Setting up the organization of the Princess Máxima Center: “Streamlining countless structures”

By | Healthcare, News

“It’s a good thing you don’t know what you’re getting yourself into, that’s a pro”, Dieneke Mandema says facetiously looking back on the last year and a half. As President of the Organization and HR, she was one of the people responsible for setting up the Princess Maxima Center.

The center, that is specialized in care, research and education in the field of pediatric oncology, opened its doors for the first time on 18 May. When Mandema took the job, there was no building, and hardly any staff or structure. Unheard of in the current market and a challenge, especially due to the staff shortages in the healthcare sector. “And what is better than being able to work on the mission to cure all kids with cancer while maintaining their quality of life?”

“We started with a blank piece of paper in November 2016. We needed new staff, nurses for example. At the same time, we didn’t have an existing company structure to fall back on. There wasn’t even a building. We were faced with the challenge of starting a center within one year and developing the foundation of the organization at the same time. We also had the opportunity to reinvent the wheel quite often thanks to the innovative character of the brand-new center and adapt it to the needs of kids and their parents”, Mandema says.

Marketing campaign to attract staff

Healthcare professionals are a rare commodity these days. To still be able to fill all positions, we deployed a so-called ‘recruitment factory’, linked to a labor market campaign. “We sold the vacancies like they were products.” The hospital played into the experience of nurses and put children at the center of the campaign. These were then brought to people’s attention via social media. It turned out to be a huge success. “When the campaign went live on Christmas Eve, we had hundreds, thousands of replies within several hours. We definitely didn’t count on that, so we all had to jump in to answer all the questions.”

‘This hospital has a unique company structure’

Hiring people is one thing but having them land in the organization is another. “The biggest groups started on 1 and 18 May. Until then, we were working for the Princess Maxima Center in five different locations. We had a construction trailer, a floor at the UMC Utrecht (Wilhelmina Children’s Hospital) and worked from an office building in Zeist”, Mandema says.

Basing the hospital’s structure entirely on an existing organization wasn’t an option, she explains. “Our basic organization is completely different. With us, the kids don’t go to the doctors, the doctors come to the kids. The entire logistical process of the hospital revolves around the child. That is unique.”

To make sure this ambitious plan wouldn’t strand in chaos, Mandema also decided to hire IG&H. “I really see them as a business partner that thinks along with us and is great at developing processes. They have a pleasant way of looking at what is necessary; they’re action-oriented, but with a human dimension. A business consultant merely making decisions, isn’t going to make it. That doesn’t fit with our center.”

Mapping out structures so processes run smoothly

Mapping out processes, which had an extra layer of complexity due to all the different locations and help systems, was a challenge. “I can still see Anouk standing there with an overview of all the HR and recruitment milestones: ‘No, no wait! I have something else! Guys, be quiet for a minute'”, recalls Mandema. It didn’t take long until several rooms were covered in post-its.

“It also didn’t take long before the document was meters long”, adds Anouk Baars, Health consultant at IG&H. “The starting hospital was using several technical systems, amongst which that of the UMCU. But we also had to reinvent the wheel for ourselves a few times. There was no insight into these processes yet, so we wrote everything down first. Then it became clear that about thirty things had to be in place before someone could start providing healthcare for some jobs.”

That way we figured out which members of staff were trained where, what the team structure looked like and where they could take their questions. “Everyone wants everything to run smoothly, but there needs to be a system for that first. The IT department was recruiting people themselves, for example. The same went for the medical teams. To make sure everyone has the right training, there needs to be someone taking the lead and overlooking all of this”, she says.

Trial and Error

Every week, Baars and Mandema sat around the table with a team to structure. What are we running into, how are we going to take this on and who is responsible for this process?, were the main questions Mandema asked. “It was a challenge for everyone, because no one had experience with a similar project.”

“Sometimes we had to do things the old-fashioned way. I regularly had to walk to and from the UMC Utrecht 5 or 6 times a day to sort out IT- or HR-related cases”, Baars says. The team had an issue with digital authorizations, for example. Which doctors have access to which files? It turned out no one had taken responsibility and it had to be sorted out fast. In this case we had to take care of the problem right away. Definitely important, because children would come to our hospital at the same time as their doctors. Nothing was allowed to go wrong.”

Practical solutions for complicated problems

To prevent any issues, Mandema and Baars ran around like headless chicken the last few months before the opening. “In May, our list of priorities was huge. We realized how complex the situation really was. The fastest way to make sure all new staff could start working right away, was to implement everything they needed into an excel sheet manually. That is why I did that once. I locked myself up for an entire week to make an inventory of things every employee needed and whether they had received it or not. After the opening, we turned this into a structural process”, Baars says.

This challenging time also caused some tension between the teams. “IG&H was definitely a good mediator. They brought people together, especially if something wasn’t taken care of right away. To prevent these situations to become worse, they only looked at the content. Who needs what and how do we arrange that as quickly as possible? Afterwards we looked at how the teams involved could take their responsibilities, so these structures matched the practical applications”, says Mandema .

‘To do lists are getting shorter and shorter’

By now, the center has been open for half a year already. Dozens of children are treated and supported by doctors, nurses and pediatricians daily. They come by for a day treatment or stay at the hospital longer for the more difficult parts of the treatment. For each room the kids stay in, there is an adjoining room to for the parents, a parent-child-unit.

Baars’ and Mandema’s to do lists are getting shorter and shorter. “We are currently determining how the organizations can pick up things themselves. We are past the real hurdles; everyone is helped by the right team and are able to ask their questions to the right person. The hospital has its own routine now.”

Three opportunities for more chemistry between hospital and MSB

By | Healthcare, News

Now that the participation model does not seem to take hold, the following question arises: what can we as hospital and MSB do to join forces? “To date, the introduction of integrated funding has not meant that the hospital and MSB jointly manage healthcare in a smarter and more efficient manner”, is one of the conclusions from the ‘Integrated Fidelity Monitor’ recently published by the NZa. Three concrete opportunities in this article.

Why is it so difficult? An important reason why this objective does not get off the ground is the calculation system between hospital and MSB, which in many cases is primarily driven by volume. In some cases there are additional agreements about quality outcomes that are included in the settlement. Whatever the case, doctors who work for the MSB, are not affected by the incurring costs related to their choices – for example medicines, length of stay and diagnosis. The smart and efficient organization of healthcare in times of staff shortages remains the main concern of the managers and directors of the hospital organization.

Professional interlocutor. With the arrival of the MSB, a single point of contact has arisen for the hospital management, in which there is a joint sense of responsibility and a certain alignment of interests. This offers potential when it comes to joint performance management. How to redeem this potential as a hospital organization?

  1. Starting point: shared and concrete future vision.
    The healthcare landscape is changing, it’s clear that the role and position of the hospital is changing too. What the healthcare landscape looks like and what this actually means for the hospital and the different departments within the MSB, is to be agreed upon. It’s easy to see that directors are already on a different planet, while the MSB are occupied with production ceilings, internal calculation models and distribution of medical specialist capacity. By jointly exploring the strategic scenarios, a shared view of the urgency arises: the considerations and the opportunities that this offers.For example, in some regional hospitals together with the MSB we have experienced in practice what the different scenarios mean, also for the departments in the MSB: which healthcare do we no longer provide, which partnerships are important and which investments in technology and (ICT) infrastructure are needed? And which form of healthcare is being shifted internally to a specialist nurse?
  2. Maintaining a uniform working method: the right steering information.
    Medical and business manager form a crucial team in realizing the strategy and the clever organization of healthcare. In addition to formal authority for the medical manager, it is important that both maintain a uniform working method when it comes to steering. ‘Are we seeing the right patients? Do we provide healthcare in line with our chosen healthcare model (eg, do/do not perform surgery, e-consult versus screening, hospital stay)? Do we use our critical resources properly and how happy is our scarce staff actually?”In order to reach the right steering information, we are able to point out three success factors in practice: – Conducting the conversation about “when are you doing it right” and what do you want to know to get there, or even better; what do you want to know to stay there. – Developing together with the person in charge: making a semi-finished product better through good consultation. Only then does responsibility arise to also improve the quality of source information, after all ‘garbage in = garbage out’. – Transparency and the ability to down drill information to patient or employee level.
  3. From volume incentive to risk sharing and creating space to invest.
    It is not fair to jump to conclusions by saying that medical specialists at the MSB with the current incentives are only driven to make revenue and to monitor their own trade. However, in the current cooperation model, the MSB hardly bears any entrepreneurial risk. In the field of management accounting, sufficient research has been done to state that steering the performance is less effective without the right incentives.The path that has been taken to outcome steering offers opportunities. Let the medical and business manager themselves make a proposal for the results on which performance agreements can be made and which remuneration structure fits. Thus, with the space that has been created, a buffer for investments needed in technology and innovation can be supplied. So that the focus is no longer on distributing the proceeds, but on the transition to the right healthcare in the right place.

Princess Máxima Centre: from 11 workflows to 1 opening

By | Healthcare, News

On May 18th, 2018, the Princess Máxima Centre opened its doors. The run-up to this opening was a rather particular period of time that did not go without its struggles. Today, the second blog of a series, in which we discuss the following question with the experts involved: how did the centre move from dream to reality in just over 8 months?

“No concessions regarding the opening date and patient safety”

“The first thing I did was create urgency”, says Ben van Miltenburg, the all-round transition manager who was involved in the project at the end of the summer of 2017. “At the administrative level, the need was already felt, but this was not yet the case in every branch of the organisation. The message to everyone was therefore twofold: we have to open on May 18th, and then everything has to be assured for the patients.”

Then an alarm went off: with our plan of action at that time it was not going to be feasible. Two things were needed: overview and coordination. On basis of this, it would be possible to set priorities. The question was: where do we start? Van Miltenburg: “That was the moment IG & H came into the picture.”

“A border collie that kept the herd together”

“You have to consider that the building was still an empty concrete box at that time”, says Van Miltenburg. “Everything was needed at every business unit and there was nothing available.” Once the urgency of this had been felt, everyone started to roll up their sleeves: “One thing was clear: we would not postpone the opening date. I kept track each week of how many people said that it must be postponed. Eventually I ended up with 206 tick marks. And yet we have achieved our goal.”

The 11 workflows that have been drawn up – including ‘HR and recruitment’, ‘care processes’, ‘compliance’, ‘finance & BI’ and ‘ICT’ – played a major role in this. “These were perceived as sort of little factories that all had to deliver at the right time”, says Bart van Sambeek, consultant at IG & H. “In the beginning, we took a thorough inventory of what was needed for a sure opening. We then translated this information into milestones, which we packaged into the 11 workflows. This way, everyone knew who was going to pick up what and when.” A hospital business only works if all cogs fit well together, but naturally everyone is more concerned with themselves – with their own cogs – than with the interaction. What we have therefore in essence created is an exoskeleton that kept the organisation-in-the-making of the Princess Máxima Centre together.

“The model of the workflows also meant that we had 1 language and 1 central steering mechanism”, adds Van Miltenburg. “In the workflows, people did what they were responsible for.” The intention was deliberately chosen to designate MT members as leaders of the workflows: “After all, they also lead the regular organisation.”

“If the transition team wanted something, it happened”

“In the end, we had about thirty to forty external experts in various fields – such as personnel & organisation, ICT, construction & design and planning – delivering extra capacity and crucial knowledge”, says Van Miltenburg. “In addition to substantive knowledge and experience, IG & H also provided the people necessary to help coordinate and make everything happen.” According to Van Miltenburg, this helped enormously in achieving objectives: “When we called something together with the IG & H consultants, it happened. This was also because I was able to act with the mandate of the board of directors. Everyone within the organisation honoured this, because nobody wanted the centre to not open on time because of them.” Repeating the core message proved to be a key element to success: “we had to open on May 18th and at that time it also it had to be assured for the patients. That core message gave a focus amidst the multitude of things that screamed for attention and energy. We have always looked at and emphasised what was necessary to be able to open on May 18th. That is what we have done together.”

“No pressure or control, but support”

“I knew for sure that it would work”, says Van Miltenburg. “I never doubted that. It was, however, crucial that patient assurance was guaranteed. We have looked at the processes meticulously for that.”

Within the overall plan of action, there were 2 methods. On the one hand, IG & H took care of the milestones planning and reporting, so that people could see exactly when targets were achieved or not. On the other hand, the transition team explicitly chose not to place control or performance pressure at the centre. We did not ask people why objectives had not been achieved, but what they needed to achieve the goals. They saw this as having been given support. What you notice is that people are used to performing within set limitations. But we were dealing with a very special – and temporary – situation in which that was not enough. We therefore did not say what had to be done to do something faster or better. We provided the means to accomplish what had to happen, regardless of the limitations. That could be manpower, information, alternatives, or decisions. By doing this, we were able to set things right again.

“When you work with so much external knowledge and experience, there is always a solution”, says Van Miltenburg. “Within their own domain, people do not always see the whole picture. When we asked why something had not been delivered on time, for example, they often thought it was because it was too expensive, even though the board was prepared to make extra funds available if needed. In addition, the transition team also exerted pressure on the suppliers: “We flew in some of the apparatuses months earlier than usual. This requires a certain level of creativity that you do not need in normal business situations.”

“We would have never made it without the voting mechanism”

A final element that was essential in the coordination was the voter system. Van Sambeek explains this clearly: “The workflows and components of a hospital organisation are all interlocked. When a workflow wanted to pass on a decision or milestone that had an impact outside its own workflow, it had to be submitted to all of the other workflows for voting. So everyone could indicate whether they agreed or not, with which we could ensure that all cogs continued to connect. This meant that people had to think and co-decide on matters outside their own domain. In view of the short period, it was necessary to do this.”

“We would not have made it without that mechanism”, says Van Miltenburg. “Because everyone had to see and approve almost any final decision, we were able to avoid many unpleasant surprises and gaps. In addition, no one could ‘duck away’ at a later stage. When you make decisions together on everything, you also bear the responsibility of delivering in accordance with the agreements. The voting mechanism has therefore really been invaluable!”

UMC: performance-driven care administration

By | Clientcases, Healthcare

What they wanted
Solid business operations start with a well-performing care administration. Like many healthcare institutions, the UMC struggled with burdens: there were many correcting tasks for the care administration, registration tasks for specialists, control tasks required by the insurer, and change implementation tasks imposed by the government. To depart from all this, the care administration had to switch from stopgap solutions to improvement. The goal: timely, correct, and complete registration at the source. This would allow the institution to get in control and lay a foundation for horizontal monitoring, which means that the insurer performs checks beforehand instead of afterwards.

What we did
Together, we conducted a data analysis to identify the main sore points. Subsequently, we set up an audit program for improvement projects, which we rolled out to the departments. Then, we created a process design – new in terms of content – and set up the Lines of Defense model. Management information was organized using correct and supported performance indicators. Finally, we established a program organization with stand-up and day start meetings, as well as training courses.

What we achieved
With our help, the UMC has taken a major step towards departing from correcting tasks and creating an optimal chain of registration. We created a supported Lines of Defense model and ensured commitment to registration securities. Furthermore, we introduced a new way of working, tightening priorities, project activities, and the allocation of tasks. Also, the focus has shifted to transparent communications on processes and substantive matters. Moreover, openness and feedback have improved collaboration.

What they said
The Ministry of Health, Welfare, and Sport has made this project an exemplary case for other care administrations. At the Congres Horizontaal Toezicht Zorg (congress for horizontal monitoring in healthcare), the case was highlighted as an example of success. The client’s feedback: “In terms of quality, IG&H has done an excellent job providing methods that we can apply in practice. IG&H made a difference. It has been tangible in the solution they offered, but also in its reception and the way it works in practice. The organization has noticed a positive energy boost.”