Axel Wolf, Annette Erichsen Andersson, Ewa Wikström and Fredrik Bååthe
Value-based health care (VBHC) argues that health-care needs to re-focus to maximise value creation, defining value as the quota when dividing the outcomes important for the…
Abstract
Purpose
Value-based health care (VBHC) argues that health-care needs to re-focus to maximise value creation, defining value as the quota when dividing the outcomes important for the patient, by the cost for health care to deliver such outcomes. This study aims to explore the perception of value among different stakeholders involved in the process of implementing VBHC at a Swedish hospital to support leaders to be more efficient and effective when developing health care.
Design/methodology/approach
Participants comprised 19 clinicians and non-clinicians involved in the implementation of VBHC. Semi-structured interviews were conducted and content analysis was performed.
Findings
The clinicians described value as a dynamic concept, dependent on the patient and the clinical setting, stating that improving outcomes was more important than containing costs. The value for non-clinicians appeared more driven by the interplay between the outcome and the cost. Non-clinicians related VBHC to a strategic framework for governance or for monitoring different continuous improvement processes, while clinicians appreciated VBHC, as they perceived its introduction as an opportunity to focus more on outcomes for patients and less on cost containment.
Originality/value
There is variation in how clinicians and non-clinicians perceive the key concept of value when implementing VBHC. Clinicians focus on increasing treatment efficacy and improving medical outcomes but have a limited focus on cost and what patients consider most valuable. If the concept of value is defined primarily by clinicians’ own assumptions, there is a clear risk that the foundational premise of VBHC, to understand what outcomes patients value in their specific situation in relation to the cost to produce such outcome, will fail. Health-care leaders need to ensure that patients and the non-clinicians’ perception of value, is integrated with the clinical perception, if VBHC is to deliver on its promise.
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Fredrik Bååthe, Mia von Knorring and Karin Isaksson-Rø
This study aims to deepen the understanding of how top managers reason about handling the relationships between quality of patient care, economy and professionals’ engagement.
Abstract
Purpose
This study aims to deepen the understanding of how top managers reason about handling the relationships between quality of patient care, economy and professionals’ engagement.
Design/methodology/approach
Qualitative design. Individual in-depth interviews with all members of the executive management team at an emergency hospital in Norway were analysed using reflexive thematic method.
Findings
The top managers had the intention to balance between quality of patient care, economy and professionals’ engagement. This became increasingly difficult in times of high internal or external pressures. Then top management acted as if economy was the most important focus.
Practical implications
For health-care top managers to lead the pursuit towards increased sustainability in health care, there is a need to balance between quality of patient care, economy and professionals’ engagement. This study shows that this balancing act is not an anomaly top-managers can eradicate. Instead, they need to recognize, accept and deliberately act with that in mind, which can create virtuous development spirals where managers and health-professional communicate and collaborate, benefitting quality of patient care, economy and professionals’ engagement. However, this study builds on a limited number of participants. More research is needed.
Originality/value
Sustainable health care needs to balance quality of patient care and economy while at the same time ensure professionals’ engagement. Even though this is a central leadership task for managers at all levels, there is limited knowledge about how top managers reason about this.
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Kerstin Nilsson, Fredrik Bååthe, Annette Erichsen Andersson and Mette Sandoff
The aim of this study has been to explore learning experiences from the two first years of the implementation of value-based healthcare (VBHC) at a large Swedish University…
Abstract
Purpose
The aim of this study has been to explore learning experiences from the two first years of the implementation of value-based healthcare (VBHC) at a large Swedish University Hospital.
Design/methodology/approach
An explorative design was used in this study. Individual open-ended interviews were carried out with 19 members from four teams implementing VBHC. Qualitative analysis was used to analyse the verbatim transcripts of the interviews.
Findings
Three main themes pinpointing learning experiences emerged through the analysis: resource allocation to support implementation, anchoring to create engagement and dedicated, development-oriented leadership with power of decision. Resource allocation included the need to set aside time and administrative resources and also the need to adjust essential IT-systems. The work of anchoring to create engagement involved both patients and staff and was found to be a never-ending task calling for deep commitment. The hospital top management’s explicit decision to implement VBHC facilitated the implementation process, but the team leaders’ lack of explicit management mandate was experienced as obstructing the process. The development process contributed not only to single-loop learning but also to double-loop learning.
Originality/value
Learning experiences drawn from implementing VBHC have not been studied before, and thus the results of this study could be of importance to managers and administrators wanting to implement this concept in their respective organizations.
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Kerstin Nilsson, Fredrik Bååthe, Annette Erichsen Andersson and Mette Sandoff
This study explores four pilot teams’ experiences of improvements resulting from the implementation of value-based healthcare (VBHC) at a Swedish University Hospital. The aim of…
Abstract
Purpose
This study explores four pilot teams’ experiences of improvements resulting from the implementation of value-based healthcare (VBHC) at a Swedish University Hospital. The aim of this study is to gain a deeper understanding of VBHC when used as a management strategy to improve patients’ health outcomes.
Design/methodology/approach
An exploratory design was used and qualitative interviews were undertaken with 20 team members three times each, during a period of two years. The content of the interviews was qualitatively analysed.
Findings
VBHC worked as a trigger for initiating improvements related to processes, measurements and patients’ health outcomes. An example of improvements related to patients’ health outcomes was solving the problem of patients’ nausea. Improvement related to processes was developing care planning and increasing the number of contact nurses. Improvement related to measurements was increasing coverage ratio in the National Quality Registers used, and the development of a new coding system for measurements. VBHC contributed a structure for measurement and for identification of the need for improvements, but this structure on its own was not enough. To implement and sustain improvements, it is important to establish awareness of the need for improvements and to motivate changes not just among managers and clinical leaders directly involved in VBHC projects but also engage all other staff providing care.
Originality/value
This study shows that although the VBHC management strategy may serve as an initiator for improvements, it is not enough for the sustainable implementation of improvement initiatives. Regardless of strategy, managers and clinical leaders need to develop increased competence in change management.
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Fredrik Bååthe, Gunnar Ahlborg Jr, Lars Edgren, Annica Lagström and Kerstin Nilsson
The purpose of this paper is to uncover paradoxes emerging from physicians’ experiences of a patient-centered and team-based ward round, in an internal medicine department.
Abstract
Purpose
The purpose of this paper is to uncover paradoxes emerging from physicians’ experiences of a patient-centered and team-based ward round, in an internal medicine department.
Design/methodology/approach
Abductive reasoning relates empirical material to complex responsive processes theory in a dialectical process to further understandings.
Findings
This paper found the response from physicians, to a patient-centered and team-based ward round, related to whether the new demands challenged or confirmed individual physician’s professional identity. Two empirically divergent perspectives on enacting the role of physician during ward round emerged: We-perspective and I-perspective, based on where the physician’s professional identity was centered. Physicians with more of an I-perspective experienced challenges with the new round, while physicians with more of a We-perspective experienced alignment with their professional identity and embraced the new round. When identity is challenged, anxiety is aroused, and if anxiety is not catered to, then resistance is likely to follow and changes are likely to be hampered.
Practical implications
For change processes affecting physicians’ professional identity, it is important for managers and change leaders to acknowledge paradox and find a balance between new knowledge that needs to be learnt and who the physician is becoming in this new procedure.
Originality/value
This paper provides increased understanding about how physicians’ professional identity is interacting with a patient-centered ward round. It adds to the knowledge about developing health care in line with recent societal requests and with sustainable physician engagement.
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Fredrik Bååthe and Lars Erik Norbäck
To improve health‐care delivery from within, managers need to engage physicians in organisational development work. Physicians and managers have different mindsets/professional…
Abstract
Purpose
To improve health‐care delivery from within, managers need to engage physicians in organisational development work. Physicians and managers have different mindsets/professional identities which hinder effective communication. The aim of this paper is to explore how managers can transform this situation.
Design/methodology/approach
The authors' interview study reveals physicians' own perspective on engagement for organisational improvement. They discuss identities from three theoretical perspectives and explore the mindsets of physicians and managers. They also explore the need to modify professional identities and how this can be achieved.
Findings
If managers want physicians to engage in improvements, they must learn to understand and appreciate physician identity. This might challenge managers' identity. The paper shows how managers – primarily in a Swedish context – could act to facilitate physician engagement. This in turn might challenge physician identity.
Research limitations/implications
Studies from the western world show a coherent picture of professional identities, despite structural differences in national health‐care systems. The paper argues, therefore, that the results can be relevant to many other health‐care systems and settings.
Originality/value
The paper provides an alternative to the prevailing managerial control perspective. The alternative is simple, yet complex and challenging, and as the authors understand it, necessary for health care to evolve, from within.
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Jacinta Nzinga, Gerry McGivern and Mike English
The purpose of this paper is to explore the way “hybrid” clinical managers in Kenyan public hospitals interpret and enact hybrid clinical managerial roles in complex healthcare…
Abstract
Purpose
The purpose of this paper is to explore the way “hybrid” clinical managers in Kenyan public hospitals interpret and enact hybrid clinical managerial roles in complex healthcare settings affected by professional, managerial and practical norms.
Design/methodology/approach
The authors conducted a case study of two Kenyan district hospitals, involving repeated interviews with eight mid-level clinical managers complemented by interviews with 51 frontline workers and 6 senior managers, and 480 h of ethnographic field observations. The authors analysed and theorised data by combining inductive and deductive approaches in an iterative cycle.
Findings
Kenyan hybrid clinical managers were unprepared for managerial roles and mostly reluctant to do them. Therefore, hybrids’ understandings and enactment of their roles was determined by strong professional norms, official hospital management norms (perceived to be dysfunctional and unsupportive) and local practical norms developed in response to this context. To navigate the tensions between managerial and clinical roles in the absence of management skills and effective structures, hybrids drew meaning from clinical roles, navigating tensions using prevailing routines and unofficial practical norms.
Practical implications
Understanding hybrids’ interpretation and enactment of their roles is shaped by context and social norms and this is vital in determining the future development of health system’s leadership and governance. Thus, healthcare reforms or efforts aimed towards increasing compliance of public servants have little influence on behaviour of key actors because they fail to address or acknowledge the norms affecting behaviours in practice. The authors suggest that a key skill for clinical managers in managers in low- and middle-income country (LMIC) is learning how to read, navigate and when opportune use local practical norms to improve service delivery when possible and to help them operate in these new roles.
Originality/value
The authors believe that this paper is the first to empirically examine and discuss hybrid clinical healthcare in the LMICs context. The authors make a novel theoretical contribution by describing the important role of practical norms in LMIC healthcare contexts, alongside managerial and professional norms, and ways in which these provide hybrids with considerable agency which has not been previously discussed in the relevant literature.