Background
Value-based healthcare (VBHC), as a concept, has in recent years become established in Swedish healthcare organizations, in particular in hospitals [
1]. In this study we explore how the representatives of four project teams experienced implementing VBHC at a large university hospital in their respective patient groups. The ideas behind VBHC were introduced by Porter and Teisberg in 2006. They built their framework, concept and practice on earlier management theories concerning competition and business strategy [
2]. VBHC is based on three principles: creating value for the patients; basing the organization of medical practice on medical conditions and care cycles; and the measurement of medical outcomes and costs [
2‐
6]. Even though these articles [
2‐
6] are widely spread over the world, it has been questioned whether the original description of them fits the concept of VBHC as it is commonly understood today [
7]. However in another empirical study about understanding VBHC it was found that participants understood the different parts of the concept but did not focus on all of them. Most of all they focused measuring medical outcome [
1].
Porter and Lee suggested that creating value for patients and achieving success in implementing VBHC requires dedicated physicians and care providers within the organization [
5]. They also suggested a set of independent steps to implement VBHC within the organization. The first step is to establish the common, indisputable goal of improving value for the patients. Value is defined as health outcomes attained per ‘dollar’ expended. They argued for a strategic agenda. The main component in this agenda is organizing care delivery into integrated practice units, which means organizing care around the patient’s medical condition instead of providing care in specialized departments. A further component is measuring outcomes of importance to the patients and their cost and comparing these results with others inside and outside the organization. They also suggested moving towards a bundled payment system; creating an integrated care delivery system; creating a geographically built up and excellent specialist health service; and investing in information technology platforms [
5].
The Swedish payment system for healthcare differs from that suggested for VBHC, even though investigations and attempts to introduce bundle payment have been initiated [
8]. Therefore, in this study, we do not focus on research concerning bundle payment systems in the overview of the literature. Apart from articles written by Porter and his colleagues about principles and strategies concerning VBHC, an increasing amount of discussion papers and some case studies have been published [
9‐
14]. In one study using value-based management strategies for 4 years to improve care by employing best practice resulted in a reduction in readmissions, complications, and mortality, not to mention saving money [
15]. In another study, an estimation of the value of care was made by assessing the impact of the harmonized implementation of processes throughout the period of surgical care instead of assessing just isolated outcomes. The researcher found improved outcomes and that the care delivered was more effective and thus of greater value [
16].
In a longitudinal cross‐case comparison of implementing different management innovations in Swedish healthcare organizations [
17] it was found that management ideas were adapted and developed gradually. Furthermore, support from senior management was necessary to monitor the type of innovation they were hoping to introduce although senior management should not be involved in its actual implementation [
17]. A literature review [
18] about investigation drivers and the challenges involved in implementing quality initiatives pointed out the importance of management, extended education in the new improvement before implementation, and a systematic implementation approach in order to succeed. According to Hellström and colleagues, implementing management innovation also needs to focus on which role the internal agents of change should have and their professional competence [
19]. One example of management innovations in healthcare is process-oriented strategies. Conflicts over organizing principles and structures have been found to form obstacles to implementing process orientation [
20]. When implementing process-oriented management strategies it has been found important to clarify process managers’ responsibility and work content [
21]. Furthermore it was important to emphasize process managers’ basic requirements in order to do a good job [
22].
There are differences between the Swedish healthcare system and systems in other countries, for example concerning effectivity [
23,
24]. Thus, it is important to study how staff experience the process of implementing VBHC as described in Porter and Teisberg’s (2006) work ‘Redefining Health Care – Creating Value-Based Competition’. No studies of representatives of project teams’ experiences of implementing VBHC have been published to our knowledge up to date. This study aims to contribute to filling that gap.
Method
Aim
This study explores how the representatives of four pilot project teams experienced implementing VBHC over a period of 2 years in four different groups of patients at a large Swedish University Hospital.
Design
An explorative and qualitative design was chosen in this study in order to understand participants’ experiences better with regard to implementing VBHC. Such a design is appropriate when little is known about a phenomenon [
25].
Setting
The starting point for the implementation of VBHC at the Swedish University Hospital in question was in October 2013 after that the hospital management team had decided to implement VBHC. This hospital, with about 2,000 beds distributed between 130 inpatient wards, provides highly specialized care and treatment to both children and adults. In 2013, the hospital provided healthcare in 107,000 inpatient care episodes, and in 180 outpatient wards with 1.2 million visits. The hospital employs about 16,700 employees. The implementation process started with four pilot projects for four different diagnostic groups. Each pilot project created a project team consisting of participants with different professional qualifications. Patient representatives were not invited to all of these team meetings, but were invited to participate now and then. The concept of VBHC was introduced by the hospital management team together with consultants from a consulting agency. The hospital management team had decided to engage external consultants to support the pilot teams and jump start the process to show fast progress. During the first 3 months, the consultants continued to support the project teams with procedural experience and knowledge. The process of implementation was expected to adhere to the following steps: mapping the group of patients; defining outcome measurements, and the process of measuring; collecting and analyzing data; developing and implementing improvement initiatives; and striving towards a continuous value-based work method. The defined outcome measurements were then listed on a scorecard, where each outcome was noted frequently, and thereby the outcomes could be followed and analyzed. Based on the analysis improvements could thereafter be undertaken.
Participants
The members in respective team were appointed at department level. Each team consisted of five persons and they were all invited to participate in the study. One participant in each team had the managerial function of head of department. Participants’ profession and their function in the organization are presented in Table
1. Each team was composed differently, but every team had at least one healthcare developer, at least two physicians and one head of department (also a physician).
Table 1
Professionals represented in the teams and their function
Senior Consultants (physicians) | 9 |
Registered Nurses | 3 |
Master’s Degree in Business Administration | 3 |
Master of Engineering Degree | 2 |
Psychologists | 2 |
Occupational Therapist | 1 |
Function |
Head of department | 4 |
Healthcare developers | 6 |
Working in different health professions | 5 |
Controllers | 3 |
Logistics | 2 |
From the start, three of the pilot project teams had a physician leading the team and one team had a psychologist as team-leader. Due to employee turnover there is some small variation in age in each interview set. One participant did not want to participate at the third interview due to being too recently recruited and not yet involved in VBHC (see Table
2).
Table 2
Gender and age on each interview occasion
Women | 9 | 9 | 9 |
Men | 11 | 11 | 10a
|
Mean age | 47 (37–62) | 47,3 (35–62)b
| 46,5 (34–62) |
Data collection
With permissions from the hospital management team and the medical director responsible for implementing VBHC at the hospital, each participant in the pilot project teams was contacted by telephone asking if he/she wished to participate. All 20 of those asked agreed. Thereafter they were informed about the study and that participation was at all times voluntary. This information was in writing but was repeated orally at the interview before it was started. A digital voice recorder was used for all 59 interviews and all were accomplished in a separate room at the participants’ workplace except one, which was carried out at a participant’s home (for the participant’s personal reasons). The first data collection period was set from March to April 2014, the second from November 2014 to January 2015 and the last was carried out between September and November 2015. The first interview varied between 37 and 64 min (mean 47), the second between 17 and 49 min (mean 31) and the third between 19 and 59 min (mean 33). All the interviews were transcribed verbatim by a secretary experienced in transcribing interviews.
Data analysis
A tentative analysis was carried out directly after collecting each interview set. This was done to capture the main content in the interviews to give the participants the opportunity to provide feedback. This analysis also provides a written overview for use in subsequent interviews where the team could explore some questions in more depth. This first tentative analysis was guided by qualitative analysis [
26] and it started with reading the interviews to gain a holistic picture of the material. The interviews were imported one after another into NVIVO 10 (software for qualitative analysis QSR International Pty Ltd) and that programme was then used for the further analysis. Based on the study aim, the interviews were read to capture meaning units, i.e., words and sentences that belonged together in terms of content. These meaning units were then condensed and labelled with a code. The next step in the analysis was to group the codes with their additional meaning units having similar content and to give these groups preliminary headings. This process was repeated for each data set. When all the interviews were analyzed up to this point, a thematic coding process followed where code groups from all three data sets were compared for similarities and differences. A phase of abstraction then followed. A comprehensive and interpretative analysis of the content continued by addressing questions to the material, whereby groups were reduced in number and expanded in content finally to form three themes with additional subthemes. The quotations are used in the results to illustrate the content in the themes and are marked with an identification code.
Discussion
Creating value
for the patients is, according to Porter and colleagues, the overall goal when working with the concept of VBHC [
2‐
6]. Most of all, participants associated the implementation of VBHC with value for the patients and a focus on how to measure health outcomes. This emphasis on value for the patients is confirmed in other studies [
1,
7] and may be understood as health professionals’ intrinsic motivation [
27] to use their competence to care for, cure and relieve suffering for the patients. Participants’ positive response towards creating value for the patient may also be explained and understood in relation to NPM (New Public Management). NPM is a management model that has for more than two decades been implemented in this setting. It focuses on efficiency, the internal control of financial aspects and market-like arrangements between units in the organization [
28,
29]. NPM have been criticized due to its one-sided dominance of quantified values [
30].
For whatever reason, less attention was paid by health professionals to measuring costs. Accordingly, the results mainly emphasize two of the aspects in the concept of VBHC, i.e., value for the patients, and measuring health outcomes. It is therefore debatable whether or not VBHC was really implemented or whether it was just an inspiring concept. On the other hand that is mostly a definitional debate with limited clinical impact. As it was, it reintroduced value for patients as the overarching objective for what healthcare is all about. It also reignited the health professionals’ sense of engagement, especially that of the physicians, in the continuous journey towards the further development of quality of care.
The implementation process initiated by the Hospital Director both demanded a lot of energy and simultaneously gave energy when the participants had adjusted the concept to local practice and thus experienced improved patient care. In a study concerning staff’s responses to paradoxes experienced in organizations, it was found that Human Resources staff developed a skill that enabled them to translate top-down strategic decisions to fit different local conditions; a skill that was important for implementation [
31]. In line with this, the participants in our study also seem to have been able to translate the intention of creating value for the patients to fit their previous professional understanding of what actually does constitute value for the patients. The process of implementation was not linear but more of an evolution, similar to the way described by Øvretveit and colleagues [
17]. Most participants in our study lost momentum after the three first months when they were guided by consultants, but after some rest most of them got going again on their evolutionary development work. However, in one of the pilot project teams the process was interrupted. This study does not provide any answer to why this process was interrupted.
In this study, two parallel principles were found when implementing VBHC. One was the professionals’ voice and the other was the patients’ voice. The patients’ voice was described in Mishler’s metaphor as the ‘voice of the lifeworld’ [
32]. The ‘voice of the lifeworld’ needs to be listened to not just in each encounter between physician and patient but also when managing healthcare. Participants in the project took the concept of value for the patient as their point of departure, but at the same time their professional perspective naturally permeated everything, i.e., ‘the voice of medicine’ [
32]. Their profession-based understanding of what constitutes value for the patient mostly prevailed, especially when it came to deciding outcome measurements. However, over time and much due to the VBHC emphasis on explicitly asking patients what they considered valuable and important, realization dawned that health professionals do not always know what each specific patient finds valuable.
Patient representatives had their own ideas of what constituted valuable measurements, but these measurements were almost always considered impossible to execute. Instead, measurements were frequently chosen based upon ease of access to data. Porter and Lee warned against choosing indicators just because they are easy to measure. To avoid this pitfall they recommended three tiers of measuring, all focused on patient-related outcome. The first concerns achieved or retained health status, the second concerns the process of recovery and the last concerns the sustainability of health [
5]. Each pilot project team had existing National Quality Registers for their group of patients, and these were the preferred choice and main source of data. As these registers have mainly been developed from interest in measuring medical outcome, ‘the voice of medicine’ was reinforced while ‘the voice of the lifeworld’ was weakened. Swedish National Quality Registers include aspects of disease management and some of them include patient-reported outcome measurements but to a lesser extent [
33]. It is therefore important to raise the question: are National Quality Registers sufficient for measuring health outcomes when the intention is to create value for the patient? It would probably be important to develop local care quality registers in combination with National registers as has been done for one of the groups of patients. Another way to proceed might be to continue developing the National Quality Registers and to incorporate more of ‘the voice of the lifeworld’. If the old saying ‘what gets measured gets done’ is still valid, then this deserves further attention.
Consultants’ one-sided focus on measuring health outcomes was not always advantageous as improving health outcomes also presumed that processes were being developed. Defining clinical pathways for different groups of patients is important since it reduces variation and maximizes the outcomes [
34]. The importance of developing the process of care to decrease lengths of hospital stay ensuring optimal patient experience have recently been stipulated in a study of primary hip and knee arthroplasties [
35]. The development of any process requires basic shared understanding of the process among those working with or in it. Establishing such understanding requires leadership skills such as communication and motivation to get people involved step by step in developing the process [
21]. Along with continued implementation of VBHC, the organizational culture also needs to further evolve towards a more patient-oriented way of working. This change calls for managers’ and employees’ efforts to participate in developmental work with reflections about what could be done jointly. Then new patterns of thinking and behaving can be developed in the organization [
36]. It is important for managers to understand and respect that contradictory opinions can exist at the same time in the same organization [
37] in order to facilitate the process of change.
The appreciation participants showed for the concept VBHC was not only connected to ‘value for the patient’ but was also related to the fact that they were tired of the focus on financial control that has been the main management trend for the last decades. Value for the patient was a driving force for participants but financial aspects are also of utmost importance to the concept of VBHC. As previously mentioned, value was defined as health outcomes attained per ‘dollar’ spent. An important factor behind the concept of VBHC was the need to solve the crisis of escalating costs in healthcare and therefore a new way of measuring cost was postulated in VBHC [
5,
6]. Other explanations from the interviews related to the fact that the low interest in measuring costs might have been due to the hospital’s complicated IT system. The task of collecting particular data details of costs and not only aggregated data was too much for some participants. A further explanation of participants’ lesser degree of interest in measuring costs might be related to a reaction against the focus of NPM on internal control of financial aspects [
28,
29]. However, VBHC is unlikely to become a replacement for NPM and its variants. Instead, a development towards management models with a mixture of governance according to VBHC and NPM principles might be expected [
38]. VBHC could then be seen as supplying a broader perspective.
As already mentioned, Porter and colleagues stated that healthcare should be organized on the basis of patients’ medical conditions and care cycles [
2‐
6]. That was not in focus when implementing VBHC at this hospital. From the start participants did not give this kind of issue much attention. This is understandable considering the intensive drive to show quick results regardless of the patients’ realities. However, over time and when developments became more internalized in daily work, the importance emerged of cooperation between different departments involved in the same patient journey. Some cooperation started during the study period, but additional challenges were experienced when changes involved crossing department and/or budgetary boundaries. The development of this cooperation in line with Porter’s and colleagues’ [
2‐
6] ideas requires a very attentive upper management responding fast and accurately to new challenges as they arise – potentially reorganization of hospital departments and alignment of the budget system to patient processes. The heads of departments were central figures in the initiatives identified as including cooperation between departments, and it would be interesting to follow up this cooperation in future studies.
Conclusion
An overall conclusion from this interview study was that participants appreciated the concept of VBHC by reason of its focus on value for the patients and measuring health outcomes, as opposed to previous experiences of management attention mostly measuring financial aspects of care. Working in line with VBHC was, mostly early in the process, experienced as justifying existing practices, i.e., in the best case to cure or alleviate suffering, and always to provide comfort and care. Although patient representatives were considered contributing valuable input towards finding relevant outcome measurements, their voices, i.e., ‘the voice of the lifeworld’ were weak compared to ‘the voice of medicine’. However, over time, when working in line with VBHC, participants sometimes found themselves being challenged as they needed to change their mindset about what patients’ themselves considered value.
The implementation of VBHC was not a straight linear process; the process moved forwards and backwards, sometimes with interruptions. The consultants’ support during the startup was appreciated. On the other hand, participants experienced the risk that their own future capability to manage the implementation process was diminished due to time pressure and the strict focus on outcome measurements. Only when the implementation process had proceeded, could the care process be further developed. These processes gave insights about the total complexity and the need of working together not just in participants’ own departments but also interdepartmentally, which also implied an awareness of the importance of working with care processes across boundaries. The need experienced by participants of working together with other professions and departments required a great deal of energy as breaking through organizational and administrative systems was hard. Healthcare organizations implementing management innovations such as VBHC therefore need to be aware of recognizing the intrinsic drive of healthcare practitioners, and to understand the complexity in healthcare itself as well as in the process of implementation.