Developing and implementing a service charter for an integrated regional stroke service: an exploratory case study

Strokes are a common cause of premature death and disability and present a major global public health challenge [1]. They are one of the leading causes of death in the Netherlands [2]. Based on the concept of integrated care, regional stroke services have been established in the Netherlands. Integrated care is an organizational coordination process that seeks to achieve seamless and continuous care that is tailored to the patient’s needs and based on a holistic view of the patient [3]. Three phases of the integrated stroke service can be distinguished: acute care involving the emergency department and stroke unit of the regional hospital, rehabilitation involving rehabilitation centres, specialized nursing homes and home care and, finally, long-term support. Delivering optimal care with this range of providers requires a complex mix of collaboration on operational and individual levels involving streamlining information flows and the transfer of acute patients. On a tactical level, this can involve performance indicators on the care-chain level and, on the strategic level, financial and logistical agreements [4]. These interventions aim to improve patient care and medical outcomes, objectives that fit into the general goals of care integration: enhancing patient satisfaction and quality of life, efficiency and outcomes [5].

A service charter is a statement laying out the service level that patients can expect and what the organization will do if it fails to deliver [6]. Normally, it consists of four design elements one or more promises to patients; the tangible or intangible compensation in the event of service failure; the process to invoke the charter; and other charter characteristics. In our setting, a charter should transform an intangible health product into a measurable expectation for the patient prior to receiving the healthcare service. The concept of the service charter was originally developed in commercial organizations [7] and was then adopted by public services and healthcare. In the United Kingdom, the concept has been used in all NHS hospitals since 1991 in the form of the Patient’s Charter [8]. Healthcare organizations in Italy [9], the USA [10] and the Netherlands [11] have also adopted the concept. In several Dutch healthcare services, the multi-attribute specific service charter [12] is used. This consists of a number of promises covering the patient’s journey from general practitioner referral through to discharge from the hospital and follow-up arrangements. The specific goals in implementing service charters are: to increase the responsiveness of healthcare services to the wishes of patients; to make healthcare services more accountable; to ensure patients know what to expect so that they can become more equal partners in the healthcare process; to be used as a listening mechanism; to increase feedback from patients; and to improve patient satisfaction. Further, communicating a service charter is seen as a signal of patient-centeredness that could have beneficial marketing effects [13]. Following the use of service charters in commercial organizations and public services, healthcare organizations have started using the concept in order to improve patient satisfaction by improving their patient-centeredness.

Based on their extensive research of the literature on service charters, Hogreve and Gremler [14] have concluded that it is still challenging for scholars to show whether, and how, service charters are helpful in increasing service quality. The literature on the enablers of service charter implementation is dominated by citations and anecdotal evidence. Hays and Hill [15] have conducted intensive empirical research on the effects of using service charters on employees and the service development process. Thomassen et al. [16] have conducted a concept mapping study involving an integrated Delphi study on the enablers for implementing service charters within individual public sector organizations. However this article contributes by offering empirical research on operational aspects of service charter development and implementation in an integrated care setting. An extensive healthcare and management literature review has resulted in the conclusion that no empirical research has been published before on the implementation of a single service charter in a chain.

Our research focusses on both the development and implementation of a service charter. Implementation is the process of putting the service charter into use, making the service charter work in daily practice and institutionalizing it [17]. Implementing a service charter often requires a new set of behaviours, routines and ways of working that are directed at improving patients’ experiences. In our research, we focus on enablers. Enablers are those elements of processes, structures or states that are necessary antecedents for the successful development and implementation of a service charter [18]. Depending on their qualities, they can hamper or promote the effective development and implementation of a service charter [19]. Within the regional stroke service, the term effectiveness refers to the aggregated consistency, quality and appropriateness of service charter development and use [20] in achieving the two goals of the service charter: improving the patient-centeredness of the chain and increasing patient satisfaction.

It has been estimated that two-thirds of all innovation implementations in healthcare fail [21] and there is evidence of failures in the development and implementation of service charters. The literature presents several cases where service charter implementation has failed due to the absence of necessary enablers. Examples include a lack of involvement by employees and middle managers leading to an inconsequential use of service charters in daily practice [22] and the service charter becoming seen as a disciplinary device or as a criticism of the service offered [23] resulting in the charter being targeted for serious criticisms by employees [24]. Ohemeng [25] concludes that staff resistance to customer-oriented change is one of the most underestimated aspects of introducing a service charter.

We now describe the setting of our case study. This is followed by a description of the method used consisting of in-depth interviews and analysis based on Grounded Theory. Following this, we present the results of our research followed by a discussion and conclusions.

In our research, we used a case-study approach since case studies have proven their usefulness in the development of new theories [26]. We had the opportunity to carry out the research while the implementation process was ongoing, albeit approaching its end. The authors’ role was that of researcher, and they were not involved in the actual development or implementation. The case is unique in that no further cases are known in practice or in the literature where a chain of organizations has developed and implemented a service charter. Since this case is distinct from other implementations, there was no other option but to use a single case study approach. The uniqueness is the rationale for this single-case design [27].

In our research, we drew on the opinions of experienced practitioners who were responsible for the development and implementation of the service charter. We decided not to work with a sample but to involve all the members of the steering committee representing the five organizations. These members are managers working for the five organizations involved. Further, the current five members of the service charter taskforce, the chain coordinator and the head of the supporting hospital department that coordinated the patient research were interviewed. All practitioners we have invited to participate have done so. We have thus involved all the people responsible for and intensively participating in the development and implementation of the service charter in the chain and in its individual organizations. We obtained informed consent in writing from the participants to use and publish quotes as stated in their interviews on an anonymous basis. For this research no approval of a medical ethical committee was required according to the criteria of the Dutch law ‘Medical-scientific research among people (WMO)’ of December 1^st 1999.

Given that no frameworks exist for the enablers of an effective development and implementation of one single service charter for a chain, we used Grounded Theory to develop theory based on our data. This is an established exploratory qualitative method for analysing empirical data in order to build a general theory. After acquiring the commitment of the steering committee to start the research, relevant documents such as project documents and the results of the research among patients were obtained and studied. Individual interviews were held, and the respondents were assured of anonymity to encourage them to speak freely and not be influenced by others. Interviews are seen as a highly efficient way to gather rich empirical data, especially when, as in our situation, the phenomenon of interest is highly episodic and infrequent [28]. A total of twelve semi-structured interviews, each of approximately 1.5 hours were conducted by a single trained interviewer. An interview protocol was used (see Table 2) with open questions, seeking explanations of how the service charter was developed and implemented, the perceived enablers on both the organizational and chain levels, and what went well and what was problematic. Participants were encouraged to speak freely and share their opinions, successes and failures during the development and implementation. All the interviews were taped and later transcribed in detail in order to capture the full richness of the respondents’ views. For transcript analysis we used Glaser’s ‘tabula rasa approach’ for coding [29] and avoided forced coding based on preconceived frameworks. We used a substantive coding approach consisting of open, followed by selective, coding [30]. For the open coding, the interview transcripts were reviewed line-by-line by three independent researchers, and codes were placed in the margins of the transcripts. In an extensive consensus meeting, the three researchers established an agreed set of 44 codes. Following this, all the text fragments from the twelve transcripts were reorganized based on these 44 codes. To obtain an overview for each code, all the fragments linked to a code were combined in a single document. For each code, several sub-codes were then determined. Finally, the codes and sub-codes were analysed and re-analysed for emerging patterns and themes. This selective coding finally resulted in seven categories with a total of 27 properties (see Figure 1). The seven categories can be divided into three overarching themes: ‘the basic foundations’, ‘how to manage the project organization’ and ‘how to develop and implement the service charter’.

The extensive analysis based on Grounded Theory has resulted in seven categories of enablers. These categories are derived from the empirical study without using any predetermined or existing model or framework. The categories and their 27 associated properties are presented in Table 3.

As illustrated in Figure 1, the first three categories focus on the basic foundations for developing and implementing a service charter in an integrated regional stroke service. The fourth category addresses how to manage the project organization, and the final three categories address the way to develop and implement a service charter with a special focus on patients and employees. Of these seven categories, the third category ‘chain characteristics’ has a special position since it contains three properties that describe the context of the chain and which have an impact on the development and implementation but cannot be influenced during it. The seven categories will be briefly described below. These are illustrated by quotes of the participants that best describe the general opinion of the participants.

This exploratory research has resulted in a framework of enablers for the development and implementation of a service charter for an integrated stroke service. It consists of seven categories of enablers containing 27 properties. The results of our research contribute to the literature on service charters, patient-centred integrated care and the implementation of innovations.

Thomassen et al. developed a Public Service Charter Implementation Framework consisting of three main clusters and ten sub-clusters of enablers. This was the first empirical research on enablers for the effective development and implementation of a service charter that focused on individual organizations. The current research has extended the knowledge on this subject by conducting research on the development and implementation of a single service charter covering an integrated care setting. The results show that the enablers are not only related to the organizational level but that there are additional enablers on the chain level related to strategy and managerial commitment, the chemistry in the chain and the characteristics and context of the chain.

Our research has contributed to knowledge on improving patient-centeredness and patient satisfaction in an integrated care setting. Along with functional status, quality of life and costs, patient satisfaction is one of the most important outcome measures of integrated care. Nevertheless, in research on integrated care, patient satisfaction and patient centeredness have received little attention. As Howarth and Haigh [31] observe: ‘evidence of patient centrality from the service user perspective has not been satisfactorily explored’. Only a few studies have researched the effects of implementing the concept of integrated care on patient satisfaction. Rosendal et al. [32] concluded from their study that patient satisfaction increased after implementing integrated stroke care. The further optimization of integrated stroke care, in order to enhance patient satisfaction, is seen as an important field for research worldwide [33]. The use of service charters could be seen as a concept for further optimizing patient centeredness in integrated care. It is a means for improving communication with patients and the patient-centeredness of employees and processess.

The effectiveness of an implementation depends on power, culture and structure [34]. Power reflects the capacity to influence people in a desired direction. In the stroke service investigated, nobody is the ‘boss’. None of the organizations has enough power to force the others to participate fully. A consequence is that the content of the service charter is based on consensus, and the speed of development and implementation is determined by the slowest organization. Power in the chain would seem to be helpful in achieving a successful implementation.

Culture reflects the set of values, guiding beliefs, understandings and ways of thinking shared by members of the chain. The main goals of using the service charter were to increase patient-centeredness and patient satisfaction. Developing and implementing this concept and achieving its goals seemed to be smoother in those organizations that already had a dominant patient-centred culture because the charter corresponded with existing values, strategies, goals, skills and ways of working. Culture will also be reflected in the actual organizational goals of using a service charter. The alignment of goals within the chain is a core factor for effective change, a misalignment is a source of potential tension. Congruent goals among all five involved organizations are essential for an effective implementation. Although the formal goals were to increase patient-centeredness and patient satisfaction, some of the organizations had other goals such as having a service charter as a marketing tool or avoiding becoming separated from the chain through non-participation. This resulted in differences in the actual implementation of the necessary measures and in the effectiveness of using the service charter in the various organizations. Having a patient-centred culture and alignment on objectives seems to be very important when using a common service charter.

Finally, structure also has an impact on development and implementation. Implementing a service charter across five organizations forces micro-level standardization of practices within the healthcare system. Leutz [35] has described three prototypical models and phases in increasing integration: linkage, co-ordination and full integration. Based on the results of our interviews, we were able to conclude that the stroke service acts somewhere between linkage and co-ordination phases. The consistent use of a service charter is probably best achieved when embedded in a chain in the co-ordination or full integration phases. In our case, the development of the service charter was a joint operation, but its implementation was carried out independently by each organization. Due to differences in the approaches adopted, this led to some tensions in the chain. As such, it is important that there is a central approach not only in the development of the service charter but also in the implementation of the measures in order to realize and sustain the charter’s content in all the involved organizations.

Our research shows that beside power, culture and structure also mutual trust influences the effectiveness of an implementation. Trust among organizations is essential for the development and implementation of a joint service charter. Managing the integration necessary for the implementation of the service charter has been shown to be more of a process of deliberation and negotiation between organizations than one of ideology and prescription [36]. A lack of trust in this process could be a barrier and could block the necessary integration [37]. Trust can be developed by working together and jointly achieving successes. However, miscommunications as a result of prioritizing one’s own organization, a lack of communication and uncertainty can all be barriers to integration and sources of distrust [38].

Five organizations delivering health care in two of the three phases of an integrated regional stroke service have developed and implemented a service charter. Our research is based on the opinions of experienced practitioners working in these five organizations As such, the external validity of the study is limited: the framework could be improved by conducting similar studies on integrated healthcare and on chains in general. Since the goal of our research was to determine the organizational enablers, we have included experienced managers and employees. In our research we did not use the opinions of patients and their relatives. Follow up research could study the expectations and preferences of this important group on the for the patient relevant aspects of the implementation. By using qualitative research methods preferences concerning e.g. how to communicate and use a service charter could be researched. Furthermore research could be done on the actual effectiveness of service charters. Do they really contribute in improving the patient-centeredness and increasing patient satisfaction? This follow-up research could address the relationships between the enablers and actual results in terms of patient-centeredness and patient satisfaction. In a healthcare setting no research on this issue has been done till now.

This first exploratory study into the enablers of the effective development and implementation of a service charter for a chain has identified seven categories of enablers made up of 27 properties. This was based on a single case study in the Netherlands. This was the only integrated care chain using a single service charter that we could find. Nevertheless, the results of our explorative study provide an initial framework for the development and implementation of service charters in integrated care settings. This research contributes to the literature on service charters, on patient-centeredness in integrated care and on the implementation of innovations.