A pragmatic approach for implementation of value-based healthcare in Amsterdam UMC, the Netherlands

Worldwide, healthcare systems face the challenge of increasing costs [1]. In 2006, Porter and Teisberg introduced the principles of Value-Based Health Care (VBHC). These principles are intended to reduce costs in healthcare, while at the same time increasing the quality of healthcare by increasing the value for patients [2]. In 2013, Porter and Lee presented a strategic vision to implement VBHC. This vision includes identifying disease specific patient groups and developing a multidisciplinary team that is focused on patient centred care for this group [3‐5]. Measuring clinical and patient reported outcomes (PROs) is an essential element in this VBHC process. To standardize outcome measurement within specific patient groups, the International Consortium for Health Outcome Measurement (ICHOM) develops standard minimum sets of patient reported outcome measures (PROMs). The aim of monitoring outcomes is to improve the value of healthcare by enabling comparison of these outcomes at the levels of the individual patient and patient groups [6‐8]. Analysis of these data enables healthcare professionals to validate choices, guide improvements, learn from colleagues or other hospitals, and to motivate themselves or the team to collaborate or make changes. Ultimately, optimization of care for disease specific patient groups with regard to the quality of care and cost reduction is strived for to ensure that society is provided with affordable and accessible care [9].

Despite the overwhelming popularity of VBHC, there is also ambiguity about the interpretation and operationalization of the VBHC concept [10‐12]. Steinmann et al. showed that the very meaning of VBHC is subject to interpretation. Their research revealed different perceptions regarding VBHC, ranging from the conviction that VBHC is a toolkit to incentivize providers to the assumption that VBHC is ‘a dogma of manufacturability’. The use of PROMs and comparison of outcomes both regularly meet with resistance and scepticism from clinicians [13‐15].

In the Dutch Healthcare system, (basic) medical insurance is compulsory for all citizens and care is delivered by private and public health care providers, who have agreements with health insurance companies. There are 69 hospital organisations in the Netherlands, including 8 university medical centres. Amsterdam University Medical Centre (Amsterdam UMC) is a major academic hospital, with two locations and 15,000 employees in total. The board of directors is responsible for its management and strategy, which is carried out in a line organisation, comprising 10 divisions and several staff services divided over two locations; the Amsterdam Medical Centre (AMC) and VU University medical centre (VUmc). Enhancing patient value by delivering personalized care throughout the full cycle of care is one of the main strategic pillars of the Amsterdam UMC strategy.

The experiences and lessons learned of multiple teams have resulted in this pragmatic and iterative approach that includes five phases as shown in Fig. 2. All value teams follow the same steps, tailored to the dynamics and needs of their patient group. This provided a solid foundation for the start of the implementation of VBHC in Amsterdam UMC.

A detailed description of the approach, divided into phases with their goals, tasks and tools, is specified in Table 2. By illustrating two cases (CLP/CKD) of the value teams and the performed activities and deliverables during VBHC implementation, we provide insight into how this approach developed. Both cases have largely followed the same steps. A detailed description including activities, deliverables, facilitators and challenges during the implementation of our approach is provided in Additional file 1, where the main differences are highlighted. The following described preconditions and key points are based on the experiences of our pilot cases (Additional file 1).

Lastly, resources need to be available both from the support services and the healthcare department itself. In addition, departments’ willingness to implement changes in their work process need to be present. These are important parts to ensure organisational readiness [17]. When these preconditions are met, the step-by-step approach can be applied.

A team can indicate that they wish to start with VBHC via an intake form. When the steering committee approves this intake, by matching their goals and mutual expectations with regard to motivation, the team starts. In this approach, each phase has its own goal and key points with associated activities and stakeholders (see Fig. 2 and Table 1). First key point, to complete the preparation phase, the value team including patient representatives, must be formed to start the design sessions. In the design phase, the value team works together in several sessions, together with PROM-experts they select an outcome set and jointly establish short and long-term goals and actions for their VBHC implementation, appropriated to the needs of the patient group. A subsequently key point; the team makes a plan on how to use the outcome set in the clinical care process. In addition, in this phase, time is also made for what the team needs, such as the attention to teambuilding in the CKD team.

When the building phase starts depends on the capacity of data-IT experts. Therefore, the duration of this phase can vary between teams. After the design sessions, the proactive multidisciplinary value team immediately starts working on a regular basis with the defined actions and already available outcomes, for example the PREMs (patient-reported experience measures) or process outcomes. This was not yet applied during the pilot phase, but was taken into account as a lesson learned for further deployment of this VBHC approach, thus also in the CKD team.

As soon as the clinical and patient-reported outcomes are built in the EHR-system, the implementation phase starts after training the healthcare professionals to apply it in practice. To accomplish the building phase, the registration of the outcome set is embedded in the care process and the IT department delivers a dashboard for the value team where the outcomes are visualised.

The final two phases, implementation and continuous improvement, regularly overlap each other. The implementation of various elements of VBHC are incorporated in the care process of the specific patient group. As part of this, the healthcare professionals receive training for shared-decision making in the consultation room and the value team monitors regularly the outcomes together. Feedback is taken into account during the implementation again.

We have experienced that several defining features of the development and implementation of this approach may have contributed to its completeness and applicability. These were categorized into five elements, which will be discussed below; organisational readiness, clinical leadership, experience-based co-design (EBCD), role of expert team and monitoring outcomes. All elements are important on their own, but for a successful VBCH approach, their combination has proved essential.

Organisational readiness is a shared psychological state in which organisational members feel committed to implementing an organisational change and confident in their collective abilities to do so [17]. Within our VBHC approach, the importance of this concept became apparent as “organisational readiness” developed only over time, which manifested in later teams progressing more efficiently than the earlier teams. The lack of organisational readiness at the start of the VBHC approach in Amsterdam UMC was partly due to the bottom-up approach by conducting a pilot among enthusiastic pioneer value teams. This implied that there was team readiness, but organisational readiness was still deficient, resulting in a lack of capacity for data/IT support on the organisation level. In our cases, the dynamics in our organisation (e.g. merger) was a challenging factor which also effected and delayed the organisational readiness. Therefore, we recommend for future implementation to have sufficient support from the Board of Directors and line organisation of the VBHC program before starting, to embed the program well in the organisation [39]. Capacity for data/IT support must be prioritised by them and the supporting departments in advance, to accomplish the building phase, otherwise the implementation process will be delayed significantly which in turn causes demotivation of the team.

As stated before, to implement VBHC in a “traditionally organised” hospital, fundamental changes in daily practice are needed which require clinical leadership. Within this approach, the clinical lead, who heads the value team, serves as the primary clinical leader. Several factors were found to contribute to the success of this role. First, the leader needs to have the skills to bring about change, which include enthusiasm, good advocacy skills, effective communication and creating ownership together with the team. Second, a clinical lead with mandate and authority is needed, endorsed by the clinical team and their departments [40]. Our advice, therefore, is to provide an enthusiastic clinical leader with authority as a driving force on behalf of the multidisciplinary team. This clinical leader should be a healthcare professional with sufficient time, motivation, mandate and resources to support this process and to ensure that the ideology and ownership is carried through the department.

Experience-based co-design has, as mentioned earlier, a user-centred orientation in combination with collaborative change [30]. We did not include all eight stages of experience-based co-design, but extracted the most important ones that fitted our goal and approach [34]. The fact that with the same approach, different solutions, actions and outcomes have been formulated for different value teams, shows that the approach is a useful blueprint for a variety of different multidisciplinary healthcare teams, i.e. patient populations and stages of transformation. Diverse strategies evolved due to the distinct experiences of the stakeholders involved, including the patient representatives. It also became clear that each patient group has its own wishes and needs, which could be taken into account by using this co-design. These involved stakeholders are necessary during the redesign of the care process [39].

The expert team played a central role in our approach. They ensured connection between value teams, the supporting and facilitating departments (data/IT, communication, etc.) and the steering committee. The involvement and level of guidance of the value teams varied in our cases. We have learned that the autonomy of value teams had a positive impact on ownership by the team to ultimately ensure improvement in quality of care. When getting started with VBHC, make sure the value team is not pampered by central support. This may prevent lack of capacity and ownership. When scaling up and implement VBHC, the value team must take ownership for itself. Thus, the role of the expert team is to pay attention to ownership from the start and help the healthcare teams do the implementation themselves in which the consultants are primarily involved as experts rather than executors. To ensure knowledge sharing and sustainable employability of the experts, the expert team initiated a PROM expertise point within Amsterdam UMC and developed a VBHC toolbox. With the toolbox the value teams can get started themselves by choosing a focusing element for their start with the implementation VBHC, so that it becomes a little more manageable.

Lastly, it is important during implementation to monitor progress towards implementation goals [41]. Our experiences in the CKD and CLP value teams showed that getting straight to work with existing available outcomes was a facilitator for team motivation and subsequent steps towards implementation. As an example, in addition to long-term outcomes (e.g. 5-year survival), they formulated also short-term outcomes (e.g. surgical complications, visits emergency department) and used existing PREMs. The team defined improvement goals for these outcomes and monitored the goals. In addition, it will also be beneficial in the future if the hospital opts for one integrated system for the case mix, clinical and patient reported outcomes. Preferably linked to the hospital’s own EHR, so that the building phase can proceed quickly and the results can be collected and monitored in an unambiguous form.

Value-based healthcare was introduced in Amsterdam UMC in 2017. In this article, we describe a pragmatic approach for the implementation of VBHC among value teams in Amsterdam UMC. At present, 14 value teams are working on improving the quality of care for their patient groups by using this approach.

The approach described here serves as a first step for the implementation of VBHC, knowing that it only incorporates a number of key principles from Porter’s strategy [2]. We have chosen to simplify this originally complex process in our approach. At this point one can say the approach entails mainly a strategy for Patient Centred Care (PCC), as it lacks measurement of costs, which is an essential principle of VBHC [4, 5, 42]. At this moment, we mainly focus on improving the care process based on wishes and needs of the patients and on using outcomes at individual level in the consultation room including shared decision making, which both require culture and behavioural change [19]. This focus is a good starting point for future research into the effect of these outcomes (on an individual and population level) on quality improvement and ultimately the costs.

Strength of the present study includes the applied and tested approach which was developed over four pilot cases and refined during ten subsequent cases. As far as we know, we are the first who describe a detailed VBHC implementation with a learning approach based on evolving insight. Some limitations also need to be mentioned. First, team members of the VBHC expert team and two clinical leads were involved in development of the approach and writing process of this manuscript which may have limited the objectivity of our observations. However, this engagement also ensures valuable reflection. The impact of this close involvement of the clinical leads has been reduced by assessing the approach in iterative sessions with a wider delegation of stakeholders. Second, this approach, with associated expert team and infrastructure, will possibly not be applicable in every hospital, which reduces its potential for scalability. In addition, implementation often took a long time and therefore the effects of the outcomes and the activities of our approach are only visible at a later stage, but our advice to start immediately with the available outcomes will ensure an early start of the improvement cycle.

In conclusion, this approach has provided a good starting point for implementation of VBHC in a tertiary hospital. The approach evolved over time, while simultaneously the implementation process improved. This blueprint provides guidance for the implementation of VBHC in daily practice, to ultimately ensure care that is of personal and measurable value for the individual patient. So far the focus of the implementation in Amsterdam UMC has been gaining insight in the clinical-, process- and patient reported outcomes. The description of this pragmatic approach intended to serve as an inspiration for others who want to start implementing VBHC. In the future, this approach and the implementation of VBHC on an individual and population level will be evaluated, in order to ultimately improve the quality of care in our hospital and nationally.