Upload
lyngoc
View
213
Download
0
Embed Size (px)
Citation preview
CHAPTER 4
CAN TECHNOLOGY ENABLE SUSTAINABLE EFFECTIVENESS IN HEALTHCARE DELIVERY?
SOME LESSONS FROM A REHABILITATION HOSPITAL
Emanuele Lettieri, Ph.D.Assistant Professor
Politecnico di MilanoP.zza Leonardo da Vinci, 32
Milan, Italy 201330039 02 2399 4077
Abraham B. (Rami) Shani, Ph.D.Orfalea College of Business
California Polytechnic State University, San Luis Obispo, CA, USA, and Politecnico di Milano, Milan, Italy
Annachiara LongoniPh.D. Student
Politecnico di MilanoP.zza Leonardo da Vinci, 32
Milan, Italy 201330039 02 2399 3940
Raffaella Cagliano, Ph.D.Professor
Politecnico di MilanoP.zza Leonardo da Vinci, 32
Milan, Italy 201330039 02 2399 2795
Cristina Masella, Ph.D.Professor
Politecnico di MilanoP.zza Leonardo da Vinci, 32
Milan, Italy 201330039 02 2399 4081
Franco Molteni, M.D.Medical Doctor, Clinical Health Director
Villa BerettaVia N. Sauro, 17
Costa Masnaga, (Lecco)Italy
0039 031 [email protected]
1
ABSTRACT
Purpose
This chapter examines the impact of technology on sustainable effectiveness by focusing on
the dynamic synchronization between the technical and social subsystems at the Villa Beretta
Rehabilitation Hospital and illustrates that technology can trigger and enable sustainable
healthcare organizations.
Design/Methodology/Approach
The case study of Villa Beretta Rehabilitation Hospital (VBRH) relies on several data
sources. They include: interviews with key informants (VBRH executives, healthcare
professionals and technology suppliers), follow-up e-mails and phone conversations, direct
observations of actors’ behaviour, and notes of processes in action and archival data, such as
patient pathway protocols, technical information systems documentation, performance and
managerial reports, and administrative guidelines.
Findings
VBRH was capable to dynamically synchronize the social subsystem with the continuous
innovation of the technical subsystem. This capability enabled sustainable effectiveness in
three main areas. First, the correct alignment between technology and professionals’
practices and behaviors improved triple-bottom-line performance by promoting a more
conscious use of the environmental, social and financial resources. Second, technology-based
initiatives promoted research-oriented plans of action that nurtured a culture of change and
continuous improvement. Third, technology facilitated the extension of the research and
operations networks that generated new ideas and initiatives for achieving sustainable
2
effectiveness. Additionally, evidence from VBRH demonstrated that organization design,
change management and learning mechanisms are essential when institutionalizing new
technology that requires the disruption of current professional practices and individuals’
behavior.
Originality/Value
Previous contributions about sustainable effectiveness in healthcare failed to unveil and
frame the complexity of dynamic synchronization between the technical and the social
subsystems that is at the core of the sustainability of healthcare delivery. This chapter
provides new insights that pave the way for a deeper-level understanding of the role that
technology plays in sustainable effectiveness dynamics and outcomes in healthcare delivery.
The chapter illustrates how different groups of technology contribute to sustainable
effectiveness and the mechanisms that make them work.
Keywords: Technology, Sustainable Healthcare, Socio-Technical System Theory, Dynamic
Synchronization
Category: Research paper
3
INTRODUCTION
Rehabilitation hospitals–the ones specialized in neurorehabilitation in particular–provide
specialized healthcare services that require a mix of complex and advanced technology,
highly specialized professionals and distinct ways of organizing within the healthcare theater.
This manuscript illustrates and discusses the journey taken by a tertiary care rehabilitation
hospital located in Northern Italy. The study explores how three different groups of
technology–Biomedical Technology, Information & Communication Technology, and
Greening Technology–contributed to its journey to become sustainably effective.
Sustainable effectiveness is an increasingly important organizational and societal
concern in healthcare (Lifvergren et al., 2011; Lettieri and Masella, 2008). There are still
many unresolved debate and issues associated with what that means. At the most basic level,
sustainable effectiveness is viewed as the determination of outcomes that measure whether
the organization is sustainable through time. As such, a wide variety of factors impact the
system’s sustainable effectiveness. Examples are how the competing demands and the
synergy between the three sustainability pillars-environmental, economic and social are
managed, how human resources management practices attract, retain and develop talented
employees, how the technology and technology mix impact the quality and efficiency of
healthcare delivery.
Rehabilitation hospitals are complex entities within the healthcare field.
Neurorehabilitation hospitals in particular provide comprehensive inpatient and outpatient
services to patients who, as a result of an accident, illness or injury of the nervous system
(e.g., traumatic brain injury, stroke, spinal cord injury) have acquired a physical or cognitive
disability and who require complex specialized medical rehabilitation. While staying in the
rehabilitation hospital, these patients receive physical therapy and training to help them
regain function, behavior, and improve their quality of life upon returning home. For these
4
patients, rehabilitation hospitals are conceived as the ideal setting intermediary between acute
hospitals and patients’ home. Even if these patients naturally want to return home as soon as
possible, receiving specific rehabilitation services provides them with the possibility to return
home and work with the greatest physical and mental capacity, reducing the burden of
disability. Toward this end, each patient requires a tailored bundle of physical, occupational
or speech therapy for improving their function and of social work assistance and
psychological and neuropsychological support for training them to live a new limited life at
home or at work. Regaining–or only ameliorating–mental function, speech ability, and
function of any affected parts of the body can take time and thus these patients will require
the design of the most cost-effective therapy and follow ups to monitor progress.
Table 1 offers a brief overview of the main characteristics of this sector in Italy, in
terms of organization of the National Healthcare System, peculiarities of rehabilitation
practice, health policy for rehabilitation and technological development. This eco-system is
currently under pressure as result of the impressive pace of increase of disabled and chronic
patients as a consequence of aging and unhealthy life styles and the simultaneous decreasing
of the financial, human and environmental resources and the increasing patients’ and
caregivers’ expectations for superior outcomes and improved care experience.
-------------------------------------
Insert Table 1 about here
-------------------------------------
Policy makers are facing this challenge by reallocating the resources within the
different domains of the healthcare sector, moving resources from acute care to prevention
and chronic care. This shift is expected to improve the sustainability of healthcare delivery
5
along citizens’ whole life. With respect to rehabilitation, the challenge is helping each
disabled or chronic disease patient to regain the most functions and self-autonomy possible to
improve her quality of life and limit the need for tax-funded resources for care and assistance
in daily activities, and reducing new rehospitalization. For instance, the progressive
“domiciliation” of rehabilitation delivery through the design and implementation of
innovative home-based rehabilitation paradigms has been welcomed in Italy as in all Europe
as a concrete direction for improving the capability of national healthcare systems to deliver
higher-quality, lower-cost rehabilitation.
Two distinct peculiarities make rehabilitation hospital an ideal locus for investigating
and learning about sustainable effectiveness. First, many of these patients will receive long-
term care in order to allow them “normal life” to the extent possible, and thus patient
pathways have to be designed taken into account all three pillars of sustainability. How is it
possible to deliver high-quality and low-cost care for patients over such long periods? How is
it possible to regenerate the energy and commitment of healthcare professionals who are
never rewarded by seeing completely restored patients? How is it possible to limit the
consumption of natural resources and the impact on the environment? How can the family be
integrated into the patient pathways recovery journey? How can a web of social and
community support can be created to enhance the patient recovery process? How can
technology be used to integrate the professional care providers and the family/social support
web?
Second, rehabilitation hospitals are required to have the capability to design and tailor
individualized patient pathways since every patient needs a distinct mix of therapies and
training. Care is necessarily team-based since competences that come from different
professions and different disciplines have to be integrated to tailor each pathway. This kind of
care is knowledge-based and knowledge-enabled since different professionals have to
6
systematically exploit their current knowledge and explore new knowledge to continuously
tailor and improve care delivery. Given this, how is it possible to continuously deliver
customized care in a period of financial constraints and natural resource limits? How is the
challenge of organizing for sustainable effectiveness interconnected with knowledge
exploitation and exploration? How is it possible to continuously “bring the flag forward”
without unbalancing the delicate social, ecological and financial equilibrium?
The advancement of sustainable healthcare systems in general–and neurorehabilitation
hospitals specifically–is related to the advancement and integration of innovative medical
technologies to redesign current practice. Telemedicine, electronic medical records, robotics-
based solutions (such as robotic exoskeleton, robotized bed for delivering passive
mobilization etc.), and medical devices (such as microprocessor-controlled knees for trans-
femoral amputees, intrathecal Baclofen pump, deep brain stimulation, etc.) all are at the core
of the twenty-first century healthcare rehabilitation. The ability to continue to innovate and
experiment with technology is viewed as the most important factor in developing and
sustaining high-quality rehabilitation delivery. Yet, many new technologies tend to disrupt
organizational routines, practices and relationships, requiring all those involved to learn or re-
learn how to utilize the new technology and how all involved should work together. The
continuous integration of new technologies suggests that rehabilitation hospitals need to
develop the capabilities to experiment, implement, adopt and redesign work and management
routines. A key element in the continuous integration is bringing the patient, the family and
the social support network into the center of the technological advancement utilization.
This chapter describes the evolution of Villa Beretta Rehabilitation Hospital’s
approach to improve and sustain high-quality and low-cost rehabilitation services while
emphasizing the critical role of technology in the complex rehabilitation process.
Sociotechnical System Theory is an integrated framework that can link healthcare context,
7
strategic choices around sustainability, technology, social system, change processes, learning
mechanisms, key organization features and sustainable effectiveness. The next part of the
chapter describes this integrated framework. Next, the framework is utilized to examine the
Villa Beretta Rehabilitation Hospital (VBRH). The discussion focuses on understanding the
role that technology-driven changes had on the delivery of high quality healthcare, the
implementation of which resulted in improved and sustained performance improvements.
Furthermore, the discussion explores the role that three groups of technology – namely
Biomedical Technology, Information & Communication Technology (ICT), and Greening
Technology – play in shaping the process and outcomes of healthcare delivery, and their
impact on sustainable effectiveness.
Theoretical Foundation: Towards a Socio-Technical System-based Framework of
Sustainable Effectiveness
Since its inception in the 1950s, three major Socio-Technical Systems (STS) subfields
emerged: STS Theory, STS Design, and STS Change and Development Process (Pasmore,
1988; Eijnatten et al., 2008). The foundation of STS Theory can be found in the perspective
that every organization is composed of a social subsystem (the people) using the tools,
techniques, methods and knowledge (the technical subsystem) to produce a product or a
service valued by the environmental subsystem (Trist, 1981). The degree to which the design
of the technical subsystem, social subsystem and the environmental subsystem are integrated
determines the success and competitiveness of the organization. While every organization is
perceived as a sociotechnical system, not every organization is designed according to the
sociotechnical systems design principles, methods, processes and philosophies (Adler and
Docherty, 1998; Shani and Sena, 1994). The main focus of STS theory is to advance
understanding in the fields of management, organization, and change and development. STS
8
Design is the pragmatic and applied stream of STS Theory. Specific sets of design principles
have been developed over the years that guide the actual design or redesign of an existing
organization or the design of a new organization. This deals with the actual architecture of
the firm (Cherns, 1987; Hanna, 1988).
The third subfield is STS Change and Development Process. This subfield is devoted
to processes of creating or transforming an organization. Specific sets of phases and steps
have been advanced over the years that guide the redesign process of an existing organization
or the design process of a new organization. STS provides a comprehensive planned change
process with analytical tools and methods that were developed to facilitate the transformation
of an organization towards a more STS-based design entity. The design processes, methods
and tools are elaborate and multilevel in nature. They utilize a collaborative research
orientation and provide linkages among business-environment analysis, vision and strategy
statements, system analysis and diagnosis, exploration of new alternatives for joint
optimization of the technical and social aspects of the organization, experimental
implementation, and system-wide diffusion. Parallel learning structures, composed of
steering, study and action groups, plan and carry out the learning and redesign process
(Bushe and Shani, 1991; Pasmore, 1994). The relationship between STS Change, STS Design
and STS Theory is both implicit and explicit. In most cases STS Design principles and
Theory serve as the conceptual guide for the designing or change processes that are applied in
particular organization (Taylor & Felten, 1993). At the core of the STS field one can find the
concept of the concept of joint optimization that is the backbone of the paradigm – an
organization will function best if the social and technological systems are designed to fit the
demands of each other and of the environment (Trist et al., 1997).
Based on the sociotechnical perspective, we propose an integrative framework that
affects the sustainable effectiveness of healthcare delivery. Figure 1 portrays sustainable
9
effectiveness as an outcome of complex dynamics between business strategic choice,
organization design configurations, technological and social subsystems features, learning
mechanisms and processes and, change management orientation. The central flow in the
model is from the strategic choice based on perceived strategic capability around technology
and technological and social subsystems development vision to the design choices made
about organization and work design features, learning mechanisms and processes and, change
management. Sustainable effectiveness as the proposed model’s outcome is viewed as
synchronization between environmental (ecological), social (human) and economic
(business) performance indicators. From a sociotechnical system perspective, these elements
can be designed to impact sustainable effectiveness.
-----------------------------
Insert Figure 1 about here
------------------------------
Dynamic synchronization occurs at the interface between organization design
features, change management practices and learning mechanisms features. The organization
design features are the structures and processes that are created in grouping tasks and people
in order to achieve organizational goals. Change management refers to the practices that
allow the organization to adapt to changes in its environment. We view conscious, planned
proactive features that enable and encourage organizational learning and change as ‘learning
mechanisms’ (Popper and Lipshitz, 1998; Shani and Docherty, 2008). These features can
encourage a dynamic learning capability in general, including the learning required for the
development of a particular new organizational capability. The learning processes needed to
enhance sustainability can be designed at the individual, collective and organizational levels,
10
and interorganizational levels, and specific features can be designed to initiate, facilitate,
monitor, and reward this learning.
The next section briefly describes the challenges facing the rehabilitation eco-system
and then describes the Villa Beretta Rehabilitation Hospital Case.
Villa Beretta Rehabilitation Hospital: Features and Challenges
The Villa Beretta Rehabilitation Hospital (VBRH) is a small size tertiary care hospital (90
beds) that delivers state-of-art, specialized, compassionate medical care and rehabilitation
services for individuals who suffered or are suffering major physical disorders and disabilities
due to congenital or acquired central nervous system injury (e.g., neuromuscular genetic
disease, brain and spinal cord injury, stroke). VBRH is the specialized subsidiary of the
Valduce Hospital, a 300 bed, not-for-profit, religious, facility. The two hospitals are set in the
Lombardy Region in the North of Italy, consisting of two Counties (Lecco and Como), both
with 200,000 inhabitants. The two hospitals deliver healthcare services on behalf of the
Italian National Healthcare System and the Lombardy Regional Healthcare System and are
thus conformed to their mission, core values, political orientation, reimbursement policies,
and operating rules. VBRH is part of the Valduce Hospital, yet it has a wide autonomy in
both its strategic and operative plans of action. The relationships between the parent hospital
and its subsidiary are limited to an overview of the general coherence between their long-
term strategies and the yearly negotiation of resource within the budgeting process. The two
hospitals do not benefit from operative synergies, and the flow of patients between them is
also limited. VBRH’s key features, in terms of location, size, activities, near-term strategy,
and approaches to rehabilitation delivery are summarized in Table 2.
11
-------------------------------------
Insert Table 2 about here
-------------------------------------
At the end of 2011, VBRH employed 17 doctors, 27 physiotherapists, 2 psychologists,
2 neuropsychologists, 4 speech therapists, 36 nurses, 52 healthcare assistants, 2 social
workers, 1 coordinator of nursing staff, 5 coordinators of non-medical staff and 4 technicians
with expertise in biomedical technology and information systems. A yearly average of 1,100
in-patients and 18,000 out-patients are admitted from all Italian Regions, Europe and Africa
(mainly Mediterranean patients).
Delivery of care is characterized by complex and non-routine tasks as a consequence
of the variety of clinical and social needs that patients and their caregivers will required to be
accomplished. Every patient moves along a tailored assembly line that has to be engineered
by a multi-specialty team of healthcare professionals. The systematic and continuous tension
to increase the cost-effectiveness of rehabilitation delivery resulted in a series of changes to
the organization of care delivery during the last decade that transition it from the traditional
specialty-based paradigm to the current outcome-based paradigm. As a result, VBRH is
organized in four departments that promote and facilitate an interdisciplinary approach for the
most treated disabilities. Each department has a staff of doctors, nurses and physiotherapists
that organize themselves in inter-professional teams according to patients’ specific needs.
The departments are: Dept. for Traumatic Brain Injury (26 beds, 18 professionals); Dept. for
Spinal Cord Injury (26 beds, 24 professionals); Dept. for Stroke (26 beds, 24 professionals);
and Respiratory Dysfunctions (12 beds, 14 professionals). There is competition for resource
allocation among the four departments, and creativity and innovation are rewarded by top
12
managers. Finally, three clinical engineers support professionals to exploit current technology
and explore new ones.
The medical staff is organized in small dedicated teams composed by doctors, nurses,
physiotherapists, neuropsychologists and psychologists that take clinical decisions about
patient pathways conciliating their different professional view. The typical hierarchical rituals
and behaviors that characterize many healthcare organizations have been abandoned in
VBRH in favor of an evidence-based, hierarchy-free dialogue among professionals, where
evidence overcomes seniority and power. This structure has proven to being flexible enough
to address the complexity of rehabilitation delivery. Every department has organized its
activities. For example, while teams from the “Respiratory dysfunctions” Department used to
meet twice a day for briefing and debriefing, i.e. every morning and every end of the
workday, teams from the “Spinal Cord Injury” Department meet twice a week.
The Journey towards Sustainable Effectiveness
The journey towards Sustainable Effectiveness began in 2006, when the VBRH Health
Clinical Director expressed his concerns to the Valduce Hospital Managing Board about the
urgency to change radically the current approaches to rehabilitation delivery. The VBRH
performance could not be sustained, as both internal and external pressures were mounting.
This realization did not come from unsatisfying performances in terms of clinical outcomes,
patients’ satisfaction, length of waiting lists, or economic results, but was the result of
comprehensive analysis of the changing demographics, societal, technological, political and
environmental trends. The demand for rehabilitation services was projected to increase
significantly as consequence of combined forces such as the progressive aging of the Italian
population, the engagement of unhealthy lifestyles in children and adults, and trend to
decrease the length of stay in hospitals. Patients’ expectations for regaining function and for
13
the quality of their hospital experience were increasing, posing unrealistic pressures on
rehabilitation hospitals. The state of the economy coupled with the financial state of the
Italian healthcare system raised wide concerns for the very short term. For example, eight
regional healthcare systems (of twenty-one state wide) accrued enormous financial deficits
during the last decade and the others showed a fragile balance between cash inflows and
outflows. Lombardy Region had a still in balance regional healthcare system, but the
capability of the system to increase budgets for rehabilitation delivery was not evident.
Concerns about VBRH sustainability into the future did not originate from under
target performances. In fact, during the period 2000-2006, VBRH managers and professionals
performed beyond expected clinical targets and below expected cost targets, and, being proud
of that, they were oriented to consolidate their current practices and behaviors over the
coming years. The VBRH dashboard showed green flags (i.e. positive results) everywhere.
Quality of care was high according to different perspectives. Clinical outcomes in terms of
quality of life were measured on international scales – such as the EQ-5D measure, the
Barthel index, the SATPRO scale etc. – that confirmed outstanding results in terms of
patients’ function recovery. Internal surveys showed that patients and their relatives were
largely satisfied by their experience at VBRH in terms of information clarity and availability,
employees’ kindness and helpfulness, facilities and hotel services. Accessibility to care was
also adequate. VBRH had shorter waiting lists in comparison to other comparable
rehabilitation hospitals in Italy and had specific programs for patients coming from other
Regions and Countries (mainly from the Mediterranean Africa), helping them and their
relatives to overcome all the distance-related issues.
In this ephemeral, idyllic context, VBRH began its revolutionary journey towards a
new paradigm of rehabilitation delivery. Key questions needed a rapid answer. Will it be
feasible in the next future to deliver efficient, high-quality rehabilitation to the next
14
generation of patients with severe disabilities? How will it be possible to attract and motivate
talented healthcare professionals to do their best in a context of decreasing resources? And,
finally, how is it possible to push a major change and create an appropriate sense of urgency,
when performances are close to the targets?
Technology-based Innovation as Metaphor of Sustainable Effectiveness
To radically reshape the current practices of rehabilitation delivery, a dedicated task-force
was created, composed by three key organizational functions at VBRH: the Health Clinical
Directorate, the Operations Management Unit and the Service for Clinical Engineering. The
intent was to balance two often conflicting goals: representing and conciliating the different
perspectives in the hospital and allowing the task-force to being efficient and timely in its
actions. The presence of these three functions “brought to the table” three key perspectives in
healthcare: the clinical, the managerial, and the technological ones. Before the mid-2006 two
key decisions were taken that were to affect VBRH strategy for the next years.
First, the task-force adopted the Triple Bottom Line (TBL)–i.e. planet, people, and
profit–framework to operationalize the challenge of Sustainable Effectiveness. This choice
allowed VBRH to anchor their challenge in a wider debate in Italy about the respect of the
natural eco-system and the conscious consumption of precious social, economic, and
environmental resources. The comparison to what other industries and territories were doing
for addressing these emerging issues helped VBRH employees to understand the tremendous
(both positive and negative) impacts that a rehabilitation hospital might have on the society,
the natural eco-system and the local economy. The connection to the TBL framework was
immediate for VBRH employees. This happened because this forma mentis meets the
underlying religious culture of VBRH and Valduce Hospital. In fact, both the hospitals are
religious and not-for-profit, and are owned by the Congregation of Sisters dedicated to Our
15
Lady of Sorrows. The Congregation is committed to deliver compassionate, value-for money
care to patients and their relatives and thus employees are recommended to being responsible
of how the limited resources–human and financial–donated by the community (and provided
by the regional healthcare system) are utilized.
The second key decision was to adopt technology as the main trigger (and enabler) of
change and technology-based innovation as metaphor of the journey towards sustainable
effectiveness. As anticipated, healthcare technology was expected to significantly increase its
already tremendous pace of innovation over the next years, with relevant impacts and
implications on clinical practice and working environment. Two major changes were
expected in rehabilitation delivery. On the one hand, technology will have revolutionized the
traditional relationship between patients and healthcare professionals because of its mediating
role and the consequent reduction of the human contact between them. On the other hand,
technology will have also pushed healthcare professionals to care for patients outside of the
hospital walls, such as at patients’ homes. This means that healthcare professionals should be
ready to share both technology and services outside the hospital, and being ready to manage
any situation–also the most critical and urgent–at patients’ home, without the availability of
the most advanced technology and the multi-specialty expertise that are present in a hospital.
With respect to that period (mid-2006), the VBRH Health Clinical Director stated that:
At present, healthcare professionals work for patients who are in the hospital,
but now they must learn how to work also for patients who are outside the
hospital. The team will work outside of the hospital and many elements of this
team will be away and connected through internet. But today, our people do
not know how to work in this new manner.
16
The task-force offered a metaphor that the journey towards sustainable effectiveness
would be a transformation from a traditional rehabilitation hospital towards an “Open
Research and Development (R&D) Living Laboratory.” The was that VBHR had to become
a laboratory where clinical practice is continuously delivered, monitored, and innovated such
as in any R&D Lab, where multi-specialty teams exploit their current knowledge to achieve
superior performances and explore new knowledge to radically improve the expected
performance targets. The concept of “open” referred to the fact that any rehabilitation
hospital is naturally porous to the external environment and to any change or possibility that
occurs externally. In this view, they had to take advantage of any value-for-money
technological development in other industries. Two examples of what happened in the future
years may help to understand the vision that the task-force was setting in those years. In
2009, VBRH adopted a technology developed to entertain visitors and customers in malls by
allowing them to interact with images projected on a wall. A multi-specialty-team was
constituted in VBRH to explore the possibility to exploit this technology for delivering
advanced rehabilitation treatments to patients with severe disabilities. Nowadays this
technology is used in a routinely way and patients are benefiting from the interaction with the
variety of shapes, colors and sounds that the software is able to co-temporally manage. In
2011, another multi-specialty team explored the variety of apps that had been developed for
tablets with respect to healthcare delivery to assess their cost-effectiveness. Nowadays VBRH
is testing apps for professional education and apps for disabled people. Results are
encouraging and, when confirmed, this will lead to other small revolutions in the way
rehabilitation is perceived and delivered.
How Technology Impacted Sustainable Effectiveness
17
Since 2006 VBRH has adopted a variety of technologies to consolidate the vision of
technology-based innovation as the key enabler of sustainable effectiveness and improve
triple-bottom-line performance. The technologies are grouped into three main domains:
Biomedical Technology, Information & Communication Technology (ICT), and Greening
Technology. The first group includes all biomedical technologies that are employed for
diagnosis or treatment. They can be capital intensive technologies, such as robotics for
automated rehabilitation. An example is the robotized bed ERIGOTM whose mechanisms of
movement are controlled by a microcomputer that generates customized physiological
movements of the legs. Simpler technologies include machines for a continuous passive
mobilization of the hands and the ankles, or technology-enhanced wheelchairs, or high
robotic devices to restore gait as LokomatTM, or to restore upper limb function as ReoGoTM or
ARMEO TM.
The second group includes Information & Communications Technology (ICT). This
umbrella term covers very different technologies, such as the Electronic Medical Record
(EMR) that allows the storage, retrieval and sharing of relevant clinical data at the point of
care (i.e. close to the patient’s bed) or at remote locations (e.g., at physician’s home), the
Warning Systems that prevent adverse events (such the administration of wrong drugs) and
support the identification of cost-effective protocols for patient management, and all the
solutions for the delivery of telemedicine-based rehabilitation programs. The third group
includes technologies that VBRH has been introducing to improve the ecological
sustainability of the VBRH facility. They include such approaches as green building
standards, the adoption of solutions for exploiting the natural light instead of the artificial one
to assure the enlightening of patients’ rooms and social spaces, toxin-free paintings and
materials.
18
A synopsis of the key technologies at VBRH and their peculiar impact on Sustainable
Effectiveness is captured in Tables 3-5. Impacts have been divided in different domains to
provide readers with a better understanding of how these different groups of technologies
contributed to VBRH sustainability journey. First, they had an impact in terms of clinical
outcomes and quality of life. This is the first goal for a rehabilitation hospital that adopts new
technology and reengineers patient pathways. Second, technologies affected TBL
performance such as by increasing productivity or reducing pollution. Third, they had other
major impacts on antecedents of sustainable effectiveness, such as by promoting knowledge
sharing, revitalizing network-based relationships and creating opportunities for sustainability.
Finally, they motivated professionals to undertake VBRH journey towards sustainable
effectiveness and increased their self-efficacy.
Based on VBRH experience, robotics contributed significantly to the standardization
and implementation of new ways of healthcare delivery, and this has enabled VBRH to
increase effectiveness, efficiency and decrease the waiting lists for new patients. With this
regards, the adoption of state-of-art biomedical technologies contributed to reduce
significantly the length of stay, increasing the volume of patients who can be treated every
year. For instance, last year the 60% of patients who suffered a stroke were discharged in less
days respect to the length of stay allowed and reimbursed by the Lombardy Region.
Additionally, VBRH changed its delivery mix by admitting more severe and compromised
patients–its DRG weight increased from 1 to 1.3– in order to earn higher reimbursement fees.
This happened without increasing the total workforce and the individual workload, and
without lowering clinical outcomes. With this respect, VBRH have been acknowledged in
2010 as the number one Italian hospital in terms of percentage of severe and compromised
patients who returned home because of excellent function regain. Every year an average of
90% of patients admitted in VBRH return home and do not need long-term care in nursing
19
homes. These results in terms of both effectiveness and efficiency “gave breath” to VBRH
profit and loss account and smoothed the growing pressure from the continuous shrinking of
public budgets for healthcare delivery.
Telemedicine provided VBRH with the capability to overcome both spatial and
temporal constraints, thus offering patients a better service, e.g. by having follow-ups at their
home saving money and time, and guaranteeing a continuum of care. Moreover, the
Operations Manager observed that:
Telemedicine allowed for incrementing the number of patients that we can
care for without moving them from their home. This increases the accessibility
to our services for patients who come from other Regions or who have
difficulties in moving. Technology provided us with the power to take care of
people at distance. At present, we take care of about 60 patients at their home
every year.
The adoption of greening technologies leads to a better usage of natural resources such as
water and energy, thus contributing to save costs and limiting the impact on the environment.
These results were particularly appreciated by VBRH managers. In fact, even though
healthcare professionals felt that the ecological pillar was not as critical for sustainable
effectiveness, since the others two pillars were a priority, they became aware of the
environmental impact and the societal damage that hospitals produce because of their human-
and natural resource-intensive production function, and revised progressively their practices
and behaviors to save energy, water and paper, and reduce pollution and toxic, infective
waste.
20
Finally, technology contributed to the journey towards sustainable effectiveness by
promoting two organizational premises: research & innovation, and structural capital (i.e., the
quantity and quality of VBRH relationships with other external organizations). The
implementation of the “Open R&D Living Lab” metaphor pushed VBRH to open its clinical
processes to other players (e.g., Universities, technology developers, etc.) within the
rehabilitation eco-system to continuously improve the capability to deliver efficient, high-
quality care. For example, VBRH developed a strategic partnership with IBM and Intel to
transform the rehabilitation hospital in a Wi-Fi connected campus, where data can be
accessed, elaborated and stored everywhere and every time. A long-term collaboration was
established with the Politecnico di Milano and AeroScout, an Israeli-sited ICT company, for
developing RFId-enabled solutions for collecting data about patients inside and outside
VBRH to be used to improve current practices and behaviors by means of specific analytics.
During the last five years, partnerships with industrial partners have grown from 3 to 9, and
during the last three years agreements for joint research activities have been signed with Argo
Medical Technologies (Israel), Merz Pharmaceuticals GMbH (Germany), Hocoma
(Switzerland) as leader of robotic rehabilitation therapy, BTS (Italy), as leader of body
movement measurement in clinical environments, and the Italian National Center for
Research. Additionally, VBRH nurtured collaborations with both Italian and foreign hospitals
(e.g., Moss Rehabilitation Center (Philadelphia, US; Teaching Hospital in Cairo (Egypt) to
share best practices about technology-based innovations. Two new organizational units were
established as result of all these initiatives. An organizational n organizational Robotic Lab
was established in VBRH in 2005 and
Additionally, VBRH leveraged on its growing network to submit proposals for
funding and, within the last three years, got accepted (and funded) two international, one
European and two national research projects.
21
--------------------------------------
Insert Tables 3, 4, 5 about here
--------------------------------------
An Articulated Bundle of Mechanisms to Make Technology Work
The VBRH task-force was aware that any change effort faces the risk of achieving little
without the full engagement of the professionals involved. This is particularly true in
rehabilitation hospitals, where healthcare professionals have large autonomy in their practice
due to their training, and complexity and variability of their practice. In this regard, any
attempt to standardize clinical practice through and because of robotics or EMR could lead to
organizational resistances and thus fail. The VBRH Operations Manager stated that
The key issue was not buying the most advanced technology, but their
challenge [as task-force] was to develop the capability to design the most
appropriate organizational solutions to make technology matter. For this
reason, I used to explain to VBRH professionals that my job is to develop
more and more sophisticated clinically-flexible and managerially-useful
technology.
The task-force designed and implemented and articulated a bundle of mechanisms to
make technology work by dynamically synchronizing the technical and social sub-systems.
Table 6 offers a snapshot view by grouping them in three main groups, namely organization
design, change management and learning mechanisms. The bundle of mechanisms was
designed to organically achieve three intermediate results.
22
First, the task-force worked to create a sense of urgency for change. As anticipated
above, in previous years performances were aligned to targets and healthcare professionals
were oriented to consolidate the status quo. This context was unfrozen by developing and
adopting a tailored EMR. This two-year investment obliged all professionals to review
current patient pathways to formalize the user requirements to be delivered by IT developers.
The review process involved multi-specialty groups to conciliate the different needs and
facilitate creativity and “out of the box” solutions. The task-force took advantage of these
discussions to make employees aware of the need for more sustainable paradigms of
rehabilitation delivery by showing all available data on the expected demographic, societal,
technological, environmental and financial trends. During the implementation process key
performances such as errors in data entry, time for data entry, perception of value, ease of use
were monitored systematically and data were shown professionals to reenergize their
commitment and engagement. After six months all performances were worse compared to
paper-based records, after twelve months they become similar and only at the end of the
second year they become better (as they still are today). Nowadays, the totality of healthcare
professionals (98%) states that EMR is value-adding compared to paper based records and
ease to use. Additionally, EMR facilitated the integration of different specialties since they
access and share the same data collection platform.
During the first year the task force paid tremendous attention to professionals’
motivation. The Health Clinical Director used to repeat the very well-known Deming’s tenet:
“In God we trust, all the others must bring data.” The systematic communication of data,
even during the first year when performances were worst, reinforced the already existing
culture oriented to evidence-based decision-making and facilitated an open, pragmatic
discussion among the different professionals about the advantages of adopting new
technologies. These data reinforced professionals’ motivation and assured about the results
23
that were being achieved. Today VBRH Health Clinical Director states that without those
data, there would have been a high probability of burn-out among professionals, since they
needed data that showed the results and the improvements they had been able to achieve.
Reporting covered not only clinical quality, but also financial and human sustainability.
Despite being a non-profit hospital, professionals and technicians knew that a fair profit was
necessary to sustain innovation and growth over time. In this view, data about financial
performance increased the desire for change and boosted performance improvement. Data
about human sustainability helped monitor the internal organizational climate and implement
corrective actions when burn-out or disaffection were increasing too much, as during the first
year of EMR adoption.
Second, the task-force wanted to empower professionals by increasing their readiness
and capability to cope with technology-based innovations. During the first year of
implementation of the EMR professionals felt unconfident with the new processes for storing,
retrieving and sharing relevant clinical data with colleagues or professionals outside of
VBRH. The Operations Manager coordinated a specific multi-specialty team that
championed this innovation and helped others gain confidence with the new technology. One
physician stated:
VBRH managers showed their leadership and capabilities in mastering this
major transformational journey: they understood that some types of
innovations need to be introduced slowly, step by step, adapting the
introduction schedule to the adaptation time required by professionals.
Third, VBRH recognized the need to create a context of psychological safety to
promote and sustain innovative behaviors and new technology acceptance. Debriefings after
24
any step of change were recommended to facilitate sharing of feelings among team members
and among departments. These events were reinforced by plenary meetings where pros and
cons of the new technologies were discussed to collect feedback and design new paths of
action. Individual mistakes were also reviewed to show their multi-faceted implications
without blaming the responsible professional.. The creation of a culture oriented to an
evidence-based, hierarchy-free discussion among members of multi-specialty teams
contributed to clarify that the individual mistake was generally an organizational mistake,
consequence of weak organizational procedures or capabilities misaligned with tasks and
procedures. Psychological safety enabled VBRH to sustain the seamless adoption of new
technologies and contain the risk of organization burnout due to the continuous disruption of
routines and behaviors. Vice versa, employees committed to sharing best practices, sharing
feedback and also mistakes to push forward their journey towards sustainable effectiveness.
----------------------------------
Insert Table 6 about here
----------------------------------
DISCUSSION
Sustainability was recently acknowledged as one of the “business trends” of this decade
(Lubin and Esty, 2010). Economic, social and technological megatrends are forcing
fundamental and persistent shifts in how organizations are designed, managed and compete.
The experience of VBRH shows that technology can be a trigger and an enabler for
reinventing the current paradigms of healthcare delivery to gain sustainable effectiveness. In
this discussion we focus on two issues: i) the relevance of the proposed STS-based
framework in enhancing our understanding of sustainable effectiveness within the healthcare
25
delivery system; and ii) the mechanisms for advancing healthcare organizations towards
sustainable effectiveness. We will refer to Figure 2, which builds on Figure 1 that was
presented earlier, but incorporates some learning from the VBRH case and grounds this
discussion in the theoretical framework that we derived from the socio-technical literature.
------------------------------------
Insert Figure 2 about here
------------------------------------
The Relevance of the Proposed STS-based Framework to Enhance Understanding of the
Sustainable Effectiveness of Healthcare Delivery Systems
VBRH assumed technology as the key trigger and enabler of their journey towards
sustainable effectiveness and technology-based innovation as an evocative metaphor. It
promoted the radical change of its technical subsystem in terms of technologies employed
and competences required. Change was fast and radical.
The STS-based framework offers a valuable theoretical lens for framing the
complexity of VBRH transformational journey by suggesting the key elements to explore and
the intricate bundle of relationships between them. The dynamic synchronization between the
technical and the social subsystems confirmed to be the core enabler of the results achieved.
Any adoption of new technology was faced by the task-force with a specific package of
initiatives aimed at realigning the social subsystems in terms of attitude and abilities.
Leveraging from the STS literature (Figure 1), we contributed to it by conceptualizing a
framework for sustainable effectiveness in the particular context of a technology-based
strategy (Figure 2). This framework advances current knowledge by shedding new light on
the nature of both the elements and the relationships that compose it. Within the Technical-
26
Subsystem, we identified three groups of technology that are relevant for designing a
sustainable healthcare organization. They are Biomedical Technologies, Information &
Communication Technologies, and Greening Technologies. The experience at VBRH
provided evidence of their contribution to sustainable effectiveness and Triple-Bottom-Line
(TPB) related performances (Table 3, 4, 5). Within the Social-Subsystem, three elements
were acknowledged as affected and affecting the changes occurring in the Technical-Sub-
System. They are the professionals’ attitude, abilities and psychological safety. These
elements were impacted by the continuous adoption of new technologies and impacted the
results of their adoption, boosting or limiting expected performances.
Finally, the effectiveness of healthcare delivery increases its sustainability over time
because an improved utilization of the limited human, natural and financial resources. The
dynamic synchronization between the new technologies and the employees leads to improved
TPB performances that provide the healthcare organization with more resources for
sustaining continuous innovation and, consequently, a superior quality of care. With this
respect, our conceptualized framework generated new insight on how technology might affect
TPB performance. Technology–when dynamically synchronized with the Social-Subsystem–
directly contributes to improve sustainable effectiveness. At the same time, technology
contributes indirectly to the improvement of the sustainability of healthcare delivery over
time by facilitating the creation of an organizational context oriented to and capable of an
open, continuous innovation of current practices and behaviors. The empowerment of
research activities and networks, and the promotion of knowledge sharing behaviors among
professionals both inside and outside the healthcare organization contribute significantly to
push the organization forward along its journey towards sustainable effectiveness.
The Mechanisms for Advancing Healthcare Organizations towards Sustainable Effectiveness
27
Sustainability is a groundbreaking concept, but its operationalization and implementation is
context-specific, and we have to consider that what is clear and logical for one industry or
one organization might be fuzzy for others. During our interviews at VBRH, one physician
stated:
When the Health Clinical Director came to me with his projects for
“sustainability,” my first reply was: “What does this concept add to what I will
do to my patients? And to what extent this concept will change the way I use
to relate to my patients?” since I feel that fashionable concepts that come from
other industries might harm my patients.
Sustainability is an abstract concept and it needs to become concrete and actionable
for engaging employees in beginning and continuing a journey towards sustainable
effectiveness. VBRH set an original and interesting solution that directly affected
professionals’ practices and behaviors. The adoption of a variety of new technology obliged
professionals to cope with the implementation challenges and as such unfroze the status quo.
Biomedical Technology and ICT offered new opportunities to the delivery of care to patients
and thus healthcare professionals had the opportunity to become aware of the benefits for
patients and their relatives. Less engagement and enthusiasm was reported with respect to
Greening Technologies since individuals did not see a direct impact on the provision of care.
Because of this, healthcare professionals considered them more relevant for economic and
environmental needs, rather than for improving effectiveness of care.
Technology became the “evangelist” of the need to change current paradigms and
technology-based innovation was accepted as a metaphor for sustainable effectiveness. This
proved to be a powerful and motivating concept at VBRH. The medical professionals, who
28
focus on providing a better future quality of life to patients with severely compromised
functions, easily understood the need of assuring that at least the same quality of care that can
be delivered today must be available also to the next generations.
By leveraging on the dynamic synchronization between new technologies and
employees’ willingness and abilities, VBRH was successful in organizing itself to fuel three
synergic mechanisms for adding “sustainability” to effectiveness. The first is the continuous
improvement of social, environmental and economic performance. Performance were not bad
when VBRH decided to begin a journey towards sustainable effectiveness, but today, because
of this journey, clinical and economic performances are significantly better and integrated
into a more comprehensive dashboard that takes into account also organizational,
technological, social and environmental performances. With this regard, improving efficiency
through an increased productivity–e.g., by adopting robotics for automated rehabilitation
practices–offered the capability to face the shrinking of national and regional budgets for
healthcare delivery without increasing patients’ out of pocket contribution. Saving local
natural resources – such as water – and reducing pollution offered the opportunity to improve
the quality of life of neighbors and taught people the value of preserving the ecosystem from
the human footprint. By empowering employees with new competences and goals–and
avoiding their stress and burn-out–VBRH acquired the capability to rapidly incorporate new
technologies in current patient pathways, thus taking advantage of the tremendous pace of
technology development in healthcare that is nowadays scaring other rehabilitation hospitals.
The second is research. The willingness to improve VBRH’s international reputation
by becoming a leading research institution motivated healthcare professionals to apply the
principle of science to everyday activities. Two results are worth of discussion. First, the
task-force was successful in institutionalizing an organizational climate oriented towards an
open-minded, unbiased, multi-specialty and evidence-based discussion among professionals
29
where the most cost-effective pathway for any patient is agreed on the basis of the best
available evidence, refusing any authoritative influence. Second, as anticipated, they created
an organizational climate open to innovation and change because of their capability to
promote and guarantee a diffuse feeling of psychological safety in all multi-specialty teams
which were involved in experimenting with new technologies and practices. The perception
of psychological safety helped professionals to fully express their creativity and potentiality,
and accelerate the acceptance of new technologies. When the EMR was adopted, many
different kinds of errors occurred, but managers tolerated and accepted them as part of a
scientific process of “trial by error”. This facilitated the sharing of best practices, of feedback
about current practices and needs of improvements, and of mistakes that require an urgent
solution. Doing this, VBRH realized sustainable work systems that are able to accept and
rapidly institutionalize repeated technological or organizational changes.
The third leverage is structural capital, i.e. the capability to enlarge and strengthen the
relational network. Leveraging on national and international research projects, VBRH was
able to nurture a relevant network of collaborative research partnerships with academic–such
as the Politecnico di Milano and its Schools of Management and (Clinical) Engineering–and
industrial partners–such as IBM and Intel. The increasing wideness of this relational network
offered to VBRH professional the unique opportunity to systematically share ideas and
feedback, exploit current knowledge and explore new clinical and technological knowledge.
The positive outcomes of these collaborations–such as the development of a patented
technology for measuring the interaction between patients and healthcare professionals
through a Radio-Frequency-Identification (RFId) platform or the development of a platform
for telemedicine-based services to patients–reinforced professionals’ motivation to explore
the benefits of technological innovation and accept the potential short-term failures of
continuous change of practices and behaviors. The development of trust between healthcare
30
professionals, technology developers and academicians facilitated the creation of a common
cognitive capital, with shared core values and a shared language on sustainable effectiveness.
CONCLUSIONS
Villa Beretta Rehabilitation Hospital (VBRH) had a compelling notion that technology is
likely to provide solutions to the emerging challenges of sustainable high-quality healthcare
delivery. What it lacked initially was the capability to carry out this vision. This chapter
provides the empirical evidence that technology can enable sustainable effectiveness in
healthcare by improving the organizational capability to deliver high-quality care to patients
and achieve a more appropriate use of scarce environmental, social and financial resources.
In VBRH, technology became the metaphor of continuous change and made clear to
professionals that efficient, high-quality care requires the continuous disruption of current
paradigms of delivery and behaviors.
The case illustrated that the full engagement of healthcare professionals was crucial for
both embarking on the initiative for sustainable effectiveness and its implementation.
Healthcare managers who are committed to organizing for sustainable effectiveness by
leveraging on a bundle of technology-based initiatives must take into account the need of
dynamically synchronize the technical and the social subsystems. VBRH facilitated this
outcome by promoting a culture of evidence-based dialogue and decision-making. The
existence of an organizational context in which all professionals feel free to propose
innovations and changes without perceiving the risk of being blamed in case of failure or
being neglected because of hierarchical rituals and routines, facilitates knowledge sharing and
knowledge exploration among healthcare professionals who feel entitled to share best
practices, feedbacks and also mistakes.
31
The VBRH case paves the way for a deeper level understanding of the role that
technology can play in sustainable effectiveness dynamics and outcomes in healthcare
delivery. The complex dynamics of triggering and enhancing sustainable effectiveness
initiatives requires both a clear vision and a guiding framework. Healthcare regulators,
managers, professionals and technology suppliers can benefit from the experience of VBRH
and the guiding theoretical framework to organize healthcare delivery for sustainable
effectiveness by unveiling technology’s capability to trigger and enable their strategies.
32
REFERENCES
Adler, N., and Docherty, P. (1998). Bringing business into socio-technical theory and
practice, Human Relations, 51 (3), 319-345.
Bushe, G.R., and Shani, A.B. (1991). Parallel learning structures: Increasing innovation in
bureaucracies. Reading, MA: Addison-Wesley (series in Organization Development).
Cherns, A.B. (1987). The principles of socio-technical design revisited. Human Relations 40
(3), 153-161.
Eijnatten, van F., Shani, A.B. (Rami), & Leary, M., (2008). Sociotechnical systems:
designing and managing sustainable organizations. In T. Cummings, (ed.), Handbook
of organization development, (pp.277-309). Thousand Oaks, CA: Sage.
Hanna, D., (1988), Designing Organizations for High Performance, Reading, MA: Addison-
Wesley.
Lettieri E, Masella C, (2009), Priority Setting for Technology Adoption at a Hospital Level:
Relevant Issues from the Literature. Health Policy 2009, 90(1):81-88.
Lettieri E, Masella C. Adopting ICTs in HealthCare Organisations: a Framework to Measure
Value and Sustainability. International Journal of Healthcare Technology and
Management 2006, 7(3/4):319-332.
Lettieri E. Uncertainty inclusion in budgeting technology adoption at a hospital level:
Evidence from a multiple case study. Health Policy 2009, 93(2):128-136.
Pasmore, W.A. (1988). Designing effective organizations: The socio-technical systems
perspective. New York, NY: Wiley.
Pasmore, W.A. (1994). Social science transformed: The socio-technical perspective. Human
Relations, 48 (1), 1-21.
33
Popper, M. & Lipshitz, R. (1998) Organizational Learning mechanisms: A structural and
cultural approach to organizational learning. Journal of Applied Behavioral Science, 34,
2, 161–179.
Shani, A. B., and Docherty, P. (2008) Learning by design: key mechanisms in organization
development', in T. Cummings (ed.) Handbook of organization development,
Thousand Oaks, CA: Sage 499-518.
Shani, A.B. (Rami), and Sena J., (1994), Information technology and the integration of
change: Sociotechnical system approach, Journal of Applied Behavioral Science, 30, 2,
247-270.
Taylor, J.C, and Felten, D.F. (1993). Performance by design: Socio-technical systems in
North America. Englewood Cliffs, NJ: Prentice Hall
Trist, E.L. (1981). The evolution of socio-technical systems. A conceptual framework and an
action research program. Toronto, Ontario: Ontario Quality of Working Life Centre,
occasional paper.
Trist, E.L., Murray, H., and Emery, F.E. (Eds.) (1997), The social engagement of social
science: A Tavistock anthology. Volume III: The socio-ecological perspective.
Philadelphia: PA: The University of Pennsylvania Press.
Zanaboni P, Lettieri E. Institutionalizing Telemedicine Applications: The Challenge of
Legitimizing Decision-Making. Journal of Medical Internet Research 2011, 13(3):e72
34
Figure 1: Research Framework
35
Table 1
Overview of the Rehabilitation Eco-system
Domain Key Elements Main FeaturesHealthcare System
Aims and Scope The Italian National Healthcare System (NHS) established in 1978 by the 833/78 Law.
Universal coverage and a free access to all Italian citizens and immigrants.Decentralization The NHS is organized on 3 levels: the national, the regional and the local level.
NHS promotes decentralization of decision-making for improving an appropriate use of national resources.
Funding Sources and Transfer Prices
The NHS is a tax-based financed system “Out-of-pocket” payments have increased year after year to help the NHS
economic viability. Transfer prices from the Local level (Local Health Agencies) to providers (e.g.,
rehabilitation hospitals) based on Diagnostic Related Groups (DRGs).Rehabilitation Ecosystem
Multi-specialty Rehabilitation requires multi-specialty approaches in order to tailor the patient’s cost-effective strategy.
Clinical Protocols agreed by professionals within each rehabilitation hospital offers an integrated and coordinated care.
Complexity The Rehabilitation Ecosystem is a complex bundle of healthcare and social services.
Chronic Care Rehabilitation requires a life-long delivery of healthcare and social services.Health Policy for the Rehabilitation Sector
Continuity of Care
A continuity of care must be designed and managed, from acute hospitals to the patients’ home.
All relevant interdependencies must be identified and managed to administer quality of care.
A shift towards Home-Based Care in progress - better equilibrium between costs and effectiveness.
Evidence-Based Medicine
Clinical Protocols have to be continually advanced according to state-of-art evidence based medicine.
More for Less The Italian NHS requires an improvement of both technical and allocation efficiency.
For the past 5 years, budget reductions (3%-5%) have been administered yearly.
Technological development
eHealth Information & Communication Technology (ICT) and Internet are radically reshaping healthcare delivery.
The availability of information about rehabilitation and performance of the various providers is empowering patients’ decision-making.
Information availability is changing patient-healthcare professional relationships.
Biomedical Biomedical Technologies experienced a significant pace of innovation, (even if it is yet to be proves as superior in terms of comparative effectiveness.)
36
Table 2
Overview of VBRH Features
Domain Key Elements Main featuresOrganizational Context
Size and Activities
VBRH is a 90 beds facility, highly specialized and knowledge intensive provider of rehabilitation services.
In 2010, around 1,100 in-patients and 18,000 out-patients were treated. The patients profile included: Respiratory diseases (22%), spinal cord injuries or
diseases (15%), brain injuries (27%), neuromuscular diseases (14%), coma (13%), traumatic brain injury (6%), other (3%).
Governance and Core Values
VBRH is part of the Valduce Hospital, a 300 beds generalist hospital that delivers healthcare services on behalf of the NHS.
The Valduce Hospital is a religious – i.e. non-profit – hospital, whose core values grounds in the Christian religion.
“The patient is a person and she comes first” is the moral and integrative principle that guides strategies, practices and behaviors.
Location Location in an ancient villa on the top of a small hill in the countryside by Como Lake in Lombardy (Northern Italy).
The region grew significantly in size during the last decade. The nearest town is small with less than five thousand inhabitants. The surrounding natural beauty is one of a kind.
Team-Based Practice
Healthcare professionals are organized in small specialized teams that are patients’ centric.
Each group advances its clinical capabilities, integrates its work, determines clinical protocols and coordinates across all specialties and services to deliver the best possible care to patients.
Knowledge Management
VBRH is a knowledge-intensive organization and the exploitation of current knowledge and the exploration of new knowledge are essentials for improving health outcomes and quality of life.
Business Strategy for Sustainable Effectiveness
Scientific Leadership
VBRH aims at achieving the special status of “institute for research and patient care” that allows more decisional freedom and special funds for research.
Knowledge creation and publications in 1st tier journals are advocated and highly encouraged.
Reputation is viewed as a competitive advantage within the sector and the concept of evidence-based reputation is at the forefront.
Technological Leadership
VBRH is committed to accelerate the pace of local technology based research, prototypes and patents.
Technology is viewed as the major enabler of cost-effective care for rehabilitation patients.
Technology as a major catalyst of change in healthcare delivery: the adoption and diffusion of new technology requires agile organizations that can easily ebbed change and get improved performance.
Professionals’ engagement
All healthcare professionals who operate in the rehabilitation field face relevant psychological pressure and they might suffer burn-out or depression.
VBRH managers are fully committed to preserve professionals’ balanced engagement and motivation.
Motivation and self-realization are regenerated through going feedback cycles about the actual benefits for the patient in terms of rehabilitation treatments, such as an improved quality of life when she is at her home.
37
Table 3
How Biomedical Technology impacted on Sustainable Effectiveness
Domain Biomedical TechnologySome Examples in VBRH Robotics for passive rehabilitation
Innovative Prostheses (e.g., electronic-knee, exoskeleton) Technology-enhanced wheelchairs
EffectivenessHealth Outcome and Quality of Life
Robotics decreases variability in physic-therapy and allows to do activities overcoming constraints of labor scheduling
State-of-Art prostheses and wheelchairs improve quality of life and help patients bringing back to the most normal life
Access to care Standardization and productivity increase allow a more efficient usage of resources and thus their availability for a larger number of patients
Patient Experience (Satisfaction)
Patients feel “being in the right place” when they see State-of-Art technology everywhere and when this is employed to care for them
Patient Empowerment
The length and complexity of improving their function despite the exploitation of the most advanced biomedical technology empower patients’ motivation and ability to take care of them and prevent future wrong behaviors or practices
Triple Bottom LineEconomic Pillar Robotics promotes productivity by facilitating standardization and by replacing human labor in
heavy tasks. Biomedical technology (e.g., prostheses, wheelchairs etc.) allows to increase productivity by a
social perspective, since patients are more autonomous in their daily life and some of them can also come back to work.
Ecological PillarSocial Pillar Robotics-based rehabilitation substitutes skilled healthcare professionals with machines: VBRH
had a shortage of skilled professionals and thus no downsizing was necessary State-of-Art prostheses and wheelchairs reduce caregivers’ efforts and facilitate better
relationships with relatives and friends Being at the frontier of technological development puts sometimes healthcare employees
under pressure since they feel they have no consolidated routinesOther major impacts
Research & Knowledge
VBRH has entered both national and international projects and fund programs to develop new biomedical technologies
An increasing number of young healthcare professionals, young biomedical engineers applied to VRBC to have access to relevant research and funds
Structural Capital VBRH collaborates systematically with technology developers and, in particular, with the local district of biomedical technology
Leveraging on a dedicated grant from a Bank Foundation, VBRH, the local district and relevant research Institutes developed and patented new technologies for the rehabilitation sector
Opportunities of sustainability
The systematic adoption of new biomedical technology revealed the need for sustainable work systems and institutionalized practices for addressing change
Impacts on professionalsMotivation The availability of State-of-Art biomedical technology motivates VBRH professionals in two
ways: i) they see better outcomes for patients, ii) they understand the costs and complexity of these technologies and thus are more motivated to learn how to use them and how to improve VBRH’s sustainability over time
Capability The use of State-of-Art technology offered healthcare professional the opportunity to develop new capabilities
38
Table 4How ICT Impacted Sustainable Effectiveness
Domain Information & Communication TechnologySome Examples in VBRH Electronic Medical Record (EMR)
Home-Based Care (e.g., tele-follow-ups) Computer-based or tablet-based rehabilitation programs Wireless Hospital Campus
EffectivenessHealth Outcome and Quality of Life
Tele-follow-ups permit frequent interaction between healthcare professionals and patients: this leads to a higher adherence to therapy at home and prevents patients and relatives from engaging in wrong practices and behaviors
EMR enables multi-specialty strategies of care: the possibility to access all patient’s data from everywhere and anytime allows professionals to increase efficiency and quality of care
Computer-based physical and cognitive rehabilitation allows to design and deliver one-to-one strategies of care
Access to care Telemedicine offers high-quality care overcoming spatial and time constraints: patients have follow-ups at their home (also outside of Italy or in rural areas), saving time and money
Patient Experience (Satisfaction)
Patients feel “being in the right place” when they see State-of-Art technology everywhere and when this is employed to care for them
Access to internet everywhere allows patients and their relatives to being connect with the expertise and carry on normal-life activities
Patient Empowerment
The availability of dedicated apps that explain the right way of doing physical and cognitive therapy at home or that deliver specific exercises that can be done at home or everywhere contributes to empower patients who can
Interaction with professionals by telemedicine empowers patients who become more and more conscious and responsible of what they do at home for rehabilitate themselves
Triple Bottom LineEconomic Pillar Telemedicine-based solutions for home-based care help reducing valueless transportation
costs and save time – and productivity – of both patients and their caregivers Reduction of paper and chemical products for printing save money and time of healthcare and
clerical professionals who avoid repetitive data entryEcological Pillar Telemedicine-based solutions for home-based care help reducing valueless transportation
Paper-less applications and the use of a EMR save natural resources (paper) and prevent pollution from exhausted printing machines and chemical products for printing
Social Pillar Professionals who are allowed to access patient’s data from web everywhere and anytime have the possibility to better organize their work and better balance their work-life time
Being systematically at the frontier of technological development puts sometimes healthcare employees under pressure since they feel they have no consolidated routines
The diffusion on internet of videos, notes and diaries about the length and complexity of rehabilitating the physical or the cognitive functions that have been compromised by a stroke, or an accident help educating people about the right behaviors to prevent such events
Other major impactsResearch & Knowledge
EMR allows to collect data about clinical outcome and physical and cognitive therapies: the analysis of these data allows to evaluate the comparative effectiveness of different health strategies or their relative cost-effectiveness, enhancing an evidence-based decision-making
Structural Capital VBRH has activated a variety of collaborations with leading ICT players (e.g., IBM, Intel etc) and research hospitals to develop new ICT-enabled solutions for home-care delivery
VBRH developed and patented with Politecnico di Milano a Radio-Frequency-Identification (RFId) solution for measuring the interaction between patients and healthcare professionals
Opportunities of sustainability
The adoption of EMR as platform to integrate multi-specialty care and RFId-based device for measuring the interaction between patients and healthcare professionals showed the value of collecting data and analyze them for promoting continuous improvement in terms of both clinical outcomes and resource savings
Impacts on professionalsMotivation The systematic introduction in VBRH of new ICT-based solutions for improving clinical
outcome or process efficiency motivates healthcare professionals towards innovative behaviors and flexible working practices
Capability Healthcare professionals at VBRH developed new capabilities in terms of ICT and telemedicine-based solutions, but more than this, they developed the capability to continuously innovate their practice and protocols to embedded new technology
39
Table 5
How Greening Technology Impacted Sustainable Effectiveness
Domain Greening TechnologySome Examples in VBRH
Green building standards Natural Light for enlightening Photovoltaic Equipment Electric Hand Drier for saving toilette-napkins Toxin-free facilities and materials
Effectiveness Health Outcome and Quality of Life
No direct benefits in terms of function recovery, but indirect benefits in terms of decreased risk of allergies and infections from toxins or pollution
Access to carePatient Experience (Satisfaction)
The beauty of the countryside and the atmosphere of an ancient villa that has been transformed in an environment-friendly rehabilitation hospital (with natural light enlightening patients’ rooms, toxin-free materials and photovoltaic equipment) contributes to patient satisfaction about their choice for VBRH
Patient Empowerment
Triple Bottom LineEconomic Pillar Energy savings (about half of all energy consumption in hospitals is for
conditioning rooms and spaces) contributed to the delicate yearly balance between revenues and costs
Ecological Pillar VBRH feels that the ecological pillar is not so much critical for sustainable effectiveness at the present, since the others two are a priority; despite that VBRH is committed to save energy, water and paper, and reduce pollution and toxic, infective waste
Social PillarOther major impacts
Research & KnowledgeStructural CapitalOpportunities of sustainability
Impacts on professionalsMotivation The new layouts of spaces and patients’ rooms contribute to make
healthcare professionals proud of working for VBRH and of its commitment for a sustainable healthcare delivery
Capability
40
Figure 2
Conceptualized Framework
Technical Subsystem
Social Subsystem
Effectiveness
BiomedicalTechnology
ICTTechnology
GreeningTechnology
Professionals’ Motivation
Professionals’Capabilities
Professionals Psychological
Safety
Research &Knowledge
Triple Bottom LinePerformance
Structural Capital
Patient Experience
Clinical Outcome & Quality of Life
Patient Empowerment
Accessibility to care
DynamicSynchronization
Business Strategy
Environmental Subsystem
Sustainability
41
Table 6
Overview of the Dynamic Synchronization mechanism at VBRH
Domain Findings at VBRHOrganization Design Patients’ centric team-based care within medical disciplinary units
Targets and rationales are shared through the first line person to create a common commitment to best – and sustainable – care
Discussions and resource allocation challenges are negotiated based on evidence-based data
Teams of multi-specialty professionals are accountable for improving clinical outcomes and efficiency performance
Balancing of time dedicated to work, to innovation (e.g., for developing new protocols, new technology, new services etc.) and to own life (e.g., spare time for family, hobbies etc.)
Openness to innovations and collaborations with technology developers, Universities and Schools of Medicine; the tagline is “VBRH is an open R&D Lab”
Home visits of healthcare professionals to enhance rehabilitation activities and facilitate patients’ progress
Change Management A task-force was established to promote and facilitate technology-related research programs, review and adoption of proposals
The task-force designed and managed ad-hoc innovation teams for different technology-based initiatives
Key Performance Indicators are defined and monitored before, during and after the implementation of new technology initiative
No monetary incentives are employedLearning Mechanisms VBRH designed specific dashboards of metrics to measure clinical outcomes
and process performance, and regular and transparent feedback us provided to healthcare professionals
Continuous and rigorous evaluation about how new technology might improve clinical outcomes or efficiency performance
Creation of common language about innovation, technology and change to promote a common understanding, a common thinking and a common commitment
Institutionalization of process improvement teams that are responsible for understanding the present needs and evaluate possible technological solution
EMR encourages practice-based learning and shows the value of a multi-specialty approach to rehabilitation patients
De-briefing process and protocol after complex therapy or after patient discharge have been institutionalized to support learning and promote continuous improvement
European Community (EU) funded projects offer healthcare professionals the opportunity to share practices and outcomes with others, facilitating bench-learning and the transfer of good practices
The systematic collaboration with Universities makes VBRH a porous organization that is open to new perspectives, new ideas and new technology
42