EXPLORATIONOFTHECONTEXTANDENABLERSOFHRMINNOVATIONSINDUTCHGENERALHOSPITALS

An Empirical Study August 2016

ExplorationoftheContextandEnablersofHRMInnovationsinDutchGeneralHospitalsAnEmpiricalStudy

MarciaKremers

ABSTRACTInnovationisahottopicinDutchgeneralhospitals,duetotheincreasinglybusiness-likeenvironment.ThisresearchexploresinnovationsinHRMdepartmentsinthesespecifichospitalsaccordingtothreetypesofinnovations,employment,work,andorganisationalinnovations. Next to presenting specific innovations found, this research focuses onsector-andorganisation-relatedfactorsthatpossiblyinfluencetheoccurrenceandtypesof HRM innovations. Findings show a dominance of multi-type innovations, mostlycombining employment and work innovations. Furthermore, findings suggest thatincreased communication and knowledge sharing through internal and externalnetworks, and separate stimulation of younger and older employees within theorganisationsarelikelytoincreasetheoccurrenceandacceptanceofinnovativechangesin hospitals. The highest threat presents uncertainty and reluctance of medical stafftowardschanges.This research suggests that HRM innovations mainly result from changes in thehospital’senvironmentandobjectives,andtheyarenotimplementedforthepurposeofbeinginnovative.

UniversityofTwenteMScBusinessAdministration|HumanResourceandManagementSupervisor:Prof.dr.TanyaBondarouk2ndSupervisor:Dr.JeroenMeijerink

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ManagementSummaryInnovation is a topic of supreme importance in numerous different sectors andorganisational fields.Bynow, increasingcompetitionandneedforcostefficiencyisnolongera typical characteristicof thebusiness sector,but is a crucial aspectof generalhospitals. However, research in various fields of these organisations lacks. Inconsiderationofthis,thisresearchexploresinnovationsinHRMdepartmentsinDutchgeneral hospitals. Additionally, the presentation of contextual elements should giveindications on the presence of the innovations found as well as on possible futureaspects that need to be considered when managing human resources within Dutchgeneralhospitals.

Thisresearchdefinesinnovationsasanythingnew(processes,tools,practices,etc.)toahospital that aims at improving current standards. It makes use of three types ofinnovationsthathavebeenidentifiedbyvandenBroek(2014),whichareemployment,work, and organisational innovations. Employment innovations are related totraditionalHRfunctions,suchasrecruitmentandselection,compensation,traininganddevelopment.Workinnovationsarerelatedtothedesignoftheworkitselfaswellastheemployeesworkingconditions,suchasjobenrichment,jobsimplification,orteamwork.Organisational innovations are innovationswith a broader organisational context andimpact, but naturally include a strongHRMcomponent such as knowledge sharing orrestructuringprogrammeswithintheorganisation.

The first part of the research, a literature review, revealed that theDutchhealth caresector ischaracterisedbyasteadycompetitionamong fundingbodiesandhealthcareproviders, whereas the patient is able to influence price competition and serviceprovisionstandardsthroughinsurancearrangements.Thisin2005implementedDBCspaymentsystemincreasesthehospitals’needforfastandefficientpatienttreatmentsaswellasflexibilityandefficiencyofthestaff.Thisshifttowardsincreasedefficiencyandperformance level is often referred to as ‘New Public Management’ (NPM). Anotherchallenging factor is the scarcity of educated medical personnel, and the ageing ofemployed staff, which partly results in growing shortage of nurses and medicalspecialists.Furthermore,thedemographicchangesposeanotherchallengeastheoverallageingofpatientschangethedemandsofhealthcareservices.

The second part comprised four case studies of general hospitals across TheNetherlandswith theaimof identifyinganddescribingavailable innovations in-depth,including additional related information to enhance the understanding of themechanisms and the context. The hour-long interviews were conducted with therespective HR manager of each hospital as they were expected to have integrativeknowledgeonallHR-relatedaspectswithin theorganisation.All informationcollectedfrom the interviews aswell as the hospitals’websiteswas classified according to thebeforehand identified three innovation-types-categories (employment, work, andorganisationalinnovation)ortheforthcategorycompiledtosummariseHR-innovation-relatedcontextinformation.Overlapsbetweenthecategorieswereexpected.

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Overall findingsshowahighernumberofmulti-typethansingle-typeinnovations.Themajority of single-type innovations is work-, or employment-related and support jobenlargement of employees, increase the managements’ responsiveness, or focus onrecruitment, training and contracting respectively. Organisational innovations aremainlyrelatedtoculturalprogrammesthataimatstrengtheningself-responsibilityandtrustamongemployees.Byraisingthelevelofthesecharacteristics,HRmangershopetoincreasetheoverallefficiencyandcreativityoftheindividuals.Themajorityoftwo-typeinnovations consist of two types of innovations, primarily employment-work andemployment-organisationalinnovations.Thenumberofinnovations,whichcombineallthreetypesofinnovations,islow.

InformationfromtheinterviewsandwebsiteswerefurthermoreanalysedaccordingtoCorral’s (2006) identified five influencers of innovative behaviour, which areinstitutionalarrangements,technologicalandorganisationalcapabilities,organisationallearning, risk taking behaviour, and individual intention. This cross-case analysisshowed that especially internal communicationandknowledge sharing, closeexternalcollaborations as well as participation in external and internal networks are keyinfluenceroftheinnovativelevelofthehospitals.Close arrangements between health care institutions increase the possibility ofinnovative thinking of HR professionals, as they are able to exchange knowledge andideas,andreceiveincentivesforimprovements.Especiallyregionalcollaborationsseembeneficial as theyare influencedby similarprevailing regional-specific conditionsandtherefore make incentives and collaborations more useful and faster applicable.Furthermore, internal communicationand teamworkare likely to increase the chancefordevelopmentsand innovations.Bynetworkingandsharing individuals’knowledge,mutual understanding and interaction can be strengthened, and opportunities forimprovementsandinnovationsbecomemorevisible.However,fromthecasestudiesitappearsthatteamworkandstronginternalcommunicationisstillmainlypresentwithinwards,whereas interaction among different actorswithin the organisations is scarce.However, leaders within the hospitals were found to receive comprehensivecommunicationandleadershiptraining.Theincreasedcommunicationandmanagementresponsivenesstargetsthereductionofunknowingnessanduncertaintyofthegeneralmedical staff towards the present and future changes in the hospital sector.Unknowingness and uncertainty pose a great threat as they can result in fear andeventually in resistance, a characteristic, which the interviewed HR managers haveincreasinglynoticedamongelderlyemployeeswithintheirorganisations.

Examples for innovations,whichhavebeenfoundwithinthecontextof thisresearch’scasestudiesarelistedinthefollowingtable.

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Table1:EmpiricallydiscoveredInnovationExamples

InnovationType StudyFindings

EmploymentInnovation(EI)

• RecruitmentfacilitatingIT-tool• Adjustedemploymentcontracts

• Professionaldevelopmenttrainingsandworkshops

WorkInnovation(WI)

• Jobcrafting• Reductionofphysicalworkplaces

• Self-planningoftimetables• ‘Insideprofile’personalityquestionnaires

OrganisationalInnovation(OI) • Cost-controlmodel

EI+WI

• Reallocationofrecruitmentresponsibilities• Self-serviceAppforHRMprocesses• Strategic-personnel-planningtool

• Newworkingconcept• MDprogrammes

EI&OI• Uniformforecastingsystem

• Communicationandstrategicalignmenttrainings• Radboundworkshops

WI&OI• Reallocationofstrategy-developmentresponsibilities

• Internalandexternalnetworkdevelopment

EI&WI&OI• Personalbudgetforeachemployee

• Organisationalreconstructionprogramme

Summarising, this research identifies a number of HRM-related innovations in Dutchgeneralhospitals,whichmostoftenrelatetotheorganisations’anticipatedculturalshifttowardsbeingmoreefficient,flexibleandself-responsible.Themaincauseforthisshiftis the increased adoption of business organisations’ characteristics. Encouragingcommunicationandknowledgesharinginordertoenhanceaccessibilityofinformationto all operational areas within the organisations is crucial for the organisations’successfultransitiontowardsefficiencyandinnovation.However,throughthisresearchit became apparent that external as well as internal networks, and internalcommunicationaswellasdevelopmentarenotyetfullydeveloped.HRMdepartmentsinDutch general hospitals are still in the transition towards becoming fully strategicallyalignedwiththeorganisationasawhole.

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PrefaceThe research “Exploration of the context and enablers of HRM innovations in Dutchgeneral hospitals” has been written as the final assignment of the BusinessAdministrationmasterprogrammeoftheUniversityofTwente.IthasbeenconductedincooperationwithHRMdepartmentofthisuniversity.The research team consist of three students, who jointly prepared the researchframework, theoretical background, and research design of this study. Although thetopic was identical and the findings party overlapped, each research was conductedindividually.Thisleadstothreeseparatetheseswithvaryingemphases.Allthreethesesareavailableuponrequest.

Eventhoughtheactualconductionofthisresearchwasdoneautonomously,anumberofpeoplehavedevotedconsiderable timeandeffort toensure itssuccessful termination.Therefore, I would like to thankmy supervisor prof. dr. T. Bondarouk as well asmysecondsupervisordr.J.G.Meijerinkfortheirsupportandmotivationalthoughts.Furthermore,Iwouldliketothankmytwofellowresearchcolleaguesfortheirfeedbackandadvicethroughouttheentireresearchprocess.Finally,anotherwordofthanksgoestoallinterviewees,whotookpartinthisresearch.

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TableofContents

MANAGEMENTSUMMARY.....................................................................................................................................I

PREFACE...................................................................................................................................................................IV

TABLEOFCONTENTS............................................................................................................................................V

LISTOFTABLESANDFIGURES.........................................................................................................................VI

1. INTRODUCTION...............................................................................................................................................71.1. CONTEXTOFRESEARCH.................................................................................................................................................71.2. RESEARCHGOAL&QUESTION......................................................................................................................................9

2. THEORETICALFRAMEWORK:CONCEPTUALISATIONOFKEYTERMSANDELEMENTS......102.1. CONCEPTUALISATIONOFINNOVATIONANDHRM.................................................................................................102.2. THEEUROPEANHEALTHCARESECTOR..................................................................................................................112.3. THEDUTCHHEALTHCARESECTOR.........................................................................................................................142.4. TOWARDSARESEARCHFRAMEWORK......................................................................................................................18

3. RESEARCHDESIGN:FOURCASESTUDIES............................................................................................203.1. INTERVIEWSAMPLING................................................................................................................................................203.2. MEASUREMENT.............................................................................................................................................................233.3. DATACOLLECTION.......................................................................................................................................................253.4. DATAANALYSIS............................................................................................................................................................253.5. REACHINGVALIDITY....................................................................................................................................................26

4. FINDINGS:HRMINNOVATIONS...............................................................................................................274.1. HRMINNOVATIONSINHOSPITALA........................................................................................................................274.2. HRMINNOVATIONSINHOSPITALB........................................................................................................................304.3. HRMINNOVATIONSINHOSPITALC.........................................................................................................................334.4. HRMINNOVATIONSINHOSPITALD........................................................................................................................354.5. SUMMARYOFFINDINGS...............................................................................................................................................38

5. CROSS-CASEANALYSIS...............................................................................................................................445.1. POSSIBLEINFLUENCEROFINNOVATIONS:INSTITUTIONALARRANGEMENTS...................................................455.2. POSSIBLEINFLUENCEROFINNOVATIONS:TECHNOLOGICALANDORGANISATIONALCAPABILITIES............465.3. POSSIBLEINFLUENCEROFINNOVATIONS:ORGANISATIONALLEARNING..........................................................495.4. POSSIBLEINFLUENCEROFINNOVATIONS:ENTREPRENEURIALORRISKTAKINGBEHAVIOUR......................515.5. POSSIBLEINFLUENCEROFINNOVATIONS:INDIVIDUALINTENTION...................................................................52

6. DISCUSSION...................................................................................................................................................57

7. CONCLUSION.................................................................................................................................................62

8. CONTRIBUTIONOFRESEARCH...............................................................................................................658.1. THEORETICALRELEVANCE.........................................................................................................................................658.2. PRACTICALRELEVANCE..............................................................................................................................................65

9. LIMITATIONSANDFUTURERESEARCH...............................................................................................66

REFERENCES..........................................................................................................................................................67

APPENDIX...............................................................................................................................................................74

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ListofTablesandFiguresTable1:EmpiricallydiscoveredInnovationExamples....................................................................iiiTable2:HRMInnovations............................................................................................................................24Table3:DistributionofInnovationsAmongStudiedHospitals..................................................38Table4:SummaryofInnovationsintheStudiedHospitals...........................................................39Table5:SummaryofInfluencersofHRMInnovations....................................................................54

Figure1:TheResearchFramework:TypesofHRMInnovationsinGeneralHospitals....18Figure2:MappingofStudiedHospitals.................................................................................................22Figure3:TheUlrichModelofHRRoles(Shah,2015)......................................................................74

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1. Introduction

1.1. ContextofResearch

Innovation isa topicof supreme importance.Organisationsofallkindsare constantlycompetingfornewerandbetterproducts,services,processes,andtechnologiestostaycompetitive.This isnotonlydue to increasing customerexpectations, but alsodue toreasons of economic growth (Cohen, n.d.), “unyielding pressure for rapid results”(Clarke,n.d.,p.1),anddevelopmentsininternalbusinessstructuresandgoalspossiblycausedbymergersorchangesinbusinessstrategies.Costreductioninallorganisationalareas (Cohen, n.d.), digitalisation (Ernst & Young, 2011) and coherence withgovernmental regulations are only some further reasons for a steady need forinnovations.Especiallyinthehealthcaresector,externalandinternalfactorsarewide-ranging. The decreasing availability of nurses, the increasing need for elderly care,governmental regulations, increasing competitiveness among hospitals, aswell as theincreased need for cost-efficiency are only some elements of this sector (Lansisalmi,Kivimäki, Aalto, & Ruoranen, 2006 ;Kuhlmann, Batenburg, Groenewegen, & Larsen,2013;Daley,Gubb,Clarke,&Bidgood,2013;EUJointActiononHealthWorkforce,2014;European Commission, 2013). Hospitals are nowadays facing a great amount ofchallenges theyneedtocopewith.Notonly in termsofnewtechnologiesandmedicalprocesses,butalso inallkindsoforganisationalareas (Omachonu&Einspruch,2010;Lansisalmi et al., 2006). Thus, steady adaption to these challenges is essential forsurvival.Howdotheydoit?

Thisquestionseemssimple,however, todate research in this field is fair tomiddling.TheNHS (NationalHealth System) of England is for example enjoying great attentionandmanyresearchershaveconcernedthemselveswithitsstructureandelements(suchas the role of governments, nurses, patients, managers), but also with newestinnovations and developments related to various aspects of health care, mostlytechnologies,medicinesorpractices(Dixon-Woodsetal.,2013;Martin,Currie,Finn,&McDonald, 2011; Cresswell& Sheikh, 2013; Page, 2014). Other countries, in turn, arepracticallyun-regardedinthiscontext–littletononeresearchhasbeencarriedouttoanalysetherespectivehealthcaresectorandsystem.TheDutchhealthcaresectorhasbeendescribedandanalysedinthepastasitisconsideredtohaveoneofthebesthealthcaresystemsworldwide(EuroHealthConsumerIndex2015,2015).However,someoftheincorporatedaspectsarestillwidelyun-regarded.Oneoftheseaspectsisthefieldofhumanresourcemanagement(HRM)inthehealthcaresetting.Especiallyinnovationsinthis field, which respond to sector challenges, have been widely unnoted. Thisconstitutes a great knowledge gap, since HRM is widely accepted as an importantcontributor related to the innovativeness of organisations. It entails the plannedmanagement of an organisation’s human assets,which areperceived as one of (if noteven ‘the’) main important asset of any organisation (Keep & James, 2010). Theimplementation and execution of efficient and well-ordered HRM systems have been

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evidentlyfoundtonotonlyincreasetheefficiencyofemployees(Kepes&Delery,2007;Lepak,Liao,Chung&Harden,2006;Jiang,Lepak,Han,Hong,Kim&Winkler,2012),butto also contribute to theperformance and level of innovationof theorganisationas awhole (Zhou,HongandLiu,2013;Beugelsdijk,2008; Jiang,Wang&Zhao,2012;Blau,1964)byincreasingamongotherstheemployees’abilities,motivationandcreativity.Asemployeesareviewedasoneofthefundamentalcomponentsinhealthcareinstitutions(Townsend, Lawrence, & Wilkinson, 2013), the investigation on innovative andsuccessfulways of theirmanagement can lead to an increased state of knowledge onhow given aswell as future opportunities and threats posedwithin the Dutch healthcaresectorcanbeusedoropposed.

In 2014, van den Broek intended to narrow this knowledge gap by researching thecharacteristics of the diffusion, adoption and implementation of HRM innovations inDutch health care organisations, as well as the organisations’ influence on theseinnovation processes (van den Broek, 2014). She separates innovations into threedifferent types: employment, work and organisational innovations. Employmentinnovations relate to what is mainly called “traditional HR functions” – generalemploymentissuessuchasrecruitment,trainingorappraisal.Workinnovationsrefertothe design of work itself, the employees’ working conditions and the style ofmanagement.Organisationalinnovationshaveabroadercontextandimpact,andaffectagreaterpartof theorganisation, suchas thesharingofknowledgeandrestructuringprogrammes.Amongothers,vandenBroekpresented findings twoexamplesofHRM-related innovations in specific Dutch hospitals in her research, including agents,processes aswell asunderlying causes and risk factors.However, vandenBroekalsocallsforfutureresearchonfurtherinnovationstodeterminenotonlyunderlyinglogicsand process influencers, but also to understand “the complexity of the institutionalenvironment”(vandenBroek,2014,p.107),astheauthorpresumesittohaveagreatinfluence on the innovation process. This research accommodates this appeal, byexploring what kind of HRM-related innovations exist in Dutch general hospitalscorrespondingtothethreeidentifiedtypesofinnovations,andbyinvestigatingrelatedenvironmentalelements,riskfactorsandconditionsfortheseinnovations.

Thisstudyaimsatofferinginsightsintoinnovationprocesses,causesandconditionsinthe specific context of Dutch general hospitals. The combination of thewell-regardedtopicsHRMandinnovationpresentspointsofinterestforresearchersinthepublicandprivatesector,especiallywithinthespecificcontextofhospitals.Furthermore,throughthe elaboration of health-care-sector-specific elements, as well as innovationdevelopmentandimplementation-relatedprocesses,conditions,riskfactorsandactors,suchasmanagersworkingwithinthisspecificsectorcanfindinitiationsandsupportforpossibleadoptionsorproblemcounteracts.

This research is fully explorative even though the research question is based onpreliminaryliteratureresearchinordertodeveloparesearchframework.Additionally,this research ispartofa larger research, conductedbya teamof three researchers intotal. Each researcher addresses the same research topic through the conduction ofappropriate case studies in Dutch general hospitals. Overlaps in the choice of study

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cases are possible although the analysis and interpretation of gained information isperformedindividually.

1.2. ResearchGoal&Question

ThegoalofthisresearchistoidentifyHRMinnovationsandlessonslearnedfromHRMinnovationsinDutchgeneralhospitals.Thus,thedeterminationofastatusquoofHRM-relatedinnovationsintheDutchgeneralhospitalsistargetedasthefinaloutcomeofthisresearch.Thepresentationofcontextualelementsandconsiderationsshouldeventuallygive indications on the presence of these innovations as well as on possible futureaspects that need to be considered and adapted into the management of humanresourceswithinDutchgeneralhospitals.

The resulting central research question of this research is ‘What kind ofHRM-relatedinnovationsarepresent inDutchgeneralhospitals,whatcharacterisestheircontext,andhowdothesecharacteristicspossiblyinfluenceHRMinnovations?’.

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2. Theoretical Framework: Conceptualisation of Key Terms andElements

The following chapter summarises existing literature on the main elements of thisresearch:innovation,HRM,andtheprevailingconditionsintheDutchhealthcaresector.Firstly,theelementsaredefinedandanalysedindividually,andthensecondly,combinedincaseinformationcouldbederivedfromliterature.Asthisresearch’sfocusisgreatlyunder-researched,informationoncombinedresearchelementsissparse.

2.1. ConceptualisationofInnovationandHRM

It is a common perception that organisations should constantly strive for beinginnovativeinordertosurviveonthemarket,staycompetitiveagainstbusinessrivals,orsimply to increase their efficiency. Baregheh, Rowley and Sambrook (2009) note andsummarise that “there is agreement that in order to both sustain their competitivepositionandtostrengthenit,organisationsandeconomiesmustinnovateandpromoteinnovation”(p.1324).Theterminnovationisusedextensively,appearinginliteratureofallkindsofbackgrounds,suchastechnological,science,administrative,economical,andorganisationalmanagement.Asthesefieldsdifferintheirnature,thereisagreatvarietyof definitions of innovation. “Innovation is studied in many disciplines and has beendefined from different perspectives” (Damanpour and Schneider, 2006, p. 216).Subsequently, various researches attempted to develop a universal definition of theterminnovation,which,seemstobeverydifficultbecauseof thedifferentperceptionsand backgrounds included. Baregheh et al. (2009) included definitions from sevendifferentliteraturefieldsandsummarizedinnovationasfollows:

“Innovation is the multi-stage process whereby organisations transform ideas intonew/improved products, service or processes, in order to advance, compete anddifferentiatethemselvessuccessfullyintheirmarketplace”(p.1334).

Thispapercomprehendsinnovationinasimilarway,butthereisanimportantadditiontobemade.An idea isperceivedasnewonce it isnewtoacertainorganisation,eventhoughitmightbealreadyknowntoorexistinginotherorganisationselsewhere(VandeVen,1986).

As innovationshavebeen identified as essential for organisations in order to survive,extensive research has been conducted to identify triggers of innovations. Theorydetects various drivers for innovation, such as efficient R&D (Cassiman & Veugelers,2006), technological capabilities (Horbach, Rammer, & Rennings, 2012), external andinternalknowledgesharing(Walker,2006;Horbachetal.,2012;Cassiman&Veugelers,2006), and the enhanced creativity and new idea development through strategic andefficient HRM (Mumford, 2000; Jiménez-Jiménez & Sanz-Valle, 2008; Kepes & Delery,2007;Lepak,etal.,2006;Jiang,etal.,2012).

Thisresearchisrelatedtothehumanresourcemanagementfield.HRM“dealswiththepropermanagement[...]of individuals in theworkplace“(Marciano,1995,p.226)and

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implies tounderstand,maintain,develop,utilize,and integrate them(Marciano,1995)according to specific organisational objectives. Thus, this paper viewsHRM in amorestrategicway than the traditionalHRM,which commonly comprisespractices such asrecruitment,selection,training,appraisalandrewards(WrightandMcMahan,1992).Itcorrespondstotheauthors’definitionofstrategicHRMas“thepatternofplannedhumanresource deployments and activities intended to enable an organisation to achieve itsgoals” (Wright andMcMahan, 1992, p.298). Van den Broek (2014) refers to previousliterature of HRM and distinguishes between different types of HR practices, namelyemploymentandworkpractices.Ontheonehand,employmentpracticesattendtothemanagement of human resource and concern activities related to what this paperbeforehandreferredtoastraditionalHRMpractices,namelyrecruitmentandselection,training,appraisal,andrewards.Ontheotherhand,workpracticesattendtothedesignofworkandencompassabroaderdefinitionofHRM.

Withregardtothispaper’sdefinitionofHRManditspossiblegroupingintotwopracticefocuses,innovationsaredividedintothreecategories,namelyemploymentinnovations,workinnovations,andorganisationalinnovations(vandenBroek,2014).VandenBroek(2014) explained thepossibility of thedistinctionof innovations indifferent typesbyreferring to Boxall and Purcell (2008) definition of HRM, which “encompasses themanagementofworkandthemanagementofpeopletodothework”(Boxall&Purcell,2008,p.3invandenBroek,2014,p.9).Accordingtothisononehand,HRMinnovationscanfocusonworkdesign,ontheotherhandonHRMinstruments.Duringherresearchprocess she distinguishes an additional third innovation type, organisationalinnovations, for innovations that did notmatch the first two types. This leads to thefollowing definitions of the three innovation types explored in this research.EmploymentinnovationsarerelatedtotraditionalHRfunctions,suchasrecruitmentandselection,compensation, traininganddevelopment.Theyconcerngeneralemploymentissuesandcouldbeforexampleelectronicsrecruitment,anewtrainingprogramme,orvariablepaymentofferings.Workinnovationsarerelatedtothedesignoftheworkitselfaswellastheemployeesworkingconditions,suchasjobenrichment,jobsimplification,chain of command and reporting, or teamwork. The third type of innovation isorganisational innovations. These are innovations, which have a broader context andimpact, even though naturally include a strong HRM component. Examples could berelated to knowledge sharing or restructuring programmes within the organisation.These HRM categories present an adequate summary and coverage of possibleinnovations, andwill therefore be used as a basis for the research on and analysis ofinnovationsinliteratureandDutchgeneralhospitals.

2.2. TheEuropeanHealthCareSector

After the conceptualisation of HRM and its related innovations, and the collection ofinformation on what these terms describe and entail, it is important to gain anunderstanding on factors, which have a potentially high degree of influence on thedegreeofinnovativenessandefficientHRM.Asthisresearchfocusesonaveryspecificsector, namely theDutch general hospital sector, it is necessary to get an insight into

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prevailing sector conditions apart from this specific health care institutions settings.Innovation and HRM influencers are not factors, which can only arise in respectivebusiness organisations. They also matter in broader settings, such as in terms ofgovernmental regulations and considerations, but also in even higher contexts forexample nation treaties or commissions. In this case, prevailing conditions in the EUsetting of a specific business sector can have an influence on the operations andperformanceoforganisationalbusinesses in thisrespectivesector.Thus, the followingchapterswillpresentprevailingconditionsintheEuropeanandDutchcontext.

European health care systems increasingly face the challenge of workforce shortagesand misdistribution of skills. By 2020, the shortage of health care professionals isexpectedtoriseuptoonetoonemillion(EUJointActiononHealthWorkforce,2014),while the existing health care workforce is changing at the same time due todevelopmentsrelated to technology,organisationsandprofessionals (Kuhlmannetal.,2013).Simultaneously,healthcaredemandsareexpectedtoriseandchangeasaresultof the increasing elderly population (European Commission, 2013). Kuhlmann et al.(2013)admonishthatthiscanresult inamismatchbetweenhealthcaredemandsandsupply in European countries. The European Commission describes the challenge as“balancing the right number of health care staff with the right skills in the rightgeographical areas to meet the changing needs of populations and health systems”(European Commission, 2015, p 5). To face this problem, the European Union issuedlabourmarket regulations to allow and simplify cross-bordermobility andmigrationbetweenmemberstatesandcandidatecountries(Kuhlmannetal.,2013).

AnadditionalchallengeisthelargeamountofcostsarisingfromthehealthcaresectorsamongtheEUmemberstates.EventhoughmanyEUcountriesfaceafractionalincreaseofhealthcarespendingasashareofnationalGDPscomparedtoothercountriesaroundtheworld,health-spendingcostsarestillexpectedtoincreaseconstantly (OECD,2015).By2060,publicexpenditureonhealthcareandlong-termcare isexpectedtogrowbyone third of current expenditures (European Commission, 2013). In this context theEuropean Commission names the economic crisis, diversifying diseases, as well asstructural changes in demography (e.g. increasing population size and structure,nationalandindividual incomes,accessibilityofhealthcareservicesandgoods)asthemain causes for increasing costs. As a result, EU health care systems are required tobecomemore cost efficient and sustainable (European Commission, 2013). InitiativessuggestedbytheEuropeanCommission(2013),whichshouldleadEUmemberstatestoachieveefficiencyandsustainability,includeamongothers:

• Structuralreformsandefficiencygrowthofmemberstates:balancingthemixofstaff skills throughnon-financialbenefits, continuousprofessionaldevelopmentandevendistributionofhealthcarestaff;

• Reduction of unnecessary specialist-use and hospital care while simultaneousimprovementofprimaryhealthcareservices inorderto increasepositionsandtraining opportunities, as well as balance the distribution on generalpractitioners

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• ImproveddatacollectionamongEUmembersonhealthsystemsonthebasisofthe European Community Health Indicators (ECHI) in order to compare andincreasehealthsystems;

• The introduction of innovative technological solutions, such as the HealthTechnology Assessment (HTA) (a tool, which summarizes medical, social,economic and ethical issues related to a certain health technology or product),andanumberofE-healthdevelopments;

• Creation of supporting working conditions and providing employees withopportunities to live healthy and active in order to decrease absenteeism andincreasetheemployees’abilitytoparticipateinthelabourmarket.

Fortheachievementoftheseobjectives,theEuropeanCommissioninitiatednumeroussupporting programmes, regulations and investments. It for instance started thedevelopmentofeasilyaccessibleandreplicablee-healthapplications,whichincreasethequalityoflifeaswellastheefficiencyofthehealthcareprovider.Furthermore,itworkstowardsanEU-commonsustainablehealthmonitoringsystem,whichenablesdetailedandcost-effectivenessanalysesbasedonlatestfigures,expendituretrends,andrelatedinformation.AnEUjointactionfocusesontheforecastofhealthworkforceneedsand,thus, enables effective planning within and among EU member states. It creates theopportunityforEUmemberstatestosharelabourpowerandpractices.Additionally,theCommissionsupportsprojectsandtooldevelopmentswithexpectedfuturebenefitsonnationalandinternationallevels(EuropeanCommission,2013).

ItbecomesvisiblethathealthsystemsamongEuropeanmembercountriesarenotonlyinfluenced by regional and national factors, but also greatly by international factors,such as above-mentioned EU regulations and supportive programmes. The growingnumberof influencers, the increasing impactof stakeholders, the continuousneed forcost-efficiency,aswellas therisingcompetition forskilledandqualifiedpersonnelonnational and international level lead to a shift of organisations in the public sector tostrategicallybecomemorebusinessoriented(vandenBroek,2014;Pollitt&Dan,2011).Characteristics of this shift are often combined under the term ‘New PublicManagement’(NPM).“Newpublicmanagementistryingtoadopttheefficientbusinessorganisations management elements in public administration management“(Vienažindienė&Čiarnienė,2007,p.44).Bymakinguseofbusinessguidelinesthatarevalued in the private sector, organisations in the public sector are encouraged to notonlytakeoverthebusinesstechniquesbutalsothevalues(Vienažindienė&Čiarnienė,2007).PollittandDan(2011)conceptualiseNPMasthebelief“thatthepublicsectorcanbe improved by the importation of business concepts, techniques and values“ (p. 5).When converting this belief into practice, the authors present a set of practices andconcepts,suchas:

• Settingthefocusonperformance,i.e.output;• Establishinglean,flat,smallandspecialisedorganisationalforms;• Usingmarket-typemechanisms,suchasoutsourcing,public-privatepartnerships

(PPPs)andperformance-relatedpay;and

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• Consideringserviceusersas‘customers’andtargettheirsatisfaction.

Otherauthors identifysimilarcharacteristicsofNPMinthehealthcaresector,namely“usingmarketforcestoservepublicpurposes;demandingorganisationalperformance;fostering greater accountability and transparency from providers; increasing patientfinancialresponsibility; lookingforsavings;providinghigher-qualityservices;bringingresourceallocationclosertothepointofdelivery;usingcontracting-out;andenlargingthecoalitionofplayers“(Simonet,2008,p.619).

Inthehealthcaresector,thetwomaingoalsofNPM(betterserviceandcostreduction)(PietersoninMeijer,Boersma,&Wagenaar,2009)aredifficulttoachieveastheyfocusonelementsfromdifferentlogics.Theefficiency-striving,business-likelogicsmightnotalwaysalignperfectlywithprofessional-likelogics,whichemphasisethequalityofcare(vandenBroek,2014).Theauthorevenarguesthatthepresenceofbothlogicswithinanorganisationcouldaffecttheinnovationprocess,duetobudgetlimitsorcontrastingopinions on priorities and beneficing. This presents a problem, as innovations cansupport public organisations in improving the service quality and copewith externalchallenges(DeVries,Bekkers&Tummers,2014).

2.3. TheDutchHealthCareSector

“In times of limited resources, governments are required to demonstrate workforceplanning capability tomeet current and future challenges for service delivery and toproduce efficiency gains” (Melchor, 2013, Abstract). As presented above, higherauthorities and executives, such as the European commission, have a high degree ofinfluenceontherecourseplanningcapabilityofgovernments.However,therespectivecountries’ given conditions (such as the availability of resources, the degree ofgovernmental involvement, the legislative situation) also play a major role in theinnovation-, and HRM-related capability of governments as well as institutions andbusinessesofallkinds.AsthecontextofthisresearchhasbeensettoTheNetherlands,prevailingconditionsintheDutchhealthcaresectorarepresentedbelow.

In2012,TheNetherlandsspent11,8%ofGDPonhealth,whereofapproximately86%ofthe spending assembled from government and social insurance funds (OECD, 2014).Despite the economic crisis, health spending has increased during the past years, thespendingwas12,9%in2013(CIA,2016).Thehighestshareofhealthcareexpendituresarerelatedtothehospitalandelderlycaresectors(Schäfer,Kroneman,Boerma,VandenBerg,Westert,Devillé,&VanGinneken,2010).Thecurrentlifeexpectancyatbirthisonaverage81,23years,whereofthelifeexpectancyforwomenis83,47yearsandformen79,11(CIA,2016).Themedianageofthepopulationis42.3years(41.3yearsformenand43.2yearsforfemale)(CIA,2016).

“[Thehealthcare]sectorisoneofthelargestemployersintheNetherlands.Over13%ofthe full-time jobs available are jobs in the health [and] social welfare sector; 18% oftheseare ingeneralhospitals“ (DutchHospitalsAssociation,n.d.,p.6).ThenumberofnursesisabovetheaveragecomparedtootherEuropeancountriesand“seemsufficienttomeettheneedsofthepopulation”(Schäferetal.,2010,p.xxvi).WhereasinGermany

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one nurse is responsible for ten and in England for eight patients, a single nurse isresponsibleforfivepatientsinTheNetherlands(TechnicalUniversityofBerlin,2012).Duringthepastyears,therewasanincreasedtrendoftransferringresponsibilitiesandtasks of medical professionals to nurses. “New occupations such as practice nurses,nurse practitioners, nurse-specialists and physician assistants are trained to fill the“gap”between[medicalprofessionals]andnurses“(Schäferetal.,2010,p.131).Thisso-called“substitution“ ismainlycausebythedesiredincrease inefficiency,butalsoasameans to cope with the increasing workload of medical professionals (Schäfer et al.,2010).ThesefactorsmightinfluencefindingsthatTheNetherlandshasoneofthelowestburnout rates of nurses (10%) compared to Germany (30%) or England (42%)(TechnicalUniversityofBerlin,2012).AlsotheEuropeanissueofunevendistributionofhealthcareproviders(GPs,specialists,andhospitals)andhealthcarelabourforceislowduetothesimplefactthatTheNetherlandsarecomparablysmallanddenselypopulated(Schäferetal.,2010).

TheDutchhealthcaresystemisdivided in threecompartments,namely(1) long-termcare(forchroniccomplaintsandtreatments,aswellashomeandelderlycare);(2)basicandessentialmedical care (generalpractitioner treatments, short-termhospital stays,and specialist services); and (3) supplementary care (e.g. dental, physiotherapy, orcosmetictreatments)(Daleyetal.,2013;Schäferetal.,2010).Dutch hospitals are segmented in three types: general, academic, and specialisedhospitals.Generalhospitalsoffergeneralaswell as specialisedservices,byemployingmedicals and specialists from various fields. Academic hospitals are connected to auniversity and are mainly focused on research in the medical field. The third type,specialised hospitals, offers services in a specific medical field, such as e.g. eye-care,trauma centres or children’s hospitals. Due to mergers, a great number of Dutchhospitals operate from multiple locations (Schäfer et al., 2010). Here, especially thethree different types of hospitals often form collaborations in order to increaseattractiveness through broader service offers and higher capacity for research anddevelopment.

In2014,therewere76generalhospitalsintheNetherlands,includingsixfusionsamongthese hospitals (Dutch Hospitals Association, n.d.). Each general hospital in TheNetherlandsisamemberofoneoutofthreeclinicalassociations:SAZ(SamenwerkendeAlgemene Ziekenhuizen), STZ (Samenwerkende Topklinische opleidingsZiekenhuizen)andOvA(OverigealgemeneZiekenhuizen).TheSAZconsistsofcurrentlyapproximately40generalhospitals,whichareconsideredassmallerinsize(SAZ,n.d.;DutchHospitalData (DHD), 2015). The STZ represents the larger, top clinical hospitals. These 26hospitalsmustmeetstrictaccreditationcriteria,whicharecheckedbyavisitationeveryfive years. The OvA stands for other hospitals and includes medium-sized hospitals(DHD,2015).

A significant characteristic of the Dutch health care sector is the role of doctors andspecialists.Theyareeitheremployedbyahospitalorself-employed,althoughthere isanincreasedtendencytotheformationofgrouppracticesandhealthcentreswithinthepast years (Van Weel, Schers & Timmermans, 2012). The general practice, also not

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confirmedbyreferences,isthatthesedoctorsoftenformagreementswithhospitals,inwhich the doctor stays independent and only cooperates with hospitals on specifictreatmentsandservices.Theformulatedagreementscontaindefinitionsofthescopeofperformance and services, and obligations (such as stand-by duty, conferences orworkgroup participation). Additionally, overhead costs, such as costs arising fromtreatments,materialaswellaspersonnelcostsforsupportingstaffaredetermined.Thedoctors cannot influence the sales price of treatments because these are exclusivelynegotiatedbetweenthehospitalandthepatient’s insurancecompany.Furthermore, inthe caseof doctor-hospital agreements, thehospital takes over the role of amediatorwithinthedoctor’sremunerationprocess.Thetreatmentcostsarepaidbytheinsurertothehospital,whichthen(afterdeductingaccruedexpenses)forwardstheamounttothedoctor. This leads to a certain degree of productivity pressure among self-employeddoctors,astheyneedtohaveahighnumberofpatientsinordertobeefficient.

In2006,areformpackagewasadopted,whichincludesnation-wideuniversalmedicalcare coverage for Dutch citizen, who are required to purchase at least theminimuminsurance offered, including basic and essential health care (e.g. medical care,ambulance service, and basic medication). Additional premium packages can bepurchasedbasedontheneedsandwantsofcustomers.Insurancecompaniesareobligedto accept any applicant, they are not allowed to risk-select customers or risk-assesswhennegotiatingpremiums(Schäferetal.,2010).Primary care providers such as general practitioners (GPs), psychologists orphysiotherapists take the role as gatekeepers. They can send patients to hospitals incase a specialist is required. Thus, patients can only obtain hospital and specialistservices through direct referral of a primary care provider (except in acute andemergency cases) (Schäfer et al., 2010). At the same time, gatekeepers take on theresponsibilityofcontrollingcostsbylimitingspecialistreferrals(Daleyetal.,2013).

“Thegovernmentchangeditsrolefromdirectsteeringofthesystemtosafeguardingtheprocess from the distance” (Schäfer et al., 2010, p. xxii).While the government’s rolenow is thatof a regulatorof the system, including responsibilities suchasmonitoringthequalityofhealthcareandensuringuniversality(i.e.affordabilityandaccessibility)ofcare(Daleyetal.,2013),itisthehealthinsurers,healthcareprovidersandcitizenwhoinfluencetheprice,volumeandqualityofcare.Thesemarketplayersinteractonthreesub-markets,namelythehealthinsurancemarket,thehealthcareprovisionmarketandthe health caremarket (Schäfer et al., 2010, p. xxvi). As this thesis’ focus lies on thehealthcareprovisionmarket,theothertwosub-marketswillnotbefurtherdiscussed.

Inthehealthcareprovisionmarket,apaymentsystemcalledDiagnosisandTreatmentCombinations(Diagnosebehandelcombinaties,DBCs)hasbeenimplementedin2005.Itstatesthathospitalsarepaidaccordingtorealcostsaccrued(i.e.thecostsneededforapatientscare)whilesimultaneouslyitenablesinsurerstonegotiateonpricesforofferedcare services based on the quality of these services (Daley et al., 2013; Schäfer et al.,2010).Thus, theDBCs follow theprinciple “money follows thepatient” (Schäferetal.,2010,p.xxiii).Asinsurancecompaniesalsohavethefreedomtonotcontracthospitalsin case of poor care service standards or high service prices, the DBCs supports

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competition and increased aspiration for improvements on the health-care-service-provider side. At the same time, insurance companies compete for contractswith thebesthospitals,whichdoesnotonlyleadtonurturingpricechangesformedicationsandservices but also to an increased importance of the medical professionals’ role asnegotiator in this process. The establishment of governmental “watchdog” agencies(Schäferetal.,2010,p.xxii)shouldpreventtheemergenceofundesiredmarketeffectsinthehealthcaresector.

TheformationoftheDutchCollegeofGeneralPractitioners(DCGP),ascientificunionofGPs,aimsat“[improving]and[supporting]evidence-basedgeneralpractice”(NHG,n.d.).Theirprogramme,adevelopingand implementingguideline,aimsatmanagingqualityand safety improvement processes for GPs and primary-care–hospital-carecollaborationsinTheNetherlands.TheprogrammeisacollaborationbetweentheDCGPand university departments of primary care, in which best practice frameworks aredeveloped.Thelatter’sroleinthiscollaborationisthatoftheresearcheranddeveloperof practice innovations (Van Weel et al., 2012). In 2006, the DCGP additionallyintroducedapracticeaccreditationprogramme,inwhichpracticesneedtopassa3-yearprocess,.Itentailsthatstructures,processes,andoutcomesofcareare“assessedagainstprevailing external criteria/standards” (Van Weel et al., 2012, p.15). These DCGPprogrammes support and increase not only the quality and safety of care but alsostimulatetheinnovativenessofhealthcarepractices.

The SwedishNGOHealth ConsumerPowerhouse (HCP) has selected theDutch healthcare system as the best health care system in the EU for the past five years in theirannuallyreleasedEuroHealthConsumerIndex(EHCI).ThestudycompareshealthcaresystemsinEuropein48categories,with its focuson“patients’rightsandinformation,accessibility, prevention and outcomes”, including the patient and consumer point ofview(EuroHealthConsumerIndex2015,2015).ItaimsatimprovingtheunderstandingofEuropeanhealthcare,empoweringpatients,supportingthedetectionandcorrectionofweaknesses,aswellasprovidingmemberstateswithbestpractices.Thecommitteedescribed the Dutch health care system as ‘a chaos system’ (Euro Health ConsumerIndex2015,2015),which,eventhoughpatientsaregrantedagreatfreedominchoosingtheirhealthcareinsurerandprovider,ismanagedefficiently.

To sum it up, the Dutch health care sector is characterised by a steady competitionamongfundingbodiesandhealthcareproviders,whereasthepatientclearlyseemstobeinthepositionofmainfocus.Eventhoughthepatient’schoiceisnotabsolute,heorshe is able to influence price competition and service provision standards throughinsurance arrangements, which leads to an increased need for cost-efficiency inhospitals.Atthesametimethissystemreducesthelevelofgovernmentinvolvementasexpendituresarenotsolelyfundedbythegovernmentbutalsobyinhabitantsaswellasinsuranceprovidersthroughhealthinsuranceagreements.Although-,theavailabilityofhumanresourcesiscomparablyhigh,hospitalsstillfacethechallengeoflowpersonnellevels, andadditionally, thehandlingofdoctors apparently constitutes a challenge forHRM.

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2.4. TowardsaResearchFramework

Given the conceptualisationof innovation, it ispossible todifferentiatebetween threetypes of innovations: (1) employment innovations; (2) work innovations; and (3)organisational innovations.Thisresearchsuggests that thesethreetypesdonotsolelyexistseparatelybutoverlap.Furthermore,assuggestedbyvandenBroek(2014),“thecomplexityoftheinstitutionalenvironment”(p.107)islikelytohaveaninfluenceontheinnovation process of an organisation and is thus expected to determine the level ofinnovativenessofeachrespectiveHRdepartment.

Therefore,thetheoreticalresearchmodelhasbeenconstructedasfollows:Figure1:TheResearchFramework:TypesofHRMInnovationsinGeneralHospitals

HRdepartmentsofDutchgeneralhospitalscandevelopand implement three typesofinnovationsseparately,andatthesametimethesecanoverlap.However, internalandexternalcontextsinfluencethelevelofinnovativenessinboththeindividualcategoriesandasawhole.In this framework the Dutch general hospital context symbolises expected possibleinfluencers. For once, these influencers can be beyond the hospitals’ control andinfluence,suchaslegislative,technological,economicordemographicfactors.Therefore,theyprimarilydisplay theexternal contextofgeneralhospitals thatarepreexisting inTheNetherlands.As identified in theprevious chapter theDutchhealth care sector is

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characterisedbyanumberofspecificconditionsandregulations,whichareexpectedtoimpactoperationsofthegeneralhospitals.Additionally, factors, which differ from hospital to hospital are included in theframework’s hospital context. Here this research makes use of Corral’s (2006) mostcrucial influencers of innovative behaviour in organisations, which are institutionalarrangements, technological and organisational capabilities, organisational learning,risktakingbehaviour,andindividualintention.Theseaspectspresentacomprehensivesummaryofagreatvarietyofpreviousstudiesontheinfluencersofinnovativeness,andthereforeconstituteaninterestingopportunityfortheirapplicationtothepublicsector.Furthermore,theyrefermoretothehospitals’internalcontext.

After identifying this research framework we specify on the research question byempiricallyexploringthethreetypesofinnovationsinDutchgeneralhospitals.

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3. ResearchDesign:FourCaseStudiesThe necessary conceptualisations of themain components of this research have beenformulatedbymeansofa literature review.Adequate literaturehasbeencollectedbythe use of various search machines and databases: Scopus, Google Scholar, Web ofScience, and the online library of the University of Twente. Articles from a journal, atechnicalorresearchreportreleasedbyahealthcarerelatedinstitution,agovernmentalpublication, or reports and papers released by universities have been perceived asadequate. Literature for the conceptualisation of ‘innovation’ and ‘HRM’ was chosenbasedonthenumberofcitationsbyotherresearchers.Selectioncriterionforliteratureconcerning the European and Dutch health care sector was the year of publication.Information should be as recent as possible and not exceed the past three years.However, due to the fact that publications of sector statistics and statements arepublishedapproximatelytwotothreeyearsaftertheiroccurrence,theselectioncriteriafor sector specific information was changed to themost recent available. The theorycollectedbytheliteraturereviewisusedasaguidelineforthedatacollectionwithinthecase studies. It aims at supporting the investigation of the theoretical framework andunfoldingbothdetailsofaswellasrelationshipsamongitscomponents.

Duetotheexplorativenatureofthisresearch,namelytheinvestigationofthestatusquoofexistingHRinnovationsinDutchgeneralhospitals,aqualitativeresearchapproachischosen.More specific, qualitative case studiesare selected.This typeof studyenablesthe investigation of “a contemporary phenomenon within its real-life context [and]copes with the technically distinctive situation in which there will be many morevariables of interest thandatapoints” (Yin1994 inHsieh, 2004, p.90f). Furthermore,case studies arewidelyperceivedas suitable fornewresearchareas, aswell as thoseareaswithsparsepre-existingresearch(Eisenhardt,1989).Thiscorrelatestothetodatelittle available research that has beendone on the kinds ofHR-related innovations ingeneralhospitalsinTheNetherlands.Theconductedcasestudiestakeonanexploratorydescriptive design in form of open interviews. It enables in-depth presentations ofcontextual situation description, as well as explanations of cause-effect relationships(Hsieh, 2004). The aim is to identify and describe available innovations in-depth,including information on what, how, and why to enhance the understanding of themechanisms and the context. The focus lies on innovation-related factors such asinnovations’ causes, goals, outcomes, obstacles, etc., but also on personal experienceswith andopinions on an innovation and its context.Additionally, the case studies arecomparative inorder togain informationonhowandwhy innovations inaparticularhospitalareoriginated,needed,or(un)successfullyimplemented.

3.1. InterviewSampling

Inorder to receive thedesired in-depth informationon innovationsand theircontext,the interviews were conducted with HR managers of Dutch hospitals. Due to theirexpected integrative knowledge on all HR-related aspects within the respectiveorganisation, their authority and related participation in decision-making and

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developmentprocesses,managerswere selectedas theoptimal samplegroup. In casethat the HR manager was not available for an interview, but was interested in theparticipationintheresearch,otherHRpersonneloftherespectivehospitalwereinvitedtoparticipate.Because of the intentional limitation of the sample, the only selection criteria forhospitals were the status of a general hospital without the existence of a certaintreatment-focus,andthegeographicalpositioningwithinTheNetherlands.Factors,suchashospitalsize,operationalregion,obtainedcertificates,orcooperativeactivitieswithother hospitalswere of no importancewithin the selectionprocess. General hospitalsconstitute thebiggesthealth care institutions inTheNetherlands,notonlybecauseofthehighnumberofcareandcureemployees,butalsobecauseofthegreatvariationofprofessions.Withthat inmind, there isasupposedlygreatneedforHRadoptionsandintervention in order to manage this great number and variety of employees whilecopingwithvariousexternalinfluencersatthesametime.

Theparticipatinghospitalsweredistributedamongthethreeresearchersaccordingtothe interviewee’sagreement,ornon-agreementrespectively, toconductthe interviewinEnglish.Except forhospitalDall interviews in thisparticularresearchwereheld inEnglish. In total, four case studies have been performed. The interviews, except forhospitalC,tookapproximatelyonehour:HospitalA62minutes,HospitalB62minutesandHospitalD56minutes.HospitalC’sinterviewtook48minutesduetoalackoftimeof the interviewee. As scheduled respondents from hospitals A, B and C were HRmanagersoftherespectivegeneralhospital,hospitalsD’srespondentwasthemangerofHRServices,asubdepartmentoftheoverallHRdepartment.

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Figure2:MappingofStudiedHospitals

TheaboveshownfigureillustratesthelocationoftheDutchgeneralhospitalsthatarestudieswithinthisresearch.

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3.2. Measurement

Byconductiona literature review, exemplaryHR innovationshavebeencollectedanddeliberated.The literature reviewdidnot especially focus on sources from thehealthcaresector,butfromothersectorsalso.Widespreadandrepeatedlymentionedaswellasforthisspecificresearchpotentiallyinterestinginformationderivedfromthechosenliterature was listed in a table. Afterwards it was individually assigned to thebeforehand-definedcategoriesemploymentinnovations,workinnovations,organisationalinnovations, and additional HR-innovation-related topics (see Table 1: Possible HRMinnovationsresultingfromliteraturereview).All information that concerned innovations was classified within the first threecategories. In case an innovation did not match a single-type-innovation categorycategories were connected into a multi-type-innovation category. Information thatconcerned the hospital context, such as innovation barriers, points of criticism,suggested improvements, change requests, etc., were included in the fourth category‘additionalHR-innovation-relatedtopics’.These fourgeneric categorieswerechosenas theypresentanadequatesummaryandcoverageofpossibleinnovations,whichcouldbefoundinthestudiedpapers.ThesefourcategoriesareusedasabasisfortheopeninterviewwiththeHRmanagers.Innovationsand topics that the respondents addressed during the interviews were afterwardsassignedinaccordancewiththefourcategories’definitions.Thus,theywerenotaskedfordirectlyduringtheinterviewsbutresembleaguidelineforpossiblyappropriateandinformativefollow-upquestionsaswellasforthesubsequentanalysis.Separately,eachcategorygivesenoughscope for the interviewee’spersonalopinionandcontributions.Thus,theydonotlimitpossiblefindingsnorcreatethepossibilityforbiasesthroughapre-selectionofspecifictopicsorfoci.Incombinationtheycoverthecompletespectrumof the research onHR-related innovations inDutch general hospitals, aswell as theirconditions,andsuccessandriskfactors.Furthermore,theinterviewer’sconsiderationofthese categories functions as a mean against digression towards un-related topics.Additionally,thecategoriesareintendedtosupportthedataanalysisandcomparisonoffindings.

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Table2:HRMInnovations

Category ExemplarytopicsforinterviewsEmploymentinnovations:Relate to traditionalHR functions; concerngeneral employmentissues, such asrecruitment, trainingorappraisal

Talentmanagement:(e.g.recruitment,selection,retention&dismissal,personaldevelopmenti.e.training,Skillsescalator,waitingtimetargets,internalemployerbranding,etc.)Rewardmanagement(e.g.variablepay,bonus,etc.)E-HRM(e.g.electronicrecruitment,etc.)

Workinnovations:Relatetothedesignoftheworkitself,overallworkingconditionsforemployees as well asthe style ofmanagement

Employeeempowerment(e.g.employeeparticipationinmanagerialdecisions,promotionofanempowerment-basedmanagementstyle,employeevoice,employeeinvolvement,ideagenerationforchanges,etc.)Management(e.g.managementresponsiveness,etc.)Jobdesign(e.g.teamdevelopment,empowerment,jobenlargement,jobenrichment,jobrotation,jobsimplification,jobcrafting,etc.)Workingconditions(e.g.stressreduction,healthyfoodinthecanteen,organisationalkindergarten,freedrinks,fruitbaskets,sportactivities,staffassociating,discounts,staffshop,etc.)

Organisationalinnovations:Have a broadercontext and impactand concern a greaterpart of theorganisation, such asrestructuringprogrammes or thesharingofknowledge

Culture(e.g.Employeevoice,throughtraining,etc.)StrategicpositionHRM(e.g.internalmarketing,increaseofstrategicinfluence/powerposition,etc.)Communication(e.g.cooperationwithotherhealthcareinstitutions,academichospitals,employerbranding,Internalcommunication(e.g.knowledgesharing,knowledgebrokering,Talentmanagementpool,etc.)Digitalization(e.g.patientfiles,nopaper,etc.)

AdditionalHR-innovation-relatedtopics:Suchassuccessfactors,triggers,opportunities,threats,etc.

Barriers(e.g.money,amountofprojects,employeeparticipation,etc.)Causes(e.g.internal,externalpressure,etc.)Cooperationvs.Competitionwithotherhospitals

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3.3. DataCollection

Afterthecompilationofallhospitalsmeetingtheselectioncriteria,contactinformation,suchasname,phonenumber,postalandemailaddressoftheresponsibleHRmanagersof66hospitalswerecollectedviatelephoneinquiries.Afterwards,participationrequestlettersweresentout to thegatheredaddresses.Unfortunately, telephonecontactwiththe HR managers or respective secretaries revealed that approximately 90% of theletters did not reach the recipient. In this case, a digital version of the same requestletter was send via email to the adequate address. By repeated telephone contact,interest inresearchparticipationwas inquiredandeventually interviewappointmentswere made. The allocation of the appointments among the members of the researchteam was mainly determined by interview language possibility (English and Dutch),location-preferencecriteria,aswellastheobjectivetogetanequaldistributionintermsofquantityofconductedinterviews.Theinterviewswerescheduledwithoneandahalfhour.Theywereon-locationsothatpersonal and face-to-face interviewswere possible. It also simplified voice-recording,whichwasnecessaryforthetranscriptionprocess.Eachinterviewstartedwithanintroductionoftheresearchtopic,theresearcher,aswellastheinterviewee.Theintroductionquestionconcernedthepersonalunderstandingof‘innovation’ in order to ensure an equal definition of the term for the researcher andparticipant. The further course of the interview was dependent on the individualinterviewee’sinformationcontributions.

3.4. DataAnalysis

“Qualitative research methods involve the systematic collection, organisation, andinterpretation of textual material derived from talk or observation” (Malterud, 2001,p.483). The first step after the conduction of each interview was the writtentranscription of the voice recording, which was afterwards sent to the respectiveinterviewee. This process represents amember check, a quality control processwithwhich the participant “receive[s] the opportunity to review [his] statements foraccuracy“ (Harper & Cole, 2012, p.510). This improves the accuracy, credibility andvalidityoftherecordedinterviewandconsequentlydecreasesthepossibilityoffalsifieddata and its eventual interpretation (Harper& Cole, 2012). After the reception of theverifiedtranscripts,eachinterview’scontentisanonymouslysortedalongsidethefourgeneric categories (employment innovations, work innovations, organisationalinnovations, andadditionalHR-innovation-related topics). So the generation of a quickoverviewonthespecificinnovationsineachcategoryandthecomparisonoffindingsispossible.Thishelpstoconductindividualanalysesforeachrespectivecase,aswellasacross-case analysis to understand differences between hospitals. The manual sortingand analysis of the collected non-numeric data is considered as adequate as thevariabilityinthecontentsandthechoiceofwordsusedbytheparticipantsisexpectedtobegreatandinconsistent.

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Informationontheparticularhospitalsandintervieweesisnotdisclosedinthisresearchreportsothatall information is treatedanonymouslyaswellasconfidently. Inspecialcases,fullinterviewtranscriptsareavailableuponrequest.

3.5. ReachingValidity

“The purpose of qualitative research is to describe or understand the phenomena ofinterest from the participant's eyes, the participants are the only ones who canlegitimatelyjudgethecredibilityoftheresults”(Trochim,2006).Allrespondentsoftheinterviews actively work in the specific field (namely in the HR department of anyspecificDutchgeneralhospital)andarethereforeabletoclearlyunderstandthesubjectmatteraswellasallrelatedfactors.Theyareabletoformulateownopinionsandtakepositionsconcerningsector trends, interventions’success,etc.Furthermore,allstoriestold have been confirmed by the interviewee him-/herself, as written interviewtranscriptshavebeen send toandverifiedbyeach respective respondentand, thus, amembercheckhasbeenperformedineverycase.Forthesereasonstheinternalvalidity(credibility)ofthisresearchishigh.However,theexternalvalidity(transferability)islowastherearemanythreatsrelatedtothisresearch,whichmainlyconcernpeople,place,andtime.Morespecifically,theseare personal views as well as opinions, and current situation of the hospital such asgeographicallyorregionallyisolation,cooperationvs.competitionwithotherhospitals,reorganisationorfusion,availabilityandallocationofresources,ordownturn.Allthesefactors lead to the fact that the settingwithin each research sample is unique so thatfindings cannot be generalised to a wider population. For these same reasons, theresearchcannotbeconductedtwicewiththeexpectationoffindingsimilarresults.Thechosen research form of unstructured and open interviews, the inclusion of personalopinions as well as experiences, and the changes of interview sample settings andenvironment lead to a low dependability of this research. Additionally, the level ofconformability is rather lowasnoexternal audit of the researchhasbeenperformed,which creates a high potential for possible biases and distortions by the researcherduringthedatacollectionandanalyticalprocess.

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4. Findings:HRMInnovationsThe following part describes and summarises findings collected as a result from theconduction of several interviews with HR managers. These findings are presentedaccording to the four generic categories employment innovations, work innovations,organisationalinnovations,andadditionalHR-innovation-relatedtopics(suchassuccessandriskfactors,presentaswellasfutureopportunitiesandthreats).

4.1. HRMInnovationsInHospitalA

HospitalA is located in theprovince SouthHolland in theMidwesternNetherlands. Itoccupies390beds,andemploysapproximately1,550employees (whereof1200workfull-time), 110 specialists, and200 volunteers. Thehospital belongs to the SAZ and isthus categorised as a comparably small hospital. Its vision is to be recognised andexperienced as a reliable and trustworthy hospital by patients. TheHRM departmentencompasses approximately 20 employees that are subdivided into an academy(‘leerhuis’),personsinchargeforlabourconditions,andHRadvisors.Labourconditionsresponsibilitiesentailstaskssuchasthefurnishingofofficesandwardswithtableandchairs. HR advisorsmainly concern themselveswith general advices about personnelmatters and represent contact persons for employees in general. The academyrepresents the biggest part of the HR and is responsible for educating and trainingemployees.

In terms of employment innovations, the hospital found an innovative solution toencounterhighcostsarisingfromhiringtemporaryworkersasinforexampletimesofan insufficient nurse availability or high level of sickness leaves. HR was facing thesituation thatcommercialpartiesenticedawaynurses fromtheorganisationand thenofferedtheirre-employmentwithadditionalcosts.

“Thereweremany commercial partieswhodid direct search, andpeoplewentaway from the hospital. And then you could hire them back from the sameorganisation. The same employee youhire backbutwith plus 20%, 40%, 50%extracosts.Sowedidn’twantthat.”

The solutionwas the creation of a buyer power by developing and implementing anorganisation(‘MATCH’),whicharrangestheemploymentofsuchtemporaryworkforce.As soon as the hospital becomes aware of a temporarilymissing position, MATCH isinformed about all specifications, which then again opens an inquiry to appropriatecommercial parties. Consequently, a price competition for every needed position iscreated as commercial parties quote their services with decreased prices in order toobtainthecontract.Apartfromthedecreasedcostforthehospitaltoemploytemporaryworkers,thisinnovationhasanotherbenefitaccordingtothehospital’sHRmanager:

“Weweremoreeffectiveinthemeasurementof‘howmanypeopledoweneed?’.”

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Theintervieweestatesthatthreatsrelatedtotemporaryworkersformissingpositionsarenotashighasbefore,becausesituationsinwhichthehospitalisshortofnursesorotherpractitionersduetosicknessesorcomparablereasonsdecreased.

Due to the analysis of HR data, hospital A’s HR manager became aware of anotherproblemthehospitalwasfacing:

“Our sickness rates rise a little every year, andourpersonnel costs rise a littleeveryyear,butattheendit’stoomuchtohandlesoyoumust[react].Ifoundoutthatwehaveaproblemofpeoplewhoare60yearsoldwithalargecontracttheyweremoreoftensickintheyear.”

Accordingtohim,theseolderemployeeswithalargecontract(i.e.employmentuntiltheage of 66) seem to have a greater problemwith the performance of their tasks, andadditionallyhadincreasedprivateresponsibilitiessuchascaretakingforgrandchildren.Furthermore, they have a higher sickness rate, and work less hours and are moreexpensiveperhourcomparedwithcurrentcontractsbecauseoftheirexistingcontracts.

“SoIsawaproblemthatwouldgrowinthenextyears.Itwasn’taproblemyet,butifwewanttopreventthatitwillbeaproblem,wewillhavetofindsomethingout,asolution.”

Thedevelopmentofanew(voluntary)employmentcontractwasfoundtobeefficient.Thiscontractallowsolderemployeestoworkhalftimewhilegettingpaid75%oftheirusualwage. The remaining 25% are used by the hospital to hire younger employees,who thehospitalperceivesasmoreeffective, arepaid less, andhavea lower sicknessrateaswellaslessholidays.Themanagerisconvincedthatthisbusinessplanprovidesresults,which are expected to break even, and in the long-term even have a positiveoutcome as money is earned instead of being spent. It is exemplary for a solelyemploymentinnovation.

Anadditional innovativeapproach is thehandlingofdoctors in the intendedcaseofamerger between two hospitals, which constitutes an example for an overlap of anemployment and work innovation. The doctors were planned to form their own“doctors’company”andworkforbothhospitals.

“That situation [would be] even more difficult than now. Because when thedoctorsworkfortwohospitals,theydon’thaveanyloyaltytoonehospital,soitwasadifficultissue.”

The proposed conclusion from the HR manager for this issue is that each hospitaldirectly employs a certain number of specialised doctors (neurologists, paediatrician,etc.),whothenareresponsiblethemselvesforchoosingandhiringgeneraldoctors,suchassurgeonsfromthe“doctors’company”.Thehospitalbelievesthatemployeddoctorsare loyal to the hospital because they are paid by it directly, so they are assumed tochoose appropriate and good general doctors. With this practice it addresses theobjectives of high quality treatment as well as loyalty towards the hospital. As themergerofthetwohospitalswascarriedout,thedescribedapproachwasnotpursued.

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Beingpartofanationalprogramme,hospitalAhasanextrabudgetofonemillionEurosfor the next four years starting this year. Apart from spending it on clinical- andtechnological-related collective programmes, half of the money is spend on theemployees.Eachemployeeisgivenapersonalbudget,whichheorshecanuseforanyprojectdesired.

“Theymay choose themselves what they want to do with that money. Lots ofcompaniesdothatforyears.Butinahospitalitwasarevolution.”

HRadvisorsareadvisedbytheHRmanagertoengageintheemployees’suggestionsforbudget usage by scrutinising and discussing their choices instead of directly rejectingthem. As per themanager, finding out the reasoning behind the choices is one of theprogrammes objectives according. Another one is further education for employees.Additionally,notonlyemployeevoiceandempowerment,butalsoespeciallytheleveloftrust within the organisation should be increased. This example of a combinationbetween employment (management training and employee development), work(employee voice and management responsiveness) and organisational innovation(cultureandtruststrengthening)goeshandinhandwiththeHRmanager’sbeliefinself-responsibilityandtrustineachother.

“I think that if you can make people act more responsible by giving themresponsibility,theywilltakeresponsibilityintheirjob.Andwhenwewantpeopleto[…]actmoreresponsible,wehavetolearntotrustthem.[…]Itsabouthowweworktogether,aboutourroles,aboutresponsibility,aboutmotivation,thatkindofthings.”

Aworkandorganisational innovation relatedprogrammewasperformeda fewyearsago.

“Wewanted to do something about howpeoplework together in the hospital.That was one goal. Second goal was [to find answers related to] severalquestionsaboutwhat isour strategyasahospital.And the thirdwas,wehaveleadershipinthehospital,howdowewanttodevelopleadership?”

Insteadoffacingandtreatingeachproblemseparately,thehospitalfoundaninnovativeway to combine all three matters in one programme. All managers, whoseresponsibilities liewithin thecure sector,weregiven the samequestion: ‘How is cureorganised in 2020?’. Their taskwas to compile a proposal for the hospital on how itshould organise curewithin the organisation. Themanagerswere given facilities andcoaches,buttherewerefurtherindicationsonthematterofthequestion.

“[However]wesaidasawarninginadvance‘wewanttogiveyouonewarning:don’tforgettheotherstakeholders’.”

Theintervieweenotesthatwhilethemanagersotherwisewerealwaysonlycooperatingincasesofoperationalproblemsandwerefocusedontheirowndepartmentandward,theynowactuallyhadtofirstlycommunicateandworktogether.Secondlytheyhadtodevelop new knowledge, and especially thirdly receive an understanding onstakeholdersandotherdepartments.

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“Andmaybe thatwas themost important thing: not onlymanaging top-downyourowndepartment,buttheconsciousnessthateverythingyoudoorchangeinyourprocesseshasconsequencesforyourneighbour.”

The implementation of the programme revealed that the managers performedstakeholder analyses, and talked to other employees and managers out of their owninitiativewhichresultedintheproposaltoimplementchangesinthephilosophyaswellasdecisionmakingstructureofthehospital.

Hospital A is part of a large cooperation between hospitals in the province of SouthHolland. The cooperation entails approximately twenty cure and care organisations,including general, academic and specialised hospitals. They cooperate on variouspersonnelmatters,suchascommunicationwiththelabourmarket,employerbranding,education of specialisednurses, and sustainability. For the latter two, hospital A’sHRmanager collected information on the availability and amount of specialised nurseswithintheassociation’shospitals.Thisinformationconcernedthenumbersofcurrentlyemployedspecialisednurses, thenumbersof those thatwill leavethisyear,aswellasthenumbersofthosethatweresendtoschool.Afterusingthisinformationtocalculatethesuccessratioofspecialisednursesthatweresendtoadvancedtrainingprogrammes,itwaspossibletodevelopforecastsforthenumberofnursesthatneededtobesendtoschool inorder tohaveanadequateand sufficientnumberof specialisednurses.Thisinnovativeanalysiswasperformedforall functionswithintheorganisationsthatwereconsideredasunique.TheHRmanagerremarksthatitenablesthehospitalstohaveanoverviewon the current aswell as long-term level of specialisednurses to encounterbottlenecksorunderstaffing.This typeof forecastingmainlypresents an employmentinnovation as it is concerned with the planning of staffing. However, it also partlyrepresents an organisational innovation due to the close cooperation with otherhospitals.

4.2. HRMInnovationsInHospitalB

HospitalBis locatedinthewestofTheNetherlandsintheprovinceNorthHolland.Itspresent status and structure is the result of a recent fusion of two neighbouringhospitals. It has approximately 920 beds, employs around 5,600 employees, and 330specialists.ItbelongstotheSTZ,andthereforeisoneofthebig,topclinicalhospitalsinthecountry.Itsvisionistoberegardedasahospitalinwhichthebestmedicaltreatmentand operations go hand in hand with extraordinary hospitality. They want to berecognisedasanorganisationthatinspirespeopletodevelopandperformattheirbestpossible.TheHRdepartmentatpresent consistsofapproximately80employees,whoare organised in four teams. Employees of the service team are in charge of all backoffice related tasks, and the HR C&CC (capacity and career planning) team areemployeesareworkingflexible.ThethirdandfourthteamareHRhealth,andHRadviceanddeveloping.

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ThehospitalintendstointroduceanApp,whichdigitalisesthemajorityofHRprocesses.It enables that each process related to recruitment and selection, rewarding, anddevelopmentcouldbeaccessedviaatabletorsmartphone.TheusageofthisAppisalsopossible formanagers throughout the entire hospital, and not only limited to the HRemployees.

“AsadepartmentmanageryoucanstartanyHRprocessofsearchingforanewemployee,raisesalary,changejobdescriptions,changewards,etc.”

During the interview it became apparent that the hospital expects that changes andpersonnelrequirementscanbehandledastheyoccurwithoutanydelaysemergingfromchains of reporting and differenced in areas of responsibilities. According to the HRmanagerofhospitalB, the introductionof thisself-serviceAppisanaturalreactiontothe changing environment. Additionally, she notes that even thoughmany people areprobablynot used tomakeuse of thesedigital devices andprocess, andmight find itmoreconvenienttodiscusspersonnelmattersface-to-facewiththeemployeesoftheHRdepartment,digitalisationinallareasandofthemajorityofprocessesisanticipatedinthelong-term.

“HR is more and more losing their paperwork and is becoming digital, moreautomaticandmorestandardisedbecauseofthedigitalsurrounding.”

The implementation demonstrates a combination of employment and workinnovation as on the one hand employment issues are affected, and on the otherhandmangers’jobsareenlargedbyincreasedtasksandresponsibilitiesthroughtheprovisionofaccesstotheapplication’scontent.

Anotherproject,whichwasdevelopedby theHRdepartment, is theSPPproject– theStrategic Personnel Planning project. The instrument is a questionnaire, which teamleadersneedtofillout,andcontainsvariousquestionsrelatedtoeachparticularteam.Exemplaryquestionsof thequestionnaireconcernthepossibilityof foreseeable futurechanges, staffing needs, and the current organisation of the team. The instrument isthenusedforstaffingbudgetingforthenextcomingyear.

“It really works to see what [is needed] - now and in the future […]. You canpredictakindofscheme”

TheinstrumentisregardedasveryeffectiveandadvantageousbytheHRmanagereventhough it isnotworkingaswellasanticipated.Accordingtoher, themainreasons forthisare that thecompletionof thequestionnaire isvery time-consumingandrequiresplanningandforecastingabilities.

“Strategic thinking takes time. […] Most professionals in care are not used tothinkingyearsahead.Alotofworkis‘adhoc’,sothey’renotlookinganyfurtherthantodayortomorrow’sproblemstobesolved.Careisallabouttakingcareofthepresentproblemsofapatient[…].”

Inordertosupportthemanagers,HRadvisorsareencouragedtotalktothemanagersandteamleaders,showthemhowthequestionnaireisfilledout,andconvincethemofitsbenefitsbyexplainingtheprincipleandadvantagesofforecasting.Problems,suchas

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thecurrentpersonnelrequirementofahundrednursesatonceareexpectedtodiminishby performing awell-elaborated forecast. Again, it is an example for an employment-and-workinnovationasitaffectsrecruitment,training,andjobenlargement.

Theintervieweenoticedthatduetotherecentfusionandchangingenvironment,manyemployeesareoverwhelmedanduncertainabouttheorganisationspresentandfutureoperations.Thehospital launched twoculturalprogrammes,whichattendat reducingthe employees’ anxiety.Bothprogrammes showanoverlapbetween employment andorganisational innovations as theyboth aimat training their staff to improve internalcommunicationandtobuildaculture,whichismoreopenforchanges.

“Thechanges[thatresultfrom]thefusionarereallyabigdeal.Peoplemightbeafraidtoloosetheirjobsandarereallybusywiththeirselvesinsteadof[thinkingabout]‘whatisgoingon?’,‘howcanwemanageanddevelopthisorganisationsoitwillsustainforanothertenyears?’.”

The first programme was for the managers within the organisation, who werehierarchicallylocatedrightunderthemanagementboard.Theyweregivenaone-and-a-half-year training on leadership, covering topics such as communicating withsubordinates, anticipating and coping with the present situation as well as changes,managingefficiently,andmakingbusinesscases.Astheintervieweestated,thetrainingaimed at encouraging and supporting managers in their leadership skills so thatespecially in consideration of the fusion they can explain and talk about the comingchangeswiththeirsubordinates.

“Wenowhaveanewmissionandanewvisionofwhoweareand I think thatshouldbeoneofthethingsyoujustdiscusswithyourteam.Whatdoesitmeanforourteamandhowdowewanttoworkifthisiswhatweare?”

The second programme was organised in cooperation with two representatives ofRadboud, who are experts on the context of innovations in the healthcare sector.Employees of all kindswere invited to attendworkshopson currentdevelopments inthehealthcaresector.Theseworkshopsaddressedchangesinhealthcaresectorsuchasnew technologies or practices, and their consequences for the work in this sector.AccordingtotheHRmanager,manypeoplewhoareemployedinthehealthcaresectorareusuallyworking there fora long time.Theyareused to theirsurroundingand thefieldofactivity,whichcomplicatestheimplementationofchanges.Therealisationofthisprogrammeaimedatmakingemployeesthinkandtalkaboutchangesingeneralinorderto still their fears, and to create an understanding for the implication and possiblebenefits for on the one hand the organisation and on the other hand the individualsthemselves.Furthermore,HRadvisorsencourageandhelpemployeestotalkabouttheir fearsandneedswith supervisors in order to evaluate and possibly negotiate on employer andorganisationaldesires.

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4.3. HRMInnovationsInHospitalC

Hospital C is located in the province of Overijssel in the east of the Netherlands.Approximately3,700employeesand235specialistsareemployedbytheorganisation;and1,070bedsareavailable,whichmakesitoneofthebighospitalsintheNetherlands(categorySTZ).Itscoremissionistopromotethehealthoftheinhabitantsoftheregionbyprovidingthemwith localgeneralandtopclinicalspecialistmedicalcare,educationandresearch.Itwantstoberecognisedasasafeenvironmentforpatients,visitorsandstaff and thus invests in (clinical) leadership and the creation of a culture thatcontributestocontinuousimprovementandthereductionofriskstothepatient.TheHRdepartmentcurrentlyconsistsof60employees.

The organisation currently is in the stage of development of a reconstructionprogramme.FortheHRdepartmentthereconstructionplanimpliestheentireredesignofsubdepartmentsand functionsaswellas thedigitalisationofcertainHRprocesses.Thefirststepoftheplanisthedismissaloftwelvefull-timeemployees,whosefunctionsinthecourseoftheprogrammewillnotbeneededanylongerintheircurrentway.Thehospital’s HR manager explains this on one the one hand by referring to theimplementationofadigitalprogramme,whichaffectstheregularHRprocessesfromonboardingtothereleaseonanemployee.Eachemployeehasadigitalfilethatincludesallpersonalinformation.Incaseofchangesintheworkingcontractorreimbursementsofexpenses, an employee’s direct supervisor is now able to digitally apply for thetransactionofthechanges,whichisthencheckedandrealisedbytheHRadministrationofficer. Restating the HR manager’s opinion, the implementation of this digitalprogrammereduces theprocessing time,butalsomakes theuseof thosepeople,whoweremanuallyresponsibleforthisprocessunnecessary.AmentionedontheexampleofhospitalB, suchadigitalprogrammedemonstratesa combinationof employmentandworkinnovation.On theotherhand thereasonmentionedduring the interview for thedismissalof theemployeesistheHRmanager’sambitiontomakeagreateruseofinternalandexternalnetworks,sothatcertainresponsibilitiesandtaskscanbepassedtootheractorsinsideandoutsideofthehospital.

“I think it is important that HR changes from knowing everything yourself orhavingtheambitiontoknoweverythingyourself,[totrying]tobethedirectorofknowledge.Sowedon’twanttodoitourselves,butwehavetoknowwherewecanbuyknowledgefortheproblemwewanttosolve.”

Duringtheinterviewitemphasisedthattheconstructionofsuchanetworkisthusoneofthegoalsofthereconstructionplan.Herepossiblecooperationwithserviceproviders,suchasculturaloreducationalprogrammesisanticipated,butalsotheparticipationinprofessionals’orspecialists’networks,suchasanetworkofregionalHRprofessionals.Furthermore, HR advisors for certain business units are instructed to connect amongeachother,sothataninternalnetworkcanbebuiltup.However, intheHRmanager’sopiniononeimportantaspectwithregardtonetworkingingeneralisthatinformationand knowledge shouldnot be simply collected, but that it needs to be an exchange, a

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give-and-take inorder tobeefficient.Accordingto the intervieweethesecompetencesare mostly not present yet and thus need to be developed, currently throughconversationsanddiscussions.Thedevelopmentofsuchanetworkshowsawork-and-organisationalinnovation,asHRadvisorsarechallengedthroughanincreasedrangeofdutiesandresponsibilities,andtheinternalandexternalcommunicationistargeted.OncethedismissalsofHRemployeesarerealised, theremainingemployeesshouldbereorganised indifferentsubdepartments,withrethoughtpriorityareasand functions.Forthis,employeeswillhavetofilloutan‘insideprofile’questionnaire,whichgrantsanoverview on the individuals’ preferences, behaviour and comfort zone. Duringconversations the HR manager then expects to get an understanding on theircompetences, and thus, on their optimal functionwithin theHR team.With thisworkinnovation the interviewee aims at increasing the employees’ work-related self-confidence to motivate them to become more efficient in their job, to become moreeager to demonstrate their competences, but also possibly to realise the need for achange in tasksandresponsibilities.Shestates thateventually it should increase theirunderstandingon their individual value for theorganisation, their contribution to theoverallperformanceofthehospital.

“AndthatistheconnectionIseewithinnovation:addingvalue.Butpeoplehavetodoit.AndHRcanneverbetheexampleintheorganisationifyoudon’tknowhow to do it yourself, that is basically my motivation. […] And maybe peoplecannot change themselves, but people can get aware of the fact that theorganisationneedsadifferentapproach.Andformeitsimportantforpeopletoseethatmaybetheyarenotintherightplace.”

The interview revealed that the ultimate goal of the implementation of the HRrestructuring plan is the recognition of the HR department of something more thansolelyanadministrativeandprocessingdepartment.AccordingtotheHRmanagerthiscan only be possible when the strategy, goals and processes are aligned, whencommunication and cooperation within the team is efficient, and when the roles ofindividualsareclearlydefinedandadjustedtotheobjectivesandstrategies.Shebelievesthat the workflow of traditional and repetitive task should be automatic and wellexecuted; employees should have deep knowledge on their work field and should beable to solve problems by themselves or with appropriate external support. She ispositive that once this is achieved as a status quo chances are good to increase thestrategicimportanceoftheHRdepartmentswithintheoverallorganisationalframebycontributingtotheproductivityofthehospital.

“Idon’tthinkthatHRhasbeenabletoshowwhatitcandoinanorganisation.IthinkthatthemanagerslookatHRmostlyasanadministrator[…].SoIthinktheorganisationandmanagersdon’tknowwhatitmeansifyouhaveahighqualityHR serviceandwhat it canadd for instance in learning,development, culturalchange, talent development, [etc.], but also by being a partner in primaryprocesses.Theydon’tknowthathere.TheyarenotseeingHRinitscapabilities.”

TheHR restructuring plan is therefore regarded as an innovation,which overlaps allthreetypesofinnovations.

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4.4. HRMInnovationsInHospitalD

HospitalDislocatedinthebiggestprovinceofTheNetherlands,Gelderland,whichisinthecentraleasternpartofthecountry.ItconsistsoffourlocationsandisincludedintheSTZ.Eachlocationhasitsownprofileandroleofprovidingcarefortheregion.Currentlythehospitaloccupiesapproximately1,000bedsandemploysaround5,500employeesand 250 specialists, both often working in multiple locations. HR responsibilities areseparated in two parts: the board of directors has corporate staffs, which includes asmallpieceofHR,whichismainlyinvolvedinpoliciesmaking.TheotherpartofHRisincluded the shared service organisation, a collaboration between all shared services(facilities,IT,finance,HRservice),whereHRisresponsibleforallotherHRactivitiesandthe support of care units and management. However, currently there are concernswhetherthisseparationshouldremainorwhetheritshouldbemergedinonesingleHRbody.ReasonsforthisareforoncearisingdifficultiesfromtheseparationofHR-policy-makingresponsibilitiesfromalltheremaininginvolvedresponsibilities,andtheoverlylargenumberofcorporatestaffwithintheboardofdirectors(40people),whichshouldbereducedtoonefourth.TheHRdepartmentwithin the shared services consistsof60employees,whereof tenemployees focus solely on strategic policy, working conditions and health, and fiveemployees function as HR advisors for the 80 heads of operational issueswithin theorganisation. It operates from one location, but is responsible for all four locations.HospitalD’sHRdepartment sees theheadsofdepartmentsof thevariousoperationalfields and the internal employees are their clients and thus work according to thefollowingvision:

“Ifwedowell,ourcustomersdon’thave to thinkaboutwhatneeds tobedoneandthus,canfullyfocusontheprovisionofcare.”

The strategic HR vision is composed of the three big topics sustainability, self-responsibility,andflexibilityofemployees.

Sustainability ishereregardedasoneofthebiggest innovations.AccordingtohospitalD’sHRservicesmanageremployeesshouldconstantlycontinuelearningandareneverfullytrained.Eventhoughwhenanemployeeperformswellinhisjob,andisconfidentin and likes it, he should not rest but should keep on expanding his professionalknowledge.Forthiscoursesandprofessionaldevelopmenttrainings,whereof60%aree-learning courses, are offered, where employees are able to see their progress andstatusonadigitalplatform(employmentinnovation).Thetrainingsaremandatoryandcoveravarietyofsubjects.

“[Employees]must continue to learn, but do not always have to learn. So [weneedtolookfor]thecombinationbetween‘whereis[theindividual’s]needasamanintheagegroupheisin’andhowcanitbefilledoutwiththeappropriatework.”

The interviewee describes the expected aim of increasing and broadening theemployees’ professional knowledge level is to increase flexibility, so that especially

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nursesandmedicalprofessionalsareabletoperformawiderrangeoftasksandstepine.g. incaseofabsencesdueto illnesses.Heunderlinesthatthis isespecially importantfor hospital D, as it comprises four locations with different medical fields, thustreatments and subsequent services. Increasing flexibility of employees is not onlyapproachedthroughcontinuouslearning,butalsothrougharangeofotherprogrammesandchangeswithinthehospital.Job crafting (awork innovation) is used to narrow areas of responsibilities. Thus, forexample, one specific care job is divided into three smaller jobs, where the level ofknowledge in order to perform the job is comparably reduced. According to theinterviewee it is easier for employees from another field of activity to take on thisspecific job, so that the goal of increasing the level of flexibility has successfully beenachieved.Furthermore, the eight-hours-day concept should be abolished and instead a newworkingconceptshouldbeimplemented:

"Youhavetoworkwhenthereiswork"

Thisplancontainsthatinthemorningsfrom7to10o’clockahighernumberofmedicalpersonnelshouldbeonthewards,asthemorningstendtobebusy.Onthecontrary,thehospital noticed that between 11 and 16 o’clock work is less so that the number ofworking employees should therefore be reduced as well. Additionally, the flow ofemployees should increase: young people, who leave school, to come to work in thehospitalshouldperformthemajorityofjobs,andelderlypeopleshoulddolighterworkontheward.TheHRmanagerstatesthatthisconceptaimsatincreasingefficiencyandflexibility.Atthesametimehenotesitsimplicationonworkingcontracts,whichneedtobeadapted,resultinginsmallercontracts.Therefore,it isexemplaryforacombinationofanemploymentandworkinnovation.

“Weareincreasinglybecomingahightechhospital,manypeoplestayashorterperiod in the hospital. It is part of the care that education is well aligned.Nevertheless,wearealsojustaproductionfacilityandthereforetheproductionandallocationofstaff shouldbeproperly linkedtogether(flexibleallocationofemployees: more staff during busy periods, fewer employees when to beperformedlesswork,flexibilitybetweendepartments).”

Thethirdprogramme,whichisaimedatincreasingflexibilityiscalled“Slimmerwerken”(“Worksmarter”)andappliestotheadministrativeworkerswithinthehospital. It isapilot project, which approaches reducing the number of physical workplaces. Theinterviewee remarks that employees responsible for recruitment aremostlywith theclient, i.e. the heads of the various departments, thus they do not need a permanentworkplaceinordertoperformtheirjobs.

“Whydopeoplehavetosithereonthetwelfthfloorwhentheycouldalsoworkathomeforoneday?Whyshouldeveryonehaveapermanentworkplace?FacilitatethemwithagoodiPadorlaptopandletthemworkwheretheyshouldbe.Andwecansavemoneyonaccommodation.”

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Hestatesthatthisconceptenableemployeesbemoreflexibleintheirwork,astheycanworkonsite(i.e.directlywiththeclientregardlessofthelocation)withflexibleworkinghours. It is an example ofwork innovations, as the design of the employees’ work isaffected and employee empowerment is supported by given individuals’ the choice ofwhereandhowtoperformtheirjob.The“Slimmerwerken”projecthasalreadystarted,but according to the manager still needs further development in order to be fullyoperational among the shared services. However, employees approve of this conceptandareeagertosupportitsfinalisation.

“Thisprojecthas just startedand[weconsider itas] the threeB's: ‘bricks’ (theplacewhereyouare),‘bites’(thesupportofICT)and‘behaviour’(thecultureandbehaviouroftheemployee).Andthosecomponentsneedtobefilled.”

TheinterviewrevealedthathospitalDregardsself-responsibilityasveryimportant,andtherefore the organisation intends to shift more responsibility from managers andsuperiors on to the employee. This results in the need for a cultural change, so thatemployeesdonotonlyacceptbutalsostriveforahigherlevelofself-responsibility.Since two years hospital D offers MD programmes (management developmentprogrammes-anemployment-and-workinnovation),wheresuperiorsofvariouslevelsand operational areas learn to gain trust in their employees. One exemplarymean isherethattheyincreasetheirtrustbyleavingtheplanningofworkingtimetablestotheemployees themselves – a new concept, as the planningwas previously done by oneperson. This timetable-planning project is exemplary for job enlargement and thus,representsaworkinnovation.Furthermore,sinceoneandahalfyears theHRMemployees’ levelofpassion for theirworkistargeted.Aworkinnovationconceptsupportstoidentifywhereeachindividualemployee is good at and what he likes to do. As per the interviewee, as a resultsatisfactionisintendedtoincrease,resultinginhigherefficiency,greatercreativityandpotentiallynewideas.

“Andwhen people comewith new ideas, in any case they have thought aboutthem.Thenatleastgivethemanafternoontimetoworkoutthesesideasbetterand then get started.Don’t directly push aside ideas, because after the secondtimetheemployeewillnotcomeanylonger.”

Hospital D identified young leaders and managers within the organisation as mostpromisingrelated to innovative thinkingandworking.Thus, theyhave implementedatalent management programme (employment innovation) for this specific group ofemployees. They are offered workshops and team projects, where the individuals’talentsareworkedoutandfurtherdeveloped,sothattheycanquicklybeintroducedtoappropriate vacant jobs within the hospital. The interviewee declares that instead ofsearching externally for somebody suitable, the hospital rather prefers to instill itsyoungtalentsintoneededpositions.

“Ibelievemoreinthehumanbeinghimselfandthatonecomplementstheother,rather than if you see one or two skills then you forget about the rest of the

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person. Ibelievemore in ‘this is thedirectionwewanttogo,andtodothisweneedthistypeofperson’."

In order to reduce costs, since the beginning of this year the HR departmentimplemented a new controlmodel, which entails that clients do notmake use of thedepartments services by naming a certain budget, but that the client names specificneeds.ThecostsfortheseneedsarethencalculatedbytheHRdepartmentandsendtothe client as an invoice for approval.According to theHRmanager, thisprovides thatwhatisdoneandpaidforisonlyexactlywhatthecustomerreallyneeds,andthatthereisnopre-determinedbudgetthatiscompletelymadeupforthingsthatarenotneeded.As this control model affects the entire organisation it can be categorised as anorganisationalinnovation.

4.5. SummaryofFindings

Inorder to support the furtheranalysis the following tables illustrate thedistributionandcontentoftheHRMinnovations.Theabove-identifiedinnovationswerecategorisedand counted according to type (single-typed or combined innovation), as well as thehospitaltheyweredetectedin.Table3summarisesthedistributionofinnovationsthatbecameapparentaftertheperformanceofthefourcasestudies.Table4illustratestheidentifiedHRMinnovationsbysummarisingthemshortly.

Table3:DistributionofInnovationsAmongStudiedHospitals

InnovationType HospitalA HospitalB HospitalC HospitalD Total

EmploymentInnovation

(EI)2 - - 2 4

WorkInnovation

(WI)- - 1 3 4

OrganisationalInnovation

(OI)- - - 1 1

EI+WI 1 2 1 2 6

EI&OI 1 2 - - 3

WI&OI 1 - 1 - 2

EI&WI&OI 1 - 1 - 2

Total 6 4 4 8

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Table4:SummaryofInnovationsintheStudiedHospitals

InnovationType HospitalA HospitalB HospitalC HospitalD

EmploymentInnovation

(EI)

• IT-tooltomatchhospital

needsofspecialistswithtemporary

labourmarket(‘MATCH’)

• (Voluntary)employmentcontractwithreduced

workinghoursandwagesfor

olderemployees

- -

• Mandatoryprofessionaldevelopmenttrainings

• Workshopsandteamprojectsforyoungleaderswithinthehospital

WorkInnovation

(WI)- -

‘Insideprofile’questionnairetodetect

preferencesand

competencesofHRemployees

• Jobcrafting• “Slimmerwerken”to

reducephysicalworkplacesand

increaseflexibility

• Self-planningoftimetables

OrganisationalInnovation(OI) - - -

ControlmodeltoreduceunitcostsforHRMservices

EI+WI

Specialistdoctors

themselvesareresponsibleforrecruiting

generaldoctors

• Self-serviceAppfor

recruitment,developmentandrewardingprocesses• Strategic-personnel-

planningtooltoforecastthestaffbudget

DigitalisationofHR

processeswithincreasedself-

servicepossibilities

• Newworkingconcept

relatingtocoreworkingtimes

andthedistributionof

taskstoincrease

efficiencyandflexibility• MD

programmestoincreasetrust

EI&OI Uniformforecasting

• Communicationandstrategic

- -

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systemforspecialisedfunctionswithinthecooperatinghospitals

alignmenttrainingformanagers

• Radboundworkshopsonhealthcaresectortrendsfortheentireworkforce

WI&OI

Passingonthedevelopmentofthehospital’sstrategytomanagers

-

Internalandexternalnetwork

development

-

EI&WI&OI

Personalbudgetforeachemployee,whichcanbeusedforanychoice.HR

advisorsshoulddiscusschoices

withindividualstostrengthentrust

-

Reconstructionprogramme,reorganisationofdepartmentsandfunctions

-

Overallitisnoticeablethatthereisadominanceofmulti-typeinnovationsoversingle-types.Themajorityofcombinationsconsistoftwotypesofinnovations,thenumberofinnovations, which combine all three types of innovations is low. Among two-typeinnovations,employment-workandemployment-organisationalinnovationsprevail.Whencomparing thedistributionamongsingle-type innovations, itbecomesapparentthat the majority is work-, or employment-related. They support job enlargement ofemployees, and increase the managements’ responsiveness, or focus on recruitment,trainingandcontractingrespectively.Furthermore, the majority of organisational innovations are related to culturalprogrammes.Thestrengtheningofself-responsibilityandtrustamongemployeesseemstobeoneofthegreatestgoalsofthestudiedhospitals.Byincreasingthelevelofthesetwo employee personality characteristics, HR mangers hope to increase the overallefficiencyandcreativityoftheindividuals.Theincreasedlevelofhigh-tech,resultinginfasterhealthcareserviceprovision,mainlyexplainsthenecessityofthis.Thedemandsof patients towards hospitals are changing and patients have a shorter stay at thehospital, thus, the work of nursing personnel and doctors are changing as well. It istherefore important that employees are aware of their own and co-employees’responsibilities, and thatmanagersof all levels trust their employees’ abilities so that

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thelevelofperformancedoesnotsufferinhectictimes,butthatemployeesareflexibleand can help out. In order to achieve the goal of increasing self-responsibility ofemployees and trust ofmanagers, hospitals A and D offered specific programmes forleaders,while hospital A launched a project,where themanagers themselves – solelywiththesupportoftheiremployees-wereresponsiblefortheoutcome.

It is interesting tonote thatalmosteachoneof the four studiedhospitals complainedabout the lack of communication between the different work fields and manageriallevels within the respective organisation. On the ward level, especially thecommunication among the different wards was exposed to be among the biggestproblems. On the supportive service level not only the communication betweendepartments,butalsowithindepartmentswassometimescriticised.Inthefirstcase,theresultwas thatwardmanagerswerenotawareof theconsequences theiractionsandchoiceshadontheotherwards.Inthesecondcase,theresponsibilitieswerenotalwaysclearly defined but pushed back and forth among the different service providers, andemployees(e.g.HRadvisors)solelyhadknowledgeabouttheirownclient(i.e.aspecificwardormedicalfield)butnotonothers.

With regard to an increased need of communication and trust among employees it isinterestingtonotethatallHRmanagerscamefromadifferentprofessionalbackground,which are all not related to the health care sector. Interestingly, this goes alongwithhospital B’s notation that more and more management from other industries areenteringthehealthcaresystem.Thisisapositivefactasthesemanagersareoftenmoreused to receiving andgiving feedback,whereas thehealth care sector tends tobe toocaring, too accommodative, too non-confronting. They represent an opportunity tohonestly determine matters that go well and matters that need to be improved orchanged.

TheclashofgenerationswithinhospitalsextractstobeamainconcernforHRmanagers.This ismainlydue to tworeasons.Firstly,hospitalschange tobemoreandmorehightech hospitals and require increases flexibility, and secondly older employees areassociatedwithhighcosts.Duetotheincreasingprogressandimplementationofhigh-techtoolsandprocessesinall various operational areas, employees do not only need to adopt, but also adapt toassociating changes. This requires the acceptance of new situations, which seems toemerge as a great challenge within the studied hospitals. Older employees, whichrepresent a comparably high percentage of the hospital staff, seem to both lackknowledgeaswellascomprehensiononhowtomakeuseofthesenewopportunities,orthey are reluctant to accept their usage. Reluctance is mostly caused by uncertaintyabout the changes that come with high-tech implementations and their potentialbenefits, but also especially more likely because of uncertainty about the specificimpactsontheirownprofessionalenvironmentandtheiranxietyofpossibledismissals.HospitalsBandDreactedtothischallengebyofferingprogrammestoleaderswithinthe

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hospitalwithwhichtheylearnedhowtocommunicatewiththeiremployees,andhowtotakethemtheiruncertaintiesandanxietiesandmakethemawareofpossiblegainsandfacilitationsthatcomefrompursuedchanges.HospitalBadditionallyofferedworkshopsfor employees of all operational levels to teach them about health care sectorsdevelopmentsandtheirassociatedimpactontheworkinthissector.The second concern of HRmanagers of Dutch general hospitals related to the ageingstaffistheconnectedincreasingcosts.Foronce,managersnoticethatolderemployeesaremoreoftenaffectedbyillnessesandthusincreasethelevelofsickleaveswithinthehospital. Sick leaves imply continued payment of wages and loss of sales (i.e.treatments) apart from mentioning disturbance of workflows and possible costs fortrainingofstand-ins.Thesecondmatterofexpensesisthattheolderemployeesmostlyhave a former contractwith the hospital. Compared to new contracts these include ahigherhourlywage,lesshoursofworkandmorevacationdays.Fromthecasestudiesitcan be seen that the ageing of staff is well observed and that there are differentapproachestoopposethischallenge.HospitalAoffersvoluntarycontractmodificationstoitsolderemployees,whichspecify75%ofthepreviouswagefor50%ofthework.Incontrast, hospital C changed its organisational regulations from protecting olderemployees from dismissal to releasing all employeeswho do not work appropriatelyandefficiently.Theapproaches toreact toageingstaffareverydifferent.Eventhoughhospitalsareawareofthechallengethatageingstaffsconstituteitisnoticeablethattheydonothavefullyelaboratedmeanstoapproachthismatter,yet.

AfurtherimportantnotationshouldbetakenonthefactthatallfourstudiedhospitalsarenotoccupiedinoutsourcingofanyoftheirHRresponsibilities.AllHR-relatedserviceprovisions are performed internally, except for in some cases utilisation oforganisationalassociations.Theseassociationsofhospitalscaneitherbelocallyclosetoeach other or spread across the country. The studied hospitals, which are part ofassociations that operate in the same region, support each other in times ofinsufficienciesof staff, communicatingwith the labourmarket,or shareknowledgeonprofessional matters. Locally dispersed association members were found to mainlycooperateonimprovementsofmedicalprocedures,butalsodiscussandshareideasonsupporting service matters such as ICT or HR. Furthermore, hospital C mentionedregionalnetworksasanimportantopportunitytoshareandaccelerateknowledgeandideaswhichthencanbeusedfortheownorganisation.

Toputitinanutshell,theoveralldistributionofsingleandcombinedinnovationsisnoteven,thereisagreaterexistenceofmulti-typeinnivations.Themajorityofcombinationsconsist of two types of innovations, whereas three-type-combinations are rare. Theoverlapsmostly includeemployment innovations,whereassingle-type innovationsaremainlyworkinnovations.Furthermore, the performed case studies on the fourDutch general hospitals suggestthatthereisamarbledlevelofinnovativenessrelatedtoHRwithinthesespecifictypesoforganisations.HospitalAandDcanberegardedasmoreadvancedintheiropennessfor innovations, whereas hospital B and D seem to be restrained by the traditional

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thinkingofhospitals,eventhoughtheHRmanagersseemtobeawareofchallengesandopportunitiesandarewillingtoapproachthem.Challengesarewidelyidentifiedasthelackofcommunicationwithintheorganisation,aswellastheageingofthestaffandthetherewith-associated difficulty of handling the advanced automation and usage oftechnology. This same advanced automation and technology is at the same timeregarded as an opportunity for hospitals to increase their efficiency and to simplifyprocesses within various operational areas. The second opportunity, which wasmentionedineachhospital, is thestrengtheningofself-responsibilityandtrustamongallorganisational layers inorder to increase flexibility,efficiencyandcreativity.Theselatterthreecharacteristicsareseenasveryimportantanddesirable,inordertobeabletooperateefficientlyandwiththeabilitytoreacttothechanginghospitalsenvironment.

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5. Cross-CaseAnalysisThe following chapter’s first paragraph analyses the occurrences and contents of thevarioustypesofinnovations.Theyareexaminedindividuallyaswellasincombinationwith other types. It is followed by the analysis of possible influencers of the level ofinnovativenessofthefourstudiedhospitals.Forthispurpose,Corral’s(2006)studyoninfluencersof innovativebehaviouroforganisations is introducedandusedasabasisfor the analysis. The possible influencers, which arementioned in Corral’s study, arelistedandthenseparatelyappliedandcomparedwiththefindingsderivedfromthefourcasestudies.Thiswaypossibleconclusionsoninnovationtriggersandrequirementscanbedrawn.

Asmentionedbefore,thereisahighernumberofinnovationcombinationsthansingle-typeinnovations.Therearelownumbersofinnovationsthatcombineallthreetypesofinnovations. Only hospital A’s ‘1-million-€-extra-budget’ project and hospital C’sorganisation-encompassing reorganisation programme have been identified as acombination of employment, work, and organisational innovations. The majority ofcombinations consist of two types of innovations, whereof especially employmentinnovationsare included.Theamountofemployment-work innovations ishigher thanemployment-organisational innovations. Work-organisational innovation overlaps arecomparablylow.ThefirstexampleforoneoftheseoverlapsisthedevelopmentofaHRnetwork, which is anticipated by hospital C as the HR advisors’ duties andresponsibilitiesincrease,andtheinternalandexternalcommunicationisstrengthened.The second example is hospital A’s strategy-development project, in whichmanagerswere faced with tasks they had not done before, and internal communication wasstrengthened as increased cooperation between employees and departments wasrequired.Thereisadifferenceofthedistributionofindividualandoverlappinginnovationtypeswhenlookingatthehospitalsindividually.WhereasinnovationsofhospitalA,B,andCmainly represent combinations of primarily two types of innovations (especiallyemployment-work and employment-organisational innovations), hospital Dimplementedmainlysingle-typeinnovations.Inthiscaseanespeciallyhighrateofworkinnovationsisnoticeable.Whencomparingthedistributionamongsingle-typeinnovations,itcanbeseenthatthemajority are work-related and employment-related innovations. Work-relatedinnovations aim at job enlargement of employees, and increasing the managements’responsiveness. Employment-related innovations generally relate to issues such asrecruitment, training and contracting.HospitalDhas an especially high occurrence ofworkinnovationsincomparisontotheotherthreehospitals.Onthecontrary,hospitalAhas a noticeably high number of employment innovations. When comparing theorganisational innovationsofthefourhospitals, itbecomesapparentthattheycontainmostlyculturalprogrammes,whichfocusonstrengtheningself-responsibilityandtrustamongemployees.

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In his study, Corral (2006) refers to several researchers and summarises the mostcrucial influencers of innovative behaviour of organisations. Among these influencersare(1)institutionalarrangements,(2)technologicalandorganisationalcapabilities,(3)organisationallearning,and(4)entrepreneurialorrisktakingbehaviour.Furthermore,he refers to individual factors that also influence the overall innovative behaviour oforganisations. Especially the (5) individuals’ intention to take on certain behaviour isessential forpredicting innovativebehaviourofanentireorganisation. In thiscontext,CorralreferstoAjzen(1991),whostatesthathumanbehaviourischaracterisedbythreefactors: the (a) individual’s attitude toward the behaviour, (b) perceived behaviouralcontrol,and(c)subjectivenorm.Whenapplying thesesevenaspectson the findingsretrieved fromthe fourperformedcasestudies,itispossibletoseethattherearevariationsbetweenthehospitalsineachaspect.

5.1. PossibleInfluencerofInnovations:InstitutionalArrangements

The first factormentionedbyCorral (2006), institutionalarrangements, is respectivelyhigh for all four hospitals with regard to medical and technological interaction andknowledge sharing. All hospitals are engaged in associations and collaboration withotherhospitalsinordertoensureandincreasethequalityofcare.Thisenablesthemtoshareknowledgeandexperiencesonnewtechnologies,treatmentsandproceduresandthus makes it possible to incite adaptions or adoptions for own hospital standards.Additionally, mutual exchange on non-medical subjects, such as supportive-services-issues,isanimportantbenefitoftheseinstitutionalarrangements,andisemphasisedbyeachinterviewedHRmanager.Theyofferanopportunitytostimulateideadevelopment,setstandards,andreceivefeedbackonthoughts,practicesandideas.HospitalA transpires tobea strikinganduniqueexample.Togetherwith locallycloseorganisations theyhaveestablishedan intenseandefficient cooperationonpersonnelissuesinordertoovercometheproblemofscarcepersonnelresourcesbysynchronisingcalculations of staff requirements, communicating with the labourmarket, and risingsectorwork awareness among sophomores. Even though the individual organisationswithin this association are in competition (especially due to their regional closeness),those responsible for HR see themselves as colleagues and are not hesitant to shareinformation about ideas and processes. Compared to the other hospitals, this closecollaborationisunique.ItisregardedasavaluableinnovationbyhospitalA,andmakesitoutstandingcomparedtootherregionallycloseordistantcollaborations.Truly,suchan intenseandclosecollaborationhasnotbeenmentionedbyanyof thehospitalsbuthasbeenidentifiedasdesirablebyhospitalC’sHRmanager.Thus,itcanbesaidthatinstitutionalarrangementsandnetworksbetweenhospitalsandrelatedorganisationsseemtohaveabeneficialeffectonthelevelofimprovementsandinnovationswithinhospitals.AllfourperformedcasestudiesexposedthatHRmanagerssaw collaborations were enhancing innovative thinking by exchanging ideas andknowledgeandbyreceivingincentivesforownimprovementsorchanges.Furthermore,close and efficient cooperation between hospitals and other care organisation withinoneregionwerefoundtobeespeciallyvaluableinthiscontext,assumingly,whichmight

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bebecauseofsimilarregional-specificconditionsand thereforebetteropportunity forcooperative elaboration and usability of ideas. This proposition is based on thecomparisonofthenumberofinnovationsintroducedbyhospitalAcomparedtohospitalB,C,andD.

5.2. PossibleInfluencerofInnovations:TechnologicalandOrganisationalCapabilities

The second factor, which theory identified as one of the most crucial influencers ofinnovativebehaviouroforganisations,istechnologicalandorganisationalcapabilities.Capabilitiesare“thecollectiveskills,abilities,andexpertiseofanorganisation,[that]arethe outcome of investments in staffing, training, compensation, communication, andotherhuman resources areas.They represent theways thatpeople and resources arebroughttogethertoaccomplishwork”(Ulrich&Smallwood,2004,p.119).Eventhoughcapabilities are difficult to determine and tomeasure, they are deemed as unique foreach organisation, and are very difficult to be copied by competitors. (Ulrich &Smallwood,2004).With regard to the examined hospitals there are certain capabilities that can beidentifiedeitheruniquelyinasinglehospitalorinasimilarmannerinseveralhospitals.TheclosecooperationofhospitalA’sassociationmembers,whichwasdescribedabove,certainly is an example for an organisational capability as factors such as highwillingness for intense cooperation in all kinds of operational areas, and substantialreductionofcompetitivethinkinghaveextractedtobedifficulttomeetwhencomparingthe other studied cases. Another capability that hospital A possesses is the internallydevelopedforecastingsystemforspecifiednursesandmedicalprofessionals.Itisoneoftheresultsfromtheclosecooperationwithotherregionalmedicalinstitutionsresulting.Forecastingrequiresefficientplanning,equipment,training,andevaluationoftargetedfactors (Hospital Preparedness Program (HPP), 2012), and the development of theirstaff forecasting process supports hospital A in order for being prepared foreventualities of staff shortages or absence of specialised personnel. The processrepresents a well-functioning combination of close internal and externalcommunications as well as a coordinated and supporting IT system. Internalcommunication isdistinguishedby theexchangeofproactive statusquoof staffingonthe various positions and wards in order to identify possible needs for continuationeducationornewhires.Theexternalcommunicationhappenswithtwoentities.Ontheonehand,hospitalAcommunicateswiththemedicalorganisations(especiallyhospitals)thatarepartof the localassociationthathospitalAbelongsto.Ontheotherhand, thehospital is in contactwith the commercial parties, which offer temporary employees.Theassociation’shospitalsexchangeinformationonstaffrequirements,suggestionsorsuccess rates for training programmes, which are then incorporated in hospital A’splanning forecasting process. This inclusion of regionally close entities presents abenefit for hospital A as staffing levels, requirements and opportunities can bedependentonlocalfactors(e.g.availabilityofeducationprogrammesorinstitutions,andavailability of skilled and experienced medical staff). When comparing the level of

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external communication of hospital Awith other regional hospitals, it is highwith anadditionallyhighwillingnessforintensecooperationandlowcompetitivethinking.Talentmanagementandleadershipdevelopmentarecapabilities,whichareexistentandencouraged in all fourhospitals.HospitalA grants each individual employee a certainbudget,whichheorshecanuseforanykindofeducationandtraining.HospitalBinsistson continuous renewal of accreditations and even determined in its collectiveemploymentagreementsthat3%ofthesalarycostsareallocatedforeducation.HospitalC offers trainings in order to ensure high quality and value adding in all operationalareas. And hospital D believes that employees are never fully trained and thereforesupport continuous learning throughout the entire organisation. At the same time,hospitalDhasaspecialprogrammeforyoungtalentedpersonnelthataretrainedtotakeon leadership positions within the hospital. Hospital A and B promote leadership bycooperating with external training parties. The transmission of trust and self-responsibilityarevalues,whichall leaderswithinall fourhospitalsareencouraged tocommunicate. All leaders are taught to listen to their employees’ proposals, ideas orremarksandshowan interest in them.Thereappears tobenogreatdifference in theexistenceandpromotionoftalentmanagementandleadershipdevelopmentamongthefourstudiedhospitals.Nevertheless,hospitalDgivestheimpressionofbeingespeciallyactive inthis field. Itplacesmuchvalueofcontinuous learninganddevelopmentof itsstaff,andspecificallyrecruitsyoungleadersinternallyinordertoincreasecreativityandinnovativenessAnother factor, which can be seen as an organisational capability, is internalcommunicationandknowledgesharing.However,thisappearstobelackingwithregardto the performed interviews. Three out of four hospitals criticise that thecommunicationbetweenwardsanddepartmentsdoesnotfunctionwellenoughandthatsometimes, even within single departments, the communication is lacking. This isespeciallycrucialwithviewtoHRadvisors,whoneedtocommunicatewitheachotherinordertohaveacertaindegreeofknowledgeonallunits,andnotsolelytheirunitsofresponsibility. With regard to increasing the innovative level, the degree ofinterdependencewithin the individualHRdepartmentsappear toberelativelyhighasthe study’s examples stress the need for employees from different remits to connect,communicate and exchange knowledge in order to exchange ideas and accelerateprocesses. Furthermore, theory shows that the higher the interdependence in adepartment is, themore informationandknowledgeexchangeamongdepartmentandteam members is necessary in order to achieve the required performance (Mannix,Neale, & Goncalo, 2009). The support of others increases the level of interaction,coordination,cooperationandcommunicationamongteammembersandthoseofotherteams. By communicating within and among teams, each employee has access to abroadersetofknowledgeandexpertisethanhisown,andis thereforeabletoconnectdifferent process aspects in a simplified way, which therefore enhances findinginnovativesolutionsor ideas.Furthermore, ideas,whichhavenotyetbeenelaboratedfully, can be developed and refined quicker and more comprehensively until theirimplementationisconsideredasworthstriving,andpossiblyincreasesthevaluefortheorganisation and the employees. Subramaniam and Youndt (2005) state that the

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knowledge,whichissharedthroughinteractionsamongindividualsandtheirnetworksof interrelationships (in their paper conceptualised as social capital), positivelyinfluences innovation, regardlessofwhether theyareradicaland incremental.Thus, itcan be said that increased knowledge sharing is likely to lead tomore creativity andhence,leadstohigherinnovativebehaviourofindividuals.Thetechnologicalcapability,whichhasbeenidentifiedthroughtheperformanceofthecasestudies,istheadoptionofasupportingITsystem.Ifthesystemiswelldeveloped,ithas the advantage that particular workflows are digitalised and simplified. HRemployeesarethenabletofocusoncoreresponsibilitiesastheamountofstandardisedtasks are reduced. Hospital C recently started a digitalisation process, where basicprocesses (such as reimbursement of costs, employee on boarding or exit) wereincludedintoadigitalworkflowaccessiblebyallsuperiors.HospitalBalsoimplementedemployeeandmanagementself-servicebymakingtheirworkflowdigitalandreachablefor the entire staff, and it is additionally planning to digitalise everything concerningrecruitment and selection, rewarding, training and development which will then beaccessible via an app with which department managers can start any HR processautonomously.HospitalDmonitorsitspersonnel’sdevelopmentdigitally,offers60%ofitstrainingase-learningcoursesandsupportsHRemployeesthatworkfromhomewithIT devices and services. Further, hospital A developed a recruitment platform incooperation with IT services. Thus, it can be said that all hospitals are aware of theincreasingdigitalisationofprocesseswithintheorganisationandareslowlyadaptingtothese changes. However, it became apparent that all interviewed managers wouldwelcomeanevenhigherinclusionofITservicesthanwhatiscurrentlypossibleastheyintendtofurthersimplifybasicworkprocessesandtasks.Tosum itup, the technicalandorganisational capabilities,whichhavebeen identifiedthrough the case studies, are continuous digitalisation adoptions, close externalcommunication, talent management, leadership development, and internalcommunicationandknowledgesharing. Itbecameapparent thatespeciallyexternalaswellas internalcommunication,andaspecifically trust-conveying leadershipstyleareimportant for increasing innovativeness.The latterwasmentionedandencouraged inallfourhospitals.Targetedprogrammesandmeetingswereofferedinwhichleadersareshownhowtocorrectlycommunicatewiththeiremployeesinordertoconveyfeelingsof trust and support, and how to be recognised as contact persons for remarks andsuggestions of all kinds. External communication promotes information exchange ongeneraland localconcerns,andsupportscreativeandcomprehensivesolutionfinding,whichthencanbeincorporatedinownprocesses.Asmentionedbefore,hospitalAhasan especially close communication with external parties and has developed andimplementedanumberofinnovativeideas.However,internalcommunicationseemstobetoolittlepresentwithintheorganisations,eventhoughallHRmanagersrecogniseittobeimportanttoincreaseknowledgesharing,creativity,andefficiencyamongallkindsofemployees.

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5.3. PossibleInfluencerofInnovations:OrganisationalLearning

Organisationallearningistheprocessofcreating,retaining,andtransferringknowledgewithin an organisation. Marquardt (1996) summarises characteristics of a learningorganisation,whichamongothersare:

• Systemsthinkingisfundamental;• Theimportanceofon-goingorganisationwidelearningisrecognisedthroughout

thewholeorganisation;• Learningisaccomplishedbytheorganisationalsystemasawhole;• Continuouslearningisembeddedintotheorganisationalstrategy;• Creativityandcontinuouslearningareanticipated;• Changeisembraced,andfailuresareviewedasleaningopportunities;• The organisation is able to respond to environmental changes by continuously

adapt,renew,andrevitaliseitself;• Thecorporateclimateencourages,rewards,andacceleratesindividualandgroup

learning;• Everyoneisdrivenbyadesireforqualityandcontinuousimprovement;• Employeesparticipateininternalandexternalnetworks;• Employeesaregrantedaccesstoinformationresources.

Theverygreatmajorityof thesecharacteristicsare fulfilledbyall fourhospitals, eventhoughtheoverallapproachtosomeoftheseaspectsdiffers.Asmentionedbefore,eachhospitalofferscoursesandtrainingopportunitiestovariousgroupsofemployeeswithintheirrespectiveorganisation(leadershipprogrammes,specialisationcoursesorschoolprogrammesfornurses,etc.).However,hospitalDappearstoespeciallyattachvaluetocontinuous learningof the entire organisation as it embeds expanding andpromotingknowledge in its HRM strategy, and is eager to offer a great amount of (e-learning)courses.However,differencesinapproachesbecomeapparentwhenhavingalookatespeciallythelowerhalfofMarquardt’s(1996)characteristicsoflearningorganisations.Thefirstsmall visible difference is connected to the characteristic ‘the organisation is able torespond toenvironmental changesbycontinuouslyadapt, renew,and revitalise itself’.The greatest, during the interviews recognised environmental changes are thedemographicof thehospitalstaff,andtheproceedingdigitalisation.HospitalArevealsthe ageing of nurses as the greatest challenge and found an innovative solution byintroducing shortened contracts to older nurses in order to use the amount of savedsalariesfortherecruitmentofyoungerpersonnel.Atthesametime,hospitalBfocusesonthechallengecoming fromfemalenursesbetween30and40years,whoareat theageofbecomingmothers.Theywant changes in theirworkinghoursand thehospitalreactsbyincreasingthelevelofcooperationontermsofflexibleworkinghours.Digitalisation is recognised in all studied cases. The difference merely lies in theacceptanceand intensityof adoption.HospitalBandCare currently in theprocessofdigitalising and automating the great majority of its traditional HRM processes, andtrainingdepartmentandwardmanagersinbeingabletoaccessandmakeuseofthese

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processesontheirown.ForhospitalCthisisalargechangeasdigitalisationwasnotyetbasicandmanyprocesseswerestillperformedmanuallyorevenonpaper.In the context of being able to respond to environmental changes, it is specificallyinteresting to point out hospital B that offers Radboud workshops to all layers ofpersonnelinordertoreceiveaninsightintocurrentchangesinthehospitalsectoranddecreasetheir fearofuncertainties.Onthecontrary,accordingto theHRmanager thehospital was unfortunately not able to make great use of the opportunity for thedevelopment and implementation of changes, which the fusion of two organisationsheld.Atthemomentthehospitalisconcernedwithinternalprocessesandisthereforedistractedfromoccurrencesandopportunitiesintheexternalenvironment.Afurtherdifferencelies intheaccessibilityof informationresources,andparticipationin internal and external networks, the last two listed characteristics of learningorganisations. The difference in the usage of external networks has been analysedbefore.However,internalnetworkspresentagreatdifference.Apartfromallhospitals’encouragementofincreasedcommunicationbetweenleadersandemployees,teamworkandespeciallyteamworklearningisafactor,whichoftenseemstobeunattended.Thispresentsaninterestingfindingasorganisationallearninghasbeendetectedasatriggerforinnovation.Available research on teamwork shows that it is crucial for the innovative workbehaviour of employees within an organisation. Beugelsdijk (2008) states thatteamwork gives employees the opportunity to “expose a broad range of perspectivesandinformation”(p.824).Heespeciallyraisesattentiontocross-functionalteams,whicharecharacterisedbypeoplefromdifferentfunctionalareaswithinanorganisation,andwhich are a “critical organisational design for fostering creativity and innovation”(p.824). He draws the conclusion that a diversity of perspectives proposes moreresourcesforindividualstodrawon,offersthemagreaterpossibilitytogainknowledge,andthus leads toamorecreativeand innovativebehaviour.Supportively, Jiang,WangandZhao(2012)concludethatteamworkispositivelyrelatedtocreativity,andthatthedevelopment of innovative ideas mainly occurs through creative employees. In thisregardtheydefinecreativityas“thedevelopmentofnewideas”andinnovationas“theprocessofactuallyputtingthenewideas intopractice”(p.4027).Theauthorsrefertoformerresearchers, suchasWest (2002),Nemeth,OwensandWest (1996),andErnst(2004), and state that the efficient management of teams is fundamental to enhancecreativity and thereby innovation.Management possiblymotivates teammembers “toperform at higher levels of creativity” (p.4031) due to the provision of standardcomparisonsand feedback forboth, individualsand teams. SubramaniamandYoundt(2005) underline the social relationships among employees within an organisation(internally as well as externally) by stating that “unless individual knowledge isnetworked, shared, and channelled through relationships, it provides little benefit toorganisationsintermsofinnovativecapabilities”(p.459).Thus,thereinforcementofteamwork,especiallytheinteractionofmembersofdifferentoperationalareas,whichhospitalAachievedthroughtheperformanceoftheirstrategy-development programme, is a possible determinant for their advanced innovativebehaviour.While hospital A, B andC criticise the lack of communication between the

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different departments and wards within the organisation, there was no mention ofprojectorprogrammesinordertoovercomethisproblem.Onthecontrary,hospitalCevencriticisedthatteamworkwasnotyetenoughencouraged.To put it in a nutshell, all four studied hospitals promote organisational learning. Allorganisations recognise that continuous learning is essential in order to staycompetitive and thus pursuit comparable approaches to stimulate their employees inthis thinking and its execution. Small variations can be visible in the recognition ofenvironmental challenges, and the ability and speed to respond to changes. Thesefactors reflect differences in the level of organisational learning, as respectiveknowledge is created and transferred at different speed. The greatest differencepresents the accessibility of information resources and internal as well as externalnetworks, which already has been partly found previously during the analysis of thehospitals’ institutional arrangements. In addition to those finding, the analysis ofinternal networks exposed that teamwork supposedly has a greatly positive effect ontheleveloflearningandthusonthelevelofinnovationoftheorganisation.ApartfromhospitalA,nohospitalreferredtospecificimplementedteamwork-promotingactivities.

5.4. PossibleInfluencerofInnovations:EntrepreneurialorRiskTakingBehaviour

The fourth influencer of the level of innovation of an organisation retrieved fromprevioustheoryisentrepreneurialorrisktakingbehaviour.Consideringandincludingvariousdefinitionsofentrepreneurshipandentrepreneurialbehaviour, the latter can be summarized as an organisation’s behavioural style thatencourages innovation and innovative thinking by examining and exploiting potentialopportunitiesregardlessofcurrentlycontrolledresources.Entrepreneurialbehaviourisalso characterisedby a pro-risk-taking attitude,whichmakes itmore likely to exploitopportunities.Stevenson and Jarillo (1990) propose a number of propositions on entrepreneurialbehaviour based on previous research findings. Among others these include that thelevel of entrepreneurial behavioural is higher when firstly, internal and externalnetworks are established and knowledge is shared, secondly, individuals within theorganisationareput inaposition,andare trained todetectopportunitiesand thirdly,whenindividualsofallorganisationallayersshowapositiveattitudetowardsacertainopportunity.Withregardtothisresearch,individualswithinthehospitalaredividedintwogroups,HRstaffandmedicalstaff.Theyareanalysedseparatelyinordertodefinedifferencesandfindpossiblecausesforthelevelofinnovativeness.Asmentionedbefore, institutional collaborations andparticipations innetworkswerefound to positively relate to the innovativeness of the studied hospitals’ HRdepartments.Theyofferopportunitiestoexchangeknowledgeandreceivefeedbackandthus stimulate creativity and innovativeness. All four hospitals are engaged inassociationswithotherhospitalsaswellasrelatedmedicalinstitutions,andareeagertoestablish or strengthen a broad network of various medical and/or specialisedorganisations.However,itappearsthatthesecollaborationsareonastilltooprofoundlevel in some cases which is possibly due to an either too far distance betweeninstitutions, or a too low willingness or close regional cooperation and a too high

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competitivethinking.Additionally,itbecameapparentthatinternalcommunicationandteamworkpromotionbetweendepartmentsaswellas individualswithin thehospitalswas still lacking and thus making knowledge sharing more difficult. This possiblyreducesthelevelofdetectingopportunitiesontheoverallorganisationalaswellastheindividual employee level.With regard to the latter, the analysis of the four hospitalsshowsadifferencebetweenemployeesinleadershipandnon-leadershippositions,eventhoughallfourhospitalspromotecontinuouslearningonalloperationallevels.Thecaseanalyses create the impression that the capability of detecting opportunities forimprovementorinnovationsisratherlowontheindividualnon-leaderemployeelevelsduetoreducedknowledgeonandcapabilitytoadapttocurrenttrendsinthehealthcaresector.Nurses,especiallythoseofthehigheragegroups,weresaidtobesolicitousaboutcurrent changes, which is why all four hospitals focus leadership development ontransmittingtrustandsecurityamongthemedicalstaff.Stevenson and Jarillo’s (1990) first two propositions on entrepreneurial behaviourrequire that internal and external networks are established and knowledge is shared,andindividualswithintheorganisationareput inaposition,andare trainedtodetectopportunities.Basedonthis,thestudiedhospitalsseemstobemostlywillingtobehaveentrepreneurial, however are not fully capable of showing this behaviour, yet.Knowledge sharing through efficient external and internal networks, and internalcommunicationaswellasdevelopment isnotyet fullyalignedwith the level,which isnecessary for detecting and exploiting opportunities. The promotion of close internalandexternalcooperationseemsovershadowedbyorganisationalcompetitivethinking,anxiety on the non-leadership level, and underdeveloped leader-member exchange(LMX,i.e.therelationshipbetweensupervisorandemployee).Additionally,theabsenceof truly entrepreneurial behavior is a possible result of the default of the thirdpropositionofStevensonandJarillo(1990).This third proposition states that the level of entrepreneurial behavioural is higher,whenindividualsofallorganisationallayersshowapositiveattitudetowardsacertainopportunity. It corresponds to the three characterisations of human behaviour,establishedbyAjzen(1991)-thefifthfactorindividualintention,whichtheyidentifyasoneofthemostcrucialinfluencersofinnovativebehaviouroforganisations.

5.5. PossibleInfluencerofInnovations:IndividualIntention

Ajzen(1991)states thathumanbehaviour ischaracterisedby three factors,whicharethe individual’sattitude toward thebehaviour, thesubjectivenorm,and theperceivedbehaviouralcontrol.Thesefactorsaredescribedasfollowing:

• Attitudetowardsthebehaviour“isthedegreetowhichapersonhasafavourableorunfavourableevaluationorappraisalofthebehaviourinquestion”;

• Subjectivenorm“isasocialfactor,istheperceivedsocialpressuretoperformornottoperformthebehaviour”;

• Perceivedbehavioural control “is theperceivedeaseordifficultyofperformingthebehaviouranditisassumedtoreflectpastexperienceaswellasanticipatedimpedimentsandobstacles”(Ajzen,1991,p.188).

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As mentioned before, the interviewees point out a rather high level of anxiety anduncertaintytowardschangesinthehospitalsectoramongtheoldernursesduetoalackofknowledgeorincapabilityofapplication.Itcanresultinaprejudicedviewonrelatedinnovations, which negatively influences the attitude towards the change and likelyincreases resistance against adaption. When information and benefits of adaption tochanges are not fully transmitted to the individuals within an organisation, positiveattitudestowardsthesechangesaremoredifficult todevelop.Thisbecomesespeciallyapparent in the context of increased digitalisation of hospital and administrativeprocesses,asitcanbeforexampleseeninthecaseofhospitalBandC.Moreover, the increasing speed of digitalisation and health care related workflowscannot be controlled by the organisations because they are external environmentalchanges.Thus,thehospitalssoonerorlaterneedtoadapttothesechangesinordertostaycompetitiveandthereforekeeppushingthe implementationofnecessarychangesforward. It leads toan increasedpressureonemployees toadapt themselves to thesechanges. Furthermore, especially older employees are affected as it became apparentthat they have especially difficulties with the developments in the health care sectorwhen compared to the younger generation of employees. This ‘clash of generations’emergedfromallinterviewsandcanpossiblyresultinresistance.The interviewees argue that managers and leaders within the health care sector areusuallynotusedtogivingfeedbackorthinkingwithforesighttowhatchallengesmightbe imminent and what measured need to be taken. This also applies to the HRMdepartment within these hospitals, which seem used to a rather administrative thanstrategicrolewithintheorganisation.Thispossibleshowsadifficultyofperformingtherequired behaviour of being creative and innovative in order to manage theorganisationsstafftowardstheachievementoforganisationalobjectives.The Ulrich model (1997) is a well-fitting method to demonstrate the differencesbetween possible HRM roles and contributions [see Appendix Figure 3: The UlrichModelofHRRoles(Shah,2015)].Ontheonehand,theroleofthe‘administrativeexpert’,which is managing the organisation’s infrastructure by re-engineering processes, andthe ‘employee advocate’, managing transformation and change by listening andresponding to employees, have an operational focus. On the other hand, the ‘changeagent’ and ‘strategic partner’ role have a strategic focus (Hunter & Saunders, 2005,p.11). The ‘strategic partner’ responsibility is tomanage human resourceswithin theorganisation according to strategic objectives by aligning the HR strategy with theoverallbusinessstrategy.The‘changeagent’responsibilityistoreacttoand“meetthechallenges of the changing business environment and positioning the business toexecute strategy“ (Hunter & Saunders, 2005, p.11). Thus, managing the humanresources in a way to transform and change it towards a targeted organisationalinfrastructure. From the case studies it can be derived that all HRM departmentssuccessfully took on the roles of the administrative expert even if the performancewithin the other three roles is not fully efficient. The cause for this seems to be theincreased need for the execution of the ‘strategic partner’ role. As the hospital sectorbecomes more and more business-like, the organisational strategies and objectivesbecomeincreasinglybusiness-likeaswell.TheincorporationoftheHRMdepartmentis

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recognised as being essential for the achievement of the renewed objectives, whichmovestheHRdepartmentsintotakingonthe‘strategicpartner’role.Thechangeofthestrategy seems to create uncertainty and anxiety among (especially older) employeeswithinthehospital.Thisinturndemandsgreatereffortintermsof‘employee-advocate’activities, which are listening and responding to employees, and eventually ‘change-agent’activities.ItisnecessarythatHRprofessionalswithinthehospitalsareawareofthe transition towards the business orientation, and the arising consequences. Atpresent,thechangefromtheoperationalfocustothestrategicfocusisnotyetentirelyimplemented. The current role of HRM in the hospitals is not yet aligned with therequired role for efficiently contributing to the new organisational objectives andstrategicdirection.To sum it up, the relatively low level of innovativeness of HRM in Dutch generalhospitals can possibly be explained by the low individuals’ intention to initiate andadopt innovations. In this case especially a negatively attitude of the staff towardschanges in the health care sector seems to be predominant. A great part of the staffconsistsofelderlyemployees,whoarenotexperienced,conformableorevenwillingtoadapt possible changes in their workspace. Overstraining or excessive pressure fromanticipatedchangesfortheindividualhimselforherselfpossiblycreatesfear,whichcanthen result in a state in which the situation becomes threatening and resistanceincreases.Additionally,theHRMstaffseemstonotyetbefullycapableofacceptingthenewroleitneedstotakeoninordertobeastrategicpartnerinthenewlybusiness-likeenvironmentofDutchgeneralhospitals.

ThefollowingtablesummarisesthepossibleinfluencersofHRMinnovationsaccordingtothefourstudiedhospitals.

Table5:SummaryofInfluencersofHRMInnovations

PossibleInfluencers HospitalA HospitalB HospitalC HospitalD

InstitutionalArrangements

• Intenseandefficient

cooperationwithregionalhealthcareinstitutions• Despiterecognizing

otherinstitutionsascompetition,theHR

managersseethemselvesascolleagues

• MonthlymeetingsofHRmanagerswhichareallpartofa

cooperationthatis

geographicallydispersed,discussionofHRpoliciesand

ideas• Additionally,partoftheSTZ

• MonthlymeetingsofHRmanagerswhichareallpartofa

cooperationthatis

geographicallydispersed,discussionofHRpoliciesand

ideas• Little

participationinregional

networks,yet

• PartoftheSTZ

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• Cooperationisviewedasvaluable

• Additionally,partoftheSAZ

butparticipationis

desired• Additionally,partoftheSTZ

Technological&

OrganisationalCapabilities

• Goodinternalandexternalcommunicationandknowledge

sharing• Talent

managementandleadershipdevelopment• Advanceddigitalisationadoptions

• Talentmanagement

andleadershipdevelopment• Standarddigitalisationadoptions

• Talentmanagement

andleadershipdevelopment• Standarddigitalisationadoptions

• Enhancedtalent

managementand

leadershipdevelopment• Advanceddigitalisationadoptions

OrganisationalLearning

• Supportofcontinuouslearning

• Broadandeffective

participationinexternalnetworks

• Increasedinternal

communication• Reinforcement

ofcross-functionalteamwork• Advancedaccesstoinformationresources

• Supportofcontinuouslearning

• Promotionofstrengtheninginternal

communication• Participationin

externalnetworksandthusaccesstoinformationresources

• Non-servingoffusion-relatedopportunitiesbecauseof

internalfocus

• Supportofcontinuouslearning

• Promotionofstrengtheninginternal

communication• Participationin

externalnetworksandthusaccesstoinformationresources

• Requestforbroader

participationinnetworks

• Strongsupportofcontinuouslearning

• Participationinexternal

networksandthusaccesstoinformationresources

• Promotionofinternal

communication

RiskTakingBehaviour

• Internalandexternal

networksareeffectiveandknowledgeis

shared

• Externalnetworksareestablishedandknowledgeis

shared• Ratherlowinternal

communication• Non-servingoffusion-relatedopportunitiesbecauseof

internalfocus

• Externalnetworksareestablishedandknowledgeis

shared• Lowinternalcommunication

• Externalandinternal

networksareestablishedandknowledgeis

shared

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IndividualIntention

a)Attitudetowardsthebehaviour

• Uncertaintyamongtheoldergeneralstafftowards

theorganisational

changes

• Uncertaintyandnegativityamongthegeneralstafftowardstheorganisational

changes

• Uncertaintyandnegativityamongtheoldergeneralstafftowards

theorganisational

changes•

• Uncertaintyamongtheoldergeneralstafftowards

theorganisational

changes

b)SubjectiveNorm

• Pressuretoadapttoexternal

environmentandthereforetointernalchanges

• Pressuretoadapttoexternal

environmentandthereforetointernalchanges

• Pressuretoadapttoexternal

environmentandthereforetointernalchanges

• Pressuretoadapttoexternal

environmentandthereforetointernalchanges

c)Perceivedbehaviouralcontrol

• ProfessionalbackgroundofHRmanagerisnothealth-carebutbusiness-organisation-

related

• HRMtakesonarather

administrativethanstrategic

role• ProfessionalbackgroundofHRmanagerishealth-care-related

• HRemployeesmostlymisscapabilitiestomakeuseofnetworksand

sharedinformation• Intendedpromotionoftrainingandstrategic

deploymentofHRMstaff

• HRMtakesonarather

administrativethanstrategic

role• ProfessionalbackgroundofHRmanagerisnothealth-carebutbusiness-organisation-

related

• StrategicapproachesoftheHRM

department• Promotionoftrainingandstrategic

deploymentofHRMstaff

• ProfessionalbackgroundofHRmanagerisnothealth-carebutbusiness-organisation-

related

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6. DiscussionIngeneral, therespectiveHRM-innovation types inDutchgeneralhospitalsoftenhavesimilar characteristics and goals. The majority of employment innovations containdigitalprogrammesthatsimplifybasicHRprocesses,suchasrecruitmentandappraisal,or present training programmes for the organisations’ staff. The high frequency ofrecruitment-related innovations could be possibly connected to the constant need ofpersonnel, especially younger personnel, who are less costly,more flexible andmoreopen for changes. Leader programmes,which aim at improving communication skillsareespeciallycommon.Inthecontextofworkinnovations,jobenlargementisespeciallyoutstandingasthehospitalsgreatlyencourageincreasedself-responsibility,continuouslearning, and participation in specialisation courses. This all has consequences on theperformance, extent, and responsibilities of current jobs. The major concern oforganisationalinnovationsissupportingorganisationalchangetowardsincreasingtrustandcommunicationamongtheentireorganisation’spersonnel,andthestrengtheningofinternal and external information networks. There is an even distribution betweensingle- and multiple-type HRM-related innovations in Dutch general hospitals whencomparing the overall findings derived from the case studies. When looking at thehospitalsindividually,itbecomesapparentthatthreeoutoffourhospitalshaveahigheroccurrenceofinnovationcombinations.The amount of innovation overlaps is high as single innovations often result in therequirementofanotheradaptedinnovation.ForexampletheimplementationofadigitalHRM-self-service portal leads to an increased level of responsibilities on the leaders’side,which again requires aligned training programmes. Thus, a high level ofmutualinterdependencebetweenthedifferenttypesofinnovationscanbeseen.Thesefindingsagreetothisresearch’ssuggestionthatthevarioustypesofinnovationsdo not solely exist separately, but that they overlap and thus show characteristics ofmultipletypesofinnovations.

Whencomparingtables3and4(distributionandsummaryofinnovationsfound)withtable5 (summaryof influencersofHRM innovations) somepeculiaritiesarevisible. Itcanbeseenthathospitalsthatstronglypromotedcontinuouslearningweredominantinworkinnovations.Thosedominantinemploymentinnovationsshowadvancedinternalcommunication, advanced continuous learning, and reduced negativity of generalemployeestowardschanges.OrganisationalinnovationscanbeseeninhospitalswithagreaterstrategicfocusoftheHRMdepartment.Hospitalswithanadministrativefocusshowalowernumberofsingle-typeinnovations.In general it appears that the overall number ofHRM innovations is higherwhen therole of HRM is more strategic, and when the HR manager’s background is business-related.Weseethatthree-type-innovationsarepresentwheninternalnetworksareestablished.Additionally, thevarietyofHRMinnovationtypesappears tobegreaterwhen internalcommunicationispromotedandexternalregionalnetworksareeffective.

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Comparing table 3 and 5, it appears that there is no great difference between thenumber of HRM innovations in SAZ and STZ hospitals, even though on average thenumberofinnovationsintheSAZhospitalisslighterhigherthanthoseinSTZhospitals.Itcanbeseenthatthenegativityofgeneralemployeestowardschangeswaslowerwheninternalcommunicationandcontinuouslearningwashigh.

Withregard to theanalysisof theDutchgeneralhospitalcontext, it isvisible that it isessentially characterized by a number of legislative, technological, economic, anddemographic factors. On the one hand, a number of external factors influence theoperations within these types of organisations. The DBCs payment system, whichfollowsthe“moneyfollowsthepatient”principle,resultsinagreatpressureofhospitalstobeefficient.Atthesametime,thechangingdemandsandtheincreasedspeedofthehealth care sector result in a greater need for flexibility of hospital operations andpersonnel.So is the increasingspeedanddistributionofdigitalisation,whichpresentsopportunities as well as challenges to Dutch hospitals. Digitalisation can result insimplifyingprocessesandfacilitatetheworkofemployeesofvariousoperationalareas.However,itrequiresanadvancedleveloftechnologicalcapabilitiesandcanalsocreateanxietyanduncertaintyamongemployees,especiallyamongolderemployees.All these combined external factors, including the legislative, economic, andtechnological factors, require hospitals to change their thinking towards being morebusiness-like. At the beginning of this thesis, a set of practices and concepts ofNPM(NewPublicManagement)asmentionedbyPollittandDan’s (2001)was listed.Whencomparingthesepracticesandconceptswiththefindingsderivedfromthecasestudies,fullcomplianceapplies.Foronce,hospitalstargetthepatients’satisfactionandreacttotheirchangingneedsasthesehaveagreatinfluenceontheirperformance.Patientscanstate their preference to a GP when being referred to a hospital, and if a hospital isunattractive topatients for somereason, it isnot competitive.Moreover,hospitals settheir focus on performance because they are paid according to the number oftreatments. The medical departments and activity fields within hospitals seem to begreatly reduced and specialised so that procedures are relatively small and clearlydefined.Thisrepresentstheenhancementoftheleanconceptwithintheorganisations.Astasksaresmallandwelldefined,itiseasierfortheindividualtotakeonanunknowntask,andperformagreatervarietyoftasks.Furthermore,outsourcingisusedinorderto reduce costs and increase efficiency.However, in this respect it is striking that thegreat majority of the studied hospitals is making a rather low use of outsourcing. Ifoutsourcing takes place, it mostly only happens with cleaning and kitchen services,whereas laboratories or specialised medical services are rarely outsourced. Thisphenomenon is possibly related to the traditional thinking of hospitals, which wasmentionedbyall interviewees.Takingcareofpeopleseemstobestillmore importantthan being as efficient as possible, which could be the reason for not outsourcingmedicalprocessesthatarenotthehospital’scorebusiness.TheNPMcharacteristicsdonotonlyapply in thecaseofhospitals ingeneral,butalsowithregardtotheirHRMdepartments.

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Inaccordancewith theorganisations’overallgoalofbeingefficientand increasing thelevelofperformance,HRMservicesbecomemorestrategicallyaligned.Bychangingtheculture towards being more self-responsible and flexile, HR professional intend toincrease the flexibilityandefficiencyofemployees.Hospital staysbecomeshorterandnursesaretrainedsothattheycanperformtasksofmedicalprofessionals.Atthesametime,theyneedtohaveself-confidencesothattheyareeasilyabletoperformnewtasksin case they have to serve as stand-ins for staff on sick leave, which is why jobsimplification and continuous learning are reinforced. Within HR departments,digitalisationandautomationofbasicprocessesisincreasinglyusedtoimplementself-serviceportals,withwhichthenumberofactionsandactorsisreduced.InsomecaseswardmanagerscanstartanyHRMprocess,suchasapplyingforpersonnelrecruitmentorwageincreasedigitally,andHRprofessionalssimplyneedtoapprovetheexecution.The inclusion of digitalised basic processes seems very common andmore advancedwithregardtobusinessesinothersectors.However,inthehospitalsectorthisseemstobe not yet disseminated. HR professionals identify another characteristic of businessorganisation management, namely the utilisation of partnerships, as increasinglyattractive and beneficial. Especially the strengthening of professional networks is avaluable objective of the interviewedHRmanagers,which allow sharing and refiningideas.At thesame time, fewmadeuseofoutsourcingHRMresponsibilitiesother thanprofessional trainings.This isnotsurprisingwhenthinkingabout thecorebusinessofhospitals,whichiscaringforpatients.Apartfromknow-howandskills,theperformanceofhospitalservicesrequirescloseinteractionwithpeople,eitherpatientsorco-workers.This again requires a great level of commitment, coordination, responsiveness, andattentiveness of individual employees, as well as the compliance with respectivehospital values and beliefs. As humans and human capital are especially important inhospitals, aligned and efficient HRM is equally important because it deals with themanagement of individuals within the organisation. Thus, processes related torecruiting,maintaining, developing, and utilising employees is assumingly rather keptin-houseinserviceprovidingorganisationsthaninmanufacturingbusinesses.Adding to the technological, legislative, and economic influencers of the health caresector,thereareanumberofdemographicfactors,whichcanbeseenasexternalaswellas internal influencers. So, the ageing population does not only influence hospitals interms of necessary treatment adaptions, but also in termsof theirworkforce. A greatmajorityofhospitalemployeesarewomenofthehigheragegroupthatoftenrequiredspecial treatment. Women in their 30s and 40s are often either less flexible in theirworkinghoursduetoparenthood,orareonpregnancyormaternityleave,andthereforerequire adjusted working contracts. Women in their 50s and 60s were found to beincreasingly sick, or inflexible because of their physical condition or privateresponsibilities.Additionally, theyoftenhaveworking contracts,which grant ahigherwageforlessworkinghourscomparedtoyoungeremployees.Theyarealsofoundtobelessacceptingtowardschangesresultingfromtheincreasedbusiness-likethinkinganddigitalisationofhospitals,eitherbecauseofunwillingnessorincapability.

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When questioning the possible degree of these influencers of the innovative level ofDutch general hospitals, it become apparent that the traditional thinking withinhospitals seems to outweigh the business-like thinking, which is required to beinnovative and efficient. Even though, managers and employees in general hospitalsneedtoadoptmoreandmorecharacteristicsofbusinessorganisations,whichseemstobeagreatchallenge.Apossiblereasonforthisisthenatureofhospitals,whichiscaringfor patients and not operating as fast and efficient as possible. Asmentioned before,managerswithinthehealthcaresectorweresaidtolackspecificcharacteristics,suchasgiving feedback and thinking with foresight, which are essential in the businessorganisation context. In this connection the Ulrich model (1997) was given as ademonstrationofthedifferencesbetweenpossibleHRMroleswithinorganisations.Dueto the hospital’s transition towards becoming more and more business-like,organisationalstrategiesandobjectiveschangeaccordingly.Therefore,HRprofessionalswithinthehospitalsneedtoadapttothetransitiontowardsthebusinessorientationandits consequences. They need to steadily increase their focus on taking on Ulrich’s‘strategicpartner’roleinordertocontributetotheorganisation’ssuccess.However,atpresent HRM departments within these organisations seem to be still greatlytraditionallyoriented,whichincludesmainlytakingonroleswithanoperationalfocus.ItmightbeevenmorechallengingforthoseHRMemployees,whoworkintheirpositionfora long time,or for thosewhooriginallyhaveadifferentnon-businessprofessionalbackground,e.g.themedicalfield.Thepossiblefirststepisheretointra-departmentallyincrease awareness and know-how in order to convey changes to the rest of theorganisation.ExceptforhospitalC,allinterviewedHRmanagerscomefromadifferentprofessional background, which were all not related to the health care but differentother business sectors. Thus, they are possibly more aware of required changes andconsequences because they are accustomed to business-like thinking. However, theawarenessandreadinessamongotheremployeeswithinthedifferentHRMdepartmentspartiallyseemtobenotfullydeveloped,butwasstillintheprocessofslowlyincreasing.Literaturefromthefieldofchangemanagementidentifiesleaderswithinorganisationsaskeyenablerinthechangeprocess(Hayes,2014,p.159;Rothwell&Sullivan,2005).Theyrepresentexamplesandreflectionsoforganisationalvaluesandobjectives,andareclosesttotheemployeeswithintheorganisation.Itcanbeclearlyseenthatthestudiedhospitals are actively encouraging leaders to bemore communicative and responsive.Theyreceivespecialtrainingtoincreasetheirskillsinthisarea,andfurthermorereceivean insight into health care sector opportunities, challenges, and trends. However, thecommunication still seems to lack as HR managers still describe their employees asuncertainandafraidofwhatthefutureholdsforthem.Therearethreepossiblereasonsforthis.Leadersareeitherstillunsureorunabletoapplythelearnedskills,thetrainingwasinsufficient,ortheemployeesarereluctanttoacceptchanges.Thereareinitiativestoapproach thesepossibilities,e.g.by trainingandappointingyoung leaders,whoaremoreaccustomedtothecurrentchangesinhealthcare,byofferinginformationeventsfor the ordinarymedical staff, or by encouraging communication from the side ofHRprofessionals. However, it is necessary to realise that the different groupswithin theorganisationshavedifferentabilities toadapt tochanges,andthereforeneeddifferent

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approaches in order to be able to change and to detect opportunities. The youngergenerationoftenwantsandneedstobechallenged,whichincreasestheopportunityforflexibility.Whereas theolder generationneeds a great amount of communication andinformationaboutsectortrends,opportunities,andchallengesinordertoreducetheiruncertaintyandfeartowardsthefuturesothattheyeventuallywillrealizethenecessityand benefits of present and upcoming changes. Hospitals that adjust HR activities tothese demands are probably more likely to perform well in the roles of ‘employeeadvocate’and‘changeagent’,andultimatelyintheroleofthe‘strategicpartner’.

Referring toCorral’s (2006) five triggersof innovation itbecomesapparent thatapartfrom internal communication and knowledge sharing, close external collaborations aswell as participation in external and internal networks is a key influencer of theinnovativelevelofhospitals.External institutional arrangements offer opportunities to exchange knowledge andideas, and offer a source for additional input in process developments. However, itseems that close regional collaborations are not as exploited as possible, probablybecauseofahighdegreeofcompetitivethinking.Duetothe“money-follow-the-patient’principle,hospitalsneedtoincreasetheirperformanceandefficiency.Additionally,theavailabilityofjobapplicantsinthehealthcaresectorislow.Thesetwofactorsleadtoanincreased competitive thinking of Dutch general hospitals. Competitive thinking is acharacteristic of business organisations – a characteristic, which apparently has beenwell adopted by health care institutions. However, as the case studies show, closeregional collaboration with the so-called “healthy amount” of competitiveness cansupportcreativityaswellasincreasedknowhow,andcanthusleadtoinnovations.Itispossiblethatthenon-usageofexternalcollaborationsandnetworksareremnantsfromthe hospital-common traditional thinking. Without high pressure from performancerequirements, it ismorelikelytoworkatone’sownpace,withoutgreatneedfor lean,creativity,orexternalinput.Now,thatthepressureonDutchgeneralhospitalsishigh,theyneedtochangetheirbehaviourandbeopenforinternalandexternalstimulations.In this context, internal teamworkand informationexchangebetweendifferentwardsandoperationalareasalsoseemstobebeneficial.AsSubramaniamandYoundt(2005)state that “unless individual knowledge isnetworked, shared, and channelled throughrelationships, it provides little benefit to organisations in terms of innovativecapabilities” (p. 459). Unfortunately it seems that only teamwork within wards isexistent and efficient, whereas interaction among different actors is rather rare. Thisposesathreat,asemployeesarenotawareofconsequencesoftheirownortheirward’sdoings for other employees or wards. It also reduces the chance of detectingopportunities for improvements are innovations. Thus, increasing the understanding,interaction, and communications between the various actors and groups within thehospitalsisimportanttostimulateinnovation.

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7. ConclusionThisresearchaimsatunfoldingthecontextofHRM-relatedinnovationsinDutchgeneralhospitals. The objective is to receive insights on present innovations, their keyinfluencers,andsuccessandriskfactors.

ResultingfromtheanalysisoffourgeneralhospitalswithinTheNetherlands,itisfoundthatthereisahighfrequencyofmulti-typeinnovations,whichcombinemostoftentwoofthethreedifferenttypesofinnovations(employment,work,andorganisational)asaconsequenceofnecessaryinteractionsbetweenmultipleinnovations.ThemajorityofHRMinnovationsarerelatedtothedigitalisationofbasicprocesses,orthealignmentofHRMto theoverallorganisations’objective to increase flexibilityandself-responsibility.Workinnovations,suchasjobsimplificationareusedtodecreasetheremitandresponsibilitiesofmedical jobs,so that it iseasier foremployees to takeonjobs, which e.g. are not originally theirs. Leadership development focuses on jobenlargement, and communication trainings to encourage trust and strengthenmanagementresponsiveness.Insomehospitalstheentirestaffadditionallyparticipatesin continuous learning programmes in order to increase know how, creativity, andacceptance of the shift of the hospital towards including more business organisationmanagementelements.WithinHRdepartments,digitalisationandautomationofbasicprocessesisincreasinglyusedto implementakindofself-serviceportal,withwhichthenumberofactionsandactorsisreducedsothatbasictasksbecomefasterandsimpler.

Itisthisshift,whichisoftenreferredtoasNPMthatisthemaincausesforDutchgeneralhospitals to increase their efficiency and performance level. Especially the in 2005implemented DBCs payment system, which follows the principle “money follows thepatient”, increases the need for fast and efficient patient treatments. This in returnrequiresflexibilityandefficiencyofthestaff.Additionally,thechangingdemandsoftheoverall ageing patients, as well as the speeding digitalisation influence this need.Another challenging factor is theexternal scarcityof educatedmedicalpersonnel, andthe internal ageing of staff, which partly results in growing shortage of nurses andmedicalspecialists.Theseareallfactors,whichshapetheDutchhealthcaresectorandwhichdistinguishtheoperationalmodesoflocalgeneralhospitals.

Possibleinnovationtriggershavebeenanalysedinthecourseofthisresearch.Itbecameapparent that especially increased communication and knowledge sharing throughinternal and external networks, and separate stimulation of younger and olderemployeeswithintheorganisationsarelikelytoincreasetheoccurrenceandacceptanceofinnovativechangesinhospitals.Close arrangements between regional health care institutions can increase theinnovative thinking of HR professionals by exchanging knowledge and ideas, andreceivingincentivesforimprovements.Inthiscontext,especiallyregionalcollaborationsseembeneficialastheyareinfluencedbysimilarprevailingregional-specificconditions

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andthusincentivesandcollaborationsaremoreusefulandpossiblyneedlessadaption.Previous literature on HRM-related stimuli for innovation emphasise internalcommunicationandteamworkencouragementtoincreasethechancefordevelopmentsand innovations. By networking and sharing individuals’ knowledge, mutualunderstanding and interaction can be strengthened, and opportunities forimprovements and innovations become more visible. However, it appears thatteamwork and strong communication is still mainly present within wards, whereasinteraction among different actors is scarce. This poses a risk as wide-reachingconsequences become unnoticed. Additionally, teamwork has a positive effect on thelevel of learning, which is specifically interesting as continuous learning is acharacteristicoflearningorganisations.Particularlyaslearningorganisationsarethoseorganisations,whichareheldtobeinnovative.Thestudiedhospitalswereall foundtorecognise that continuous learning is essential in order to stay competitive and thus,promotecontinuouslearning.Especiallyleaders,whichchange-management-literatureidentifiesaskeyenabler in thechangeprocessreceivecomprehensivecommunicationand leadership training. Increased communication and management responsivenesstargetthereductionofunknowingnessanduncertaintyofthestafftowardsthepresentandfuturechangesinthehospitalsector.Unknowingnessanduncertaintyposeagreatthreat as they can result in fear and eventually in resistance. In this context, it isbeneficial to realise that (and also identify) the different employee groupswithin theorganisationshavedifferentabilities toadapt tochanges,and thereforeneeddifferentapproaches in order to be able to change and to detect opportunities. Whereas theyoungergenerationneedstobechallenged,theoldergenerationneedsagreatamountof communication and information on sector trends, opportunities, and challenges inorder toreducetheiruncertaintyand fear towardsthe future,andeventually increasetheirflexibilityandadaptability.In the course of this research it emerged that outsourcing of HRM activities is rarelyused.Itcorrespondstothetheory,whichsuggeststhatcorecompetencesshouldbekeptin-house. Hospitals are service organisations inwhich the performance of the staff isverycloselyrelatedtotheoverallperformanceofthehospitals.Thus,humancapital isthemostimportantcapitalinhospitals,anditsmanagementshouldbekeptinternally.

In summary, this research identified a number of HRM-related innovations in Dutchgeneralhospitals,whichmostoftenweremulti-typeemploymentorwork innovationsrelatedtotheorganisations’targetedculturalshifttowardsbeingmoreefficient,flexibleand self-responsible. The main cause for this shift is the increasing necessity forbusiness-like thinking and adoption of business organisations’ managementcharacteristics,whichalsorequiresHRMtobecomelesstraditionalandmorestrategic.Increasedaccessibilityof information toalloperationalareaswithin theorganisationshas been identified as crucial for the organisations’ successful transition towardsefficiency and innovation in order to raise acceptance and adaption to the newoperationalmode.Encouragingcommunicationandknowledgesharingthroughouttheorganisationandinstitutionalassociationsisaneffectivemethodtoachievethisgoal.

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However, it became apparent that external aswell as internal networks, and internalcommunicationaswellasdevelopmentisnotyetfullyalignedwiththelevelneededfordetectingandexploitingopportunities.ItcanthereforebeconcludedthatHRMdepartmentsinDutchgeneralhospitalsarestillinthetransitiontowardsbecomingfullystrategicallyalignedwiththeorganisationasawhole.Furthermore,HRMinnovationsareonlyelaboratedandimplementedinordertoachieveacertainobjective;theyarenotusedforthepurepurposeofbeinginnovative.

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8. ContributionofResearchThis thesis contributes to the scientific field of human resource management andinnovationsinthehealthcaresectorinseveraltheoreticalaswellaspracticalways.

8.1. TheoreticalRelevance

This research presents a link between two current subjects, HRM in the health caresector and innovations. Both research fields are enjoying great importance, but areunder-researched when combined into one field of interest. This investigative workaimsatnarrowingthisresearchgapbyofferingtheopportunitytoreceiveinsightsintoinnovation processes, causes and conditions in the specific context of Dutch generalhospitals. The combinationof these specific fields represents relevant information forresearchers in the public and private sector, especially within the specific context ofhospitals. It generates new insights into current proceedings in the hospital sector,whichisnotonlyduetointhecourseofthisworkpresentedfindingsonHRinnovations,but also due to the conceptualization of the specific sector environment, prevailingcircumstancesaswellaselements.

8.2. PracticalRelevance

This investigativeworkalsocontributes toknowledge inapracticalway.Byrevealingsector-specificelements,processes,conditions,riskfactorsandactorswithininnovationdevelopment and implementation processes, managers in a similar environment andcircumstances can find support and suggestions for possible adoptions or problemcounteracts. As the increased competitive rivalry among general hospitalswithin TheNetherlands isdecreasingdue tovariousreasons, theowncompetitivenessconstantlyneeds to be kept or even increased. This research adds to this factor by presentingseveralinnovationstoopposestaffturnoverorincreasecost-efficiencyorbyadvertingtoelementsthatmightbecomerelevantinthehospitalsectorinthefuture.

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9. LimitationsandFutureResearchThis research’s findings are limited as the source of information is comprises a smallnumber of solely HR managers. However, after just two interviews certain influencetrends,challenges,andnotesonthehospitalcontextemerged.Additionally,comparisonoffindingswiththeotherjuniorresearcherstookplacetoensurethatthefindingscanbetrusted.

This limitation leads to the possibility for future research on the three types of HRMinnovationswithothertypesofinformationsources,suchasotherHRspecialistsorthehospital’sunitmanagers. Furthermore, researchondifferences inHRM innovations indifferentlevelsispossible,suchastheorganisational,unit,orindividuallevel.The comparisonbetween the findings in table1, 2 and3 exposedpeculiarities,whichpresent interesting opportunities for future research. Here, connections between thetypesofinnovationsandtheirinfluencerscanbeexamined.ThiswouldpossiblysupportHRMdepartmentsofgeneralhospitalstodevelopspecificchangestoopposechallengesorspecificallyapproachcertaininfluencers.

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AppendixFigure3:TheUlrichModelofHRRoles(Shah,2015)