and document analysis. A DISC-based survey was sent to 55 stakeholders in whole-school health promotion in one Dutch region. The survey consisted of 22 scales with 3 to 8 items. Only scales with a reliability score of 0.60 were accepted. The analysis provided for comparisons between stakeholders from education, public service and public health.The survey was followed by approaching 14 stakeholders for a semi-structured DISC-based interview. As the interviews were timed after the survey, the interviews were used to clarify unexpected and unclear outcomes of the survey as well.Additionally, a DISC-based document analysis was conducted including minutes of meetings, project descriptions and correspondence with schools and municipalities. RESULTS: Response of the survey was 77% and of the interviews 86%. Significant differences between respondents of different domains were found for the following scales: organizational characteristics scale, the change strategies, network development, project management, willingness to commit and innovative actions and adaptations. The interviews provided a more specific picture of the state of the art of the studied collaboration regarding the DISC-constructs. CONCLUSION: The DISC-model is more than just the sum of the different parameters provided in the literature on interorganizational collaboration, organization change, networking and setting-approaches. Monitoring a collaboration based on the DISC-model yields insight into windows of opportunity and current impediments for collaborative change. DISC-based monitoring is a promising strategy enabling project managers and social entrepreneurs to plan change management strategies systematically.

Comparing integrated care policy in Europe: does policy matter?

This paper addresses the interplay between integrated care policies and integrated care development in various national contexts. It is based on a secondary analysis of six country reports, written by scientists with expert knowledge on integrated care policies and practices in their respective countries. The country reports are structured according to the same descriptive framework, which includes characteristics of the national health systems, integrated care target groups and providers, coordinating mechanisms and promoting and inhibiting factors. The reports are analysed with help of a neo-institutionalist conceptual framework. This analysis indicates that a clear proactive policy by national government as well as regional and local authorities matters and that a lack of integrated care policies goes hand in hand with a weak primary care sector. However, although an active integrated care policy is necessary, it is not sufficient. It is also needed that all actors involved adequately manage dividing lines in the system and the fragmentation of services, such as lack of coordination, different professional values and interests. Although fragmentation is persistent in European health and social care systems, the endeavours to combat this problem are persistent either.

Comprehensive quality assessment of healthy school interventions.

OBJECTIVES: The number of healthy school interventions of unknown quality overwhelms schools. Quality is a construct that is differently interpreted by teachers and health promoters. The schoolBeat checklist for quality assessment of healthy school interventions incorporates the quality perceptions of both professional groups. To support quality improvements - and thus effectiveness - in school health promotion, this study evaluates the schoolBeat checklist. METHODS: Twenty-nine healthy school interventions were assessed in the Netherlands, each by two health promoters and two teachers-individually and at a consensus meeting. Generalizability coefficients were calculated for the nine specific quality criteria. RESULTS: The mean consensus score differs from the mean average individual score for two out of nine criteria. To obtain a threshold Generalizability coefficient of 0.70, the number of assessors required per criterion ranges from 1.6 to 10.8, with an average of 4.7. CONCLUSION: Quality assessment procedures of healthy school interventions using the schoolBeat checklist require about four experienced assessors from each professional domain to facilitate reliable quality scores based on individual assessment only. Publicly available quality scores enable the inclusion of high quality interventions in school policies in order to increase the impact of school health.

Why do health and social care providers co-operate?

Within Europe, although there are numerous examples of poor co-ordination in the delivery of integrated care, many providers do co-operate. We wanted to know why providers are moved to co-operate. In terms of systematic research, this is a new field; researchers have only begun to theorise about the rationales for co-operation. Practically, the issue of achieving co-operation attracts much attention from policymakers. Understanding the reasons for co-operation is a prerequisite for developing effective policy in support of integrated care. Our aim is to explore the comparative validity of different theoretical perspectives on the reasons for co-operation, to indicate directions for further study and for policy making. We used data from three successive studies to perform pattern matching with six established theoretical perspectives: transaction costs economics, strategic choice theory, resource dependence theory, learning theory, stakeholder theory and institutional theory. Insights from the studies were compared for validating purposes (triangulation). The first study concerned the evaluation of the Dutch 'National Home Health Care Programme' according to the case study methodology. The second and third studies were surveys among project directors: questionnaires were based on the concepts derived from the first study. Researchers should combine normative institutional theory, resource dependence theory and stakeholder theory into one perspective, in order to study relationship formation in health and social care. The concept of institutions (rules) is the linchpin between the theories. Policy makers must map the institutions of stakeholders and enable integrated care policy to correspond with these institutions as much as possible.

Development of a collaborative model to improve school health promotion in The Netherlands.

In recent decades, school health promotion programs have been developing into whole-school health approaches. This has been accompanied by a greater understanding among health promoters of the core-business of schools, namely education, and how health promotion objectives can be integrated into this task. Evidence of the positive impact of school health promotion on health risk behavior of students is increasing. This article focuses on the processes and initial results of developing a collaborative model tailored for whole-school health in the Netherlands, named schoolBeat. The Dutch situation is characterized by fragmentation, a variety of health and welfare groups supporting schools, and a lack of sound integrated youth policies. A literature review, observations, and stakeholder consultation provided a clear picture of the current situation in school health promotion, and factors limiting a comprehensive and needs-based approach to school health. This revealed that a health promotion team within a school is fundamental to an effective approach to tailored school health promotion. A respected member of school staff should chair this team. To strengthen the link with the school care team, the school care coordinator should be a member of both teams. To provide coordinated support to all schools in a region, participating organizations decided to share advisory tasks. These tasks are included in the regular health promotion work of their staff. This means working with one advisor representing all school-health organizations per school, and using a comprehensive overview of possible support and projects promoting health. Empowering schools in needs assessments and comprehensive school health promotion is an important element of the developed approach. This article concludes with an examination of emerging issues in evaluating collaborative school health support during the first 18 months of development, and implementation and future perspectives regarding sustainable collaboration and quality improvement.

Nurse-led shared care diabetes projects: lessons from the nurses' viewpoint.

This paper explores the experiences of four nurse practitioners specialised in diabetes care, in the development and implementation of two Dutch nurse-led shared care projects to improve quality of care. The focus is on the impeding factors involved. The nurses' views are compared to those of the 38 participating physicians by using instruments of qualitative research. Both nurses and physicians consider the way shared care delivery has been structured as the most impeding factor, particularly downward substitution of care from doctor to nurse. In the end, lessons are drawn for nurses, doctors and managers, to solve the assessed impediments to shared care.

Development of integrated care in England and the Netherlands: managing across public-private boundaries.

This paper addresses the impact of the public-private mix in the Dutch and English health and social care systems on the development and delivery of integrated care. Integrated care is conceived of as an organisational process of coordination which seeks to achieve seamless and continuous care, tailored to the patients' needs and based on a holistic view of the patient. We describe both systems' structures and characteristics from a historical perspective, which means that developments and processes within the systems are put in the spotlight. We demonstrate that the dividing- or fault-lines, such as the financial split between short-term and long-term care in the Netherlands and the divisions between health and social care as well as between the public, private and voluntary sectors in England have hindered integrated care development and delivery in both countries. Contradictory interests, differences in professional and organisational cultures, power relations, and mistrust between and within these sectors have had a clear impact on integrated care development and delivery within networks of public authorities and public and/or private providers. We explain these phenomena in terms of network theory as a basis for drawing lessons for policy makers and those developing integrated care networks.

Market competition: everybody is talking, but what do they say?. A sociological analysis of market competition in policy networks.

From providers and insurers to governments and consumers, it appears that everybody is talking about market competition in health care. However, what do they actually mean? Are they talking about the same things? These questions are relevant for health systems consisting of policy networks, such as in the Netherlands. In policy networks, different actors (besides the government) are engaged in policy-making. Based on their particular frame ('mode of interpretation'), actors proceed and, from this, give meaning to the concept of market competition. Since there are differences in frames (of reference) among the various actors, it is important to understand what market competition means from the perspective of each network participant. This study, with regard to the Dutch health care system, demonstrates 'market competition' as a broad concept, relating to 13 different frames. Only four frames (i.e. cost control, deregulation, competition and increased power) are shared by a maximum of two (out of a total of four) network participants. Clearly, there are differences in the meanings and underlying frames about market competition amongst the key players. The resulting implications and options for policy-making are discussed.

Patient focus groups about nurse-led shared care for the chronically ill.

Traditional care offered to chronically ill people does not succeed in bridging the gap between primary and secondary care in a way that suits chronic patients' needs. So-called nurse-led shared care may offer a solution, in which a specialised nurse practitioner plays a co-ordinating role at patient level. In this article two nurse-led shared care models for patients with diabetes mellitus type 2 and chronic obstructive pulmonary disease (COPD) are looked upon through the patient's eye. Joint focus groups are conducted in which patients judge the models according to their experiences and indicate the importance they attribute to quality issues. Most of them experience the shared care models as positive and prefer them compared to traditional care. The main quality aspect concerns the provision of information, although its performance needs improvement. The outcome indicates that the qualitative method of patient focus groups should become standard procedure in evaluating the shared care, supported by quantitative means.