Jeroen David Hendrikus Van Wijngaarden

Background: Value-Based Health Care (VBHC) was developed to improve patient outcomes relative to costs and has been promoted internationally as a strategy to enhance quality and efficiency by stimulating competition on value between hospitals. However, the concept was originally designed for the United States and assumes organizational structures, financial incentives, and competitive dynamics that differ across health systems. This study examines how VBHC is implemented in Dutch hospitals, considering the expectation in The Netherlands that doctors and nurses should lead the process to integrate professional and managerial logics, and explores the conditions that influence the adaptation of the concept when introduced into a different institutional and local context. Methods: A qualitative multi-case study was conducted in four Dutch hospitals. Data were collected through 68 semi-structured interviews. Data were analyzed using a thematic analysis approach as described by Braun & Clarke (2006). Results: A mismatch emerged between the assumptions of VBHC and the Dutch hospital context. Dutch hospitals especially lack the structures and financial systems needed to measure costs per patient, a cornerstone of VBHC. Although hospital boards strongly endorse the concept, they place doctors and nurses at the forefront of the implementation process, expecting them to act as informal leaders. Doctors and nurses, however, receive limited resources, unclear mandates, and little organizational support. This seems to contribute to a significant adaptation of the concept. Instead of emphasizing the relationship between outcomes and costs, hospitals reinterpret VBHC as an approach focused on shared decision-making and improved communication between professionals and patients. Patient-reported outcome measures are used mainly to support clinical conversations rather than for benchmarking or cost-outcome evaluation to improve competition, as VBHC assumes. Conclusion: The Dutch experience indicates how transferring management concepts like VBHC across national borders can lead to substantial reinterpretation when local structures and professional dynamics differ from those assumed in the original model. The prominent but unsupported role assigned to doctors and nurses strongly shaped this adaptation: rather than integrating professional and managerial perspectives, VBHC evolved into a patient-centered communication approach focused on shared decision-making. This suggests how expectations placed on professional groups—especially doctors and nurses—play a decisive role in reshaping international management concepts in practice.

Background: Perceived community environment is important for shaping older people's participation in their communities and for their well-being. Social cohesion and social belonging are two important yet distinct dimensions of perceived community environment that may influence support-behaviour and well-being in different ways. However, previous studies often treated both belonging and support behaviour as components of social cohesion. As a result, the associations between social cohesion and belonging with support provision behaviors and well-being among community-dwelling older people remains underexplored. This study aims at addressing this gap. Methods: A longitudinal survey study design was employed. Data were collected among community-dwelling older people in the Netherlands across two waves with a six-month interval ( N = 675). Multivariate linear auto-regressions and cross-lagged panel models (CLPMs) were used to explore the longitudinal associations among support provision, social cohesion, social belonging, and well-being. Sensitivity analyses using change-score regressions were conducted to assess robustness at the intra-individual level. Results: We found that support provision, social cohesion, and social belonging were all positively associated with follow-up well-being. Cross-lagged analyses revealed distinct longitudinal relationships that, social cohesion at T0 was positively associated with increased support provision at T1, whereas social belonging at T0 was not. Sensitivity analyses confirmed that within-person increases in cohesion were associated with increases in support provision, while changes in belonging were not positively related to support changes. Conclusions: Our study offers a new understanding of how the community environment may influence older people's support behaviors. Findings suggest that social cohesion and social belonging play distinct roles in relation to support provision among older people. Practices aimed at facilitating mutual support and well-being may need to take specific roles of different dimensions of community environment into account.

Background: Clinical decision support systems (CDSS) have the potential to improve patient safety and reduce costs in primary care. However, CDSS adoption remains limited due to development and implementation challenges. CDSSs are complex interventions involving multiple interacting components that require technological innovation and behavioral and organizational change. Additionally, the primary care context is considered a complex system with high care demand, fragmented structures, and many independent yet interdependent organizations. Established determinant frameworks for implementing and scaling up complex health care interventions support the identification of implementation determinants. However, they offer limited guidance on the underlying processes of these determinants, such as the implementation processes involved in complex interorganizational collaboration in primary care. Objective: This study examined how an interorganizational collaboration in Dutch primary care ( Gezonde zorg, Gezonde regio [ GzGr ]) achieved an iterative CDSS development and implementation. We aimed to identify the mechanisms that supported the collaboration in overcoming challenges. Methods: We performed an exploratory process-level case study. Data were collected through 15 semistructured interviews. The nonadoption, abandonment, scale-up, spread, and sustainability framework was used to ensure comprehensive topic coverage during the interviews, but not as an analytical framework. We triangulated the interviews with internal and external documents and expert input. Using a thematic, inductive approach, we developed a chronological overview of the collaboration and identified mechanisms offering insights into how GzGr navigated complexity in the development and implementation of CDSS. Results: We identified two mechanisms: (1) enacting an interorganizational value model and (2) iterative, co-creative experimentation. First, GzGr was driven by a coalition of the willing (ie, individuals willing to take an extra step), with shared goals that prioritized collective benefit while respecting organizational values. They established shared principles that translated the broad GzGr mission into concrete CDSS development choices, while also guiding strategic expansion by involving mission-aligned, innovative organizations. Second, after initial prototypes, GzGr established an iterative learning and improvement experimentation for both the technology and the collaboration. This process allowed for rapid feedback, validation of added value, and ongoing refinement. Additionally, this experimentation approached the development and implementation phase as a continuous process involving multistakeholders, supporting both the technology and the collaboration. Conclusions: This study identified 2 mechanisms that sustained interorganizational collaboration and CDSS development. These mechanisms connected collaborative and technical changes across people, technology, and organizational levels, enabling technological viability, stakeholder value, and multilevel support. The mechanisms operated both within and between organizations through iterative cycles of development and implementation. Practical implications include involving multilevel, innovative, and influential stakeholders; maintaining alignment through an orchestrating actor; and adopting an iterative approach between development and implementation. Our findings extend existing determinant frameworks by offering process-level insights into how such mechanisms help overcome challenges in the development and implementation of CDSS within interorganizational collaborations.

Background: Integrated care is enhanced by integration on system, organizational, professional, and clinical levels including functional and normative integration. Many studies have been done on functional integration on these different levels, less studies focus on how normative integration takes place. In this study, we focus on the question: what differences in frames of refence must be addressed to establish consensus on appropriate care for People with Multiple Problems? Methods: A mixed-method Delphi study was carried out in which professionals and managers regularly involved in care for people with multiple problems (PWMPs) worked towards consensus on appropriate care delivery through the assessment of 15 vignettes representing real trajectories of PWMPs. Results: No consensus on appropriate care delivery was reached on any of the 15 vignettes. Five differences in perspective explained the dissensus: 1) an individual versus a systemic perspective on the client; 2) a focus on self-expressed needs of clients or professionally assessed (normative) needs; 3) client-directed or caregiver-directed care; 4) client as victim of circumstances or responsible for circumstances; 5) a focus on barriers or opportunities. Conclusions: In general, panelists agreed that care for PWMPs should be integrated. However, the further integrated care was to be operationalized in practice the greater the dissensus between panelists emerged. To understand how these differences in perspectives may be overcome to provide care for PWMPs normative integration needs to be studied during actual processes of care delivery.

Background. Being a nurse or physician in todays complex healthcare practice involves more than just responsibility for one aspect of care during one episode in a patients care trajectory. Both professionals are expected to take on a clinical leadership role and contribute positively to the reduction of care fragmentation and help in spanning professional boundaries. Although nurses may be well placed to identify the needs for integration, they may lack the position and status (compared to physicians) to address those needs as leaders. The aim of this study is to analyse similarities and differences between nurses and physicians in clinical leadership roles within a hospital context and explore how this relates to their interdisciplinary collaborative behaviours and perception on their job. Method. A cross-sectional survey among physicians and nurses was conducted to measure clinical leadership, job satisfaction, workload, and interdisciplinary collaborative behaviours. Results. Our results suggest that nurses (n=329) and physicians (n=100) show similar clinical leadership behaviours, based on equivalent scores on the clinical leadership scale. However, physicians score higher on the global leadership scale indicating they are more likely to perceive themselves as leaders than nurses. As clinical leaders, both nurses and physicians are more likely to express interdisciplinary collaborative behaviours. Furthermore, physicians who scored higher on the clinical leadership scale reported higher satisfaction with their job, whereas, for nurses, their score on the clinical leadership scale did not relate to their job satisfaction. Conclusion. As nurses in hospitals have the most frequent and direct involvement with patients, it seems inevitable for them to act as clinical leaders to promote patient-centred care. However, nurses less often perceived themselves as clinical leaders while showing suitable behaviours. Future studies should focus on the strategies nurses use to exert their clinical leadership, and for example, if nurses require the use of more dominant strategies to effect change.

The COVID-19 pandemic hit long-term care, and particularly nursing homes hard. We aimed to explore how crisis management goals and tasks evolve during such a prolonged crisis, using the crisis management tasks as identified by Boin and ‘t Hart as a starting point. This longitudinal, qualitative study comprises 47 interviews with seven Dutch nursing home directors and a focus group. We identified two phases to the crisis response: an acute phase with a linear, rational perspective of saving lives and compliancy to centralized decision-making and an adaptive phase characterized by more decentralized decision-making, reflection, and competing values and perspectives. This study confirms the usability of Boin and ‘t Hart’s typology of crisis management tasks and shows that these tasks “changed color” in the second phase. We also revealed three types of additional work in managing such a crisis: resilience work, emotion work, and normative work.

Hospitals have been encouraged to develop more process-oriented designs, structured around patient needs, to better deal with patients suffering from multi-morbidity. However, most hospitals still have traditional designs built around medical specialties. We aimed to understand how hospital designs are currently developing and what the important drivers are. We built a typology to categorize all Dutch general hospitals (61), and we interviewed hospital managers and staff. The inventory showed three types of hospital building blocks: units built around specific medical specialties, clusters housing different medical specialty units, and centers; multi-specialty entities provide the most suitable structure for a process-oriented approach. Only some Dutch hospitals (5) are mainly designed around centers. However, most hospitals are slowly developing towards hybrid designs. Competitive drivers are not important for stimulating these redesigns. Institutional pressures from within the health care sector and institutional ‘mimicking’ are the main drivers, but the specific path they take is dependent on their ‘heritage’. We found that hospital structures are more the result of incremental, path-dependent choices than ‘grand-designs’. Although the majority of the Dutch general hospitals still have a general design built around medical specialties, most hospitals are moving towards a more process-oriented design.

Older persons are vulnerable to depression SFduring the ageing process. Financial resources and social participation are expected to have an impact on depressive symptoms. This study investigated the relationship between financial support from children and depression among Chinese older persons, as well as the mediating effect of social participation in this relationship. Data from 7163 participants aged 60 and above were extracted from wave 2015 and 2018 of the China Health and Retirement Longitudinal Survey (CHARLS). A multivariate regression analysis was performed on both cross-sectional data and two-wave longitudinal data to test our hypotheses. The results revealed that financial support from children was negatively associated with depressive symptoms in both the short-term and the long-term. In addition, this relationship was partially mediated by social participation in the short-term association and fully mediated by social participation in the long-term, where financial support was positively related to social participation, and social participation was negatively associated with depressive symptoms. This study offers an in-depth insight into the relationship between financial support from children and depression among Chinese older persons. Policies and initiatives to stimulate social participation should be promoted to improve older persons’ mental health.

Health care today is characterized by an increasing number of patients with comorbidities for whom interphysician collaboration seems very important. We reviewed the literature to understand what factors affect interphysician collaboration, determine how interphysician collaboration is measured, and determine its effects. We systematically searched six major databases. Based on 63 articles, we identified five categories that influence interphysician collaboration: personal factors, professional factors, preconditions and tools, organizational elements, and contextual characteristics. We identified a diverse set of mostly unvalidated tools for measuring interphysician collaboration that focus on information being transferred and understood, frequency of interaction and tone of the relationship, and value judgements about quality or satisfaction. We found that interphysician collaboration increased clinical outcomes as well as patient and staff satisfaction, while error rates and length of stay were reduced. The results should, however, be interpreted with caution, as most of the studies provide a low level of evidence.