PDF(Pubmed)
Abstract：
BACKGROUND: While healthcare organizations in several countries are embracing Value-Based Health Care (VBHC), there are limited insights into how to achieve this paradigm shift. This study examines the decade-long (2012-2023) change towards VBHC in a pioneering Dutch university hospital.
METHODS: Through retrospective, complexity-informed process research, we study how a Dutch university hospital\'s strategy to implement VBHC evolved, how implementation outcomes unfolded, and the underlying logic behind these developments. Data include the hospital\'s internal documents (n = 10,536), implementation outcome indicators (n = 4), a survey among clinicians (n = 47), and interviews with individuals contributing to VBHC at the hospital level (n = 20).
RESULTS: The change towards VBHC is characterized by three sequential strategies. Initially, the focus was on deep change through local, tailored implementation of multiple VBHC elements. The strategy then transitioned to a hospital-wide program aimed at evolutionary change on a large scale, emphasizing the integration of VBHC into mainstream IT and policies. Recognizing the advantages and limitations of both strategies, the hospital currently adopts a \"hybrid\" strategy. This strategy delicately combines deep and broad change efforts. The strategy evolved based on accumulated insights, contextual developments and shifts in decision-makers. The complexity of change was downplayed in plans and stakeholder communication. By the end of 2023, 68 (sub)departments engaged in VBHC, enabled to discuss patients\' responses to Patient Reported Outcomes Measures (PROMs) during outpatient care. However, clinicians\' use of PROMs data showed limitations. While pioneers delved deeper into VBHC, laggards have yet to initiate it.
CONCLUSIONS: VBHC does not lend itself to linear planning and is not easily scalable. While there appears to be no golden standard for implementation, blending local and larger-scale actions appears advantageous. Local, deep yet harmonized and system-integrated changes culminate in large scale transformation. Embracing complexity and focusing on the ultimate aims of (re)institutionalization and (re)professionalization are crucial.
METHODS: Through retrospective, complexity-informed process research, we study how a Dutch university hospital\'s strategy to implement VBHC evolved, how implementation outcomes unfolded, and the underlying logic behind these developments. Data include the hospital\'s internal documents (n = 10,536), implementation outcome indicators (n = 4), a survey among clinicians (n = 47), and interviews with individuals contributing to VBHC at the hospital level (n = 20).
RESULTS: The change towards VBHC is characterized by three sequential strategies. Initially, the focus was on deep change through local, tailored implementation of multiple VBHC elements. The strategy then transitioned to a hospital-wide program aimed at evolutionary change on a large scale, emphasizing the integration of VBHC into mainstream IT and policies. Recognizing the advantages and limitations of both strategies, the hospital currently adopts a \"hybrid\" strategy. This strategy delicately combines deep and broad change efforts. The strategy evolved based on accumulated insights, contextual developments and shifts in decision-makers. The complexity of change was downplayed in plans and stakeholder communication. By the end of 2023, 68 (sub)departments engaged in VBHC, enabled to discuss patients\' responses to Patient Reported Outcomes Measures (PROMs) during outpatient care. However, clinicians\' use of PROMs data showed limitations. While pioneers delved deeper into VBHC, laggards have yet to initiate it.
CONCLUSIONS: VBHC does not lend itself to linear planning and is not easily scalable. While there appears to be no golden standard for implementation, blending local and larger-scale actions appears advantageous. Local, deep yet harmonized and system-integrated changes culminate in large scale transformation. Embracing complexity and focusing on the ultimate aims of (re)institutionalization and (re)professionalization are crucial.
摘要：
背景：虽然一些国家的医疗保健组织正在接受基于价值的医疗保健（VBHC），关于如何实现这种范式转变的见解有限。这项研究考察了荷兰开创性大学医院对VBHC的十年（2012-2023年）变化。
方法：通过回顾性研究，复杂性知情过程研究，我们研究了荷兰大学医院实施VBHC的战略是如何演变的，实施成果是如何展开的，以及这些发展背后的潜在逻辑。数据包括医院内部文件(n=10536)，实施成果指标(n=4)，一项对临床医生的调查(n=47)，以及在医院层面对VBHC做出贡献的个人的访谈(n=20)。
结果：向VBHC的变化具有三个顺序策略的特征。最初，重点是通过本地的深刻变化，定制实现多个VBHC元素。然后，该战略过渡到旨在大规模进化变革的全医院计划，强调将VBHC集成到主流IT和政策中。认识到这两种策略的优点和局限性，医院目前采取“混合”策略。这一战略巧妙地结合了深刻和广泛的变革努力。战略是基于积累的洞察力而演变的，背景发展和决策者的转变。变化的复杂性在计划和利益相关者沟通中被淡化。到2023年底，68个（子）部门从事VBHC，能够在门诊护理期间讨论患者对患者报告结果测量(PROMs)的反应。然而,临床医生使用PROM数据显示出局限性。当先驱者深入研究VBHC时，落后者尚未开始。
结论：VBHC不适合线性规划，不易扩展。虽然似乎没有执行的黄金标准，混合局部和更大规模的行动似乎是有利的。当地,深刻而协调和系统整合的变化最终导致大规模的转变。拥抱复杂性并专注于（重新）制度化和（重新）专业化的最终目标至关重要。
方法：通过回顾性研究，复杂性知情过程研究，我们研究了荷兰大学医院实施VBHC的战略是如何演变的，实施成果是如何展开的，以及这些发展背后的潜在逻辑。数据包括医院内部文件(n=10536)，实施成果指标(n=4)，一项对临床医生的调查(n=47)，以及在医院层面对VBHC做出贡献的个人的访谈(n=20)。
结果：向VBHC的变化具有三个顺序策略的特征。最初，重点是通过本地的深刻变化，定制实现多个VBHC元素。然后，该战略过渡到旨在大规模进化变革的全医院计划，强调将VBHC集成到主流IT和政策中。认识到这两种策略的优点和局限性，医院目前采取“混合”策略。这一战略巧妙地结合了深刻和广泛的变革努力。战略是基于积累的洞察力而演变的，背景发展和决策者的转变。变化的复杂性在计划和利益相关者沟通中被淡化。到2023年底，68个（子）部门从事VBHC，能够在门诊护理期间讨论患者对患者报告结果测量(PROMs)的反应。然而,临床医生使用PROM数据显示出局限性。当先驱者深入研究VBHC时，落后者尚未开始。
结论：VBHC不适合线性规划，不易扩展。虽然似乎没有执行的黄金标准，混合局部和更大规模的行动似乎是有利的。当地,深刻而协调和系统整合的变化最终导致大规模的转变。拥抱复杂性并专注于（重新）制度化和（重新）专业化的最终目标至关重要。
