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

Emanuele.lettieri@polimi.it

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

+1-805-756-1756ashani@calpoly.edu

Annachiara LongoniPh.D. Student

Politecnico di MilanoP.zza Leonardo da Vinci, 32

Milan, Italy 201330039 02 2399 3940

Annachiara.longoni@mail.polimi.it

Raffaella Cagliano, Ph.D.Professor

Politecnico di MilanoP.zza Leonardo da Vinci, 32

Milan, Italy 201330039 02 2399 2795

Raffaella.caglianao@polimi.it

Cristina Masella, Ph.D.Professor

Politecnico di MilanoP.zza Leonardo da Vinci, 32

Milan, Italy 201330039 02 2399 4081

Cristina.masella@polimi.it

Franco Molteni, M.D.Medical Doctor, Clinical Health Director

Villa BerettaVia N. Sauro, 17

Costa Masnaga, (Lecco)Italy

0039 031 8544211fmolteni@valduce.it

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