Search and Selection of Scoping Review
The research yielded 1297 articles. After filtering the articles for the language "English" and document type "article" and removing duplicates, 596 articles were sustained. In the next step, 507 articles were excluded because these were either not empirical (246) or not about implementing VBHC (261). This led to a total of 89, which were the subject of our second round of inclusion analysis. At this stage, to focus on VBHC, we checked if the papers discussed the implementation of an initiative and abstracts contained one of the following words in the goal: value, value-based, or improve outcomes and reduce costs.
Furthermore, we identified additional articles that could not be considered empirical. This led to a sample of 26 articles for full-text assessment, of which two full-text papers were inaccessible through institutional libraries. We sent out a request to the authors to provide the two missing articles. However, no response was received. Consequently, the final set for qualitative analysis consisted of 24 articles. Figure 1 presents an overview of the search and selection process.
General Characteristics of Included Studies
We provide an overview of the general characteristics of the included studies in Additional file 1. The included articles were published between 2013 and 2020. Of the studies included in our review, 13 (58.3%) were conducted in the USA, eight (33.3%) in Europe (Italy, Sweden, and the Netherlands), and the remaining three (12.5%) in Singapore. Five (20.8%) studies took place within the discipline of orthopedics, four (16.7%) studies within the field of cardiology, and three (12.5%) within the oncology discipline. Additionally, five (20.8%) articles were more management-focused and did not relate to any specific medical discipline. The remaining six (25%) articles were divided over obstetrics, pediatric surgery, urology, bariatrics, and psychiatry.
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In line with our aim for this study, we provide an overview of what we discovered about implementing VBHC. In line with our coding scheme, we present our findings thematically following the why, what, how, outcomes, and barriers of the change to VBHC.
Why VBHC is implemented
Concerning why a VBHC-related initiative is implemented, arguments for the goal of the change, the reasons for the change, and the need for a shared vision have been found in 21 studies— an overview of which papers address which factors is presented in Table 1.
For the goal of the change, the general idea of improving care was mentioned the most. Most of the other mentioned goals were related to increased cost efficiency, such as improving utilization rates or reducing care costs. Two articles expressed different goals, namely identifying improvement areas23 and the standardization of care24.
We identified three main forces as reasons for change. In some articles, implementing VBHC seemed to be primarily a top-management decision. In other articles, it became clear that the studied organizations followed the footsteps of other organizations focusing on VBHC. In the last group of articles, institutional pressures were the predominant force for change, for instance, when a bundled payment system was introduced25 or when regulatory requirements demanded change26.
Top management and others should acknowledge the goal and reason for the change. A shared vision should be dispersed throughout the organization. This need for a shared vision is addressed in four included articles. The change initiative's project team members should have a shared vision and a common language, and a shared toolkit for change.27 Having the common goal of creating value increases the willingness to work, according to VBHC.28 Leadership and behavior modeling, which we further elaborate upon in the how-section, can help establish this needed shared vision.27
To conclude, concerning the need for change (why), two frequently mentioned goals, three reasons to change, and the need for a shared vision were identified. While the primary goal of VBHC is to improve value, only three studies aim to both improve patient-centric outcomes and increase cost-efficiency. More commonly, the goal or objective of the improvement is unclear, and when goals are shared, these tend to relate to cost efficiency solely. As far as enclosed, the main reason for initiating a change towards VBHC is top management's pressure or external pressures outside the organization. Finally, most studies did not report creating a shared vision as part of the change strategy. This raises doubts about whether the need for change was felt throughout the organization.
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What element(s) of VBHC is/are implemented
Concerning what was changed relating to VBHC, we found six types of change in 21 articles (Table 2). Most articles implemented some variation of IPU, explaining that multidisciplinary teams are responsible for organizing care. Moreover, half of the articles expressed that new outcome measures were established. Another frequently mentioned element was the coordination of care. The institutionalization of the last three contents of change was mentioned to a lower degree: bundled payment, risk assessment, and the spread of services across geography.
Outcome measures. Of the five different outcome measures applied (Table 3), the implementation of costs and general outcome measures were mentioned the most. In the cases of general outcome measures, it was not explicit what the outcome measures would entail at that point. Furthermore, only six articles specified that (a part of) the implemented measures were patient-centric.
The content of the change focused on different components of VBHC (bundled payment, IPU, services across geography, and outcome measures) and care coordination and risk assessment. The implementation of care coordination or risk management was viewed as a possible strategy to enhance value, as both were, in most cases, associated with improved outcome measures. Even though different components of VBHC were implemented, one can question the extent to which VBHC is genuinely implemented in the included studies. While the content of change often focused on implementing outcome measures and multidisciplinary teams, other components of VBHC, such as the bundled payment or services across geography, were often forsaken. Moreover, while the outcomes element of value is patient-centric, most studies only addressed costs or clinical outcomes. As not one VBHC initiative implemented all six components, one could conclude that none of the initiatives implemented the complete concept of VBHC.
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How is VBHC implemented?
When deciding how to implement VBHC-related initiatives, the studies highlight six essential areas: communication, creating an incentive, involvement, support, team alignment, and execution. Table 4 shows the distribution of these factors over the studied articles.
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Communication.To successfully transform a health care organization, continuous and effective communication is crucial. Frequent (multidisciplinary) team meetings can be used to communicate about the change, for example, to visualize the goals27 or reflect on results.36 Communication and cooperation are needed between employees,38 departments,28 different levels in the organization, and with the patients.30 Effective communication is the underlying factor for successful change.
Create incentive.Anincentive needs to be created and maintained to change the present affairs. The motivation for VBHC needs to be continually stimulated amongst all staff involved.38 Given that implementing VBHC is a never-ending process, Nilsson et al. argue that endurance and purposefulness need to be maintained, yet they do not explain how to organize it.37 An important decision is whether to focus on intrinsic or extrinsic motivation. While extrinsic motivation (e.g., through making physicians' adherence to protocols an item of their salary43 or gainsharing through funds to divisions40) could be decisive, intrinsic motivation should not be underestimated either. The study from Zipfel et al. shows that the implementation process improves when individuals have the intrinsic motivation to change through a feeling of personal relevance.42 In addition, when a change is implemented because another health care institution implemented it, this could negatively influence the success of the change through social pressure.42 Therefore, it is vital to make well-thought decisions regarding how to motivate employees.
An incentive could be created through monitoring. In reporting the results, transparency is critical. Results should be shared with everyone involved, and progress needs to be discussed in dedicated meetings30 to enable the change process to move forward.38 By reflecting on the outcomes, areas of improvement can be identified23, and the visualization of undesired outcomes can create a willingness to change through people's pride and morale.27
Five studies showed another way to increase compliance to change, namely through protocols.24,26,43,45,49 Protocols enable compliance with new metrics49 and the standardization of risk assessment.24 However, protocol compliance is still subordinate to improved outcomes.43 Therefore, while protocols can be used to increase compliance or incentive to change, they should not be the primary goal.
Lastly, success and goals must be translated frequently. "Employees need to be able to visualize the connection between each of their everyday activities and one or more of the organizational goals".27p379 If participants cannot see the results of their efforts to change, engagement for VBHC decreases.28 Moreover, before the change implementation, staff already needs to be engaged.37 The formulation of clear goals facilitates the successful implementation of VBHC.
Involvement. The involvement of all levels of the organization is a recurrent theme in the studies. Chatfield et al. (2017) argue that strategy development and planning should include as many stakeholders as possible, crossing multiple levels. Similarly, Nilsson et al. (2017a) argue that change initiatives could be ineffective when not involving staff from multiple levels from the start of the change to VBHC. Nilsson et al. (2018) show that when staff is engaged later in the process, this can result in difficulties. Employees had to learn what VBHC was about at the same time as they were implementing it. Correspondingly, lacking involvement could lead to frustration and less engagement with the initiative.42 Therefore, the entire workforce should be involved from the start of the change to VBHC.
Besides the involvement of all affected employees, patient involvement is crucial for the successful implementation of VBHC. As the core of the change is "the care relationship between the patient and the multidisciplinary team",30p6 patients cannot be kept uninvolved. Discrepancies between the providers' perceptions of value delivered and the value experienced by patients28 show that patients have an important role. Hence, patient representatives should be invited to the discussions to discuss relevant questions with all representatives.27 However, the engagement of patients can be challenging. Patients are not a homogeneous group; representatives talk from their point of view.37 In addition, the voice of medicine is often more potent than the voice of the patient representatives.28
Support. Support for the change can be shown and materialized through multiple means. Support should be made visible through leadership, behavior modeling, and a supportive culture. Furthermore, it can be materialized through empowering the front line and making resources available, especially an enabling IT system.
Leadership and the leader's commitment to VBHC are key factors in successful change to VBHC. The success of a change is "a product of how the organization is led".27p380 Leadership should be dedicated, development-oriented, have the power to make decisions,37 and be appointed, as ambiguity on who is responsible for the outcomes could result in a lack of uptake of the initiative.42 Furthermore, leaders should model the desired behavior while managing the department,27 being the most enthusiastic about the VBHC initiative.37 Thus, the commitment to VBHC needs to be clearly expressed by leaders in the health care organization.
Alongside committed leadership, having a culture supportive of change will also contribute to the success of the organizational change. A high-reliability learning culture is imperative for organizational transformation.27 The literature recommends creating trust through transparency and a no-blame culture that propagates continuous learning, critical thinking, and knowledge sharing throughout the organization.27 Similarly, a favorable climate is necessary for successful change.42 However, van Veghel et al. (2020) observed that such a culture existed within specialties but not across specialties. Accordingly, constant efforts should be invested in developing and maintaining a supportive culture throughout the entire care organization.
Furthermore, (a lack of) resources can enable (hinder) change. Resources should be allocated to support working, according to VBHC.37 For example, a lack of time for preparation, reflection, or anchoring the changes in daily work can hinder implementation.28,37 Correspondingly, in the study of Pelt et al. (2018), additional resources in the form of other employees were necessary to change the delivery of care to VBHC. A rather vital resource for implementing VBHC is an enabling IT system. Nine studies expressed the need for an enabling IT system. Most of these stated that newly established outcome measures needed to be, or were, collected and updated with the help of an IT system, in which the measures are accessible at all times.32,34,40,43 To conclude, sufficient resources should be provided, particularly for an enabling IT system.
Team alignment. It is essential to ensure that the efforts to change to VBHC are made in teams. Health care is "the ultimate team sport".27p376 Multiple studies expressed that project teams targeted the implementation of VBHC.35-37 Nonetheless, ensuring that the change is considered teamwork is not enough. Van Veghel et al. (2020) expressed issues arising from ambiguities in roles and responsibilities. Hence, the roles and responsibilities of each team member should be communicated. Changing to VBHC should be targeted in teams in unison regarding the vision for change, as discussed earlier, and the roles and responsibilities.
Execution.Two main themes emerged concerning the actual execution of the change to VBHC: the use of consultancy and the development or absence of a change plan.
Consultancy was used to start the implementation of VBHC in four studies.28,29,37,38 However, inconveniences can be experienced in working with consultants. Nilsson et al. (2017b) showed that care providers perceived working with consultants as time demanding. Accordingly, consultancy can aid the start of changing to VBHC, although enough resources should be provided to reap the benefits.
While a change plan is essential, very few studies elaborated on a plan concerning the implementation of VBHC. In most cases, the authors simply mentioned that the initiative was rolled out in phases.29,36 Analyzing the effects of the absence or presence of an implementation model, Zipfel et al. (2019) observed that the use of an implementation model resulted in better uptake of and a more positive experience of the change and developed the Integrated Implementation Model to be used for quality improvement interventions, such as VBHC. Nonetheless, the presence of a change plan does not ensure success either. In one case, the plan was adapted throughout the change process, ending with only a partial implementation of VBHC.28
Meanwhile, the management's plan failed in its execution phase.29 Furthermore, although planning and preparation before the launch of the implementation process are important,40 Colldén and Hellström (2018) argue that an instrumental view of a pre-planned process does not always reap benefits. A change execution plan should not be overlooked or be considered unchangeable, yet it is largely ignored within the included studies.
In sum, most of the studies have not elaborated much on the process (how) of the change. Nevertheless, apparent factors were identified as necessary to implement VBHC successfully. The studies showed that change managers should address effective communication, incentives, employee and patient involvement, support, team alignment, and execution. Despite the identified factors, the effect of the different process strategies cannot clearly be distinguished from this study as no clear link can be found between how the change is undertaken and the outcomes of the change process. Consequently, questions remain on how the implementation of VBHC can be approached most successfully.
Outcomes of VBHC implementation
Discussed elements relevant to the outcomes of the implementation efforts were classified into four categories: adherence to protocols, partial implementation, the impression of VBHC, and improved outcome measures. Table 6 provides an overview of which studied articles discussed elements relevant to each category.
Adherence to protocols. When protocols are used, compliance can measure the outcome of the change. Increased adherence was associated with reduced costs,24,49 and a shorter stay of patients in the hospital.30 Implementing VBHC can also affect adherence to protocols of existing programs. The study by Pelt et al. (2018) showed that implementing VBHC in an enhanced recovery after surgery (ERAS) program increased the patients' adherence to the ERAS program.
Partial implementation. Four studies explicitly stressed that only a part of the original change plan or a part of the VBHC concept was implemented. Colldén and Hellström (2018) argue a lack of faithfulness to the original VBHC concept in their case. The implemented VBHC initiative was adapted throughout the change process, resulting in improved measurements and a future vision to benchmark these against other health care centers. Similarly, in another study, in the end, little attention was paid to measuring costs, making it debatable whether VBHC was implemented.28 In addition, the VBHC initiative, in one case studied by Zipfel et al. (2019), was not perceived as value-adding and was stopped. Lastly, Van Den Berg et al. (2019) disclose that they could not collect data on patient-centric outcomes, viewing this as a future target. The remaining twenty studies do not address the extent to which the VBHC concept was implemented. Nonetheless, the studies that reported on the extent of the implementation underline that the implementation of VBHC is challenging.
Impression of VBHC.Gorman et al. (2019) learned that two-thirds of their respondents felt they did not properly understand VBHC. Moreover, Colldén and Hellström (2018) noted that there were different perspectives on the meaning of VBHC among the involved employees. This significantly impacted the results, as individuals attributed improvement projects to the VBHC initiative according to their ideas on what VBHC constitutes. In addition, studying the perceptions on VBHC, over half believed value-based payments were coming, and 57% of the respondents reported that VBHC was important to their institution.31 Nonetheless, in another study, VBHC reminded the care providers of what health care was about value for the patient28 and was thus perceived very positively. Hence, perceptions of VBHC differ among cases.
Improved outcome measures.Improved outcomes were a typical result of the change initiatives, as depicted in Table 5. Eighteen studies used the improvement of outcome measures to determine the success of the change. What exactly was measured varied among articles. Four studies reported improved outcomes, and two reported enhanced performance. In seven cases, most studies reported reduced costs linked to a reduced length-of-stay (LOS) (without an increase in mortality rate). Three other reported outcomes are also related to lower costs: a lower rate of discharge, a lower rate of readmission, and lower resource utilization. More importantly, only four studies report some improvement in patient-centric outcomes. All in all, most studies reported improved outcomes, concluding that the change was successful.
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In sum, the dominant result of the change initiatives was improved outcomes, which could be expected since outcome measurement is one of the six core elements of VBHC. However, while over half of the articles that reported an improvement in their outcome measures showed a decrease in costs, only four reported improved patient-centric outcomes. Although outcomes show perceived success of change through adherence to protocols or reduced costs, it is questionable whether the value was genuinely increased in the cases. In general, the conclusion that value increased was drawn quickly when the established outcome measures improved, while the cost or patient-centric outcomes were not adequately measured, barely knowing the total effect on value. Moreover, changes were not always entirely successful, as some studies reported a partial implementation.
Barriers to VBHC implementation
The implementation of VBHC is not without difficulties. Barriers were discussed in nine of the studies (Table 7). The most prominent barrier was the lack of enabling IT. IT systems were underdeveloped, especially for measuring outcomes that should be monitored to offer VBHC.29,29,36 Furthermore, Gorman et al. (2019) identified three barriers to the implementation of VBHC. There was a lack of collecting patient-relevant and cost data, costs were not transparent, and the understanding of the value concept was low, making it impossible to implement value-based payments.31 In addition, studies indicate that limited or absent management of the implementation or change initiative was influential. Factors that could lead to poor implementation are: a limited understanding of change management and change practice,38,44 a lack of governance regarding roles and responsibilities,44 the absence of a shared vision for change,27,32 and lack of change behaviour.33
Overall, the identified barriers show the importance of change management when implementing VBHC. When general change management, a shared vision, or support through resources is absent, it becomes difficult to implement VBHC. Moreover, the importance an enabling IT is evident.
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