Deliverable D5.1: Stakeholder and change management maps · 2016-10-13 · Stakeholder and change...

This publication arises from the ACT@Scale (Advancing Care Coordination and Telehealth deployment at Scale) Programme which has received funding from the European Union, in the framework of the Health Programme under grant agreement 709770. The ACT@Scale programme is fully aligned with the European Innovation Partnership in Active and Healthy Ageing objectives to deploy integrated care for chronically ill patients.

Deliverable D5.1:

Stakeholder and change management maps

WP 5: Stakeholder and change management

ACT@Scale Advancing Care Coordination

and Telehealth @ Scale

D 5.1: WP5. Stakeholders and Change Management

Public of 91 V3.0 30 Sept 2016

Document Information PROJECT ACRONYM: ACT@Scale

CONTRACT NUMBER: 709770

DISSEMINATION LEVEL: Public

NATURE OF DOCUMENT: Report

TITLE OF DOCUMENT: Deliverable 5.1

REFERENCE NUMBER: D5.1

WORKPACKAGE: WP5

VERSION: V3.0

EXPECTED DELIVERY DATE: M6

DATE: 30 Sept 2016

AUTHORS:

M.Moharra T.Salas

EDITOR: AQuAS

Short description of the Deliverable: The work package 5 (WP5) of the Advancing Care Coordination and Telehealth deployment at Scale (ACT@Scale) project, which strives for obtaining commitment and support from interest groups related to care coordination and telehealth, intends also to consider those specifically designed to address the organisational adaptations needed to scale the different programmes included within ACT@Scale. To accomplish the aim of WP5, a survey on stakeholder and change management was conducted, results of which will be presented in this deliverable (5.1)

REVISION HISTORY

REVISION DATE COMMENTS AUTHOR (NAME AND ORGANISATION)

1.1 29.07.2016 First versions AQuAS

1.2 11.08.2016 Updated version AQUAS

1.3 09.09.2016 Initial Individual Analysis of Programmes

AQUAS

1.4 14.09.2016 Comments and amendments from SN and DB

AQuAS

1.5 30.09.2016 Information updated



Executive Summary

Aims and objectives

The specific objective of Workpackage 5 (WP5) is to achieve an appropriate level of support and commitment from the stakeholders to innovative health services, specifically care coordination and telehealth (CC & TH).

The main target will be to gather baseline information of staff engaged within the ACT@Scale programme, to know stakeholder engagement through knowing the overall staff engagement across programmes and finally validate the change management through the maturity map of the EIP-AHA B3.

Methods

For the purpose of the development of the questionnaire, the instruments of the previous ACT programme project and the surveys EIP AHA1 were reviewed. EIP AHA has identified key areas for CC&TH deployment, and has assessed the maturity level of several regions, as well as barriers for change.

Regions were sent a survey in the form of a Word document to be printed and filled out. The questionnaire was intended to be addressed to the programme managers of each of the ACT @ Scale programmes involved in the project, in order to ascertain the current situation in the area of stakeholder management and change management.

Results

A total of 14 questionnaires were received from the 5 regions participating in the project (Basque Country; Catalonia; Groningen; Northern Ireland and South Denmark.) 10 out of 14 programmes declared that they have a specific strategy to identify stakeholders and a total of 14 programmes declared that they primarily involved health professionals (primary and secondary care), health administrators and patients/users. Concerning change management, the key elements that programmes are addressing first are: strategy and communications followed by and alignment and monitoring.

Conclusions

1 1 http://ec.europa.eu/research/innovation-union/index_en.cfm?section=active-healthy-ageing&pg=action_group_b3

http://ec.europa.eu/research/innovation-union/index_en.cfm?section=active-healthy-ageing&pg=action_group_b3




In general, programmes used an adhoc management process to identify stakeholders in their programme rather than a more defined and established process. Most of the programmes declared having a specific strategy to identify stakeholders whereas a few programmes do not have a specific strategy. In most cases, stakeholders are involved through giving information, consulting or collaborating with the programme management.

Concerning Change Management, most of the programmes declared that strategy, communications, alignment and monitoring are key elements that they are addressing initially. Main barriers reported by programmes were lack of leadership especially in phase 1 (Planning) and phase 2 (Adaptation) of the programmes. However, in phase 3 (Implementation) and phase 4 (Improvement) the two main barriers were related to pressure to produce short term results and stakeholder resistance.



Glossary

The following phases have been considered in order to assess deployment status of programmes:

Phase 1 (Planning): Planning of change: the designing phase of the program. The case for change is built and all aspects for the program are defined (intervention, scope, timeframe, resources, etc)

Phase 2 (Adaptation): Adaptation phase: in which the program is tested in a pilot implementation

Phase 3 (Implementation): Full scale implementation phase: final implementation of the program

Phase 4 (Improvement): Continuous improvement after deployment, once the program is implemented, outcomes are assessed and adaptations of the program may occur in order to improve their performance



Content Deliverable D5.1: ..................................................................................................... 1

Stakeholder and change management maps ........................................................ 1

Document Information ........................................................................................... 2

Executive Summary ................................................................................................ 3

Glossary .................................................................................................................. 5

INTRODUCTION ...................................................................................................... 7

PURPOSE AND OBJECTIVES .................................................................................... 9

METHODS ............................................................................................................. 10

RESULTS ................................................................................................................. 11

Overall Results .................................................................................................... 11

Stakeholder Management .............................................................................. 11

Change Management .................................................................................... 19

Results per region and programme – Change Management ............................. 29

North of the Netherlands (NN) .................................................................... 29

Region of South Denmark (RSD) ................................................................... 30

Basque Country(BC) ...................................................................................... 31

Northern Ireland (NIRE) ................................................................................ 32

Catalonia (CAT).............................................................................................. 34

Results per region and programme –Stakeholder Management ........................ 38

North of the Netherlands (NN) ..................................................................... 38

Basque Country(BC) ..................................................................................... 44

Northern Ireland (NIRE) ................................................................................48

Catalonia (CAT).............................................................................................. 52

CONCUSIONS ........................................................................................................59

Appendix 1. WP5 Questionnaires on stakeholder and change management .... 60

Appendix 2. Close-ended answers to stakeholder and change management questions .............................................................................................................. 77

Appendix 3. Open-ended answers to Stakeholder and Change Management Questions .............................................................................................................. 82

Appendix 4. Stakeholder maps ............................................................................ 91



INTRODUCTION Increased life expectancy and longevity, together with a declining birth rate, have led to an ageing Europe, with a higher prevalence of people suffering from multiple chronic long term conditions.

This demographic shift has an impact on healthcare systems and challenges them in several ways:

1. The growing demand for health services threatens the sustainability of health systems

2. Health care systems face a foreseeable shortage of healthcare professionals

3. As life expectancy increases, quality of life becomes a relevant outcome for citizens

In view of this situation, there is a clear consensus on the need for a new model of health services delivery, a model which makes a more efficient utilization of available resources and meets societal expectations in terms of health outcomes.

Even if there is currently no clear vision of how this new model will be, it is possible to envisage some of its key features:

1. Effective collaboration among different health care professionals and providers

2. Bringing together of health and social services as well as formal and informal care

3. Takes advantage of an extensive use of information and communication technologies

4. Takes into account social determinants of health such as socioeconomic, life styles and environmental factors.

5. A requirement for citizen engagement

This new model will mean a major change involving central governments, municipalities, health and social care professionals, schools, citizens, etc.

Such as societal change will not be accomplished unless a strong stakeholder community, works actively to make it happen.



Stakeholder management is crucial to achieve programme success and sustainability, as well as to underpin their ability to scale up. At the moment, however, it is not well understood what the key aspects of good quality stakeholder’s management is.

Stakeholders are individuals, groups, or organizations who may affect, be affected by, or perceive themselves to be affected by a decision, activity, or outcome of a project2. Recipient stakeholders are those who are impacted in the form of any change with respect to their previous situation (e.g. healthcare professionals). Their needs and expectations should be managed by specific processes (Change Management) Change management is the process, tools and techniques to manage the people-side of change to achieve the required business outcome. Change management incorporates the organizational tools that can be utilized to help individuals make successful personal transitions resulting in the adoption and realization of change.

ACT@Scale aims to benchmark stakeholders management plans for the 14 programmes included within the project, and from that benchmark identify good practice which could help these programmes to scale up.

The work package 5 (WP5) of the ACT@Scale project strives for obtaining commitment and support from interest groups related to care coordination and telehealth, intends also to consider those specifically designed to address the organisational adaptations needed to scale the different programmes included within ACT@Scale. To accomplish the objectives of WP5, will be the Stakeholder maps, influence maps and baseline change management maturity maps for all programmes, a survey on stakeholder and change management was conducted, the results of which will be presented in this deliverable.

2 Project Management Institute



PURPOSE AND OBJECTIVES The objectives of WP5 are:

• To identify stakeholders and analyse their contribution and commitment to the project as well as issues related to organisational or technological change.

• To develop and deploy a tool to provide a baseline for stakeholder

engagement.

• To design an action plan aimed to increase stakeholder contributions to the project.

The survey conducted within the framework of this WP5 on Stakeholder and Change Management was designed to identify stakeholders and analyse their contribution and commitment to the programme as well as to gain insights into issues related to organisational or technological change.



METHODS For the purpose of the development of the questionnaire, the instruments of the previous Advancing Care Coordination and Telehealth (ACT) programme project3 and the surveys EIP AHA4 (European Innovation Partnership on Active Healthy Ageing) were reviewed and selected information was used as the basis of the questionnaire. EIP AHA has identified key areas for CC&TH deployment, and has assessed the maturity level for several regions, as well as barriers for change.

The questionnaire, in the form of a Word document to be printed and filled out, contains 16 questions (5 multiple choice questions, 7 dichotomous questions and 4 open-ended questions) divided into two different sections: section 1 devoted to Stakeholder Management and section 2 to Change Management Process. The questionnaire was sent to the five programme managers involved in the project. A copy of the questionnaire can be found in Appendix 1.

The content of the open-ended questions was analysed for each question separately through an iterative process of coding and analysis of the coded text. The results section shows either in tables or in comments in the text the results of the responses to the questions included in the questionnaire.

3 https://www.act-programme.eu/ 4 4 http://ec.europa.eu/research/innovation-union/index_en.cfm?section=active-healthy-ageing&pg=action_group_b3

https://www.act-programme.eu/





RESULTS

A total of 14 questionnaires were received from the 5 regions participating in the project. Appendix 2 includes the answers of the close-ended questions (dichotomous questions and multiple choice questions) and Appendix 3 includes the information collected in the open-ended questions.

Overall Results

Stakeholder Management Most programmes (N=10) have specific strategies for identifying their stakeholders in the programme (Figure 1).

Figure 1. Responses to Q1. “In the strategic plan of your programme, is there any specific strategy of identification and selection of stakeholders of your programme?” (N=14)

However Figure 2 shows that half of the programmes (N=7) do not have an implementation plan for the identification of stakeholders. Figure 2. Reponses to Q2. “Is there an implementation plan available for the identification and selection of stakeholders in your programme?”

0

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12

Yes No



Table 1 shows the usual process that programmes follow to identify stakeholders. In general, the identification goes through a list of a wide range of groups and organizations and mapping and prioritization is not usually performed.

Responses to Q3. Could you please describe what the process you usually follow to identify is, select and prioritize stakeholders (identification: listing of relevant groups, organizations; analyzing: understanding stakeholder perspectives and interests; mapping: visualising relationships and other stakeholders; prioritizing: ranking stakeholder relevance and identifying issues. Table 1. Process followed for the identification of stakeholders PROCESS FOLLOWED TO IDENTIFY STAKEHOLDERS Identification: listing of relevant groups, organizations

• Stakeholders (The care professionals, the patients and the decision makers) are identified from the beginning of the programme in order to understand their needs, perspectives and interests.

• Stakeholders and organizations such as secondary care, healthcare insurance company, private companies, patient users, GP offices, laboratory organizations, delivery of care and support in primary care: local GP (group) practices, primary care organizations, welfare organizations, nursing homes, homes for the elderly are identified.

Analysing: understanding stakeholder perspectives and

• Defined in partnership agreements with partners • Once the list is completed, the head of the corresponding

department, such as general director of the healthcare organization, is approached in order to engage them and

0

1

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6

7

8

Yes No



interests obtain their commitment to be involved in the program. • Prioritizing: not performed. All stakeholders mentioned are

considered key for continued implementation. Mapping • Mapping: not performed Prioritizing • Prioritizing: not performed.

• Once all relevant stakeholders are on board, a multidisciplinary working team is formed to ensure all perspectives are considered in the definition of the care pathway and the up-scaling process.

Regarding which stakeholders are involved in the programmes, most of the programmes involved health professionals (N=14) (primary and secondary care) and health administrators N=14) followed by patients/users (N=13).

Figure 3. Responses to Q4.”Describe which stakeholders are involved in your progamme?” (Please select all that apply)*

*Multiple choice question which allows to select more than one correct answer

Figure 4.shows the type of stakeholders involved depending on each Region. The figure shows that most of the regions involve patient/user, health professionals and health administrators and politicians. Payers and private health providers are involved by three and two regions respectively.

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Figure 4. Stakeholders involved by each Region

Concerning how the programmes involved stakeholders, most of them involved them mainly by giving information and through collaborations and working with them. The strategy is different depending on the type of stakeholder. For instance, patient and users are involved through informing, consulting and collaborating whereas politicians are involved mainly by informing and consulting.

Figure 5. Responses to Q5.How did you involve stakeholders in your programme?(please select all that apply)



*Multiple choice question which allows to select more than one correct answer

Most of the programmes (N=9) showed that there is neither an assessment prior to the beginning of the programme nor have the risks related to the stakeholder commitment been analysed (Figure 4 and 5)

Questions 6 and 7 indicate that most of the programmes have not performed any stakeholder commitment assessment nor analysed the risk related (to the lack of) stakeholder commitment.

0

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12

Give information Ask for info Collaborate Give responsibility



Figure 6. Responses to Q6 “Has the programme performed a stakeholder commitment assessment prior to the beginning of the programme?” Figure 6. Number of programmes that have performed a stakeholder commitment assessment prior to the beginning of the programme (N=14)

Figure 7. Number of programmes that have analysed risk related to stakeholder commitment (N=14)

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Question number 8 shows that a total of eight have adopted mitigating measures for the risks identified.

Figure 8. Number of programmes that adopted mitigating measures (N=14)

Most of the programmes (N=12) declared that they have an action plan oriented to maintain and increase the commitment of stakeholders in their programme. Figure 9. Number of programmes that have an action plan oriented to maintain and increase stakeholders commitment (N=14)

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Most of the programmes (N=8) do not perform periodic assessments of their stakeholders’ management process. Figure 10. Responses to Q10. “Does the programme perform periodic assessments on the stakeholders’ management process?” Figure 10. Number of programmes that perform periodic assessments on stakeholders’ management process (N=14)

0123456789

Yes No



Change Management

Section 1. CHANGE MANAGEMENT PROCESS AND KEY ELEMENTS TO ADDRESS CHANGE MANAGEMENT

Table 2 shows the answers to Q1. If any, which methodology for change management are you applying in your programme? Please give a short description. Most programmes do not have a specific methodology to apply change management and other programmes used adhoc processes for change management (i.e through specific offices, methodologies or promote professionals engagement) Table 2. Methodologies used for change management

METHODOLOGY USED FOR CHANGE MANAGEMENT • Not applicable, no methodology applied • PDCA methodology, maintaining periodic (at least every year) meetings with

stakeholders, and analyzing weekly performance data and every six month quality indicators. Then, we plan involving the professionals and, occasionally the users, and implement the changes

• New projects are coordinated through the Clinical Transformation Office. The main objective of the office is to control form a strategical perspective the changes that would affect the way professionals work.

• The main steps followed to boost change management among healthcare professionals are focused on two main objectives: 1. Definition of a sustainable patient-centered care pathway 2. Promote professionals ́ engagement and increase their sense of belonging with respect to the program

• The methodology is based on a proactive assistance to the population provided by a multidisciplinary team who promote the adequacy of resources (pharmacy, visits to emergency centers, ...)

Concerning the elements of change management that programmes are addressing, all of the programmes declared that they are addressing strategy and communications(N=12) and most are addressing alignment and monitoring (N=11). Other elements such as leadership and guidance, capabilities, financing and culture are addressed by fewer programmes (Figure 9).

Figure 11. Responses to Q2. “Which elements of change management are you addressing?



Table 3, 4 and 5 show the summary of answers to Question 3: please describe how are you addressing the previously selected elements

Few programmes reported that they addressed the analysis of readiness to change and innovation culture (N=4). However, they all declared that they addressed strategy and reorganisation (N=12) through first involving and taking into account the stakeholders’ perspectives and secondly through analysing and evaluating the programme

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Which elements of change management are you

addressing?



Table 3.Methods of addressing “Culture” and “Strategy/reorganization” of change management METHODS FOR ADDRESSING CULTURE AND STRATEGY/REORGANIZATION Culture • Involvement of stakeholders along the entire chain of care to implement the

program. This process is done by interviews held with stakeholders, by informing and consulting, training and coaching on job professionals and by regular evaluations.

• Through the Innovation office which is in charge of promoting the culture through all levels of the organisation with open sessions and open innovation exercises either with professionals, companies and citizens

Strategy/re-organization

• Through a design-thinking process to evaluate possible changes to improve discharge of our patients.

• Current efforts include involving all stakeholders to develop sustainable implementation and scaling up the program. This is done by assessment of the true costs of each (virtual) consultation, assessment of the impact of the AC service for the stakeholders and formulating alternative financing schemes, making the program self sustainable in the future. To this end, several meetings are set up with management of the laboratory , health administrators on the one hand, and payers on the other hand.

• The different programmes are continuously assessed to check on their performance and the Clinical Transformation Office is always looking for new ways to improve the services provided to the citizens from two perspectives: efficacy and efficiency.

• The care pathway specifically depicts the function each professional has to perform and the communication channels between them. All the care pathway´s aspects have been discussed and agreed between all stakeholders (with thenexception of tye patient), ensuring all perceptions are considered.

• The programme has been designed by the managers and clinicians of both Hospitals and Primary Care Centres involved. All stakeholders' perspectives have been taken into account and a clear methodology in the designing of the intervention has been carried on (analysis of current model, detection of improvement areas, prioritize actions and define the new care pathway).

• Care professionals and decision makers are involved in the development and are

consulted in relation the needs and the changes needed in the organisation to accommodate telehealth solutions in comparison with usual care. The telehealth approach is reflected in national guidelines for telemedicine and health agreements in the region.

Regarding Leadership and guidance (N=6), programmes reported that they usually identify health care professionals who are the most suitable to lead new challenges and therefore transform current care practices. Communication and Dissemination is widely addressed by all of the programmes (N=12). A mixed method approach of both top-down and bottom-up initiatives are used among programmes together with different strategies through mass emails, meetings and websites.

Table 4. Methods for addressing Leadership and guidance and Communication



METHODS FOR ADDRESSING Leadership and Communication Leadership and guidance

• Identifying champions with each stakeholder group within each stakeholder group.

• Through the Clinical Transformation Office that is in charge of promoting and controlling the change process from all the different perspectives. Within that strategy, champions are also identified

Communications. Dissemination of the new strategy in the organization

• Communication flow through massive email to professionals, sharing weekly results and indicating changes. This is a formal strategy, besides periodic meetings and informal meetings.

• Through the website on which news updates, and a thorough explanation of the program. In addition, regular meetings are held with all stakeholders; from professionals to health administrators, care organisations and payers.

• Bottom up and to-down approach. The care pathway is shared with peers and the general directorate After that, a wider deployment of the service is pushed from the top manager (top-down approach).

Table 5. Methods for addressing Capabilities, Alignment, Financing and Monitoring. Some of the programmes (N=5) declared that they addressed capabilities by analysing and reorganising existing resources or developed new roles. Regarding alignment, most of the programmes (N=11) are aligned at political level through strategic plans of the region or they are aligned at organisational level with other EU projects. Fewer than half of programmes (N=5) addressed financing and incentives as a way of promoting change and overcome resistance. Finally, monitoring and the availability of performance indicators is addressed by most of the programmes (N=11) who report that it is a way of managing continuous improvement.



METHODS FOR ADDRESSING Capabilities, Alignment, Financing and Monitoring.

Capabilities • For the professionals function analysis was developed that described

the new roles and competencies in detail. • The care pathway deployed is based on re-organization of existing

resources by creating new roles (especially those of the nursing). • Wider deployment of the reference internist and hospital liaison nurse

into other hospitals in the region. • Telehealth and telepsychiatry is part of the strategic goals for the

politicians and health organisations. The programme has a high level of political attention.

Alignment • Collaboration in several (EU) project • Political, legal and organisational support/endorsement towards

integrated care is done at regional level • The City Council made a fusion of the Department of healthcare and

the Department of Welfare and Family back in year 2000 in order to break the classical separation between the health and social care provision. This makes the alignment of all the key stakeholders a perfect environment for the development of integrated care services.

• Alignment with the strategic plan of the Department of Health of the Region.

• Clear strategic vision of the Region towards the challenge of ageing, chronicity and dependency has provided explicit support, distributed leadership and created capacities in the organizations to transform the health and social care system. The Health Plan 2013-2020 also addresses all fields relevant to EIP AHA. Moreover, The Strategic Guidelines 2013-2016 of the Healthcare service, reinforced and extended an integrated approach and as a consequence, during the last few years a number of processes and tools have been developed.

Financing and Incentives

• Change strategy within personalized financial incentives to our staff. • Collaborations with other regions in the Region in which laboratory

organizations adopt the program working mechanism. • Alternative financing structure through capitation • The programme has contact to the decision makers in region to

ensure the focus on the financing. Monitoring • Monitoring of performance indicators is performed continuously by

the program, because it has a large academic component; e.g. data is collected each year on patient level.

• The development of a modeling predictive tool in the form of Budget Impact Analysis allows to manage continuous improvement in the implementation of integrated healthcare for multi-morbid patients.

Section 2. CHANGE MANAGEMENT AREAS AND PHASES

The following questions examine the areas that are followed and covered by each programme depending on the phase (Planning, Adaptation, Implementation and Improvement). Most of the programmes cover all the aspects in each of the steps of the programme. Only two aspects such as Organisational models and integrated care pathways are covered in phase 3 and phase 4 (full scale implementation and continuous improvement) and are not taken into account during the initial phases of the programmes.



Figure 12. Responses to Q4. “In which step are you in the process within the following integrated care areas? (select all that apply)”

Section 3: CHANGE MANAGEMENT BARRIERS AND MAIN TOOLS TO OVERCOME THEM

With regard to barriers that programmes are facing at each phase, many declared that lack of leadership was the most important factor with an average of 5 points in phase 1 and phase 2 of their programme (Figures 13 and 14). However, barriers faced in phases 3 and 4 appeared to show some change, and the findings showed that pressure for short term results and stakeholder resistance (Figure 15 and 16) are the most important barriers faced.

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Phase 1

Phase 2

Phase ·

Phase 4



Figure 13. Responses to Q5 – phase 1. “indicate barriers you have faced for change management (Please tick the appropriate box)”


2.63.4

5.14.4 4.6

5.1 4.9 4.6 4.6

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Q6. Strategies/tools that you are using/have used with success to overcome the above indicated barriers. Please explain why there were successful.

One of the main barriers declared by programmes was the Lack of leadership, especially in phase 1 and phase 2 of the programmes. The main strategies and tools to overcome this were through the identification of stakeholders, project leaders and involvement of decision makers at the beginning of the project (Table 6) Table 6. Strategies/tools to overcome Lack of leadership.

STRATEGIES/TOOLS TO OVERCOME LACK OF LEADERSHIP Lack of leadership • Strategies involve identification of champions among

all stakeholders. Qualitative measures such as interviews and stakeholders meeting were used as tools

• The management level and decision makers have been involved early in the process to ensure the proper support to avoid a lack of leadership.

• The Clinical Transformation Office has helped into two things: 1) Identifying the professionals that will lead the change project and 2) Involving all the stakeholders to achieve a good result of the project

Pressure for short time results and stakeholder resistance were two of main barriers reported by programmes during phase 3 and phase 4. Again, the involvement of decision makers and stakeholders from the beginning of the project was a strategy to overcome them. In addition, strategies used involved project management tools for stakeholder involvement and designing pathways to progressive achievement of results (Table 7)



Table 7. Strategies/tools to overcome Pressure for short time results and stakeholder resistance

STRATEGIES/TOOLS TO OVERCOME PRESSURE FOR SHORT TIME RESULTS AND STAKEHOLDER RESISTANCE Pressure for short term results.

• Fragment or calendarize results in order to design a path oriented to progressive achievement of refined results.

• Involvement and engagement of politicians and decision-makers has been key to decease the pressure on the short term results. The management layer has had focus on ongoing quality assurance which has removed some of the pressure.

• Building block approach combining short-term and medium/long-term goals

• Strategies used involve added involvement of researchers. Stakeholder resistance

• Individual analysis and approach. Starting from the leader. • Involving all stakeholders from the very start of the

program. And to ask for their input throughout all phases. Strategies used involved project management tools for stakeholder involvement (e.g. RACI tables).

• Regular stakeholder communication and participation in service design and redesign

• Identification of the appropriate professionals to be part of the programmes

• To keep up the information flow and communicating important activities on an ongoing basis to keep the support from all stakeholders.



Results per region and programme – Change Management

North of the Netherlands (NN) Asthma / COPD Telehealth service

The program has not yet reached its full development, as shown by the fact that different areas are in different stages of implementation, from the planning phase to the continuous improvement one.

Plan

ning

Ada

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Impl

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tati

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Impr

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ent

Organisational models Workforce development Stratification tools Integrated care pathways Patient engagement Support of technology

Strategic and implementation plans exist for stakeholders identification.Stakeholders are involved early in the programme (Planning phase).There is a plan to maintain and increase stakeholders commitment.Elements of change management are almost completely adressed, which the only exception of Capabilities.Barriers for change management are being addressed.

Embrace – Connecting health and community services

Program fully developed to the stage of large-scale implementation, still to reach the stage of continuous improvement.

Plan

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Organisational models Workforce development



Stratification tools Integrated care pathways Patient engagement Support of technology

Stakeholders are involved early in the programme (Planning phase).There is a plan to maintain and increase stakeholders commitment.All elements of change management, as well as barriers for, are being adressed.

Heart Failure Program

Almost completely developed program, with all areas in the continuous improvement phase with the exception of stratification tools and technology support.

Plan

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Ada

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Stakeholders are involved early in the programme (Planning phase).There is a plan to maintain and increase stakeholders commitment.All elements of change management, as well as barriers are being adressed.

Region of South Denmark (RSD) Center for Telepsychiatry

Program fully developed to the stage of large-scale implementation, still to reach the stage of continuous improvement.



Plan

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Impl

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Organisational models Workforce development Stratification tools (1) Integrated care pathways Patient engagement Support of technology

(1) Not Applicable

A Strategic plan exists for stakeholders identification.Stakeholders were involved early in the programme (Planning phase).There is a plan to maintain and increase stakeholders commitment.Elements of change management are partially being addressed.Barriers for Change management are being addressed.

Basque Country(BC) Multimorbid Population Integrated Intervention Programme

The program has not yet reached its full development, as shown by the fact that different areas are in different stages of implementation, from the adaptation phase to the continuous improvement Phase.

Workforce development and Patient engagement are the areas still pending to reach full scale implementation phase.

Plan

ning

Ada

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Impl

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tati

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Organisational models Workforce development Stratification tools Integrated care pathways Patient engagement



Support of technology

Strategic and implementation plans exist for stakeholders identification.Stakeholders are involved early in the programme (Planning phase).Elements of change management are partially being adressed.Barriers for change management are not being addresssed (pending confirmation with the program manager)

Telemonitoring services for Congestive Heart Failure

The program has not yet reached its full development, as shown by the fact that different areas are in different stages of implementation, from the adaptation phase to the continuous improvement one.

Workforce development and Patient engagement are the areas still pending to reach the full scale implementation phase.

Plan

ning

Ada

ptat

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Impl

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tati

on

Impr

ovem

ent


Stakeholders are involved early in the programme (Planning phase).Elements of change management, as well as barriers to change management, are partially being adressed.

Northern Ireland (NIRE) COPD telemonitoring services

The program has not yet reached its full development, as shown by the fact that the areas are in different stages of implementation, from the planning phase to the continuous improvement phase.



Plan

ning

Ada

ptat

ion

Impl

emen

tati

on

Impr

ovem

ent


Strategic and implementation plans exist for stakeholders identification.Stakeholders are involved early in the programme (Planning phase).There is a plan to maintain and increase stakeholders commitment.Elements of Change Management are being partially addressed.Barriers for change management are being addresssed although partially (pending to confirm with the program manager)

Diabetes telemonitoring services

The program has not yet reached its full development, as shown by the fact that different areas are in different stages of implementation, from the planning phase to the continuous improvement one.

Plan

ning

Ada

ptat

ion

Impl

emen

tati

on

Impr

ovem

ent


Strategic and implementation plans exist for stakeholders identification.Stakeholders are involved early in the programme (Planning



phase).There is a plan to maintain and increase stakeholders commitment.Elements of Change Management are being partially addressed.Barriers for change management are being addresssed although only partially (pending to confirm with the program manager)

Weight management telemonitoring services

The program has not yet reached its full development, as shown by the fact that different areas are in different stages of implementation, from the planning phase to the continuous improvement Phase.

Plan

ning

Ada

ptat

ion

Impl

emen

tati

on

Impr

ovem

ent


Strategic and implementation plans exist for stakeholders identification.Stakeholders are involved early in the programme (Planning phase).There is a plan to maintain and increase stakeholders commitment.Elements of Change Management are being partially addressed.Barriers for change management are being addresssed although partially (pending to confirm with the program manager)

Catalonia (CAT) Healthcare support programmes for nursing homes

Program is almost fully developed, with all but one of the areas at the stage of continous improvement. The only exception is Patient engagement which remains at the large-scale implementation phase.



Plan

ning

Ada

ptat

ion

Impl

emen

tati

on

Impr

ovem

ent


A Strategic plan exists for stakeholders identification.Stakeholders were involved early in the programme (Planning phase).There is a plan to maintain and increase stakeholders commitment.Elements of change management are being addressed almost fully, with the only exception being that of Culture.Barriers for change management are not being addresssed (pending to confirmation with the program manager)

The Chronic Patient Programme – Badalona Serveis Assistencials

Program is almost fully developed, with all but two of the areas at the stage of continous improvement. The only exceptions are the Stratification tools and Technology support, which are currently between phases 3 and 4.

Plan

ning

Ada

ptat

ion

Impl

emen

tati

on

Impr

ovem

ent


Stakeholders were involved early in the programme (Planning phase).



The program has performed a risk analysis related to stakeholders commitment and mitigating measures have been adopted.Elements of Change Management are being addressed partially.Barriers for Change Management are addressed almost completely.

Integrated care for subacute and frail older adults PSPV

Mixed programme, where half of the areas have reached continuous improvement phase, while the other half still remain at the Planning phase.

Plan

ning

Ada

ptat

ion

Impl

emen

tati

on

Impr

ovem

ent


A Strategic plan exists for stakeholders identification.Stakeholders are involved early in the programme (Planning phase).There is a plan to maintain and increase stakeholders commitment.Elements of Change Management are being addressed partially.Barriers for Change Management are addressed almost completely.

Promotion of Physical Activity (PA) at AISBE

The program has not yet reached its full development, as shown by the fact that different areas are in the planning phase (organisational models,integrated care pathways and patient engagemetn.



Plan

ning

Ada

ptat

ion

Impl

emen

tati

on

Impr

ovem

ent


Management of Complex Chronic Patients (CCP) at AISBE

The program has reached its full implementation but still there is one area on patient engagement that is in the adaptation phase.

Plan

ning

Ada

ptat

ion

Impl

emen

tati

on

Impr

ovem

ent




Results per region and programme –Stakeholder Management

North of the Netherlands (NN) Asthma / COPD Telehealth service

Stakeholders involved in the COPD programme:

Primary and secondary care providers cooperate closely within the program. A web based Electronic Diagnostic Support (EDS) system, specially developed for this project plays a central role in the processing of data, communication between various care providers and support to the management of asthma and COPD. Four principles are defined: (1) integrated care should optimize the diagnosis, treatment and management of patients with asthma and or COPD, (2) the general practitioner is the leading organiser, (3) integrated care should be easy accessible for both patients and healthcare providers in both primary and secondary care and (4) the allocation of tasks and cooperation between primary and secondary care has to be defined clearly.

The lung function assistant collects data about the medical history: age, gender, age of onset, family history, current and past symptoms, burden of disease , smoking history as well as motivation to stop smoking, current medication use, the number of exacerbations in the past year, stimuli provoking symptoms, and the height, weight and body mass index (BMI). All data are collected in a structured way and subsequently fed into the EDS system together with the result of the lung function test. The EDS contains an on guidelines based algorithm and supports the advice of the pulmonologists for the general practitioner. In case the pulmonologist is unable to generate a correct diagnosis based on these data, he can advise the general practitioner for a one-time referral of the patient to the pulmonologist in order to perform additional diagnostic investigations. Finally, all data including the diagnosis and therapeutic advice of the pulmonologist are fed into the computer of the general practitioner. The general practitioner is responsible to discuss the test results, the diagnosis, and therapeutic advice to the patient. General practitioners participating in the integrated care consented to take the advice of the pulmonologist in serious consideration when advising the patient. In case a change in therapy is advised patients are automatically scheduled for a follow-up visit to the primary care asthma/COPD diagnostic service after 3 months. In all other cases patients have an annual follow-up.

What attitude do the various stakeholders have towards the programme?



Mostly in favour of change

Mostly against change

Patient/users X Health professionals – primary care

X

Health professionals – secondary care

X


X

Health administrators X Payers X Politicians X Private health providers X Other stakeholder (please specify)

What power do the various stakeholders have towards the programme?

(Has the power to influence change) (Has no power or limited power to influence change) Has the power to

influence change Has no power or limited to influence change


X


X


X

Health administrators X Payers X Politicians X Private health providers X Other stakeholder (please specify)

Embrace – Connecting health and community services

Stakeholders involve in the Embrace programme:

The delivery system design includes Elderly Care Teams (ECTs). These multidisciplinary teams are led by the GP and further consist of an elderly care physician, a district nurse, and a social worker. The focus of the ECTs is on realizing patient centered, proactive, preventive, and coherent care and support taking into account all aspects of functioning and disability, along with environmental aspects. The district nurse or social worker, in the role of case manager, will navigate the elderly person through the complex processes of



organizing appropriate care and support in the most efficient, effective, and acceptable way. The GP and elderly care physician will manage the medical care for elderly people with multimorbidity. Monthly ECT meetings will be scheduled, in which (health) problems and treatment options of elderly people and caregivers will be discussed and evaluated.

What attitude do the various stakeholders have towards the programme? Mostly in favour of

change Mostly against change


X


X


X

Health administrators

X

Payers X X Politicians X Private health providers X Other stakeholder (please specify)

What power do the various stakeholders have towards the programme? (Has the power to influence change) (Has no power or limited power to influence change)

Has the power to influence change

Has no power or limited to influence change

Patient/users X X Health professionals – primary care

X X


X X


X X


X

Payers X Politicians X Private health providers X X Other stakeholder (please specify)



Effective cardio

Stakeholders involve in the Effective cardio programme:

The unit’s cardiologists and nurse practitioners provide care to heart failure patients in the region, involving the patient’s general practitioner, nurses from a local home care agency and physicians at the nursing home, if patients reside at such facilities. Staff had prescription and treatment authorisation, preventing delay in response-treatment times and preventing burden on the workload of the cardiologist. The telemonitoring system was used to obtain and check patient vital sign measurements (blood pressure, pulse, weight) on a daily basis. All members of the cardiology department had access to the telemonitoring system, allowing them to check vital sign measurements at every moment and react accordingly. Patients were given automated devices for daily measurements of blood pressure, heart rate and weight at home. A nurse practitioner evaluated the measurements every day using a dedicated clinical user interface. With tailored alarm settings, the nurse practitioner could identify which patients exceeded the alarm limits and needed extra attention. The situation was evaluated with a phone call or extra visit and if necessary the nurse practitioner altered the treatment.



Patient/users

X

Health professionals – primary care

X


X X


X X


X X

Payers X Politicians X Private health providers X X Other stakeholder (please specify)



What power do the various stakeholders have towards the programme? (Has the power to influence change) (Has no power or limited power to influence change) Has the power to



X


X


Health administrators X Payers X Politicians X Private health providers Other stakeholder (please specify)

Region of South Denmark (RSD)

Center for Telepsychiatry

Stakeholders involve in the Center for Telepsychiatry:

In the telepsychiatric service in ACT@Scale, the patients are responsible for referring themselves to the treatment. Usually, the GPs in the region are the gatekeepers for a patient’s treatment but in this case, they can only recommend the service to the patient and create awareness of the opportunity to enter the service.

After the self-referral, the psychiatrists at the telepsychiatric center assess the referral and invite the patient to a video consultation in order to determine if the telepsychiatric service is the optimal solution for the individual patient. The communication between the psychiatrists and the patients are online communication but face to face via video consultation. The online treatment is conducted in certain modules that the patient will follow and it constitutes a form of “self-treatment”. During the course of treatment, the psychiatrists follow the activities and results for each patient.

The care professionals, patients and decision makers have been and are a top priority as stakeholder since the project was initiated as their perspectives are key in order to sustain the service. The health administrators, regional politicians and payers are responsible for the payment schemes for the health and psychiatric treatment in the region.



The implementation of the service has changed the reimbursement flows for psychiatric treatment and included telepsychiatric treatment on the same level as “usual” psychiatric treatment.




Patient/users x Health professionals – primary care

x


x



x

Payers x Politicians x Private health providers Other stakeholder (please specify)


(Has the power to influence change) (Has no power or limited power to influence change)




x


x



X

Payers X Politicians X Private health providers Other stakeholder (please specify)



Basque Country(BC) Multimorbid Population Integrated Intervention Programme

Stakeholders involve in the Multimorbid Population Integrated Intervention Programme

Primary Care professionals (GP and GP nurse) are principally responsible for a patient´s case management, therapeutic/care plan definition, drug prescription, patient training, home visits and follow-up when the patient is stable. While the communication between healthcare professionals and patient is mainly via traditional channels (f2f, phone), GP and GP nurse can communicate and share information through the EHR and the electronic prescription. Additionally, healthcare professionals can exchange patient-related documentation by meeting on a periodic-basis, phone or a social EHR.

The Telecare Centre is in charge of coordinating health and social care professionals. In fact, operators of the Telecare Centre can activate services entrusted to the eHealth Centre, such as telemonitoring or emergency department. Nursing of the eHealth centre is, in turn, responsible for managing telemonitoring alarms following validated protocols and giving health advice to patients.

Once the patient shows worsening symptoms but still is out of hospital care (unstable stage), additional healthcare actors take part in the caring process. The care manager takes charge of case management and either they or the GP refers the patient to a specialist if necessary. Upon a patient´s request, the Deputy health Service can be activated out of care hours and healthcare professionals can visit the patient at home to perform the clinical interventions required.

The roles that have to be highlighted in hospital care are those of reference internist and hospital liaison nurse. The former is responsible for carrying out tests and diagnotics, defining the therapeutic plan, following up the pharmacological plan, coordinating specialists, informing GP on patient´s health status, referring the patient to the long-term hospital (if required) and activating hospital social care team. The latter, in turn, supervises patient´s hospital discharge by sharing information with GP nurse and providing patient with information on therapeutic plan and health education.

Upon hospital discharge, GP and GP nurse perform an intensive follow-up, including home-visits, in order to ensure that patient´s health status is not worsening. The GP nurse carries out the patient´s integrated frailty assessment and, depending on the outcomes, community social services can be activated.






x


x

Health administrators x Payers NA Politicians x Private health providers NA Other stakeholder (please specify)Manager of integrated care organizations

x






X


X



X

Payers X Politicians X Private health providers X Other stakeholder Manager of integrated care organizations

X



Telemonitoring services for Congestive Heart Failure

Stakeholders involve in the Telemonitoring services for Congestive Heart Failure

Potential patients are approached by either the cardiologist or the hospital nurse during their admission in the hospital. These healthcare professionals explain the project to the patient and invite him/her to participate. If the patient accepts, once the informed consent is signed, the telemonitoring service is activated. After hospital discharge, the operator from the Telecare Centre, who has received the service activation, calls the patient to plan the installation of the devices at home. In 5-10 days after discharge, the technical staff from the Telecare Centre visits the patient at home and proceed to device installation. In parallel, 72 hours after hospital discharge, a nurse from the eHealth Centre calls the patient to investigate his/her health status and detect early symptoms of worsening. To do so, the nurse uses a validated and structured questionnaire. Depending on the answers collected form the patient the actions to be taken differ (no action, appointment with the GP or activation of emergency service). Once the patient starts transmitting telemonitoring data, the cardiologist revises the information and, based on clinical criteria, contacts the patient to adjust the pharmacological treatment if necessary. When the patient is considered stable, primary care professionals are responsible for patient management and proactive follow up. During this phase, if the GP considers important, he/she contacts the patient to investigate his/her health situation.





x


x x



x

Payers NA Politicians x Private health providers NA Other stakeholder (please specify)




(Has the power to influence change) (Has no power or limited power to influence change) Has the power to



x


x


Health administrators x Payers x Politicians x Private health providers x Other stakeholder (please specify)



Northern Ireland (NIRE) Stakeholders involve in the COPD telemonitoring services

Patient/users, health professionals – primary care & secondary care, health administrators and politicians are identified stakeholders Each patient is managed by a key worker who is usually a specialist respiratory nurse or physiotherapist. The key worker will refer the patient to the program and monitor their readings via the portal. The key worker is responsible for setting care plan and parameters for each patient. COPD patients are usually monitored by the telemonitoring centre triage team. These are qualified nurses who will monitor the patients’ readings and contact them by telephone if there is an issue. If the triage nurse feels that the patient needs care they will contact the key worker by telephone and email. The respiratory team are also responsible for contacting the patient of there is an issue with readings. This may mean they need to see the patient or contact another health professional e.g GP Health administrators within the Centre for Connected Health and Social Care at the Public Health Agency in NIRE are responsible for managing the telemonitoring programme regionally. They are involved in regular meetings with service provider and health professionals to develop service and evaluate progress. Politians support the use of telemonitoring in NIRE



Patient/users Health professionals – primary care



Payers Politicians








Payers Politicians

Diabetes telemonitoring services

Stakeholders involve in the Diabetes telemonitoring services

Patient/users, health professionals – primary care & secondary care, health administrators and politicians are identified stakeholders

Each patient is managed by a key worker who is usually a specialist diabetes nurse. This nurse will refer the patient to the program and monitor their readings (blood glucose ) via the portal.

The specialist nurse is responsible for contacting the patient of there is an issue with blood glucose readings. This may mean they need to see the patient or contact another health professional e.g GP

Health administrators within the Centre for Connected Health and Social Care at the Public Health Agency in NIRE are responsible for managing the telemonitoring programme regionally. They are involved in regular meetings with service provider and health professionals to develop service and evaluate progress.

Politicians support the use of telemonitoring in NIRE





Patient/users




Payers

Politicians

What power do the various stakeholders have towards the programme? (Has the power to influence change) (Has no power or limited power to influence change)






Payers Politicians

Weight management telemonitoring services

Stakeholders involve in the Weight management telemonitoring services

Patient/users, health professionals – primary care & secondary care, health administrators and politicians are identified stakeholders

Patients are identified as suitable for program ( criteria used) by the midwife when they attend for first appointment.

Patient is given information about program and asked for consent to join.

Each patient is managed by a midwife and a dietician who will monitor weight readings sent to the portal by patient.



The midwife or dietician is responsible for contacting the patient of there is an issue with readings. This may mean they need to see the patient.

Health administrators within the Centre for Connected Health and Social Care at the Public Health Agency in NIRE are responsible for managing the telemonitoring programme regionally. Another directorate within PHA is responsible for the Weigh to a Healthy pregnancy initiative.

Regular meetings with service provider and health professionals to develop service and evaluate progress. Professionals are encourage to get feedback from patients on the program

Politicians support the use of telemonitoring in NIRE



Patient/users




Payers

Politicians



Patient/users




Payers



Politicians

Catalonia (CAT)

Integrated care for subacute and frail older adults PSPV

Stakeholders involve in the Integrated care for subacute and frail older adults PSPV

Our internal professionals (geriatricians, nurses, physical therapists, social workers) are one relevant internal stakeholder. They are responsible for the whole process of patient care, and they are aware and also committed in meeting quality and performance indicators. One specific physician (rotating task), is the responsible for beds management in collaboration with the Admission Committee of the facility. We involve them through strategic meetings (they were responsible for the proposal of their functional plan), through periodic meetings, and through financial incentives in their contracts. They receive weekly information about their global performance.

The patients are our main internal stakeholder. We involve them in therapeutic decisions, with a constant but not fully standardized approach. We consult them through a satisfaction survey every two years, and through annual focus groups.

The referring acute care (mainly emergency care) and primary care professionals are our main external stakeholders. They are responsible for an optimal selection of candidate patients, and, in case of primary care, for continuity of care at discharge. We are in constant telephonic contact with them, and we organize an annual meeting to receive their feedback and discuss improvement plans.

We also hold at least annual meetings with health administrators and payers, to discuss about the contract and about performance and quality indicators.




X


X




X


X

Payers X Politicians Private health providers Other stakeholder (please specify)



Patient/users

X


X


X



X

Payers X Politicians Private health providers Other stakeholder (please specify)

Healthcare support programmes for nursing homes

Stakeholders involve in the Healthcare support programmes for nursing homes

EAR teams are active in the residences/nursing homes.The EAR teams are principally responsible for the institutionalized patient’s case management. EAR professionals handled the resources necessary for addressing health problems through protocols and circuits that are enable at primary and secondary care.

EAR professionals use electronic medical history of primary care, ensuring that the patient's history is accessible to all health workers involved in the



management of health problems the patient through the shared medical history of Catalunya.

The EAR teams are annually evaluated based on the indicators that are specified in the purchase contract of CatSalut (health administrators). Quantitative and qualitative indicators (activity and health outcomes) are evaluated.

The EAR program charges by the CatSalut an annual amount (according clause) and a variable part according to the results of the evaluation.

The relationship of the EAR teams with the Department of Social Care, is tracking quality indicators from the nursing homes.




x


x


x


x

Payers x Politicians x Private health providers x Other stakeholder (please specify)Nursing homes, and Social Care Department.

x





Patient/users

x


x




x


x


x

Payers

x

Politicians

x

Private health providers

x

Other stakeholder (please specify)Nursing homes, and social care department

x

Management of Complex Chronic Patients (CCP) at AISBE

Stakeholders involve in the Management of Complex Chronic Patients (CCP) at AISBE

What attitude do the various stakeholders have towards the programme? Mostly in favour of change Mostly against

change Patient/users

FAVOUR with no resistances


FAVOUR, but the programs implies three conditions: (i) Higher resolution capacity of primary; (ii) Novel ways of coordination and collaborative work with specialists; and, (iii) incorporation & consensus on collaborative tools.


FAVOUR; but conditions (ii) and (iii) of the primary care professionals are valid for specialists


FAVOUR – But change management generates new challenges. Resistances are varying over time.



Payers

FAVOUR – But there is need for full new scope of calculations of costs. Not implemented yet

Politicians

FAVOUR - But often not mature enough to understand/support specificities of the implementation


ANXIOUS because they usually don’t feel comfortable with changing scenarios

ACADEMIC SLOWLY ADAPTING – Still management changes is not viewed as an academic issue. But very slowly are aware that methods/focus of academic areas need to evolve. Convergence between Integrated Care and Systems Medicine is a must.



Patient/users

Weak power


Strong power


Strong power


Strong power

Payers

Strong power

Politicians

Moderate power as individual (but to put integrated care in the center is key)


Weak power (are followers)

Academic STRONG POWER – Deserve more attention



Promotion of Physical Activity (PA) at AISBE

Stakeholders involve in the Promotion of Physical Activity (PA) at AISBE




Patient/users

FAVOUR with no resistances


FAVOUR, but the programs implies three conditions: (i) Higher resolution capacity of primary; (ii) Novel ways of coordination and collaborative work with specialists; and, (iii) incorporation & consensus on collaborative tools.


FAVOUR; but conditions (ii) and (iii) of the primary care professionals are valid for specialists


FAVOUR – But change management generates new challenges. Resistances are varying over time.

Payers

FAVOUR – But there is need for full new scope of calculations of costs. Not implemented yet

Politicians

FAVOUR - But often not mature enough to understand/support specificities of the implementation


ANXIOUS because they usually don’t feel comfortable with changing scenarios

ACADEMIC SLOWLY ADAPTING –



Still management changes is not viewed as an academic issue. But very slowly are aware that methods/focus of academic areas need to evolve. Convergence between Integrated Care and Systems Medicine is a must.





Patient/users

Weak power


Strong power


Strong power


Strong power

Payers

Strong power

Politicians

Moderate power as individual (but to put integrated care in the center is key)


Weak power (are followers)

Academic STRONG POWER – Deserve more attention



CONCUSIONS • In general, programmes used an adhoc management process to identify

stakeholders in their programme rather than a much more defined and established process. Therefore, programmes do not usually carry out activities related to the assessment of stakeholder commitment such as risk analysis and periodic evaluation of stakeholders’ management

• Most of the programmes declared having a specific strategy to identify stakeholders. A few programmes do not have any specific strategy to identify stakeholders.

• The strategy/communications and alignment and monitoring are key elements that programmes are addressing first as change management elements.

• Most of the programmes declared that lack of leadership was the most important barrier in phase 1 and phase 2. Barriers faced in phases 3 and 4 were a little different, and results showed that pressure for short term results and stakeholder resistance are the most important barriers at these Phases.

• Strategies such as identification of stakeholders and project leaders and involvement of decision makers at the beginning of the programme were key factors utilised to overcome lack of leadership.

• It should be noted that programmes do not always report tools and strategies to overcome barriers they are facing such as inadequate skills or lack of recognition of need of change.



Appendix 1. WP5 Questionnaires on stakeholder and change management

WP5 Mapping information

Region:

Programme: Due date:

ACT@Scale

Advancing Care Coordination and Telehealth @ Scale



Background The specific objective of Workpackage 5 (WP5) is to achieve an appropriate level of support and commitment from the stakeholders to innovative health services, specifically care coordination and telehealth.

The main target will be to gather baseline information of staff engaged within the ACT@Scale programme, to know stakeholder engagement through knowing the overall staff engagement across programmes and finally validate the change management through the maturity map of the EIP-AHA B3.

The specific objectives of WP5 are:

1. To identify stakeholders and analyse their contribution and commitment to the project, as well as issues related to organisational or technological change.

2. To develop and deploy a tool to provide a baseline for stakeholder engagement.

3. To design an action plan aimed to increase stakeholder contributions to the project.

This questionnaire is intended to be addressed to the programme managers of each of the ACT@Scale programmes involved in the project to collect the map of current situation in the area of stakeholder management and change management.



Mapping: description of structural items

Stakeholder Management 1. In the strategic plan of your programme, is there any specific strategy of

identification and selection of stakeholders of your programme? • Yes • No

2. Is there an implementation plan available for the identification and selection of stakeholders in your programme? • Yes • No

3. Could you please describe what the process you usually follow to identify is, select and prioritize stakeholders (identification: listing of relevant groups, organizations; analyzing: understanding stakeholder perspectives and interests; mapping: visualising relationships and other stakeholders; prioritizing: ranking stakeholder relevance and identifying issues.

4. Please describe which stakeholders are involved in your progamme? (please select all that apply)

• Patient/users • Health professionals – primary care • Health professionals – secondary care • Health administrators • Payers • Politicians • Private health providers • Other stakeholder (please specify)

Considering:

Phase 1: Planning of change, is the designing phase of the program. The case for change is built, all aspects for the program are defined (intervention, scope, timeframe, resources, etc.), and support for the program needs to be gathered



Phase 2: Adaptation phase, in which the program is tested in a pilot implementation

Phase 3: Full scale implementation phase, final implementation of the program

Phase 4: Continuous improvement after deployment, once the program is implemented, outcomes are assessed and adaptations of the program may occur in order to improve their performance

4.1 What attitude do the various stakeholders have towards the programme?






Health administrators Payers Politicians Private health providers Other stakeholder (please specify)

4.2 What power do the various stakeholders have towards the programme? (Has the power to influence change) (Has no power or limited power to influence change)






Health administrators x Payers x Politicians x Private health providers x Other stakeholder (please specify)



5. How did you involve stakeholders in your programme? (please select all that apply)

Phase 1: Planning of change

Phase 2: Adaptation phase

Phase 3: Full scale implementation phase

Phase 4: Continuous improvement after

deployment Patients/Users 1 – inform (give info)

2 – consult (ask for info) 3 – collaborate (work with) 4 –Give responsibility to stakeholder

1 – inform (give info) 2 – consult (ask for info) 3 – collaborate (work with) 4 –Give responsibility to stakeholder



Health professionals –primary care





Health professionals –secondary care

1 – inform (give info) 2 – consult (ask for info) 3 – collaborate (work






with) 4 –Give responsibility to stakeholder




Health administrators 1 – inform (give info) 2 – consult (ask for info) 3 – collaborate (work with) 4 –Give responsibility to stakeholder




Payers 1 – inform (give info) 2 – consult (ask for info) 3 – collaborate (work with) 4 –Give responsibility to stakeholder




Politicians 1 – inform (give info) 2 – consult (ask for info) 3 – collaborate (work with) 4 –Give responsibility to stakeholder






Private health providers 1 – inform (give info)





ICT Industry 1 – inform (give info) 2 – consult (ask for info) 3 – collaborate (work with) 4 –Give responsibility to stakeholder




Academy 1 – inform (give info) 2 – consult (ask for info) 3 – collaborate (work with) 4 –Give responsibility to stakeholder




Other stakeholder 1 – inform (give info) 1 – inform (give info) 1 – inform (give info) 1 – inform (give info)



6. Has the programme performed a stakeholder commitment assessment prior to the beginning of the programme? • Yes • No

7. Have risk related to stakeholders commitment been analysed? • Yes • No

8. Have mitigating measures been adopted? • Yes • No

9. Has the programme an action plan oriented to maintain and increase stakeholders commitment? • Yes • No

10. Does the programme perform periodic assessments on the stakeholders management process? • Yes • No



Change Management The survey is in three main sections. Section 1 collects the usual process and key elements you follow for change management in your programme. Section 2 collects in which areas and phases of change management is your programme at the moment. Finally, section 3 collects the main barriers faced for change management.

Section 1. CHANGE MANAGEMENT PROCESS AND KEY ELEMENTS FOR ADDRESSING IT

1. If any, which methodology for change management are you applying in your programme? Please give a short explanation.

1. Which elements of change management are you addressing? (select all that apply)

1. Culture. Analysis of the readiness to change and innovation culture. 2. Strategy/re-organization. Towards chronic care management and

integrated care and implementation plans. 3. Leadership and guidance. Selection of leaders, type of leadership and

sponsors of the changes.



4. Communications. Dissemination of the new strategy in the organization.

Possibility of top-down and bottom-up initiatives. 5. Capabilities. Analysis of the new roles and capabilities required. Processing

of old-role models. 6. Alignment. Availability of political, legal and organisational

support/endorsement towards integrated care. 7. Financing and Incentives. Mechanisms to promote the change and

overcome resistance 8. Monitoring. Availability of performance indicators related to integrated care

in primary, secondary levels and programs. 9. Availability of public data.

3. Please describe how are you addressing the previously selected elements

Culture. Analysis of the readiness to change and innovation culture.

Strategy/re-organization. Towards chronic care management and integrated care and implementation plans.

Leadership and guidance. Selection of leaders, type of leadership and sponsors of the changes.

Communications. Dissemination of the new strategy in the organization. Possibility of top-down and bottom-up initiatives.

Capabilities. Analysis of the new roles and capabilities required. Processing of old-role models.

Alignment. Availability of political, legal and organisational support/endorsement towards integrated care? At which level?

Financing and Incentives. Mechanisms to promote the change and overcome resistance



Monitoring. Availability of performance indicators related to integrated care in primary, secondary levels and programs. Availability of public data.

Section 2. CHANGE MANAGEMENT AREAS AND PHASES

4. In which step are you in the process within the following integrated care areas? (select all that apply)

Phase 1: Planning of

change

Phase 2: Adaptation

phase

Phase 3: Full scale

implementation phase

Phase 4: Continuous

improvement after

deployment

a. Organisational models

X

b. Workforce development

X

c. Development of population stratification tools

d. Integrated care pathways

X

e. User involvement/Patient engagement

X

f. Support of technology for the new care model

X

Phase 1: Planning of change, is the designing phase of the program. The case for change is built, all aspects for the program are defined (intervention, scope, timeframe, resources, etc.), and support for the program needs to be gathered

Phase 2: Adaptation phase, in which the program is tested in a pilot implementation

Phase 3: Full scale implementation phase, final implementation of the program

Phase 4: Continuous improvement after deployment, once the program is implemented, outcomes are assessed and adaptations of the program may occur in order to improve their performance



Section 3: CHANGE MANAGEMENT BARRIERS AND MAIN TOOLS TO OVERCOME THEM

5. Please indicate barriers you have faced for change management (Please tick the appropriate box)

(Please rate the following aspects, where 10 means that it can block change and 0 is irrelevant or not applicable)

Phase 1:

Planning of change

Phase 2: Adaptation

phase

Phase 3: Full scale implementation

phase

Phase 4: Continuous

improvement after

deployment

a. Lack of time

10- essential (potentially can block change) 9 8 7 6 5 4 3 2 1 0 – irrelevant /not applicable




b. Pressure for short term results

10- essential (potentially can block change) 9 8 7 6 5 4 3 2 1 0 – irrelevant






/not applicable /not applicable

c. Stakeholder resistance (specific stakeholder).





d. Unstructured approach to change management





e. Lack of recognition of need for change

10- essential (potentially can block change) 9 8 7 6 5

10- essential (potentially can block change) 9 8 7 6 5

10- essential (potentially can block change) 9 8 7 6 5 4

10- essential (potentially can block change) 9 8 7 6 5 4



4 3 2 1 0 – irrelevant /not applicable

4 3 2 1 0 – irrelevant /not applicable

3 2 1 0 – irrelevant /not applicable

3 2 1 0 – irrelevant /not applicable

f. Lack of leadership





g. Lack of vision





h. Inadequate skills

10- essential (potentially can block change)

10- essential (potentially can block change)

10- essential (potentially can block change) 9

10- essential (potentially can block change) 9



9 8 7 6 5 4 3 2 1 0 – irrelevant /not applicable

9 8 7 6 5 4 3 2 1 0 – irrelevant /not applicable

8 7 6 5 4 3 2 1 0 – irrelevant /not applicable

8 7 6 5 4 3 2 1 0 – irrelevant /not applicable

i. Inflexible Information technology





j. Lack of funding







/not applicable /not applicable

k. Lack of adequate incentive schemes for change





6. Strategies/tools that you are using/have used with success to overcome the above indicated barriers. Please explain why there were successful.

a. Lack of time

b. Pressure for short term results

c. Stakeholder resistance (specific stakeholder).

d. Unstructured approach to change management

e. Lack of recognition of need for change

f. Lack of leadership

g. Lack of vision

h. Inadequate skills

i. Inflexible Information technology

j. Lack of funding

k. Lack of adequate incentive schemes for change



Appendix 2. Close-ended answers to stakeholder and change management questions



Table 1. Stakeholder Management: answers to questions 1, 2, 4,6,7,8,9 and 10.

Basque Country Catalonia SD N Netherlands -

Groningen NIRE

Question Nbr Question Possible Answers

Tele

mon

itorin

g of

Co

nges

tive

Hear

t Fa

ilure

Mul

timor

bid

Popu

latio

n In

tegr

ated

Inte

rven

tion

Prog

ram

me

Pere

Virg

ili

Heal

thca

re su

ppor

t Pr

ogra

mm

e fo

r Nur

sing

Hom

es

Chro

nic

Patie

nt

Prog

ram

me

Com

plex

cas

e m

anag

emen

t De

ploy

men

t of

colla

bora

tive

self‐

man

agem

ent s

ervi

ces

prom

otin

g he

alth

y lif

esty

les:

phy

sical

ti

it

Cent

re fo

r Te

leps

ychi

atry

Asth

ma

COPD

Te

lehe

alth

Ser

vice

Embr

ace

Effe

ctiv

e Ca

rdio

COPD

tele

mon

itorin

g se

rvic

es

Diab

etes

te

lem

onito

ring

Wei

ght m

anag

emen

t te

lem

onito

ring

serv

ices

1 In the strategic plan of your programme, is there any specific strategy of identification and selection of stakeholders of your programme?

Yes = 1 No = 0 No Yes Yes Yes No Yes Yes No No Yes Yes Yes

2 Is there an implementation plan available for the identification and selection of stakeholders in your programme?

Yes = 1 No = 0 No Yes No No No No Yes No No Yes Yes Yes

4 Please describe which stakeholders are involved in your progamme? (please select all that apply)

Patient/users = 1 Health professionals – primary care = 2 Health professionals – secondary care = 3 Health administrators = 4 Payers = 5 Politicians = 6 Private health providers = 7 Other stakeholder (please specify) = 8

X X X X X X X X X X X

X X X X X X X X X X X X



X X X X X X X X

X X X X X X X

X

X X X

6 Has the programme performed a stakeholder commitment assessment prior to the beginning of the programme?

Yes = 1 No = 0 Yes Yes No No No No No Yes No No No No

7 Have risk related to stakeholders commitment been analysed?

Yes = 1 No = 0 Yes No No No Yes Yes No No No No No No

8 Have mitigating measures been adopted? Yes = 1

No = 0 Yes No No No Yes NA No Yes No Yes Yes Yes

9

Has the programme an action plan oriented to maintain and increase stakeholders commitment?

Yes = 1 No = 0 No Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes

10

Does the programme perform periodic assessments on the stakeholders management process?

Yes = 1 No = 0 No No Yes Yes No No Yes No Yes No No No



Stakeholder management: Collection of answers to the Question 5: How did you involve stakeholders in your programme?

Table 2.Stakeholder Management: answers to question 5

Give information (N) Ask for info (N) Collaborate (N) Give responsibility (N)

Patient/User 11 12 8 5 Healthcare professionals 8 8 11 11 Health administrators 8 10 9 8 Payers 8 6 7 6 Politicians 7 3 1 2 Private health providers 3 3 3 2 ICT industry 6 7 12 6 Academy 8 6 7 5



Change Management: Collection of answers to Questions 1,2 and 4.

Table 3. Change Management: answers to questions 1,2 and 4.

Basque Country

Catalonia SD N Netherlands - Groningen

NIRE

Question Nbr

Question Possible Answers

CHF

tele

mon

itor

ing

Mul

tim

orbi

d In

tegr

atio

n

Frai

l old

er a

dult

s

Nur

sing

hom

es

Chro

nic

Care

Com

plex

cas

e m

anag

emen

t

Phys

ical

act

ivit

y

Tele

psyc

hiat

ry

Ast

hma/

COPD

Embr

ace

Effe

ctiv

e Ca

rdio

COPD

Tel

emon

itor

ing

Dia

bete

s t

elem

onit

orin

g

Wei

ght

man

agem

ent

1 Which methodology for change management are you applying in your programme?

Yes

Yes Yes

No Yes

Yes

No No No No No No No

2 Which elements of change management are you addressing?

Culture Strategy Leadership and guidance Communications Capabilities Alignment Financing and incentives Monitoring Availability of publica data

X X X X

X X X X X X X X X X X X X X

X X X X X X X

X X X X X X X X X X X X X X

X X X X X


X X X X X X X

X X X X X X X X X X X X X

X X X X X X X X X X

4 In which step are you in the process within the following integrated care areas?

Organisational models Workforce development Development of population stratification tools Integrated care pathways User involvement/Patient

3 3 4 4 4 3 1 3 4 3 4 4 4 4

2 2 4 4 4 3 2 3 3 3 4 1 1 1

4 4 1 4 3 4 4 2 3 3 1 1 1

3 3 4 4 4 3 1 3 4 3 4 4 4 4

2 2 1 3 4 2 1 3 1 3 4 4 4 4

3 4 1 4 3 4 2 3 2 3 3 2 2 2



engagement Support of technology for the new care model



Appendix 3. Open-ended answers to Stakeholder and Change Management Questions Stakeholder management: Collection of answers to the Question 3: Could you please describe what process you usually follow to identify stakeholders

PROCESS FOLLOWED TO IDENTIFY STAKEHOLDERS There is a formalised process for the collaboration between stakeholders in the regional set up (SAM:BO). According to the collaboration agreements certain stakeholders are part of each care pathway and therefore they have to be part of the stakeholder management. The care professionals, the patients and the decision makers have had top priority from the beginning in order to understand their needs, perspectives and interests. Organizations for delivery of care and support in primary care: local GP (group) practices, primary care organizations, welfare organizations, nursing homes, homes for the elderly; in secondary care: community hospitals, tertiary academic hospital. Organizations for financing care and support: healthcare insurance company, care administration offices, municipalities organizations representing older adults Analyzing: Defined in partnership agreements with partners. Mapping: see attachment. Prioritizing: not performed. All stakeholders mentioned are considered key for continued implementation of the Embrace program. Identification: secondary care, healthcare insurance company, private companies, patient users. Analyzing: Defined in partnership agreements with partners. Mapping: not performed. Prioritizing: not performed. All stakeholders mentioned are considered key for continued implementation of the Effective Cardio program. Identification:relevant groups GP offices, laboratory organizations, secondary care.Analyzing:Defined in partnership agreements with partners. Mapping:not applicable.Prioritizing:not performed. All stakeholders mentioned are considered key for continued implementation of the program. Analyzing: understanding stakeholder perspectives and interests Identification includes the list of relevant groups involved in our healthcare program; we also collect and analyse their perspectives and suggestions, usually following a qualitative methodology (focus groups etc). We identify our stakeholders and analize which are the needs of our programme and our stakeholdres’ needs, and try to match all them to obtain the best benefit for the patients who are living in nursing homes and for the sostenibility of the health and social system. We are able to do this by participating in different commissions that are available to coordinate the different levels of care (health and social), including nursing homes. On commencement of the programme key stakeholders were identified and listed according to their interest and contribution to the design and implementation of telemonitoring. Regular meetings are held with stakeholders Based on the care pathway of the telemonitoring service for congestive heart failure patient, the actors involved are identified and numbered (eg. cardiologists, hospital nurses, GPs, GP practice nurses, eHealth Centre etc). Once the list is completed, the head of the corresponding department, such as general director of the healthcare organization, is approached in order to engage them and obtain their commitment to be involved in the program. Once all relevant stakeholders are on board, a multidisciplinary working team is formed to ensure all perspectives are considered in the definition of the care pathway and the up-scaling process.



Change Management: Collection of answers to the Question 1: If any, which methodology for change management are you applying in your programme? Please give a short explanation

METHODOLOGY USED FOR CHANGE MANAGEMENT We apply a PDCA methodology, maintaining periodic (at least every year) meetings with stakeholders, and analyzing weekly performance data and every six month quality indicators. Then, we plan involving the professionals and, occasionally the users, and implement the changes (CAT IL IC) Nospecific methodology applied explicitly, but all ellements were adressed (more ore less) during the four phases mentioned above. (NNL IL IC) New projects are coordinated through the Clinical Transformation Office.The main objective of the office is to control form a strategical perspective the changes that would affect the way professionals work. It involves all the directors affected by the possible change and the Quality Department. The directors discuss from a strategical perspective each change/project and the Quality Department is in charge of assessing those. The office selects the project teams amongst the professionals for the good implementation of the project. Within that decision, champions amongst the professionals are chosen in order to help with the change management process. So the methodology would be involving all the relevant stakeholders since the very begining of the process in order they feel the project is from themselves and chosing champions amongst the professionals that will help convincing others (CAT CHRON IC). Not applicable, no methodology applied (NNL CARD TH) Not applicable, no methodology applied (NNL RESP TH) Nospecific methodology applied explicitly, but all elements were adressed (more ore less) during the four phases mentioned above (NNL IL IC) No formal methodology(NIRE) The main steps followed to boost change management among healthcare professionals are focused on two main objetives: 1. Definition of a sustainable patient-centered care pathway 2. Promote professionals ́ engagement and increase their sense of belonging with respect to the program The process to create integration pathway was conceived according to the “Design thinking” methodology developed by Tim Brown. This is a method for meeting people’s needs and desires in a technologically feasible and strategically viable way by using different steps: empathize, define, ideate, prototype and test. This multidisciplinary approach process was implemented in four phases: the analysis of existing services, the definition of current organisational models, self-assessment of such models and definition of improvement areas. (BAS CARD TH) We are a programme, that is funded by the CatSalut (administrators). The goal is to give a integrated care to the people who live in nursing homes, making this care sustainable for the system. The population that who take care of are 87 years old of mediana, and need to use a lot of public resources for their health needs. So our methodology is a proactive assistance to this population provided by a multidisciplinary team who promote the adequacy of resources (pharmacy, visits to emergency centers, ...) We monitorate the use of this resources (CAT IL SUP) The program is in a phase of refining and articulating previous existing programs following a building blocks approach. Basically, the Home Hospitalization program, already well consolidated, is expanding; whereas the transitional care program and the long-term care programs are being remodelled and better linked with Home Hospitalization and, in general, enhancing the bridging between specialized care and primary care/social support. Overall, the process can be defined as improvement of vertical integration. (CAT CHRON IC) The process to create integration pathway was conceived according to the “Design thinking” methodology developed by Tim Brown. This is a method for meeting people’s needs and desires in a technologically feasible and strategically viable way by using different steps: empathize, define, ideate, prototype and test. This multidisciplinary approach process was implemented in four phases: the analysis of existing services, the definition of current organisational models, self-assessment of such models and definition of improvement areas.(BAS MM IC)



Change Management: collection of answers to the Question 3: Please describe how are you addressing the previously selected elements:

HOW ARE YOU ADDRESSING CHANGE MANAGEMENT? Culture Local pulmonologists General practitioners and nurses were involved in developing of the scheme by three evening discussions (NNL

RESP TH). Involve stakeholders along the entire chain of care to implement the program. Several interviews were held to obtain stakeholder input and willingness to change (NNL CARD TH) By informing and consulting stakeholders, training and coaching on the job of professionals and regular evaluations (NNL IL IC). Innovation culture is one of the key aspects of the organisation. In fact, innovation has been part of the strategic plans of the organisation since year 2000. The representation of that cultural treat of the organisation is the Direction of Innovation, Research and ICT which is in charge of promoting the culture through all the levels of the organisation. Innovations based on product, process and service are oriented through the Innovation Office which is a place where all the professionals are able to come with ideas and are helped (if worth) to make them become real. Further to that, the Innovation Office is in charge of promoting the culture of innovation where it periodically does open sessions and open innovation exercises either with professionals, companies and citizens (CAT CHRON IC).

Strategy/re-organization

As said, we implement organization changes involving stakeholders (for example, we run a design-thinking process to evaluate possible changes to improve discharge of our patients; we also took advantage of the reorganization of the pharmacy to include the pharmacist in our program)(CAT IL IC) Current efforts include involving all stakeholders to develop sustainable implementation and scaling up of the Asthma COPD Telehealth program. This is done by assessment of the true costs of each (virtual) consultation, assessment of the impact of the AC service for the stakeholders and formulating alternative financing schemes, making the program self sustainable in the future. To this end, several meetings are set up with management of the laboratory , health administrators on the one hand, and payers on the other hand. (NNL CARD TH) Current efforts include involving all stakeholders to develop sustainable implementation and integration of the Effective Cardio program. This is done by formulating alternative financing schemes, making the program self sustainable in the future. To this end, several meeting are set up with health administrators on the one hand, and payers on the other hand ( NNL CARD TH). Current efforts include involving all stakeholders to develop sustainable implementation and integration of the Embrace program. Stakholders are united in steering committees to formulate and to negotiate alternative financing schemes to making the program (financial) sustainable for the future ( NNL IL IC). Strategy/re-organization. Towards chronic care management and integrated care and implementation plans. Integrated care and chronic care management is an inherent part of the organisation strategy. Managing the three classical levels of health care and the social services within the same organisation makes it a must to take into account when planning the strategy. The different programmes are continuously assessed to check on their performance and the Clinical Transformation Office is always looking for new ways to improve the services provided to the citizens from two perspectives: efficacy and efficiency ( CAT CHRON IC). The care pathway based on the telemonitoring service puts the patient in the centre and all healthcare professionals are coordinated to provide a service meeting patient´s needs, avoiding duplicities and deficiencies. The care pathway specifically depicts the function each professional has to perform and the communication channels between them. All the care pathway´s aspects have been discussed and agreed between all stakeholders (with thenexception of tye patient), ensuring all perceptions are considered ( BAS CARD TH)



Population Integrated Intervention Program (PII) for multimorbid patient has been designed by the managers and clinicians of both Hospitals and Primary Care Centres involved. All stakeholders' perspectives have been taken into account and a clear methodology in the designing of the intervention has been carried on (analysis of current model, detection of improvement areas, prioritize actions and define the new care pathway)( BAS MM IC). Care professionals and decision makers are involved in the development and are consulted in relation the needs and the changes needed in the organisation to accommodate telehealth solutions in comparison with usual care. The telehealth approach is a strong focus point for RSD and is reflected in national guidelines for telemedicine and health agreements in the region ( RSD MH TH).

We are expert in geriatrics and multidisciplinary teams (doctor and nurses, and social worker) that attend people in their home (nursing homes), and promote the adequacy of the resources and the use of the resources in the adequate place for the people (CAT IL IC)

Strategy/re-organization. Towards chronic care management and integrated care and implementation plans. (CAT CHRON IC) Leadership and guidance

Identify champions within each stakeholder group, with a willingness to transform current care practices( NNL RESP TH). Identify champions within each stakeholder group, with a willingness to transform current care practices, into a sustainable care models inclusive of integrated care models such as Effective Cardio ( NNL CARD TH). Identify champions within each stakeholder group, with a willingness to transform current care practices, into a sustainable model for person centred and integrated care such as Embrace. These leaders are supported by policy staff and researchers ( NNL IL IC). As it was previously mentioned, the Clinical Transformation Office is in charge of promoting and controlling the change process from all the different perspectives. This includes identifying all those professionals that are the most suitable to lead a new challenge. Within that strategy, champions are also identified in order to make them the project as it was from themselves which ultimately will lead to convince the other professionals about the change and avoid possible internal user buy-in problems (CAT CHRON IC). Some care providers were selected to lead the change and take the first steps towards changing the service ( RSD MH TH).

Our teams are led by expert managers who relacionate with the stakeholders, and also are led by expert clinical doctors and nurses (CAT IL IC).

Communications. Dissemination of the new strategy in the organization

We created a communication flow through massive email to our professionals, sharing weekly results and indicating changes. This is a formal strategy, besides periodic meetings and informal meetings. We also communicate results to partner institutions, at least every year ( CAT IL IC). The Asthma COPD Telehealth program communicates through several ways. First, there is website on which news updates, and a thourough explanation of the program. In addition, regular meetings are held with all stakeholders; from professionals to health administrators, care organisations and payers ( NNL RESP TH). The Effective Cardio program communicates through several ways. Publications have been made on academic and non/academic websites. In addition, regular meetings are held with all stakeholders; from end users and professionals to health administrators, care organisations and payers ( NNL CARD TH). The Embrace program communicates through several ways. First, there is website on which news updates, publications etc are posted. In addition, regular meetings are held with all stakeholders; from end users and professionals to health administrators, care organisations and payers ( NNL IL IC). Communication is one of the most important parts of change management and more concretely when you are working in an organisation including all this environments that have been historically separated. Further to that, from and Steering Board perspective there is a clear strategy to foster bottom-up initiatives that are oriented either from the Innovation Office or from the Clinical Transformation Office. The most strategic projects are normally organised in a top-down approach ( CAT CHRON IC). The basis of the telemonitoring service has been defined mainly by front-line professionals, who best know the main problems



while providing care, and managers of the healthcare organizations involved, who give an accurate perspective of the feasibility and sustainability of the processes/pathways. The care pathway agreed was shared with peers and the general directorate of the Basque Health Service (bottom-up approach). However, once the general directorate was convinced of the appropriateness and relevance of the service, a wider deployment of the service was pushed from the top manager (top-down approach)( BAS CARD TH). In order to ensure a sustainable care pathway implementation, it has been used a bottom-up and top-down approach. The pathway has been designed by the managers and clinicians of both Hospitals and Primary Care Centres involved. All stakeholders' perspectives have been taken into account and a clear methodology in the designing of the intervention has been carried on (analysis of current model, detection of improvement areas, prioritize actions and define the new care pathway). Professionals have been involved from the beginning ( BAS MM IC). Dissemination is key in spreading the results and activities related to the new services. This is done both top-down from the management and bottom up from the care providers and staff involved in the programme ( RSD MH TH).

Communications. Dissemination of the new strategy in the organization. Possibility of top-down and bottom-up initiatives (CAT CHRON IC)

We promote all the clinical practices that improve care and ensure continuity of care (CAT IL IC) Capabilities. Not applicable

Described in academic and non-academic publications (NNL CARD TH). For the professisonals in the Elderly team function analysis were developed that described the new roles and competencies in detail ( NNL IL IC). The care pathway deployed is based on tye re-organization of existing resources by creating new roles (especially those of the nursing), no new staff has been hired. This approach facilitates the sustainability of the telemonitoring service in long term. All the managerial teams of the organizations involved inteh up-scaling accepted to re-model the funtions of the professionlas involved ( BAS CARD TH). Wider deployment of the reference internist and hospital liaison nurse into other hospitals in the region; follow-up phone calls by the GP practice nurse on a monthly basis to monitor patient's health status; further develop the care pathways for frail older people to extend the eHealth Centre; provide symptom management questionnaires in the Personal Health Folder to further support self-management; rolling out the electronic prescription to additional healthcare professionals including pharmacists; development of a structured and standard empowerment programme for frail elderly patients and caregivers and provision of self-care and self-management educational material through the Personal Health Folder and Osakidetza web portal ( BAS MM IC). As mentioned earlier, telehealth and telepsychiatry is part of the strategic goals for the politicians and health organisations in RSD. Therefore, the programme has a high level of political attention (( RSD MH TH). We are continuously analyzing the needs of the residential population to improve healthcare care by the health professionals, according to the established circuits with territorial partners to contribute to sustainability (CAT IL IC).

Alignment. This is in part stated in the sections strategy and leadership above. In addition, the Asthma COPD Telehealth program program partners in several (EU) project (such as ACT@Scale) in which these type of questions are worked out( NNL RESP TH). This is in part stated in the sections strategy and leadership above. In addition, the Effective Cardio program partners in several (EU) project (such as ACT@Scale) in which these type of questions are worked out ( NNL CARD TH). This is in part stated in the sections strategy and leadership above. In addition, the Embrace program partners in several (EU) project (such as ACT@Scale) in which these type of questions are worked out ( NNL IL IC). Integrated care is the key aspect of the organisation and as it was previously mentioned it’s inherent to the nature of the



organisation. When it comes to the alignment at a political level, we must say that is total because the City Council of Badalona is the unique holder of the organisation. Further to that, the City Council, made a fusion of the Department of healthcare and the Department of Welfare and Family back in year 2000 in order to break the classical separation between the health and social care provision. This, has not changed since then even the political changes at a city level and it’s a model which is fully supported by all parties. This makes the alignment of all the key stakeholders a perfect environment for the development of integrated care services ( CAT CHRON IC). Once the telemonitoring service for heart failure showed to be beneficial in a smaller pilot (comprehensive evaluation performed), the general directorate of the Basque Health System decided to support the deployment at scale. Basically a corporative service program has been launched at Basque Country level which is completely aligned with the strategic plan of the Department of Health of the Basque Country ( BAS CARD TH). There is a clear strategic vision by the Basque Government towards the challenge of ageing, chronicity and dependency has provided explicit support, distributed leadership and created capacities in the organizations to transform the health and social care system in the Basque Country . The Health Plan 2013-2020 addresses all fields relevant to EIP AHA: 1. Equity and responsibility. 2. People with diseases, 3. Healthy Ageing, 4. Child and Adolescent Health and 5. Healthy environments and behaviors. In fact an explicit Strategy on Chronicity was already approved in 2010 designed to create an all-round patient-centred model capable of providing continuity of care on both health and social level. The Strategic Guidelines 2013-2016 of the Healthcare service, Osakidetza, reinforced and extended an integrated approach. As a consequence, during the last few years a number of processes and tools have been developed. They include: People as the core of the actions proposed, an integrated response to ageing, chronicity and dependence, Culture of prevention and health promotion, Ensure the sustainability of the system, Prominence and involvement of professionals and the Strengthening of research and innovation. A plan to achieve Integrated Care has been launched. Moreover, a specific strategy has been issued to bring together the efforts of the health and social and community care agents, the 2013-2016 Social and Health Care Plan. Its mission is the development of a model of effective and sustainable health and social care coordination, focused on the person, taking special care on security, autonomy, right to choose and decide, equity and wellbeing. A multidisciplinary Social and Health Care Commission that represents all agents involved in social and health care takes care of its deployment. The Basque Strategy on Ageing 2015-2020, establishes an interdepartmental government body to guarantee the mainstreaming among health and social providers and to foster an integral and coordinated care. All in all, the Basque Healthcare model aims to enhance patient cantered and seamless care by improving coordination and continuity of care between service levels and adapting care to patient needs. All actions promoted are completely aligned with it. For this reason, it is not only alignment with the strategic guidelines of the Department of Health Basque Government, but it is considered good practice in Osakidetza and there is a strong commitment of Osakidetza headquarters to scale it up (BAS MM IC).

We are applying the strategic lines of the Cronicity Plan and The Health Plan from the Helath Department. (CAT IL IC).

Financing and Incentives

We included our change strategy within personalized financial incentives to our staff ( CAT IL IC). The Asthma COPD Telehealth program program has started collaborations with other regions in the Netherlands in which laboratory organizations adopt the Asthma COPD Telehealth program working mechanism. (NNL RESP TH). The Effective Cardio program is financed through a combination of fee-for-service (FFS) and bundled payment of the health insurer to compensate the hospital department (NNL CARD TH) The Embrace program has started a pilot with capitation as an alternative financing structure for integrated care models for elderly



(NNL IL IC). It has been an important focus for the programme to look into the financing elements when a new telehealth service is provided to ensure that it is part of usual care. The programme has contact to the decision makers in region to ensure the focus on the financing ( RSD MH TH)

Mechanisms to promote the change and overcome resistance (CAT CHRON IC) We are funded by the government (CAT IL IC) Monitoring Monitoring of performance indicators is performed continuously by the program, because it has a large academic component; e.g.

data is collected each year on patient level ( NNL IL IC) Monitoring of performance indicators is performed continuously by the program ( NNL RESP TH) Monitoring of performance indicators is performed continuously by the program, because it has a large academic component; e.g. data is collected each year on patient level (NNL CARD TH). Monitoring. Availability of performance indicators related to integrated care in primary, secondary levels and programs. Availability of public data. Continuous monitoring and performance of the different programmes is one of the key points each time a new service is put in place. A corporate dashboard is made accessible to management team and all the professionals in order to track, improve and apply corrective measures where available. The set of indicators is defined by the Clinical Transformation Office that integrates a representative from the Quality Department ( CAT CHRON IC). The development of a modeling predictive tool in the form of Budget Impact Analysis allows to manage continuous improvement in the implementation of integrated healthcare for multi-morbid patients. The simulation model showed that, by considering ageing of the population, the multi-morbid patient population will increase by 8% by 2020. As the target population is larger and older, conventional health-care costs will have increased by 21%. If interventions could successfully reduce emergency costs annually by 2%, this budget would decrease 18%, with cumulative savings of over 500,000 euros in the study period ( BAS MM IC).

Availability of performance indicators related to integrated care in primary, secondary levels and programs.(CAT CHRON IC) We monitor indicators pharmacy and activity. We work with electronics and shared clinical history. CAT IL IC



Change Management: Collection of answers to the Question 6: Strategies/tools that you are using/have used with success to overcome the above indicated barriers. Please explain why there were successful.

Unstructured approach to change management

• Strategies involve project management tools for stakeholder involvement (e.g. RACI tables). (NNL) • The Clinical Transformation Office was the key instrument to tackle such an issue. It provided us from a tool to

overcome all the problems related to an unstructured approach to change management (CAT) • To secure strong leadership and project management to ensure that all stakeholders especially care

professionals, patients and politicians were informed of the changes being implemented ( RSD) Lack of recognition of need for change

• Strategies involve project management tools for stkeholder involvement (e.g. RACI tables). (NNL) • To involve professionals resistant to changes as the first ones to be introduced in the project team (CAT) • The flow of information has been key to support this challenge and strong collaboration with clinicians,

researchers and patients. >(RSD ) Lack of leadership • Strategies involve identification of champions among all stakeholders. Qualitative measures such as interviews

and stakeholders meeting were used as tools (NNL) • The management level and decision makers have been involved early in the process to ensure the proper

support to avoid a lack of leadership. (RSD) • The Clinical Transformation Office has helped into two things: 1) Identifying the professionals that will lead the

Lack of Time • Strategies used involve project management tools for planning (NIRE / NNL ) • Involving people that are motivated to be part of the project (CAT) • In the implementation phase the reimbursement structures have been an important way to ensure the proper

resources were available (RSD) Pressure for short term results.

• Fragment or calendarize results in order to design a pathw oriented to progressive achievement of refined results (CAT)

• Involvement and engagement of politicians and decision-makers has been key to decease the pressure on the short term results. The management layer has had focus on ongoing quality assurance which has removed some of the pressure. (RSD)

• Strategies used involve added involvement of researchers (NNL) Stakeholder resistance

• Individual analysis and approach. Starting from the leader(CAT) • Involving all stakeholders from the very start of the program. And to ask for their input throughout all phases.

Strategies used involved project management tools for stakeholder involvement (e.g. RACI tables)( NIRE / NNL) • Regular stakeholder communication and participation in service design and redesign (NIRE) • Identification of the appropriate professionals to be part of the programmes (NNL) • To keep up the information flow and communicating important activities on an ongoing basis to keep the support

from all stakeholders ( NNL)



change project and 2) Involving all the stakeholders to achieve a good result of the project (CAT). Lack of vision • A formal study of efficiency is taking place in order to generate the scientific evidence that will provide the

clinical justification for a need for change and scaling-up telemonitoring (BAS) • Strategies involve identification of champions among all stakeholders and use their idea’s.

Qualitative measures such as interviews, review of profiles, and stakeholders meeting were used as tools (NNL)

Inadequate skills • Involve highly qualified personnel in the set-up and implementation of the program. Qualitative measures such as interviews, review of profiles, and stakeholders meeting were used as tools (NNL)

• Resources have been allocated to provide the adequate education, training and development of the needed competences to run the service. (RSD)

• A good assessment of skills must be done well in advance. In here, the Coaching and Training Department has a lot to do when identifying the gaps of the professional groups involved and putting the appropriate solutions in place (CAT).

Inflexible Information technology

• Information technology was developed by one stakeholder as part of their research and development programme. The information technology was developed to be flexible in the further less flexible environment (NNL)

• Important is all phases, also early on as the program only can function with a well integrated and functioning IT system (NNL)

Lack of adequate incentive schemes for change

• Tools involve a combination of quantitative information (data) as collected as performance indicators in the program, and qualitative information gathered during (focused) interviews with stakeholders (NNL).

• As the service is new, it was necessary to create new incentives and e.g. the reimbursement system has supported this ( RSD)

Inflexible Information technology

• When talking about Integrated Care, technology is just a support tool and not the main point. A lot can be done without technology even, of course, it helps a lot having appropriate and flexible ICT systems. Inventive and interoperability have helped a lot when dealing with such (CAT)

• Close collaboration with suppliers and users in the development phase. Also good requirements specifications have been an important part (RSD).

Lack of funding • Funding from government for development of telemonitoring • Strong management support from beginning of the programme has supported the need for adequate funding

to carry out the activities. Also, the programme has become part of the reimbursement system in the full implementation phase (RSD)



Appendix 4. Stakeholder maps

Catalonia NetherlandsBasque country Southern DenmarkNorthern Ireland

Mainstakeholders

Healthcareprofessionals


Politicians

Patient/user



Politicians

Patient/user

ICT industry



Politicians

Patient/user

ICT industry



Politicians

Patient/user

ICT industry



Politicians

Patient/user

ICT industry

Payers

Academy

PayersAcademy

Academy

PayersOtherStakeholders

Stakeholderlandscape

CataloniaIntegrated care for subacute and frail older adults. Parc Sanitari Pere Virgili

Mainstakeholders Healthcare

professionals

Health administratorsPatient/user ICT industry

When did you involve your main stakeholders?

Phase 1. Planning of change

Phase 2. Adaptation phase

Phase 3. Full scaleimplementation phase

Phase 4. Continuousimprovement after

deployment



Payers



ICT industry

Inform (give info) and consult (ask for info)Patient/user Healthcare

professionalsCollaborate (work with) Give responsibility to stakeholder

Inform (give info) and consult (ask for info)

Patient/user



Payers

Payers

Payers


Collaborate (work with)Inform (give info) and consult (ask for info)

PayersICT industry

How did you involve your main stakeholders?

Stakeholder committment assessment performed prior to the beginning of the programme

Risks related to stakeholders have been analysed

Mitigating measures adopted

An action plan has been adopted to mantain and increase stakeholders commitment

The programme performs periodic assessments on stakeholder management process

CataloniaIntegrated care for subacute and frail older adults. Parc Sanitari Pere Virgili

CataloniaThe Chronic Patient Programme – Badalona Serveis Assistencials


professionalsHealth

administratorsPatient/user ICT industry





Payers


Collaborate (work with) Give responsibility to stakeholder


Payers

Inform (give info) and consult (ask for info)Payers


Politicians Academy Social care

ICT industry

Academy

Phase 2. Adaptation phase Phase 3. Full scaleimplementation phase


deployment



Payers

Patient/userPayers

Politicians

ICT industrySocial care


ICT industryCollaborate with

AcademyConsult and collaborate with

Social care

Patient/user

Academy

CataloniaHealthcare support programmes for nursing homes ‐MUTUAM


professionalsHealth

administratorsPatient/user


Payers




Inform (give info), collaborate and give responsibility toPayers


Politicians Academy


AcademyInform, collaborate and give responsibility to

Social care

Patient/user

Phase 1. Planning of change Phase 2. Adaptation phase Phase 3. Full scaleimplementation phase


deployment



PayersPoliticians

Patient/user

Phase 3. Full scale implementation phase Phase 4. Continuous improvement after deployment



PayersPoliticians

Patient/user Academy

PoliticiansInform and give responsibility to






CataloniaHealthcare support programmes for nursing homes ‐MUTUAM

CataloniaSupport for complex case management AISBE


professionalsHealth



Phase 1. Planning of change Phase 2. Adaptation phase

Phase 3. Full scaleimplementationphase

Phase 4. Continuousimprovement afterdeployment



Payers






Payers




ICT industry

Academy

Patient/userPayers

Politicians





Social care

Patient/user

Academy

CataloniaServices promoting healthy lifestyles: physical activity ‐ AISBE


professionalsHealth









Payers






Payers




ICT industry

Academy

Patient/user

Payers

Politicians





Social care

Patient/user

Academy

Northern Ireland


professionalsHealth







Politicians

Politicians







Patient/user ICT industry


ICT industry

Patient/user



Inform (give info) and consult (ask for info) and collaborate with

PoliticiansInform (give info)






Northern Ireland

Basque Country Multimorbid Population Integrated Intervention Programme


professionalsHealth





Politicians

Politicians







Patient/user



Patient/user

Payers


Payers

Give responsibility to stakeholder

Inform (give info)Politicians Payers







Basque CountryMultimorbid Population Integrated Intervention Programme

Basque CountryTelemonitoring of Congestive Heart Failure


professionalsHealth







Patient/user

Consult, collaborate with and give responsibility to stakeholder

Collaborate and give responsibility to

NursingTelecare centre


Phase 3. Full scaleimplementationphase Healthcare

professionals


Patient/user

Telecare centreNursing




Health administratorsTelecare centre

Telecare centre

Telecare centre

Nursing

Nursing


Health administratorsPatient/user Nursing






Basque CountryMultimorbid Population Integrated Intervention Programme


professionalsHealth




Consult (ask for info) and collaborate withPatient/user

Politicians Payers

Phase 2. Adaptation phasePhase 3. Full scale implementation phase

Phase 4. Continuous improvement afterdeployment


Health administrators Patient/user ICT industry


Phase 4. Continuous improvement afterdeployment

Phase 3. Full scale implementation phase

Politicians

Academy

Academy


Phase 3. Full scale implementationphase

ICT industry

Consult (ask for info)Health

administrators

Politicians



Collaborate withICT industry

Academy Inform (give info)

Southern DenmarkTelepsychiatric treatment





Southern DenmarkTelepsychiatric treatment


professionalsHealth





deployment

Patient/User



Payers





Payers Payers Payers

ICT Industry Academy ICT Industry Academy

Patient/User



Payers

ICT Industry Academy ICT industry Academy

Patient/User

Northern Netherlands ‐ Asthma / COPD Telehealth service

Academy


professionalsHealth

administratorsPatient/user ICT industryPayers

Patient/user

HealthcareProfessionals

Inform (give info) Consult (ask for info)Collaborate (work with)Give responsibility to stakeholder


Inform (give info)Consult (ask for info)Collaborate (work with)Payers

ICT industry


Academy

Academy

Inform (give info)Consult (ask for info)


Stakeholder committment assessment performed prior to thebeginning of the programme



An action plan has been adopted to mantain and increasestakeholders commitment

The programme performs periodic assessments on stakeholdermanagement process



professionalsHealth





deployment

Patient/User



Payers



Payers Payers

ICT Industry

Academy

Politicians

Patient/User

ICT Industry

Academy

Patient/User



Payers

ICT Industry

Academy

Politicians Politicians

The programhas not

reached yetImprovement

phase



professionalsHealth


HealthcareProfessionals

Inform (give info)

Consult (ask for info)

Collaborate (work with)

Give responsibility to stakeholder


Inform (give info)Consult (ask for info)Collaborate (work with)

ICT industry


Academy

Academy

Patient/user

Payers Politicians

Other Stakeholders –Welfare organizationsPatient organizations



professionalsHealth





deployment

Patient/User



Payers





Payers Payers Payers

ICT Industry

Academy

Private HealthProviders

Patient/User

ICT Industry Academy

Patient/User



Payers

ICT Industry Academy ICT industry Academy

Patient/User



professionalsHealth


Patient/user HealthcareProfessionals

Inform (give info) Consult (ask for info)Collaborate (work with)Give responsibility to stakeholder


Inform (give info)Consult (ask for info)Collaborate (work with)Payers

ICT industry


Academy

Academy


Deliverable D5.1: Stakeholder and change management maps · 2016-10-13 · Stakeholder and change...

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Transcript of Deliverable D5.1: Stakeholder and change management maps · 2016-10-13 · Stakeholder and change...