Can an elephant crack a nut with a sledge hammer?

In this chapter we analyze the working of a Transitional Incident Prevention Program (TIPP) designed to improve the safety of patients during their transition between primary and hospital care. We systematically describe what the TIPP entails and how its elements link to the outcomes of the program achieved so far (Mayne 2010, Dixon-Woods 2011)

IT-supported skill-mix change and standardisation in integrated eyecare: lessons from two screening projects in The Netherlands

<b>Introduction:</b> Information Technology (IT) has the potential to significantly support skill-mix change and, thereby, to improve the efficiency and effectiveness of integrated care.<br><br> <b>Theory and methods:</b> IT and skill-mix change share an important precondition: the standardisation of work processes. Standardisation plays a crucial role in IT-supported skill-mix change. It is not a matter of more or less standardisation than in the ‘old’ situation, but about creating an optimal fit. We used qualitative data from our evaluation of two integrated-care projects in Dutch eyecare to identify domains where this fit is important.<br><br> <b>Results:</b> While standardisation was needed to delegate screening tasks from physicians to non-physicians, and to assure the quality of the integrated-care process as a whole, tensions arose in three domains: the performance of clinical tasks, the documentation, and the communication between professionals. Unfunctional standardisation led to dissatisfaction and distrust between the professionals involved in screening.<br><br> <b>Discussion and conclusion:</b> Although the integration seems promising, much work is needed to ensure a synergistic relationship between skill-mix change and IT. Developing IT-supported skill-mix change by means of standardisation is a matter of tailoring standardisation to fit the situation at hand, while dealing with the local constraints of available technology and organisational context

Unexpected Advantages Of Less Accurate Performance Measurements

In this paper we argue that performance measurement can better be done by general, less accurate measurements than by complex – and possible more accurate - ones. The conclusions of this study are drawn from a case study of the Dutch Foundation for effective use of medication. While most studies about performance measurements focus on the management of public service organizations, this case study - informed by the literature from Science and Technology Studies – focuses on the active role of the measurements themselves. Indicators, we show, do not have to be as complex as the practices they represent, as long as they are part of a chain of intermediary data that allow traveling from the general or simple indicators to detailed data in day-to-day practices and vice versa. Furthermore, general indicators enable stakeholders to take distance from each other. Rather than the involvement of stakeholders, it is this reflexive distancing that explains the degree of compliance to performance measurement and thereby the prospect for effective co-governance

Under careful construction:Combining findings, arguments, and values into robust health care coverage decisions

BACKGROUND: Health care coverage decisions deal with health care technology provision or reimbursement at a national level. The coverage decision report, i.e., the publicly available document giving reasons for the decision, may contain various elements: quantitative calculations like cost and clinical effectiveness analyses and formalised and non-formalised qualitative considerations. We know little about the process of combining these heterogeneous elements into robust decisions. METHODS: This study describes a model for combining different elements in coverage decisions. We build on two qualitative cases of coverage appraisals at the Dutch National Health Care Institute, for which we analysed observations at committee meetings (n = 2, with field notes taken) and the corresponding audio files (n = 3), interviews with appraisal committee members (n = 10 in seven interviews) and with Institute employees (n = 5 in three interviews), and relevant documents (n = 4). RESULTS: We conceptualise decisions as combinations of elements, specifically (quantitative) findings and (qualitative) arguments and values. Our model contains three steps: 1) identifying elements; 2) designing the combinations of elements, which entails articulating links, broadening the scope of designed combinations, and black-boxing links; and 3) testing these combinations and choosing one as the final decision. CONCLUSIONS: Based on the proposed model, we suggest actively identifying a wider variety of elements and stepping up in terms of engaging patients and the public, including facilitating appeals. Future research could explore how different actors perceive the robustness of decisions and how this relates to their perceived legitimacy

Necessity under construction-societal weighing rationality in the appraisal of health care technologies

Health care coverage decisions may employ many different considerations, which are brought together across two phases. The assessment phase examines the available scientific evidence, such as the cost-effectiveness, of the technology. The appraisal then contextualises this evidence to arrive at an (advised) coverage decision, but little is known about how this is done. In the Netherlands, the appraisal is set up to achieve a societal weighing and is the primary place where need- and solidarity-related (‘necessity’) argumentations are used. To elucidate how the Dutch appraisal committee ‘constructs necessity’, we analysed observations and recordings of two appraisal committee meetings at the National Health Care Institute, the corresponding documents (five), and interviews with committee members and policy makers (13 interviewees in 12 interviews), with attention to specific necessity argumentations. The Dutch appraisal committee constructs necessity in four phases: (1) allowing explicit criteria to steer the process; (2) allowing patient (representative) contributions to challenge the process; (3) bringing new argumentations in from outside and weaving them together; and (4) formulating recommendations to societal stakeholders. We argue that in these ways, the appraisal committee achieves societal weighing rationality, as the committee actively uses argumentations from society and embeds the decision outcome in society

The organizational dynamics enabling patient portal impacts upon organizational performance and patient health: a qualitative study of Kaiser Permanente.

BackgroundPatient portals may lead to enhanced disease management, health plan retention, changes in channel utilization, and lower environmental waste. However, despite growing research on patient portals and their effects, our understanding of the organizational dynamics that explain how effects come about is limited.MethodsThis paper uses qualitative methods to advance our understanding of the organizational dynamics that influence the impact of a patient portal on organizational performance and patient health. The study setting is Kaiser Permanente, the world's largest not-for-profit integrated delivery system, which has been using a portal for over ten years. We interviewed eighteen physician leaders and executives particularly knowledgeable about the portal to learn about how they believe the patient portal works and what organizational factors affect its workings. Our analytical framework centered on two research questions. (1) How does the patient portal impact care delivery to produce the documented effects?; and (2) What are the important organizational factors that influence the patient portal's development?ResultsWe identify five ways in which the patient portal may impact care delivery to produce reported effects. First, the portal's ability to ease access to services improves some patients' satisfaction as well as changes the way patients seek care. Second, the transparency and activation of information enable some patients to better manage their care. Third, care management may also be improved through augmented patient-physician interaction. This augmented interaction may also increase the 'stickiness' of some patients to their providers. Forth, a similar effect may be triggered by a closer connection between Kaiser Permanente and patients, which may reduce the likelihood that patients will switch health plans. Finally, the portal may induce efficiencies in physician workflow and administrative tasks, stimulating certain operational savings and deeper involvement of patients in medical decisions. Moreover, our analysis illuminated seven organizational factors of particular importance to the portal's development--and thereby ability to impact care delivery: alignment with financial incentives, synergy with existing IT infrastructure and operations, physician-led governance, inclusive decision making and knowledge sharing, regional flexibility to implementation, continuous innovation, and emphasis on patient-centered design.ConclusionsThese findings show how organizational dynamics enable the patient portal to affect care delivery by summoning organization-wide support for and use of a portal that meets patient needs

From ‘if only’ to ‘what if’:An ethnographic study into design thinking and organizational change

We aim to understand how public sector organizations practise ‘design thinking’ to respond to changing demands and develop alternative courses of action. The literature on design thinking is largely prescriptive; few studies analyse how change is actually brought about through situated design practices. Design scholars have therefore argued that such practices themselves should take centre stage as objects of analysis. We take an ethnographic approach to studying the design thinking journey of the Dutch Health Inspectorate, using participatory observations and interviews to collect our data. Drawing on the anthropological concept of ritualization, we identify two important mechanisms through which design thinking helped the Inspectorate disrupt existing organizational strategies and engage with stakeholders in a fundamentally new way.</p