Annelies Van Der Ham

agents. Different coordination mechanisms result in different interaction patterns, resulting in a certain network structure, i.e., integration and differentiation. For planning and performing surgeries, 314 rules were found, of which the majority applies hospital-wide. Because rules are often undocumented, they are not always generally known. Moreover, 82% of all documents concern local or personal documents such as checklists and memos or were delivered in internal presentations. As a consequence, rules are often shared throughout the hospital through social interaction, as most rules exist predominantly in people’s minds.

Coordination mostly takes place through standardization of work and mutual adjustment. In the early planning stages for a surgery procedure, mutual adjustment based on hospital-wide rules is dominant. Closer to the day of surgery, local rules are used and open loops are closed through mutual adjustment, thus achieving integration. Open loops are created by long term schedules that are not based on future patient demand. Open loop systems are affected by their environment, but do not utilize feedback nor take action to improve the workflow, which potentially leads to instability. On the day of surgery, there is mainly standardization of work and output, based on hospital-wide rules. Both Chapters 3 and 4 discuss the hospital’s stability and potential vulnerability and propose to further develop Slingeland Hospital’s logistical system in order to increase its robustness.

Chapter 5 describes the results of the evaluation of the hospital’s social network, rules, coordination mechanisms and performance after a hospital planning centre (HPC) was introduced. Following the introduction of the HPC, bed utilization increased with peak utilization of beds and operating rooms decreasing, and increases were observed in the waiting list, in cancellations and in waiting list variability. More integration was observed for specific planning tasks, but not for the hospital network as a whole. Differentiation based on medical discipline, organizational unit, length of stay and patient characteristics remained. More hospital-wide and fewer local rules exist, and these have remained largely undocumented, i.e., exist in people’s minds. Coordination mechanisms both before and after the introduction of the HPC are mainly mutual adjustment and standardization of work. Based on these observations and literature, Chapter 5 proposes further development and system redesign from a system-wide perspective that includes network structure, rules and coordination mechanisms.

Chapter 6 presents the main findings of this thesis, reflects on these from a theoretical and methodological perspective and discusses implications for policy, practice and research. From a theoretical perspective, the concepts of integration, differentiation and fragmentation are discussed. The appropriate integration or differentiation depends on the demands from the environment that the hospital needs to respond to. In hospital practice, essentially, integration is about closing loops, for which a certain degree of integration, differentiation and coordination mechanisms based on rules, are required. Integration and differentiation in hospitals, however, do not seem to be designed or premeditated beforehand in conjunction with each other, and this could lead to instability. A more deliberate approach towards integration and differentiation is proposed, which includes stepwise learning aimed at system stabilization under changing circumstances. Hospital leadership is important for this to succeed.

It is recommended to conduct more empirical studies, based on theory with regard to planning, performance measurement, simulation modelling and mathematical algorithms, organization theory and social network theory. Accordingly, recommendations are presented on how to conduct such research, which includes hospital-wide or even healthcare network case study research using social network analysis and naturalistic inquiry.