Académique Documents
Professionnel Documents
Culture Documents
Introduction
1.1
in sustaining their competitiveness (e.g. Tidd et al, 2005; Bernstein & Singh, 2006;
Ussman et al, 2001; De Propris, 2002). Blumentritt et al (2005), whose study
concentrates on how entrepreneurs develop internal cultures that may inspire and impel
innovation, argue that continuous innovation requires organisational systems and
procedures that are embedded, so as to ensure growth. From an entrepreneurial point of
view, Simmons et al (2009) state that entrepreneurship creates value through
innovation, seizing business opportunities. Similarly, Johnson (2001), who conducted
research on entrepreneurship and innovation, contends that entrepreneurship is the
conversion of ideas into marketable products or services.
Little research has been conducted about new service development in the health
service industry, with only a select number of notable works available: Duncan and
Breslin, 2009; Windrum and Garcia-Goni, 2008; Booz et al, 1982. Elsewhere,
Nambisans study (2002, p. 394) argues that in many different markets and situations,
customers are an excellent source of innovation (a view supported by Veryzer & de
Mozata, 2005). Tobin et al (2002, p. 93) also stress the importance of communication
and building a relationship with patients, stating: the opportunities for consumer
participation occur first at this clinical interface in terms of what information is
transferred, in what direction, and in how the communication takes place. Nurturing
participation at this level has a fundamental role in consumer empowerment.
Despite the importance of both entrepreneurship and customer-orientation in the
health care market, little has been written on either subject. The present study focuses
on the health services industry, examining both the demand for and provision of mental
health care in Greece. Within the structure of the health system in Greece, the private
health services sector includes Diagnostic Centres and Hospitals (general and obstetric
clinics), which are classed respectively in Primary and Secondary Health Care.
However, in recent years the industry has experienced great change following mergers
of organisations operating in the three wider sectors (general clinics, obstetrical &
1
gynaecological clinics, and diagnostic centres). This has resulted in the growth of health
care groups offering a full range of diagnostic and treatment services. As the market for
private health care has grown, so too has the competition between organisations, each
trying to offer better service quality, promptness, and facilities than one another.
As regards the mental health care sector, it becomes apparent that there is a
noteworthy improvement in the areas of decentralisation of mental health services
(Madianos et al, 1999b). Yet there is much still to be done in terms of quality and
delivery of mental health care services. What is more, the mental health service sector
is not very highly exploited. There are few private independent hospitals of this kind
across Greece, even though the public sector appears not to satisfy the needs of the
patients. Detailed information can be found in Chapter 2.2.4.
The organisation that is the focus of this study is a leading player in the area of
diagnosis, prevention, and hospital care in Greece. Euromedica Group is mainly
involved in the foundation, organisation, and operation of clinical and scientific centres,
equipped with high-technology appliances. The organisations facilities serve ten
prefectures in Greece, while it invests in its personnel through continuous and extensive
training of its employees. In 2008, Euromedica recognised an unfilled niche in the
market for health care, that of mental health services. Following extensive market
research into this area of the health care market, including the limited availability of
such treatments geographically, the organisation decided to invest in and develop their
own services in this area. Therefore, this research provides important managerial
implications for the top management team of the Euromedica Group, regarding its
overall operation and particularly its mental health care division. Specifically, the
results of this research work give a factual picture of mental health services provision
within the organisation, along with the techniques that should be adopted to develop
and implement customised or personalised offerings for customers. Such action should
offer substantial competitive advantages to the Euromedica Group as well as the
opportunity to expand its operations within the mental health sector.
1.2
to identify the knowledge gaps and critical problems in the Greek health care industry
and especially in the private sector. After reviewing these resources, the research
questions relating to these knowledge gaps and aiming to solve critical problems were
composed.
particularly the countries of Eastern Europe and Turkey, which show significant
deficiencies in health infrastructure, have concentrated, especially in recent years, the
interest of investors of large business groups. The geographic imbalance of private
nursing units also creates growth opportunities beyond Athens and Thessaloniki, where
the largest number of them is currently concentrated. This is reinforced by the fact that
there is considerable room for improvement in the quality of health care in regions
outside of Athens and Thessaloniki. The extension of cooperation of private health
facilities with an increasing number of private insurance companies, as well as the
contracts with insurance funds, has resulted in broadening their customer base through
the coverage of medical expenses for a greater range of patients.
Moreover, the increasing number of migrants, whose economic profile does not
enable them to benefit from private health services, has led to congestion of public
hospitals, an element that turns a part of demand towards the private sector. In addition,
the proliferation of programmes through interest-free instalment payment is a reality
now in the field of private health, as is the outpatient card, which offers scalable
discounts for series of medical tests. Lastly, home care, provision of day nursing
services, tele-medicine, and robotic surgery, rehabilitation centres, nursing hostels and
geriatric clinics and stem cell banks are all areas that have significant growth potential
in Greece, while paediatric, gynaecological and oncology units, plastic surgery centres,
IVF centres, and even centres of natural health and wellness, concentrate the interest of
investors.
1.2.1.1 The Greek Health Care Market
Especially in recent years, the industry is characterised by significant changes due
to mergers and acquisitions between companies in three broad areas of activity (general
clinics, obstetric and gynaecological clinics, diagnostic centres). One result of this trend
is the prevalence of multi-purpose business groups for medical services, which offer a
full range of services for diagnosis and treatment. The competition between private
health units, has been particularly intense in recent years and focuses primarily on the
replacement of medical equipment; the range, quality enhancement and the speed of the
services provided; the extension of the network (presence in most areas); and
cooperation with insurance funds.
Furthermore, the total domestic market for private health services (in value) shows
longitudinal growth during the period of 1998-2008; its size was estimated in 2008 at
1.985 million, compared to 574 million in 1998, representing average annual growth
4
rate 13.2%. In the area of private hospitals, the greatest market shares appear to be held,
for 2008, by Hygeia Group and IASO Group, followed by BIOMED and Euromedica.
1.2.1.2 Euromedica Group
Euromedica Group has 44 diagnostic centres covering all medical specialities; 18
general, obstetrics and gynaecology hospitals; 9 rehabilitation and recovery centres, as
well as one spa, health and cosmetic surgery centre, having a total capacity of 1621
beds. The Group's principal activities are the provision of health and wellness solutions,
all over Greece.
Euromedica Neurological Services is the leading provider of private mental health
treatment and associated care services in Greece, with a network of 3 acute hospitals
and care homes (Thermaikos, Castalia and Galini), which employ more than 350
people. The organisation offers a range of inpatient, outpatient, day patient and
residential treatment programmes, as well as therapy services that include condition
management programmes as well as psychological and psychiatric services, such as
secure and step-down services, complex care and rehabilitation services. It also
provides autism services and care of the elderly. It continues to establish new services
each year in partnership with government bodies.
regard to managers potentially feeling that they are losing their control over an
organisation or department when they allow for increased creativity and freedom for
staff.
Some authors support the opinion that corporate venturing is a viable option only
for large organisations who are able to supply the expenditure realistically required to
succeed in this task (Gapp & Fisher, 2007; Zahra, 1996). However, corporate venturing
can prove an effective option for firms to gain knowledge and skills that will often lead
to future revenue streams (Greene et al, 1999). According to Tidd and Barnes (2000, p.
109), however, many firms (in life sciences industries) have failed to differentiate
sufficiently between strategic, financial and operational goals, and have therefore
created inappropriate forms of corporate venture. Therefore, one of the key objectives
of this research is to investigate the relationship between innovation and corporate
venturing within the health care industry.
1.2.2.2 New Service Development and Customer Orientation
Continuous service innovation has been described by many authors (e.g. Smith et
al, 2007; Tidd & Hull, 2003; Day & Wensley, 1988; Storey & Easingwood, 1999) as
the most valuable means for companies to achieve long-term success and organic
growth (Melton & Hartline, 2010). It is also suggested that for service firms to achieve
even greater success, a customer-orientation perspective should be adopted (Sing Wong
& Tong, 2012; Svendsen et al, 2011; Ottenbacher & Harrington, 2008). This position is
enhanced by Greer and Leis (2012, p. 63) recent study, which emphasises how
enterprises undertake collaborative innovation with individuals and business customers
and concludes, Collaborative innovation with customers or users is increasingly
important for the development of new products and services.
Rehme and Svensson (2011), combine entrepreneurship and marketing theories to
illustrate the approaches that new ventures employ to achieve key milestones. They (p.
6) clearly support the above viewpoint mentioning that firms that involve customers
or users in their product development processes are more likely to succeed in the market
than firms that do not at an early stage receive feedback from users, and direct customer
involvement in the development of their offering is likely to increase revenues with a
guaranteed sale, making it necessary for them to have a strategic view on customer
involvement. Similarly, Jenssen and Aasheim (2010) carried out research that analyses
the effects of organisational factors on innovation and performance in knowledgeintensive businesses and argue that the success of product development depends on the
7
health care and in particularly, in mental health care. In addition, few studies have
focused on the interaction and involvement of patients in the development of new health
services and even less in the design and development of new mental health services.
Lastly, there is no study that aims to investigate the growth and sustainability of a health
care organisation from two different perspectives, that of service innovation and how
can this lead to the exploitation of entrepreneurial opportunities, and, on the other hand,
the involvement of customers, aiming at the development of new services that could be
used as the tool for the above growth, leading the organisation to sustainable
development. The researcher reviewed the research context of the Greek health care as
well as the relevant literature in order to develop the research questions below.
The health care industry is one characterised by innovation (Bowers, 1987), with
hospitals often acting as leaders in innovation as new treatments and technologies in
this arena emerge daily. However, this rapid rate of change can often stifle organisations
who may not have the resources to keep up and will end up suffering from business
inertia (Rohrbeck & Gemnden, 2011). Other potential problems regarding innovation
in the health care can lie in the bureaucracy and other such problems often associated
with the industry (Duncan & Breslin, 2009; Bellou, 2010). Efforts to ameliorate
problems and issues such as these have been illustrated in research by various authors
(e.g. Nijssen et al, 2006; Menor & Roth, 2007; Cooper, 1988) who suggest a rigid,
systematic approach to new service development as being able to provide a more
effective approach to successful innovation. Additionally, several studies have pointed
out the importance and contribution of customers and of the market in general in
successful service innovation, underlining that the degree of novelty depends on
customer-producer interaction as well as on the creation of a new value system among
the business partners (market orientation) (e.g. Den Hertog et al, 2010; Agarwal &
Selen, 2009). In this context, the following research question aims to examine the role
of the customers in the organisations innovation strategy. This will allow the researcher
to see whether Euromedica is extrovert or introvert, and also to gain a deeper
understanding regarding how the Group values customer participation:
RQ1: What is the role of customer (and of the market) in the development of
health services in Euromedica Group?
consistent with Bowers (1987), who found that both external and internal inputs are
needed for the development of new service concepts, which then should be evaluated
by both therapists and doctors and patients. Likewise, Windrum and Garcia-Goni
(2008) developed a framework for new health service development that involves, on
one hand policy makers, and service providers and on the other, firms and consumers.
They highlighted the competences of health professionals, and their interactions with
patients, mentioning that those determine service characteristics. Nevertheless, it
became clear in the review of the literature, and as it is shown in the subsections 4.2.2.3
and 4.2.2.4, in the past years, health care organisations used to focus more on the
expectations of their medical staff and third-party payers and less on their medical
consumers needs (e.g. Ford & Fottler, 2000). In addition, Charles et al (1997) indicate
clinicians as the perfect agents for their patients, and other studies have shown that
there are still doctors and nurses who believe that mental health service users have not
much to contribute to decision-making and to new service development (e.g. Bennetts
et al, 2011). The above arguments lead to the question whether medical staff agrees
with the involvement of patients in such processes and what role would they play if the
management of a hospital decides to take action by asking customers (patients and
relatives) to contribute to its innovation activities. The following research question aims
to explore medical staffs perceptions of customer orientation, as there is no clear
picture in the literature about their role in the development of patient-oriented services:
RQ3: What are medical staffs perceptions of customer orientation and what role
do such perceptions play in the development of patient-oriented services?
(Ford & Fottler, 2000). All this implies that executives must always consider effective
ways to provide health care services. Wood et als (2000) study, suggests that health
care organisations should focus on new approaches, such as customer orientation, to
achieve patient satisfaction. Similarly, Lord (1989) concluded that the aims of involving
patients are generally to advance health outcomes, raise satisfaction, and/or reduce cost.
In recent years, users of psychiatric services have taken a more active role in their
treatment and hospitalisation. Research by Barnes and Wistow (1994) and Campbell
(2001) found that until the early 1980s, patients used to be passive recipients of their
treatment, having no participation in and little influence over the services they used.
Indeed, the World Health Organization (1990) advised that patients should be involved
in the decision-making process with regard to their treatment, yet it has been reported
in the literature that mental health patients have not been treated with equal
consideration as other types of patients (Lammers & Happell, 2003). Nevertheless,
many changes have occurred since the 1980s that have led to mental health patients
gaining increased influence over the services they receive, including users having
increased control of their care and the decisions involved, and better availability of
knowledge of the types of treatments delivered. This shows that patients are a critical
actor in service development, especially in mental health care environments. Therefore,
as many studies have noted, there is a gap in the literature regarding how mental patients
should participate in new service development (e.g. Ford & Fottler, 2000; Davies et al,
2009; Bennetts et al, 2011). The last research question below aims to address this gap:
RQ4: How should mental health service users be involved in the service
development process?
1.3
12
This research highlights the observation that, despite the health care industry's being
an excellent example of an industry with many opportunities for innovation and new
service development, it remains an underexplored area of research. This lack of
research is particularly apparent in the sector of mental health care, where customer
involvement in service development is of particular importance. Even though patients
are a critical actor in the service development process, users preferences and
competencies have not been widely explored. Moreover, the author has found that no
substantial research has been undertaken regarding entrepreneurship in the health care
industry. It would be useful to study how health care organisations choose to develop
new business ventures in order to deliver new service offerings.
1.4
of its conceptual framework (see Chapter 5). The conceptual framework consists of
four key concepts, showing also the driving forces that push health care organisations
to innovate as well as the entrepreneurial and the new service opportunities that emerge
from the multiple combination of service innovation and corporate venturing and, on
the other hand, of new service development and customer orientation. Although these
key concepts have been derived from different disciplines and areas of research, it has
been essential to incorporate them into a study and also understand their influence in
the Greek health care industry. The rationale of integrating each of these key concepts
into the development of the conceptual framework is discussed in detail in Sections 5.4
and 5.5 in Chapter 5.
1.5
table (Table 1.1) illustrates the contributions of this study, which were divided into two
parts based on their respective theoretical, practical and pedagogical functions (see also
chapter 12).
13
Beneficiaries
Practical contribution
Conceptual framework
oriented services, and entrepreneurial growth. The argument for changing attitudes,
which will bring about more flexible and adaptable organisational structures and more
inclusive care services is formed.
This study reviews the relevant literature and develops a framework that
investigates and explores the level of patient involvement required for successful new
service development and how these new services could aid the organisation of new
establishment and growth in the sector of mental health hospitals. The purpose of this
study is, therefore, to investigate the influence of service user involvement on new
service development and how the outcome can enhance a firms entrepreneurial
activity, within the context of the health care market. This research responds to calls for
the further development and investigation of the concepts of customer participation in
the new service development process as well as of the link between innovation and
entrepreneurship (e.g. Jones & Rowley, 2011; Melton & Hartline, 2010; Alam & Perry,
2002; Matthing et al, 2004; Zhao, 2005a; Shaw et al, 2005). It also attempts to bring
the promising lens of entrepreneurship to the still emerging field of service innovation.
The main output of this study is the development of a conceptual framework within
which to examine how new service development contributes to corporate
entrepreneurship activities. More specifically, the conceptual framework devised in this
research contributes to the existing service development literature by providing
guidance on how to investigate the way health care organisations develop services that
meet the needs of their customers, whilst also identifying and capitalising upon
emergent entrepreneurial opportunities. This study also contributes to the discussion on
customer-oriented new service development. Customer participation in new service
development is a relatively new area of research, with few authors having discussed the
related benefits and potential issues. The current research work is the first to apply this
concept to the health care industry.
This study and the framework devised have highlighted the relationship and
interaction of innovation and entrepreneurship, and it is again the first of its kind to
apply this theory and discussion to the health care industry. Furthermore, it is found that
for organisations within this industry to be successful, they must adopt service
innovation strategies that will allow them the ability to identify entrepreneurial
opportunities. This framework represents a step forward in innovation and
entrepreneurship research as it provides a new insight into the identification of
15
activities,
augment
entrepreneurial
opportunities,
and
improve
1.6
of Rohrbeck and Gemnden (2011, p. 234), who state, for research fields that are
relatively new and about which the knowledge is limited, a qualitative research design
is recommended. The study was implemented in three research sections. Each section
stressed the issues to be addressed. The first included in-depth lite interviews with
higher executives of the Euromedica Group, as well as with the administrator of each
psychiatric hospital. The aim was to investigate issues relating to innovation,
entrepreneurship, and customer orientation from the standpoint of management. The
second section comprised semi-structured investigative interviews with selected
medical staff of each hospital in order to examine issues, from a medical point of view,
involving the participation of users in developing and delivering services. The third
16
section carried out semi-structured interviews with chosen patients from each hospital
to present the views and beliefs of mental patients about their own treatment and the
conditions under which they live. The main goal was the acquisition of a deeper
understanding of their positions and thereafter a comparison with the views of other
stakeholders.
Notwithstanding the fact that each section of the research is independent, together
they provide extensive and useful information from different angles. The information,
compared and combined, provides answers to important questions: how should patients
be involved in service development; what is the role of the client (and of the market) in
the development of health services in the Euromedica Group, and what is the opinion
of medical staff with respect to customer orientation, and what role do they play in
developing patient-oriented services? Therefore, the views of all kinds of stakeholders
are comprehensively appreciated, as regards the development of new customer-oriented
health care services and exploitation of business opportunities through corporate
investments. The interviews, in all the sections of the research, were conducted during
the period of December 2010 - March 2011.
Given that this research was carried out through semi-structured and exploratory
interviews, all sections of the research followed the same qualitative analysis process.
The main objective was to identify, investigate, and further compare the data collected
from all types of participants so as to achieve factual and constructive answers to the
research questions (Brown & Lloyd, 2001).
1.7
to identify customer needs and assess the health market, such as adequate information
systems, questionnaires, and so on, despite the fact that these have not yet been
established in their psychiatric clinics. Informal, rather than formal, processes of
developing new services have been adopted. Moreover, there is some disagreement
between management and scientific personnel on the rationale for and the establishment
of a culture where continuous improvement is to be considered as a rule. The former
maintain that there are on-going efforts to develop a business practice where everyone
will be enabled to take initiatives to improve service quality, satisfy customer
requirements and reduce operating costs, while the latter reported that such actions are
having no effect and that the firm is falling short of expectations.
Nevertheless, all participants agreed that the role of both senior executives and
medical staff is critical in adopting innovation and in enhancing the process of services
development. There is room for improvement, though, as there are gaps in staff
participation in decision-making and cooperation with management. Despite this, it has
been found that the company is not rigorous in condemning efforts that fail, but prefers
to acquire knowledge from experience. In any case, few people claimed that the
company has created a system where innovation thrives without restrictions; most
respondents stated that further measures should be implemented to enhance the
organisation's structure and achieve better results. Participants argued that the stimulus
of development encourages innovative activity and Euromedica has shown that its
business goal is to expand its activities in all sectors of the health sector, and beyond
national borders, as well as developing new services that meet the growing needs of
customers.
This last is particularly important, as management observed that customers together
with other stakeholders lead innovation efforts. Therefore, they have developed
services that meet the needs of patients and take into account their demands. However,
the management team claimed that patients are able to play a role in enhancing
residential services in hospitals and stressed that only some users of psychiatric services
are able to contribute to the development process. However, there were respondents
who stressed that in psychiatric settings, there is no culture and organisation such as to
cater for the desires of customers and their integration into the process of service
development.
18
19
20
treatment and indicated that they prefer to manage their concerns without assistance.
Moreover, many patients have confirmed the sufficient number of nursing staff and
noted that are satisfied with the overall service, indicating though that there is room for
improvement in the diet. In addition, participants argued that the behaviour of staff is
appropriate; they therefore feel comfortable discussing a personal matter or sharing
their thoughts. Respondents were positive about the facilities of the hospitals, namely
the condition of the buildings, environment, amenities, etc. There were some, however,
who indicated that further improvements should take place.
Beyond that, participants said that they enjoy participating in activities, as these
strengthen their treatment and help them overcome their health difficulties. Moreover,
it is revealed that a large number of stakeholders were willing to participate in decisionmaking regarding their health care. They recognised that this would be extremely
beneficial for the development of treatment and so for their psychological condition.
Only some argued the opposite. Still, it is noteworthy that in two hospitals, patients had
not so far been invited to comment on the services provided.
Nevertheless, many respondents argued that it would be exciting to join a
programme in which they could express their beliefs and perceptions about treatment,
so they are willing to contribute further to improving services. Furthermore, they agreed
that they should be employed to work in the hospitals, as this would be beneficial to
their health and would make them feel useful and creative.
1.8
Research Structure
Overall, this study comprises twelve chapters, which are briefly described below.
21
Chapter 1
Introduction
Chapter 2
Research
Context
Chapter 3
Service Innovation &
Corporate Entrepreneurship
Chapter 6
Research
Methodology
Chapter 4
New Service Development
& Customer Orientation
Chapter 5
Conceptual
Framework
Chapter 12
Conclusions
Chapter 11
Review of
Key Findings
Chapter 7
Analysis of
Senior Executives
Chapter 8
Analysis of
Thermaikos Hospital
Chapter 9
Analysis of
Castalia Hospital
Chapter 10
Analysis of
Galini Hospital
The second chapter focuses on the health care market, considering both demand and
provision. In particular, it encompasses general information on the Greek health care
industry, such as the structure of health services in Greece, the characteristics of the
industry, health expenditure, and an overview of the mental health care system of
Greece. With regard to the demand and provision of private health services, this chapter
includes the characteristics of and the factors affecting the demand for private health
services, as well as the development of its infrastructure and industry structure; the
conditions of competition, and a presentation of the private health care corporations. In
addition, the chapter describes the private health care market in Greece in terms of
domestic market size and the market shares of the health care groups. Finally, it gives
a profile of the Euromedica Group and Euromedica Neurological Services.
The third chapter reviews the literature and theories of service innovation,
entrepreneurship, and corporate venturing. Specifically, it defines service innovation,
22
survey instruments;
samples;
processes employed to develop new health services, the entrepreneurial model used by
Euromedica to expand its operations, and the strategy followed on customer
involvement in developing new offerings.
Chapters Eight to Ten investigate the operation of three mental health hospitals,
case-by-case. Each chapter falls into two parts. The first examines the views of both
administrative and medical staff regarding the factors that determine innovative
activity; the tools and the processes applied for new service development; the
contribution of customers and the role of executives and medical personnel into the
innovation process and the customer involvement in new health service development.
The second part explores the perspective of patients regarding hospitals operation and
infrastructure along with their enthusiasm to be a part of the service development
process.
The eleventh chapter summarises the key findings of three sections of the research
and includes a cross-case synthesis. The twelfth and concluding chapter evaluates the
research findings and considers the contribution of this research to the field of study. In
particular, it relates the innovation and corporate venturing literature to theories
concerning new service development and customer orientation, resulting in the
development of a distinct conceptual framework. Implications of the findings at firm
level are also discussed, to suggest future research directions. The limitations of this
research are also discussed.
24
Chapter II
Research Context: Overview and Development of the Private
Health Care Industry in Greece
2.1
Introduction
The introduction of the National Health System (NHS) in 1983 set the basis for the
provision and distribution of both public and private health services in Greece. The
objective of this chapter is to explore the Greek private health services market and more
specifically, the sector of mental health, including addictions (substance abuse
rehabilitation). The chapter also includes the general characteristics of the industry, the
factors that affect the demand for private health services, and the supply of health
services by private health groups. The size of the health services market is presented,
with the market shares of the leading groups. The Euromedica Group's company profile
is presented, as well as the prospects of the Greek health care industry.
2.2
Microbiological Laboratories;
Diagnostic Centres;
Secondary and Tertiary Health Care: This refers to services for patients who are
hospitalised in hospitals or clinics as offered by: a) 144 public hospitals of the
NHS and outside the NHS (military, S.I.I.) and 196 private hospitals (Health
25
Government
Central Health
Council
Ministry of Labour
& Social Insurance
Ministry of Health
& Welfare
Under-Secretary
of Welfare
Under-Secretary
of Health
Deputy Ministry of
Social Insurance
Social Services
General Directorate
of Public Health
Regional Hospitals
Direct Health
Directorates
Private Hospitals
Social Insurance Institute
(S.I.I.) urban polyclinics
District Hospitals
Health Centres
Rural Clinics
Fig. 2.1 Organisational Chart of Health Care System (source: W.H.O., 1996)
26
have been transformations in the private hospital sector, since small regional units have
consolidated with larger ones. Furthermore, in some cases, large units in the industry
became international by expanding their operations in foreign countries. An example is
the Athens Medical Centre, which has expanded its activities in various countries of the
Balkan area. The difficulty of the smaller units in responding to the rapid development
of medical technology and also the high cost of construction and equipment for new
treatment units are the two main reasons for the strategic acquisitions - mergers
consolidation of the smaller firms.
28
Ambulatory mental health units in areas with particular problems of access such
as islands and mountainous regions;
Mental health community centres for adults and child guidance centres for
children and adolescents;
Counselling services to meet the needs of families caring for the mentally ill
(Grove et al. 2002, Madianos 2002).
a system of service quality assessment on the part of public entities and private
legal entities, profit and non-profit,
connection of the funding of the mental health structures with the findings of
the evaluation,
updating and completing the legal framework, taking into account the White
Paper of the European Union and the perceptions of both the World Health
Organization and the World Association for Psychosocial Rehabilitation,
a decisive role for the Sectoral Committees of Mental Health, maintaining their
operation and promoting service networking in each area,
Furthermore, the following issues were revealed from the interactions and the
positions developed in a conference entitled The child with mental health problems:
The right to psychosocial rehabilitation", organised by the Greek Ombudsman (5th
February 2009):
lack of facilities for young people in need of urgent treatment (child and
adolescent psychiatry),
lack of structures for psychosocial rehabilitation of children and adolescents
with mental health disorders or other serious problems that require medical
rehabilitation,
serious malfunction of private non-profit bodies and delays due to reductions in
funding.
Resolving these issues is crucial to improve the quality of care for people with
mental health problems and to provide greater protection of their rights. However, no
policy on mental health can be successful if not accompanied by measures that combat
the stigma of mental illness and social prejudices. At the same time, it is necessary to
develop a support system for those families that have a mentally ill member
(Stylianidis, 2009).
Psychiatric reform regards the safeguarding the rights of people with mental health
issues and the role this can play both as a philosophy for the modernisation of services
that are focused on the asylum, and as a model for launching relevant procedures across
the Balkan region (Henderson, 2009). Although the value of psychiatric reform is
recognised, its evolution so far has proven incomplete. This emerged from the
conference Psychiatric Reform in Greece: Requirements, recommendations and
solutions, organised by the Greek Ombudsman in March 2009 (Sakellis, 2009). It was
also highlighted that:
1) Psychiatric reform is not well established in Greece. It was emphasised at the
conference that there lacks a movement which would focus on the cooperation of
workers in mental health care with patients and their families. It is worth noting that
individual initiatives cover the absence of a comprehensive state response of
institutional shortcomings and problems.
2) Current progress in mental health reform was rated as perverse because:
31
i.
ii.
it has not yet achieved the desired ideological and institutional change that
will lead to the disappearance of the concept and practice of detention and
other restrictive methods,
iii.
the power relations with patients have not been reshaped in such a way as
to transform them into subjects of change,
iv.
the rationale and practice of the inpatient bed, either for housing or for
treatment, continues to dominate at the expense of support and alternatives
to the asylum.
3) The absence of longstanding and precise planning and the lack of guidelines on key
issues were identified in official mental health policy. In addition, the parallel
existence of the immunity system and care services in the community is regarded
as problematic, while the lack of prevention, the inadequate accessibility to health
services and the poor quality of care were reported as chasms in mental health.
4) The issue of segmenting mental health services is regarded as important. Both the
rudimentary network of outpatient services with inpatient units and the inadequate
horizontal communication between the outpatient services cause major difficulties.
5) Mental health of children and adolescents is assessed as a neglected priority. In
particular, many in the conference noted that:
i.
ii.
iii.
32
new structures as well as structures for day care (e.g. for young people with
autism),
iv.
It must be understood that every action that delays Psychiatric Reform does not
harm simply the mentally ill and their families, but works against the entire project of
reform in the area of social solidarity and acts against the people, social action, and the
richness of diversity in social aggregation (P. Giannoulatos, personal communication,
March 9, 2011).
2.3
in their usual health. Consequently, it is obvious that Parsons viewed the role of the
patient as a temporary social role that has been instituted by society, which aims to
return sick people to a state of health and restore them to fully functioning members of
it as quickly as possible. Finally the role of the patient is also considered to be a
universal role which has its obligations and expectations that apply to all sick people,
regardless their age, gender, ethnicity, occupation or status in other spheres.
On the other hand, the role of the doctor is viewed as complementary to the role of
the patient. As the patient is expected to cooperate fully with the doctor, doctors are
expected to apply their specialist knowledge and skills for the benefit of the patient, as
well as to act for the welfare of the patient and community rather than in their own selfinterest. Doctors are also supposed to be objective and emotionally detached, and also
to be guided by the rules of professional practice, as the conformity with these general
expectations is a vital requirement in order to carry out the tasks of diagnosis and
treatment, and most importantly when this process involves the need to know.
34
specialised knowledge, and often must be made under conditions in which the patient
is debilitated or under severe stress with no time for discussion. Krugman also adds that
the professionalism of doctors or nurses, and the relationship they have built with their
patients, is damaged by turning health care into a transaction where doctors are just
providers that sell services to patients- health care consumers.
Health care is considered a fundamentally different market sector, which provides
services that are not elective or refutable, as well as involve asymmetry of information.
Details are given below regarding the meaning of those terms as well as the effect is
shown in the health care industry. For example, in recent years, users of psychiatric
services have taken a more active role in their treatment and hospitalisation. However,
patient involvement and satisfaction are not always connected with treatment success
(El-Guebaly et al, 1983), and there are still many stakeholders (e.g. doctors, nurses,
hospital managers) who believe that service users have not much to contribute to
decision-making on their care (Bennetts et al, 2011).
there is good evidence that arthroscopy of the knee provides no more benefit than
placebo (e.g. Patel et al, 2013; Brim & Miller, 2012; Hunt et al, 2002), but 99% of
patients are not going to be aware of this and they will not do any research to find it
out. Those that do some research, might find that the surgeon has an explanation why,
in one case, he thinks arthroscopy will be helpful despite the studies showing otherwise
for other people, and in most cases, the patient must trust the physician to provide
accurate information on what is really needed. Nonetheless, if the patient would ask the
surgeon what the cost of the treatment will be, the answer will probably be that he does
not know, as price transparency is poor (e.g. Kyle & Ridley, 2007; Kanavos et al, 1999;
Austin & Gravelle, 2007). Additionally, there is the very real fact that the cost will vary
dramatically based on a patient's individual payer status, and the surgeon probably does
not know what the cost will be for each case. Finally, it is evident that when consumers
make health care providers compete against one another to decide by whom and where
the care will be given, they tend to be concerned primarily with quality and considering
cost as a secondary concern.
All these factors greatly restrain competition and the development of a free market.
To some extent it is possible to mitigate these, by, for instance all-payer price setting,
mandatory disclosures and publishing outcomes data; however, according to criticism
the third variable cannot be diminished.
36
2.4
as opposed to smaller units, which in some cases are unable to respond to the
rapid depreciation of their equipment. Leasing provides an alternative, in order
for many companies in the industry to obtain the required machinery by helping
to meet their investment needs.
Service quality: the quality of service plays the most important role in the
development of the industry. It is ensured by the renewal of the diagnostic and
medical equipment, as well as by continuing education and better training of the
nursing staff at all levels.
Swiftness of services: the integrity of the existing diagnostic equipment and the
adequacy and extent of education of the medical and non-medical personnel,
are determinants of the swiftness with which the patients tests are conducted
and the results are returned.
In addition, the advance of medical technology leads to a reduction of
hospitalisation days and as a result, most of the large private clinics in the
country have avoided increasing the number of hospital beds. Instead, their aim
is to reduce the time of admission, diagnosis, and hospitalisation of patients,
while with the implementation of one day surgery, patients remain at the
hospital for a few hours after surgery then leave for home nursing and
convalescence.
Collaboration with insurers: some units in primary and secondary care often
have a stable clientele, through their cooperation with various insurance
agencies in the public and private sector. Basic criteria for selection in
concluding contracts with these organisations are their financial strength and
creditworthiness as well as the range of benefits to the insured.
Access to medical services: what is also included in the objectives particularly
of the large private diagnostic centres is the development of branches scattered
in different geographical regions, so that their services can be available to a
growing part of the population.
Company size: the health service groups have a comparative advantage over
many of the individual enterprises in the industry, as these are not always able
to offer a wide range of services combining, at the same time, high quality at
competitive prices.
Pricing policy - Alternative payment methods: in an era of squeezed income for
many Greek households, large industry companies offer new financial tools for
38
the users of their services, namely the ability to repay the costs of hospitalisation
through interest-free monthly instalments. Furthermore, they also offer the
possibility of special deductions for undertaking successive tests in different
units of the same group, while the medical treatment card is a fact for some
large private clinics.
39
therapeutic, and research services. Iasos priority is to promote medical science and
health care management beyond national borders.
BIOMED is at the forefront (20.8% market share) of the clinical laboratory
industry in Greece. BIOMED became the national leader clinical laboratories, having
3 hospitals (2 in Athens and 1 in Thessaloniki) and 24 medical centres (17 in Athens
and 7 in Thessaloniki). BIOMED has made a point of providing a full range of medical
services to individuals, organisations, social security funds, and insurance companies
through a network of medical diagnostic centres. Their laboratory operation provides
quality assured services for fast and efficient test results for patients in both the public
and private health care sectors.
Table 2.3 Presentation of the Leading Groups
Name
Euromedica
Diagnostic and
Therapeutic
Centre of Athens
(Hygeia)
Athens Medical
Group
Iaso Group
BIOMED
2.5
Year of
establishment
Number of
hospitals
Number
of Beds
Number of
diagnostic centres
Number of
employees
1989
28
1,621
51
2,646
1970
1,422
4,500
353,000,000
1983
1,200
3,000
233,365,000
1996
891
1,657
149,070,950
1,398
87,942,586
1981
3
329
26
Source: Financial Statements (2010)
Turnover
()
223,732,000
254,246,000
providers of primary and secondary health care in the Balkan area. Euromedica is active
mainly in the foundation, organisation, and operation of clinical and scientific centres,
equipped with high-technology appliances, as well as in the provision of every kind of
medical services. Euromedica Group has 44 diagnostic centres covering all medical
specialisms, 18 general and obstetrics and gynaecology hospitals, 9 rehabilitation and
recovery centres and 1 spa-health and cosmetic surgery centre, having a total capacity
of 1621 beds. The Group's principal activities are the provision of health and wellness
solutions, carried out all over Greece.
Facilities
Euromedicas facilities serve 10 prefectures in Greece (Fig. 2.2). Its medical
departments, which occupy premises of approximately 76,000 square metres, welcome
40
a large number of patients every year, offering them treatment wherever they live in
Greece.
Work force
Euromedica invests in its personnel through continuous and extensive training and
by familiarising its employees with new developments in the health care industry. The
2,646 non-medical permanent personnel and more than 10,000 collaborating medical
doctors guarantee the provision of care to every patient for every type of treatment.
Euromedica now operates an organised network of collaborating physicians. Their
recognition, trust, and support reinforce Euromedicas rapid growth. Figure 2.3 presents
the organisational chart of the Group.
Modern technological equipment
As far as medical equipment is concerned, Euromedicas technological equipment
represents a significant investment, making it a leading player in the area of diagnosis,
prevention, and hospital care in Greece. All of Euromedicas medical centres and
hospitals are connected through an on-line network. This is an innovative step for
Greece, considerably increasing the rate at which tests are conducted and dramatically
limiting the possibility of human error. At the same time, the installation and operation
of the computerised health care system in Greece makes it possible to produce
centralised computer files on each of its patients, enabling doctors to have full updates
on their patients and to provide immediate care anywhere in Greece.
Contracts with all types of insurance funds
Contracts with almost every public insurance fund and with many private insurance
companies enable Euromedica to provide quality and reliable medical services to its
patients. This broad and flourishing collaboration is continuously being expanded and
upgraded.
Continuous development
All its existing units are evolving and developing, being modernised and upgraded
into contemporary health care centres. Euromedica is investing in the optimum
organisation of a network that can provide thorough and reliable services, making it the
equal of the worlds largest medical centres.
41
42
2.6
Conclusion
This chapter has presented the research context of the study by providing a
discussion of three main areas. Firstly, there was an overview of the Greek health care
industry comprising of a discussion of the structure of the health services, the general
characteristics, as well as an overview was presented of the mental health care system
in Greece. Secondly, there was a review of the factors affecting the demand as well as
the conditions of competition were presented. Thirdly, a presentation was given of the
private health care organisations.
In addition to this, it was explained the relationship between the doctor and patient,
presenting Parsons perception as well as providing the reader the new terminology that
is used to better describe and explain this kind of relationship. Fifthly, a description of
the market shares of the health care groups. Finally, the company profile of the case
organisation was presented. The next chapter will review the literature, providing more
details about the use of corporate venturing to deliver service innovation.
46
Chapter III
Literature Review I: The use of Corporate Venturing to deliver
Service Innovation
This chapter reviews literature and theory on service innovation, entrepreneurship,
and corporate venturing. Initially, the definition and categorisation of service
innovation are presented so as to offer a thorough understanding of the term. Then the
importance of service innovation strategy is indicated as well as the identification of
those strategies that help organisations to minimise the risk and gain competitive
advantages. Closing the service innovation section, the processes that a firm adopts in
order to develop new services are identified, mentioning both the benefits and
limitations of each process. Further, the concept of corporate venturing is defined and
its types, dimensions, and characteristics are examined to provide the wider picture of
the factors that affect the success in the mental health sector.
3.1
Service Innovation
This section defines service innovation, presents and discusses about the importance
of service innovation strategies and illustrates models and processes for service
innovation development.
3.1.1 Introduction
It is widely recognised in the literature that innovation is the key to the growth and
economic performance of firms (e.g. Eisingerich et al, 2009; van der Panne et al, 2003).
Many studies have concluded that being innovative has become one of the most
important factors for organisations in sustaining their competitiveness (e.g. Bernstein
& Singh, 2006; Rohrbeck & Gemnden, 2011). Innovation appears to be essential for
companies to generate long-term stability, growth, shareholder returns, sustainable
performance, maximised employee contentment, and a sustained position at the leading
edge of the industry (Cottam et al, 2001; van der Panne et al, 2003). Thus, the concepts
of service innovation, and service innovation strategy are explored further below
using studies relevant to the health care industry, especially the mental health sector.
47
Hipp et al (2000) argue that firms that innovate are more likely both to increase
their sales and to expect to increase their sales in the future than are non-innovating
firms. Likewise, studies by Fitzsimmons and Fitzsimmons (2008) and Blumentritt et al
(2005) concluded that firms that fail to innovate will not be threatened in the short-term,
but their ability to grow will slow down and therefore, organised continuous innovation
efforts are required. For example, the health care industry is characterised by constant
change, as major innovations have altered the forms in which health services are
developed and health care is delivered (Bowers, 1987). Hospitals are often leaders in
innovation and adaptation to change, as new treatments emerge almost every day and
cutting-edge technology forces science to move forward.
It is worth noting the reasons why firms choose to innovate. Tether (2003, p. 497),
who carried out a study to explore the degree and the sources of innovation in five
service sectors, suggests that firms innovate to replace old services being phased out;
to improve service quality; to extend the service range; to open up new markets or
increase market share; to fulfil regulations and/or standards; and/or to reduce costs,
energy consumption or environmental damage. Nevertheless, a recent study by
Rohrbeck and Gemnden (2011), which seeks to discover the potential of corporate
foresight in increasing a companys innovation capacity, mentions that there are
enterprises that find it difficult to renew their products, as there is high rate of change,
as well as ignorance and business inertia. What is more, there is a high rate of innovation
failure, which translates into wasted time, money and human resources as well as poor
public image and poor employee morale (Ottenbacher & Harrington, 2010).
As regards health care, Duncan and Breslin (2009) conducted a study, which sets
out to portray a design programme for converting patients needs into health service
innovation. They explain why health service providers labour to promote innovation,
stating (p. 13) that increasingly tied to large governmental and private payers, health
service providers lack sufficient incentive to provide care in highly innovative ways
even if they were to show better outcomes. Although their research was formed in the
U.S., the results are valid for other countries as well. For example, the Greek health
care system is highly bureaucratic and inefficient in resources management (Bellou,
2010), resulting in a hesitance on the side of entrepreneurs to implement innovative
processes and to develop new ventures.
48
49
Figure 3.1 Service Innovation Matrix (source: Berry et al, 2006, p. 56)
50
implementation of those practices while ensuring the safety and best outcomes for
patients and whose adoption might also affect the performance of the organization.
Lin et al (2013), who carried out a study combining the concepts of service design,
healthcare compliane, and gamification to develop a web-based behavior motivation
tool to improve patients health compliance, described the innovation of motivationembedded services using a service innovation matrix for behaviour-motivationembedded services (Fig. 3.2). They argue that since older service systems have evolved
due to the evolution of information and communication technology, service innovations
now begin from technology, involving social-organizational novelty, and contributing
to business innovations. Within this process of service innovation; engineering, desing
and management issues need to be addressed (left diagram in Fig. 3.2). Then again, the
three phases of feasibility studies also need to be considered, because the aim of this
matrix is to guide service innovation (right table in Fig. 3.2).
Figure 3.2
Innovation also focuses the effort of the entire organisation on a common goal (Oke,
2007). Furthermore, a study by van der Panne et al (2003) underlines the importance
of strategy, stating (p. 314), strategically planned projects enable the firm to take
advantage of synergy between parallel innovation projects.
Oke (2001, 2007) adds to this, mentioning that a top management team needs to
develop the strategy and communicate the role of innovation within the company, to
decide how to use technology and to drive performance improvements using
appropriate innovation indicators. He also suggests (2002) that the first step in
developing an innovation strategy is to define what innovation means to the firm.
Several studies address innovation strategy as a success factor (e.g. van der Panne et al,
2003; Oke, 2007). For example, reports by Cottam et al (2001) and van der Panne et al
(2003) maintain that innovative activities should be given a strategic direction to
maximise the benefits of previous innovations. Similarly, many authors argue that firms
that are more successful have a greater commitment to innovation (e.g. Oke, 2007;
Martin & Horne, 1993). This evidence points out that most firms have some form of
innovation strategy, with successful firms being more committed to such planning.
A Mercer Management Consulting (1994) study suggested that high performing
companies had visible signs of commitment to product innovation, especially in terms
of providing adequate funding and resources, and communicated their strategy to all
the stakeholders. Likewise, Oke (2007) observed that highly innovative service firms
have an explicit service innovation strategy that guides the development of new
services. Martin and Horne (1993) also recognised that innovations should be based on
a new product plan or a product innovation charter, which according to Crawford (2006,
p. 59) is the strategy statement which flows from a situation analysis. He also
highlights that the product innovation charter is constituted by three elements, the
strategic arena, the goals of the new product activity, and the programme to achieve
these goals.
3.1.3.1 Identifying Innovation Strategies
The previous sections interpret the numerous innovation strategies defined in the
literature. Another common typology, though, distinguishes proactive from reactive
strategies. Van der Panne et al (2003) note that proactive innovation strategies pursue
product innovations to obtain product leadership. Gilbert (1994) adds that proactive
strategies favour the development and introduction of early and breakthrough
innovations. He also notes that the management of such innovations should have a
52
tolerance for failure, along with a strong focus on the key innovation that will change
the whole competitive structure of an industry.
On the other hand, innovations that are incremental and relatively late are called
reactive (Gilbert, 1994). Reactive innovation strategies pursue product development as
a protection against competing products (van der Panne et al, 2003) and place more
emphasis on process innovation rather than product innovation (Gilbert, 1994). This
proposes that such innovators adopt others innovations, as there is a need for them to
stay current, so they spend more time and attention on their competitors than do
proactive innovators. Nevertheless, Gilbert (1994) points out that most companies
choose to pursue an innovation strategy that mixes the pure proactive and the pure
reactive. He brings out three factors for the selection of an innovation strategy. The first
one is the industry in which the firm operates. Several studies have shown that this is
an important factor in the formation of an innovation strategy (e.g. Cassiman &
Veugelers, 2006; Martins & Terblanche, 2003). The second factor is the history and the
overall strategy of the firm. Each company pursues a particular innovation strategy
according to its business strategy and its support systems (Ritter & Gemnden, 2004).
The last factor is the human and the material resources that the firm possesses. A study
by Gupta and Singhal (1993) argues that creative people and an R&D operation are
needed for a proactive innovation strategy to be successful.
3.2
Corporate Venturing
This section defines corporate venturing and presents the different types that affect
the level and the outcome of innovation. It also describes the characteristics of corporate
venturing that affect organisational innovativeness, growth, and sustainability.
53
organisational renewal and product or process innovation that reinstate the organisation
- produce competitive advantages and lead to business survival.
54
3.2.2 Types of Corporate Venturing Affecting the Level and the Outcome
of Innovation
Many researchers have tried to identify the types of corporate venturing (e.g. Keil,
2004; Miles & Covin, 2002). For example, Narayanan et al (2008) found that there are
different opinions among existing typologies. MacMillan and George (1985) was one
of the first who linked corporate venturing to service innovation. They (p. 34)
conceptualised 6 types of corporate venturing based on increasing levels of difficulty:
1. New enhancements to current products and services;
2. New products and services to be sold to current markets within one to two years;
3. Existing products and services that can be sold to new markets within one to
two years;
4. New products and services that can be sold to current markets, or existing
products and services that can be sold to new markets;
5. New products and services that are unfamiliar to the company but are already
being produced and sold by other companies; and
55
6. New products and services that do not exist today, but could be developed to
replace current products and services in known markets or entirely new markets
that could be created for the new products and services.
On the other hand, Stopford and Baden-Fuller (1994) presented a typology of the
different levels of corporate entrepreneurship, commencing from the individual or
corporate entrepreneurship to developing a process of product development and
strategic renewal. Yet other researchers have used an internal-external distinction based
on either the focus of venturing (e.g. Sharma & Chrisman, 1999; Keil, 2004) or whether
the entrepreneurial ideas hail from inside or outside the firm (e.g. Narayanan et al,
2008). Similarly, Miles and Covin (2002, p. 26) proposed a four-form typology of
corporate venturing, in which they distinguish direct from indirect investments in the
venture (Table 3.1).
Focus of
Entrepreneurship
Internal to the
organisation
Direct-internal venturing
Indirect-internal venturing
External to the
organisation
Direct-external venturing
Indirect-external venturing
(source: Miles & Covin, 2002)
Direct-internal venturing is the most nave type of corporate venturing, where the
organisation motivates its employees to develop and exploit profitable ideas, providing
all the necessary resources for these ideas to flourish. Another type of direct venturing
refers to a firm that recognises entrepreneurial opportunities and chooses to exchange
knowledge, technology, and/or resources with a smaller venture to acquire all the
essential requirements to enter into a market or develop a new product. This form is
called direct-external venturing and is beneficial when the business entities develop
strong and long-term strategic partnerships. A similar activity to direct-internal
venturing is the indirect-internal venturing, where entrepreneurial thinking is also
supported within organisation. The difference consists in an independent intermediate,
which operates as a venture fund and is managed by corporate employees. Finally,
indirect-external venturing refers to venture capital funds that are developed by
56
investors, providing strategic and/or financial benefits. Their main aims are the creation
or the expansion of existing products and services into new markets, amplifying the
operation of the R&D departments.
It is clear in the aforementioned study that corporations that wish to have integral
control over the new venture should choose a direct approach, whereas organisations
that seek to build a more independent venture should prefer an indirect investment
approach. In addition, corporations that actively seek corporate venturing as a method
to innovate, pursuing culture differentiation and organisational change, should focus on
internal venturing, while organisations that pursue quick financial returns should
concentrate more on the external mode. However, both internal and/or external focus
are appropriate for companies that seek to expand their operations into new
markets/industries, exploring business opportunities, or to renew their strategies in
order to sustain or improve their competitive positioning. It is important to note,
however, that the authors of this typology suggest that organisations that pursue
business development and competitive advantages should combine the external and the
internal types.
New ventures and new businesses, where firms create new autonomous or semiautonomous businesses;
Likewise, Covin and Slevin, (1991) underlined that proactive organisations are
those which pursue leadership through developing new products and introducing new
technologies or administrative techniques. Competitive aggressiveness is the final
dimension, where the firm chooses to challenge its rivals, in order to prevail over them
(Lumpkin & Dess, 1996).
58
Figure 3.4 CV Model for the For-Profit Sector (source: Narayanan et al, 2008)
3.3
Health Care
Corporate venturing is a term encompassing various organisational acts aiming at
creation, renewal, or innovation. It embodies a number of entrepreneurial efforts such
as internal resources (Jones & Butler, 1992), internalisation (Schllhammer, 1994;
Vesper, 1984) and external networks. The above analysis implies three domains in
which a company can concentrate its entrepreneurial efforts towards innovation.
59
Although very different, these domains are all rooted in organisational resources.
Burgleman (1985) stresses that in order for the organisation to achieve diversification
through internal development, new resource combinations are required which present
the potential of exploiting areas of organisational activity unrelated or marginally
related to the organisations current domain of competence.
Ireland et al (2003) introduced the importance of top management teams and
governance, explaining that organisational leadership and performance is enhanced
through the strategic and entrepreneurial use of the intellectual capital of the
organisations force. If anything, top management teams influence can be paramount,
translating a shared vision into goals and strategies. However, this approach focuses on
the role of top management, reward systems and governance as the enablers of
innovation and growth, all linked with new processes, products or services, strategic
renewal or creating new types of business (The author takes those studies into account
for the development of the research instrument). While the target and desired outcome
is that of innovation, coining a comprehensive term remains ellusive. In the literature,
it is a broad and often confused term. A strand of research has deemed innovation as a
process (e.g. Suchman & Bishop, 2000; Adams et al, 2006), whilst other researchers
have equated it with the result or commercialisation of a companys entrepreneurial
activities (e.g. Van de Ven 1986; Wolfe, 1994). This is a concept considered to be
complex and multifaceted, comprising of various events and activities taking place in
sequence or simultaneously, which are expected not only to generate new ideas, but to
focus on enhanced performance and sustainable competitive advantage. This may set
the organisation ahead of competitors in the long run (Shields & West, 2000;
Silberstang & Hazy, 2008). It is determined by both internal factors, which characterise
the organisation and external conditions of the market in which the organisation
operates.
In the challenging global landscape, which requires companies to respond to change
with adaptability in order to benefit from these shifts, and emerging opportunities in the
global market, new collaborations and partnerships are of paramount importance. This
strategic approach can foster simultaneous innovation at multiple points; collaboration
between businesses, government departments, research institutions, funders, and
investors could really be a catalyst for exchanging new forms of knowledge and sharing
cutting-edge business innovation. In this instance, new opportunities arise in the form
of novel products, services, systems or in the form of incremental improvement in
60
existing methods, products and so on. Drucker (1985) identified an array of discrepant
processes, industrial structures, market demographics, changes in perspective and
knowledge as the source for emerging opportunities leading to innovation. Shane
(2003), on the other hand, emphasised the key aspect of successful (commercial)
application and launching of novel ideas to the market in a way that is consistent and
systematic. In this scope of the topic of innovation as a development continuum
fuelled by relentless investment in research and technology advancements, innovation
involves investment expenditures which are not guaranteed to yield secure returns in
the future.
Close collaboration, new forms of partnerships and knowledge networking can
result in inter-organisational learning and dissemination of new, valuable information.
Powell et al (2005) underlined the importance of participating in such networks because
of the key growth factors they offer such as access to new forms of information,
reliability, and responsiveness to change. Below the three perspectives of corporate
venturing are described.
Internal Resources
Recent advances in technology innovation and science in conjunction with global
capital movement have influenced industrial activity, creating new industries while
displacing others. In this new fast changing environment, health care firms need to
invest in their intellectual capital and create an intangible asset class as a key factor to
their sustainable advantage. While tangible resources are easily accessible or subject to
imitation by rivals, intangible resources is an invaluable capital asset leading the firm
to intra-organisational achievements and significant financing mechanisms. Hussi
(2004) stressed the potential of turning intangible knowledge assets into commercially
exploitable intangible assets. This aspect of intangible resources is very important to
corporate entrepreneurship, as also emphasized by Drucker (1993).
The strength of intangible resources lies in coordinating existing, tangible resources
to generate innovations and competitive advantage and secure thus continuous business
development. In advanced technology sectors especially (e.g. health care), the skill and
intellectual capital embedded in the companys workforce may be the ultimate
acquisition goal. In order to create knowledge-based value, intangible assets must be
applied and integrated in a way that allows knowledge sharing and data dissemination
across different parts of the organisation, as well as the identification, and exploitation
of new commercial possibilities, all of which are crucial factors enabling innovation
61
62
key role in developing the questions for the members and executives of the Euromedica
Group (see section 6.4.3).
Table 3.2 Key Concepts Influencing the Success of Service Innovation and Corporate
Venturing in this Study
Authors of related studies
Hipp et al (2000)
Fitzsimmons and Fitzsimmons
(2008)
Blumentritt et al (2005)
Tether (2003)
Rohrbeck
and
Gemnden
(2011)
Duncan and Breslin (2009)
Chaharbaghi and Newman
(1996)
Knox (2002)
Cumming (1998)
Galanakis (2006)
Fitzsimmons and Fitzsimmons
(2008)
Thakur et al (2012)
van der Panne et al (2003)
Bernstein and Singh (2006)
Den Hertog et al (2010)
Agarwal and Selen (2009)
Varadarajan (2009)
Ireland et al (2003)
Oke (2007)
Crawford (2006)
de Brentani (1993)
Edgett (1994, 1996)
Edvardsson et al (1995)
Johnson et al (2000)
Menor and Roth (2007)
Avlonitis et al (2001)
Cooper et al (1994)
Agarwal and Selen (2009)
Oke (2001, 2007)
Tidd et al (2005)
Korsgaard and Anderson (2011)
Husted and Vintergaard (2004)
Narayanan et al (2008)
Sharma and Chrisman (1999)
Antoncic and Hisrich (2003)
Service Innovation
Service
innovation
process and systematic
approaches
Degree of innovation
Service
innovation
strategy
Personnel
expertise
development
and
adaptation
Customer satisfaction
Organisational innovation
Business culture
Organisational structure
Risk-taking policy
Business
development
strategy
Strategic change and
renewal
Proactiveness and risktaking strategy
Intangible resources
Business development
Knowledge-based value
creation
Creation of systemic
knowledge
Business growth
Corporate venturing
Hussi (2004)
Saint-Onge (1996)
Internal resources
External networks
acquisition
and
Knowledge
63
66
are multifaceted for both users and the reputation of the company, but also the benefits
for innovation opportunities are evident:
1) Identifying and prioritising the users needs.
2) Evaluating product development processes from the generation of ideas right
through to their commercialisation.
Traditional decision-making structures need to change to be more inclusive of users.
Barnes and Bowl (2001) underlined the concentrating power held by healthcare
professionals who are reluctant to give part of it. Linnett (1999) suggested that this
process involves essentially a change in the power balance in the organisation.
Although the outcomes of user involvement in mental health have not been
systematically assessed, there is a growing body of research on many different cases
where the user involvement agenda has been implemented with various results. What
is more, partnerships through joint ventures will facilitate the collaboration and
partnership between different key players in the market with a view to offering
individualised services. Setting clear outcomes over set periods with effective
assessment mechanisms will provide service users with even more flexible, customised,
and reciprocal services. Through ventures, opportunities to identify areas of under
provision can arise where coordination of funds, knowledge, and expertise can generate
added value for all parties involved.
The secret of success in such cases involves getting as close as it gets to the patients
and focus carefully on their established behaviour patterns. This enables the creation of
innovative services that significantly lower distribution costs while improving abiding
to clinical protocols. Technology can extend access, increase standardisation, and drive
labour productivity. The innovative models identified could be used to prove
technologies in new ways, repurposing rather than reinventing. Successful innovations
strictly link skills to the task, questioning existing practices. By doing so, entrepreneurs
manage to decrease labour costs and at the same time eliminate all kind of constraints.
building an ecosystem (Henderson & Leleux, 2005). As the service economy grows
into a networked collection of resources, competencies and activities, the value of
coordinated networks within the same industry is immerse. In a sector that is undeniably
financially constrained, investments in technologies that could reduce costs and
improve care are imperative. Interest has risen as a result in innovations that could
provide more efficient and cost-effective care while at the same time generating
sufficient financial returns. Through such mechanisms, such as flexible, long-term
capital, including targeted grants, programme-related investments, social venture funds
and endowments, all healthcare stakeholders could benefit from increased financial
returns, mitigating risks and technological improvements.
The intersection of various healthcare stakeholders, corporate, academic,
governmental, and philanthropic partners could join forces in improving basic and
applied research; deliver networks and resources for more timely and improved care.
This could also contribute to the design of functional mechanisms in order to bridge the
gap between knowledge and practice. Corporate venturing efforts could effect change
on a scale that develops momentum and long-lasting power. Various stakeholders
participate in developing action and policy; achieve cross-sectoral successful outcomes
and sustainable progress. The economic crisis has boosted the emergence of new,
innovative business entities, which aim to provide concrete, well-planned, and
visionary business models as a response to the wasteful failure of traditional practices
in the healthcare sector.
3.3.3.1 Critical Factors Affecting Innovation and Corporate Venture Strategies in
the Greek Mental Health Sector
The current situation in Greece calls for a reorganisation of the mental health care
delivery system with particular emphasis being paid on flexible and innovative models
that could benefit the public, especially in regions with limited socioeconomic
resources. The joint venture approach in the mental health sector in Greece can provide
such innovative and flexible solutions to long lasting problems in the sector regarding
inadequate inpatient facilities, fragmented provision of services and inadequate policy
planning, understaffed, and underfinanced mental health units. This approach could
prove to be particularly beneficial at a time when Greece is facing a serious social,
economic, and humanitarian crisis. People with mental health disorders are especially
vulnerable and at risk at not being able to cope with problems such as poverty,
unemployment, uncertainty and lack of social support.
68
managed by the Euromedica Group in Greece, the potential for innovation and
leadership under a user perspective and the cultural obstacles that may hinder such
efforts. A framework can then be developed, which will analyse the stakeholder relation
in mental health services and suggest changes in strategic, service and organisational
planning following a user led approach to management innovation and
entrepreneurship.
70
questions below aimed to investigate whether and how those two concepts lead to the
exploitation of entrepreneurial opportunities, and therefore to business growth:
Question 9 asked the participants, Do you believe that the stimulus of growth
could help you become more innovative, developing new services and
approaching new markets and why?
There was a consensus that service innovation together with corporate venturing
initiate activities for growth, either by developing new services and exploiting this
knowledge in business expansions or by establishing a new venture in order to develop
a new health service (i.e. a new hospital department, or a new unit within an existing
operation). Those answers, in fact, prove that entrepreneurial opportunities are likely to
be identified and exploited by new ventures and new services.
3.4
goal (Oke, 2007). There are numerous of service innovation strategies defined in the
literature. The most common typology distinguishes proactive from reactive strategies.
Nevertheless, most companies choose to pursue an innovation strategy that mixes the
pure proactive and the pure reactive (Gilbert, 1994).
Corporate venturing, on the other hand, has become a core concept in the strategic
planning of some organisations as a means for achieving long-term growth and
competitive advantages (Husted & Vintergaard, 2004). Furthermore, it concerns
investment in highly risk activities, frequently related to those of the parent
organisation, which introduces new products or enter into new markets, establishing
new companies (Elfring & Foss, 1997). However, ideas for new businesses can generate
either inside or outside the organisation. Firms usually harness both internal and
external sources to have access to information, technologies, innovation, business
practices, and/or networking with other companies that can enhance growth and
profitability (Narayanan et al, 2008).
The next chapter continues the review of the literature on new service development
and customer orientation. Apart from the definitions and the characteristics of the two
concepts, this chapter aims to overview, describe, and explain how customers can be
involved in the new service development process. The key concepts and the factors that
influence the success are presented as well as the factors and the benefits of patient
involvement in mental health care innovation. Finally, customer orientation and new
service development are presented as the key indicators for the identification of new
service opportunities.
72
Chapter IV
Literature Review II: Customer-oriented New Service
Development
This chapter reviews both new service development and customer orientation
literature and theories. In first half of the chapter, the types and characteristics of
services are discussed as well as the critical factors for success in the development of
new service offerings. As firms operate in a fluid and competitive business
environment, they should develop new services to gain competitive advantages.
Organisations should therefore develop the right new service development strategy,
which will link the organisations objectives and goals with any new offering. Then the
models of both new product and new service development are reviewed in order to
illustrate and explain the new service development process.
Customer orientation is next investigated, to gain a better understanding of its value
and importance in the development of new services. Customer roles in service
innovation are examined as well as customer orientation in the health services industry.
Finally, the methods and techniques of customer orientation development are discussed.
4.1
the factors that affect the success of new service development. It also presents the
strategies for success as well as the models of new service development.
4.1.1 Introduction
Many studies have highlighted that service development research is seen as an
extension of the development process for tangible products (e.g. Dolfsma, 2004;
Bowers, 1989). Likewise, Storey and Hull (2010), who carried out a study aiming to
realise how service firms competitiveness performs as a strategic contingency affecting
both service development and innovation performance; they argued that new service
development theory is underdeveloped in both innovation and service management
literatures. However, Ottenbacher, Harrington (2010), de Jong and Vermeulen (2003),
73
Anxo, and Storrie (2001) noted that services constitute a considerable part of the
worlds production, employment, and general economic growth, especially in western
economies.
Considering that corporations operate in a very insecure, highly competitive, and
globalised environment, they should always make efforts to differentiate their offerings
in order to obtain corporate survival, wealth creation, and growth. This fierce
international competition along with the rapid technological evolution and the
advancing expectations of consumers has led to phenomenal changes in service
industries (Storey & Hull, 2010). Enterprises, therefore, need to create and sustain
competitive advantages and continuously innovate, adopting new processes, creating
novel ideas, developing, and launching successful new outcomes. This is supported by
many authors including Porter (2004), de Jong and Vermeulen (2003) and Kelly and
Storey (2000). In addition to the reasons why firms should develop new products, it
should be noted that hospitals, for example, must develop new services to extend the
time people live or to enhance the quality of living, by curing severe illnesses. This is
also underlined by Bowers (1987, p. 35), who stated, Hospitals must develop new
services and modify present ones in order to remain current.
Moreover, it appears in the literature that new service development activities are of
vital importance, as they strengthen current business and provide new business ventures
(e.g. Frambach et al, 2003; Igel & Islam, 2001). Menor and Roth (2007) and Brown
and Eisenhardt (1995) also argued that effective new service development is critical to
business prosperity and becomes the field of competition for many service
organisations. Whats more, service innovation focuses on the design of the service
prerequisites that meet customers needs and preferences, but some authors still believe
that the majority of service enterprises have not adopted modern and formal processes
as product companies have done (e.g. Smith et al, 2007; Menor & Roth, 2007). Bowers
(1989), for example, argues that those companies who do not restructure and restrategise will not remain competitive. Still, regardless of the incentives of every firm
to develop new services, this is usually attained either internally through R&D and/or
new service development process or externally through licensing or acquisition
(Cowell, 1988).
74
75
76
Storey, 1998), but instead make minor changes to existing offerings, trying more to
sustain their positioning than to improve it (Atuahene-Gima, 1996; Ozdemir, 2007).
Inseparability is another characteristic of services. The production and consumption
of intangible products are simultaneous, as provider and user are parts of the experience
(Alam, 2006; Johne & Storey, 1998). As production and delivery in services is quite the
same process, operational staff is able to see whether the customer is satisfied. This
emerges from Cowells (1988) arguments that staff performs a double role, operational
and marketing. Customers feedback and suggestions provide an important source for
quality improvements and further developments.
Heterogeneity is also related to the new service development process, as service
experience seems to be unique every time. Many factors influence the special
characteristics of services. For instance, service experience varies across service
providers and since users are actively involved in the process, the place and time of the
transaction play a critical role (Alam, 2006; Cowell, 1988). Furthermore, the coproduction element usually affects the quality of service outcomes, as the requirements
and the preferences of the customers are rarely the same (Dolfsma, 2004; Johne &
Storey, 1998). In addition, service users are unable to assess a service offering prior to
purchase, because it is difficult for businesses to standardise a service (Cowell, 1988;
Johne & Storey, 1998). However, Ozdemir (2007) reveals in her doctoral thesis that
technological services seem to be less heterogeneous than others, as technology
increases the level of standardisation from the producer side. This enhances the notion
that highly customised services, such as mental health care services, are almost
impossible to standardise.
Perishability is the last characteristic of services. According to Cowell (1988),
services are disposable offerings that cannot be saved, stored, or returned. Thus, lack of
ownership is a basic element and a difference between intangible and tangible products.
Customers usually pay for the use of or access to facilities, therefore, service
organisations have to make decisions and plans to cope with fluctuating demands
(Cowell, 1988).
77
Other researchers present a range of factors that strongly influence new product
success. For example, Cooper (1994b) proposes four success factors:
1. A differentiated new product that delivers superior value to the customer and a
customer-oriented new product process; these separate winners from losers;
2. Pre-development activities, such as idea screening, market research and
business analysis, with a sharp product definition, also lead to success;
3. The establishment of a cross-functional team with the implementation of a
multi-stage game plan increases the success rate while it also speeds products
to market;
4. The focus and determination on decision-making together with quality of
execution are required in the new product development process.
Likewise, Lester (1998) has identified three key fields that benefit the performance
of the new product development process.
1. Senior management commitment with a supportive culture within organisation
constitute essential elements for success;
2. Organisational structure and processes and innovative product concepts
enhance the possibility of success;
3. A new product development team with the appropriate knowledge, resources,
and project management that focuses on reducing risks are key prerequisites for
success.
Based on those studies, some researchers focused on the factors that benefit service
innovation (e.g. Jin et al, 2010; Oke, 2007). For example, Smith et al (2007) identified
seven criteria that lead to successful innovation in health care firms. They argue that
the design of a new service outcome should focus on customers needs and preferences
and be consistent with the objectives, values, and strategies of the organisation. In
addition, service companies should be flexible and responsive to changes either in
customers needs or in external environment (political, social etc). The first three
criteria concern service design, while the following four deal with the new service
development process. As in service design, customer participation is also crucial to new
service development. A structured and well-organised new service development
process is essential, with the use of cross-functional teams and stakeholder groups.
Finally, effective leadership of the development process is pivotal to success as the
senior management team applies its skills and competencies (political, influence and
79
project management) in order to overcome any difficulties and meet the financial
targets.
Additionally, Edgett and Parkinson (1994) have identified the determinants of
success in new financial services. Services developed by strong cross-functional team
cooperation, market synergy and effective market research seem to have a high
probability of success. More recently, Jin et al (2010) attempted to identify the key new
service development factors that determine the success of a new offering. They found
that new service success is connected with practices in the related administrative
methods, and thus they sort the success factors into four management processes, i.e.
NSD strategy management; customer involvement; NSD knowledge management; and
NSD process management. They made an in-depth review of the literature and
assembled the major success factors from several studies in a table (Table 4.1).
80
81
It has been clear in the product and service innovation literature that the factors that
benefit the development of a new outcome are quite concrete (e.g. Ottenbacher &
Harrington, 2010; Brady & Cronin, 2001). For example, Edgett (1994) investigated
new service development activities in British financial institutions and concluded that
successful firms have managed to develop organisational activities in parallel with
appropriate resource allocation. He found that both formalisation of the development
process and up-front activities appeared to have significant value in new service
success. In addition, customer orientation, via market research and market potential,
and harmonisation with the companys values, image, and strategies are critical to
success (Brady & Cronin, 2001). In other words, the appeal of the market place and the
organisations aptitude to launch new offerings that respond to market needs lead to
financial success. On the other hand, when it comes to services, Ottenbacher and
Harrington (2010) argue that it is the perceived quality of the interaction with the
customers - such as the expertise and enthusiasm of frontline staff, rather than the
service product itself - that should be considered the key success factor. All the same,
financial analysis and project updates contribute to the success of the development
project. Finally, launch effectiveness is closely related to the success of the new service
offering. A well-planned promotion process using effective marketing tools, supported
with adequate resources, is demonstrably beneficial to the development of new services.
In addition, Smith et al (2007), who implemented five different models on the
design and development of new health care services, found that in order for a
development process for health services to be successful, service design should be
harmonised with, on one hand the organisations objectives and strategies, and on the
other with the interests and expectations of the key stakeholders (government, health
board, etc). Moreover, they mentioned that service design should focus on users needs
and involve customers in the development process, utilising a range of other
stakeholders, such as front-line staff, managers and so on. Finally, it is emphasised that
the development process must be well structured, flexible, and fast.
82
relates to the overall business strategy for development success (e.g. Krishnan & Ulrich,
2001; Cooper & Edgett, 1999). In other words, a product plan should accord well with
the organisations strategic goals, image, and vision (Menor & Roth, 2007; Krishnan &
Ulrich, 2001) and therefore, new product development strategy is a prerequisite for
successful product innovation (Edgett, 1993).
Product strategy and planning determines the decisions about designing and
delivering products, targeting markets, adopting technologies and allocating resources
(Menor & Roth, 2007; Krishnan & Ulrich, 2001). Additionally, effective new product
development strategies secure that the new outcome meets customers expectations and
demands. Storey and Kelly (2001), however, noticed that many firms speed up the
development process without first forming and implementing a strategy. This often
leads to unsuccessful attempts of innovation. Many scholars have focused their research
on the strategies that service firms should develop and follow (e.g. Alam, 2006). For
instance, Barczak (1995) argues that new service strategy determines the
innovativeness of a new service offering, while Storey and Kelly (2001) report that the
firms that constantly develop successful new services feel inclined to have a clearer
development strategy than their less successful counterparts. They also note that these
strategies should be formal and aim at long-term success. In addition, Jin et al (2010,
p. 2010) state, an NSD strategy defines the roles of NSD within the overall business
strategy and drives and directs the NSD efforts. Yet, they mention that best-performing
companies consume considerable resources than less successful challengers and quote
survey outcomes, which confirm that successful firms are expected to build up
strategies for the development of new offerings.
Scheuning and Johnson (1989) developed a matrix that illustrates four service
strategies (Fig. 4.1). First is the share building strategy, which aims to sell more
offerings that are current to existing customers, often by aggressive promotions. Second
is the line extension strategy, where companies seek to promote new services to current
buyers. Third is the market extension strategy, where firms plan to promote existing
services to new market segments either nationally or internationally. Last is the new
business strategy, where enterprises create new business ventures and develop new
offerings in order to expand into new markets and seize on unexploited opportunities.
83
Figure 4.1 New Service Strategy Matrix (source: Scheuning & Johnson, 1989)
84
Table 4.2 New Product Development Strategies and the Product Life Cycle
Strategy
Pioneer
Introduction
First mover
advantage
Growth
N/A
Maturity
N/A
Decline
N/A
Imitator
Strong
benefit
Decreasing
benefit
Only useful if
cost advantages
Only useful if
cost advantages
Rapid innovation
First mover
advantage
Steal
competitors'
growth
Extend life
cycle
Limited benefit
85
Disruptive
technologies
Create new
market - First
mover
advantages
Strong
benefit
Terminate
incumbents
N/A
Preannouncement
Financing
strategy,
perceptual
barriers
Standard
setting,
switching
costs
Strategic
communication,
competitive
games
Strategic
communication,
competitive
games
Partnering
Strong
benefit absorptive
capacity
Strong
benefit growth and
learning
Limited benefit
- cost only
Limited benefit
- cost only
Standard setting
Cooperate
until
technology is
legitimate
Standard set,
market
segmentation
and cost
Competitive
phase - erect
entry barriers
Competitive
phase
Use of platforms
Limited
applicability
Strong aid to
growth
Critical
component of
survival
Weakens but
some lasting
benefits
86
commercialisation of the new service. Then the top management team decides
which concept should be developed and commits the necessary resources,
through project authorisation. In that case, this is the right time to design and
test the new service. In this stage, participation of front-line employees and
customer involvement are crucial (see Section 4.2), as the former delivers the
new offering and the latter purchases it. Another important aspect is to design
the delivery process and system in detail. As services are intangible and
inseparable, production and delivery happen simultaneously, so it is critical to
implement smooth delivery; a marketing programme should be formulated and
tested to ensure that all the employees (personnel training) are familiar with the
new service and know how to promote it effectively.
3. After that comes the testing stage. Service testing ascertains the acceptance of
the customers and pilot run ensures that the entire development process operates
satisfactory. If this is not the case, then improvements can be made at any of the
stages to amend its functioning. Test marketing, on the other hand investigates
whether the current marketing mix is efficient or modifications should be made
to bring more customers to the firm.
4. The final stage is the introduction of the new service offering to the market
place. When the organisation is certain that the development process has
functioned smoothly and that customers are well aware of the new outcome,
then the firm launches the new service. A post-launch review is also necessary
to ensure whether the objectives are attained or further refinements should be
made. However, the findings cannot be generalised, so further research and
model testing in other service industries should be conducted.
88
Figure 4.2 Normative Model of New Service Development (source: Scheuing & Johnson, 1989)
89
Figure 4.3 The New Service Development Cycle (Johnson et al, 2000; source: Stevens & Dimitriadis,
2005)
Similarly, Stevens and Dimitriadis (2005, p. 191) developed a systemic model for
financial services focusing on organisational learning, which seems to be essential for
the success of innovation projects. They included some learning actions that benefit the
effectiveness of the model. The model (Fig. 4.4) consists of five actors, namely
interactors who create knowledge by constant interaction with each other. These
interactions create the dynamics of both new service development and organisational
learning. The concept of interactors applies to individuals and groups within
organisation. Apart from human interactors, the model includes the firms infrastructure
that contributes to the interaction process, as individuals use it to obtain or transform
information. This study concluded that technical and physical infrastructure and
information systems play a critical role in the design and development of the new
service. In addition, the organisation of a firm appears to be vital for the knowledgebuilding process. Finally, the external environment of the company is of high
importance, as it enables the knowledge-building process, providing information about
customers needs, competitors planning, and legal changes. Nonetheless, this model is
90
not without limitations. It is risky to generalise its adoption to other types of products
or services, because it is based on qualitative methodologies and on small number of
cases.
Figure 4.4 The Systemic Learning Model of New Service Development (source: Stevens & Dimitriadis,
2005)
Additionally, Alam and Perry (2002) carried out research on the financial services
industry, identifying the stages in the new service development process and addressing
the issue of how customers can benefit that process. They developed a framework of
ten stages, presenting it in two different models (Fig. 4.5). The first is a linear
development process and the second involves parallel processing at some stages. It is
noteworthy that the researchers added customer input at every stage of the development
process (Fig. 4.6). However, the study is based on a small number of financial firms,
thus the findings should be deemed as tentative, and further research should be
established in other types of service industries, such as health care. Moreover, the study
did not investigate the relationship between customer involvement and new service
success.
91
Figure 4.5 Two Models of New Service Development (source: Alam & Perry, 2002)
92
Figure 4.6 Customers Input in New Service Development Process (source: Alam & Perry, 2002)
Bowers, 1987; Windrum & Garcia-Goni, 2008; Duncan & Breslin, 2009). Bowers
(1987) was the first to perform extensive research on a large number of hospitals, based
on Booz et als (1982) model of new product development. He suggested that hospitals
should not adopt bureaucratic approaches to new service development, but instead
should implement systematic market-driven processes that will offer them competitive
advantages. Health care institutions should be sensitive to patients wishes and
stakeholders requirements. His research was the first to discover that hospitals do not
use external inputs to new service development, so their new services may not meet
customers needs. He used those results to develop a normative market-driven model
of new service development for hospitals (Fig. 4.7), putting forward that hospitals
should develop a business strategy to set the strategic orientation of the organisation
and prepare for the development of the new service strategy. This leads to the
exploration of opportunities and to the initial evaluation of the new service ideas. Next,
a formal process of idea generation should be adopted, combining external and internal
inputs. This leads to the development of new service concepts, which are evaluated by
employees, doctors and potential customers. Business analysis is the next step, where
the development team screens the surviving concepts and evaluates their potential
performance.
Subsequently, the development and evaluation of the new service is performed with
the support of contact personnel (therapists, nurses, paramedics) and customers
(patients, relatives). Market testing is also a critical step, as it evaluates the marketing
mix that the management team has chosen. This step is the last opportunity to assess
the entire development process and make the necessary modifications. The last step is
commercialisation of the new service offering in the market. Front-line employees
undertake the responsibility for offering superior value to customers. This model
illustrates a simplified and linear process; it therefore has the same kind of drawbacks
as other sequential models, and does not address many other issues, such as crossfunctional team working, up-front activities, and post-launch review.
94
Figure 4.7 A Normative Model of New Service Development for Hospitals (source: Bowers, 1987)
A study that is worth discussing was carried out by Windrum and Garcia-Goni
(2008). They combined the characteristics approach of Saviotti and Metcalfe (1984)
with Gallouj and Weinsteins (1997) competences framework. The purpose was to build
a multi-agent framework that involves, on one hand policy makers, and service
providers and on the other, firms and consumers (Fig. 4.8). They also applied Barras
theory (1986, 1990) to interpret the multi-agent framework as a new health services
model. This framework includes Schumpeters five types of innovation: organisational,
product, market, process, and input.
First, the multi-agent framework highlights the actors competences and
preferences, where technology is the medium through which multiple agents
communicate. Although medical technology is important at most health services (e.g.
not that important in mental health or withdrawal services), the competences of health
professionals, and their interactions with patients determine service characteristics
95
(Windrum & Garcia-Goni, 2008). Second, although policy makers are not service
providers, they have an enhanced role in the provision of health services as they make
major decisions about public health. They actually draw up the framework within which
service providers operate. What is more, patients are a critical actor in service
development, especially in health care environments. Even though users preferences
and competences have not been widely explored, it is matter-of-course that patients
should be fully aware of their treatment. Additionally, it has been mentioned in the
literature that customers decisions are also influenced by the family or social group to
which they belong (e.g. Becker, 1996).
Moreover, there are service provider competencies, distinguished as user-facing or
back office. The former refers to skills, expertise, and technologies that define, produce
and deliver the new service in interaction with users. The latter considers skills and
administrative techniques that support user-facing competences and activities. It should
be noted, here, that although the model is applicable to types of services other than
health care, it focuses on knowledge-intensive industries so further research should be
carried out in human and physical capital-intensive sectors.
Figure 4.8 Operationalised Model with User-Facing Competencies and Back Office Competencies
(source: Windrum & Garcia-Goni, 2008)
96
More recently, Duncan and Breslin (2009, p. 14) presented an innovative new health
service development programme that has been developed and adopted by the Mayo
Clinic. The programme consists of a four-step human-centred process. First is the topicframing step, where a general subject is explored to develop an essential understanding
of the issues and relationships related to the empirical practice of that subject. The aim
of this step is to call all stakeholders to decide the direction of the project and share it
with the project team. Then, there follows the research step, where data are collected
through field observations, interviews and mediated questioning tools. Researchers and
strategists cooperate to identify opportunities and challenges. Third is the design and
development step, where researchers are called on to generate ideas through multisystem approaches and develop new concepts. These approaches often combine novel
ideas related to people, resources, technology and so on. Then the new concepts are
evaluated by real patients and clinicians as an effort to determine their value and
describe the clinical experience. This provides the firm with the necessary information
about the performance of the new service before its final launch. Both research results
and design tools are used by the organisation to understand human behaviour and this
understanding becomes a locus for innovation. Finally, there is the implementation step,
where the new service is launched. A researcher keeps up with the new offering in a
consultant role to review the new service and its development process. Although this is
a simplified model for new service development in the health care industry, it is
probably the first in the literature that describes a user-oriented process, which is
developed and used by the largest multi-specialty non-profit organisation in the world.
4.2
Customer Orientation
This section defines customer orientation, presents its different types that affect the
success of new service development as well as shows the role of customers. It also
discusses the limitations that emerge from customer involvement.
98
Otherwise, they can be led to ineffective plans and cursory changes in organisational
practice that could jeopardise their future.
It seems, however, that a small number of studies have attempted to define customer
orientation. For example, Deshpande et al (1993, p. 27) adopted a philosophical point
of view, stating that customer orientation is the set of beliefs that puts the customers
interest first, while not excluding those of all other stakeholdersin order to develop a
long-term profitable enterprise. Matthing et al (2004, p. 487) focused on methods,
efforts and dealings that the service provider utilises to identify customers needs, while
Hoyer et al (2010) employ the term co-creation to describe the active participation of
consumers in a new product development process. They mention that customer
involvement enhances product quality, reduces risk, and increases market acceptance,
because ideas generated through co-creation process are likely to meet customers
needs. Likewise, OHerm and Rindfleisch (2009, p. 4) define co-creation as a
collaborative new product development (NPD) activity in which consumers actively
contribute and select various elements of a new product offering. Additionally,
Gatignon and Xuereb (1997, p. 78) carried out a study that focuses on the correlation
of strategic orientation of the firm and product performance. Given that customer
orientation is one of the three strategic orientations that determine the success or failure
of new offerings, they (p. 78) define customer-oriented firms as those with the ability
and the will to identify, analyze, understand, and answer user needs.
99
101
Figure 4.9 User-oriented Design Impact on New Product Development (source: Veryzer & de Mozota,
2005)
However, despite the potential gains from this kind of cooperation, firms should be
aware of the potential risks. Nambisan (2002), Lengnick-Hall (1996) and Gupta and
Wilemon (1990) set out the most important threats: an increase in the level of
uncertainty; implicit costs that the co-creators might need to understand when using the
technology; the (lack of) connection between them and the new service development
team. Furthermore, Lengnick-Hall (1996) indicates the buyer role as the middle stage
between potential customer and service user. Many researchers argue that the
relationship between organisation and customer and the quality that the customer
receives are the two major factors that direct the potential customer to make the
purchase of the service (e.g. Peppers & Rogers, 1995). Therefore, companies should
invest on these two values to build a good reputation, as it is well known that customers
share their experiences with potential customers directly or indirectly (Lengnick-Hall,
1996).
An additional role played by customers is that of contributor to quality, satisfaction,
and value (Bitner et al, 1997). At this point, users produce an internal and an external
outcome. The internal outcome is the satisfaction that they obtain using a product or a
service, while the external is that they are able to raise competition in an industry,
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103
104
105
4.3
Innovation
Several studies have noted that services involve customers in their production and
delivery owing to the interaction (information and/or effort) between service provider
and user (e.g. Alam & Perry, 2002; Kelley et al, 1990). Hence, customer orientation
appears to play an important role, particularly in service firms, because of
heterogeneity, inseparability, intangibility, and perishability (Lovelock, 1983; Zeithaml
et al, 1985). Although customers do not pay much attention to this interaction, service
firms should reconsider their strategies and appoint lead customers as organisational
members or partial employees (Mills et al, 1983). This is associated with what has been
written in the strategic marketing literature. Many scholars argue that customer
involvement is critical for the acquisition of sustainable competitive advantages, which
lead to business profitability (e.g. Slater & Narver, 2000; Gouthier & Schmid, 2003).
Therefore, the question is how service firms should develop a successful customer
orientation.
Gouthier and Schmids study (2003, p. 132) suggests that companies should
implement a strong customer orientation throughout the firm and not only in customerrelated functions. They mention that, given that the ultimate goal of every organisation
is to create and keep customers, service firms should manage to have their focus and
resources turned towards them. Practically, this signifies that companies should include
this intention in their strategy, structure, organisational culture, information systems,
and human resources. Nwankwos study (1995) goes a step forward and advises firms
to create a high customer-oriented profile through the development of a value system
(Fig. 4.10). This allows the entire organisation to become more responsive to the
demands of its customers, thus, firms should define the needs of their customers well
in order to satisfy them. Companies should also be perceptive, proactive, and flexible
as to future expectations or problems that might come up. What is more, companies
should attain measurement validation using formal tools that provide feedback on
whether customer needs are included in the programmes and how these customer
orientation programmes are implemented. Finally, the interpretation of those
programmes into action is vital and therefore, is divided between responsibilities
(where the staff is chosen) and tasks that pertain to organisational systems, procedures,
and interactions.
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Figure 4.10 A Framework for Auditing a Customer Orientation Profile (source: Nwankwo, 1995)
Studies by Nambisan (2002) and Kelley et al (1990) underline that firms have to
identify customers as being in some sense part of their workforce. This appears to be
essential, because active customer involvement is likely to guide firms to innovative
activities, leading to the possession of competitive advantages. This is supported by
both Lundkvist and Yakhlefs (2004) and Bonners (2010) studies. The first reports that
companies should consider their customers as fully legitimate actors and active
participants in providing valuable information about their needs and in suggesting
modifications. Similarly, the latter contributes to the marketing literature, identifying
two moderating conditions of customer interactivity and the new product performance
relationship. At one end, formal and impartial resources, such as survey feedbacks
and/or formal documents, are used by the development team to obtain information
about customers preferences, while at the other, frequent meetings between the two
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groups take place to solve problems. Bonner (2010) also concluded that customer
involvement processes that incorporate bidirectional communications, direct customer
participation in development projects and joint problem solving, let firms better
appreciate customers needs and develop successful new offerings.
More recently, Witell et al (2011) carried out research aiming to understand the
differences between proactive and reactive market research techniques during the
development of new market offerings. They have found that customers are not usually
keen to participate in the value creation process and proposed (p. 4) that replacing
the passive view of customers with an active view, in which customers are invited to
use their own initiative rather than simply react to predetermined questions and
instructions, will provide new opportunities for companies to create market offerings
with greater customer value.
To sum up, firms should define their product-market orientation and place
customers in the thick of it, as many companies fail to meet their customers needs
(Nwankwo, 1995). This develops a creative collaboration between firms employees
and customers with feedback, suggestions, and new ideas that emerge during their
cooperation (Lundkvist & Yakhlef, 2004). Nwankwos study (1995, p. 8) suggests that,
in order to accomplish this, customer-focused organisations should:
specify customer care objectives and use feedback systems, enabling the
organisation to reach its customers and vice versa;
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Then, these categories were adapted and combined to related key concepts (Column 3)
to cover and be relevant to the health care providers. These key concepts are used in the
development of this study, playing also a key role in developing the questions for the
members and executives of the Euromedica Group (see section 6.4.3).
Table 4.3 Key Concepts Influencing the Customer Orientation and New Service Development in This
Study
Authors of related studies
Customer Orientation
Customers needs
Customer observation
Experimentation
Selective partnering
Customer value
Customer satisfaction
Service quality
Customer empowerment
Consumer co-creation
Patient-focused NSD
Users behaviour
Patient satisfaction
Patients motivation
Organisational improvement
Service environment design
Knowledge transfer
Patient Involvement
meet customers needs, enhance service quality, and increase customer empowerment.
More details can be found in Section 4.2. Similarly, the third category focuses on patient
involvement and describes the benefits of this in developing health services that address
the needs of patients. Several authors have also noted that patient participation has a
positive impact on knowledge transfer within health care organisations and also
improves their morale and overall psychology, which are both critical in, and many
times define, treatments success.
All of these key concepts: New service development, Customer orientation, and
Patient involvement have been investigated in this chapter, and also support the creation
of the conceptual framework in Chapter 5. The rationale behind each of these key
concepts causing the development of customer-oriented new services is presented in
Section 5.3 in Chapter 5.
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effective and pleasant ways to provide health care services. For example, Wood et al
(2000) suggest that health care organisations should focus on new approaches, such as
customer orientation, to achieve patient satisfaction. Additionally, a study by
Ottenbacher and Harrington (2010) concludes that successful services need to be
provided by highly skilled personnel (e.g. clinical and administrative staff), with good
facilities both functional (e.g. the computer system) and aesthetic (e.g. the ambiance of
the hospital).
On the other hand, Tobin et al (2002) explored the influence and efficiency of user
involvement and discovered low levels of willingness and commitment from service
users due to lack of motivation or invitation, stigma, and lack of information. They have
stressed the importance of the background, mentioning (p. 93) that the opportunities
for consumer participation occur first at this clinical interface in terms of what
information is transferred, in what direction, and in how the communication takes place.
Nurturing participation at this level has a fundamental role in consumer empowerment.
Therefore, they proposed the development of a wide system that would integrate all
kinds of activities, while Ford and Fottler (2000) add that this may be the only way for
health care providers to deliver highly customised services.
As it is increasingly difficult in this highly competitive environment for health care
organisations to gain and sustain a competitive advantage, they need to create a new
value for patients, understanding better their needs and meeting both emotional and
physical ones. Duncan and Breslin (2009), however, argue that there is a limited
understanding of those needs as well as lack of strategic orientation for exploring and
exploiting that knowledge. Based on these issues, Ford and Fottler (2000) advised
health care providers to move from the old paradigm to the new one. The old paradigm
relied on medical staff and third party payers satisfaction, while the new one refers to
patient-consumers experience, which is more than a clinical outcome. Therefore, Ford
and Fottler (2000) developed a framework of ten strategic areas, suggesting health care
organisations develop those organisational capabilities, which would allow them to
improve their competitive positioning. Table 4.4 shows the differences between the two
paradigms on the ten strategic areas. Considering the analysis of the Greek mental
health sector in Section 2.2.3, the importance and value of this outline becomes
apparent.
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Table 4.4 A Comparison of the Old Paradigm (Focus on Physicians/Third Party Payers) vs New Paradigm
(Focus on the Patient as Customer)
Strategic area
Old paradigm
New paradigm
Culture
Provider-driven
Patient-customer driven
Motivational strategies
Management of waits
Measures of effectiveness
Organisational improvement
Similarly, a study by Raju et al (1995) reports that hospitals should gather and use
information to reduce customers complaints; improve customer satisfaction and
respond to customers needs. However, they differentiate customer satisfaction from
responsiveness to customers. The former refers to quality improvements and product
modifications to keep patients happy, while latter relates to monitoring patients
preferences and environmental changes. Considering the above, Gafni et al (1998), who
further explored and compared two treatment decision-making models - the physician
as a perfect agent for the patient vs. informed treatment decision-making -, suggested
three alternatives for the decision-making process for treatments. First, the clinician
appears to be the perfect agent for their patients, as they trust their doctor to choose
the appropriate treatment, based on users preferences. Second is the shared decisionmaking option (Charles et al, 1997), where the patient and doctor come to a decision
together. Few patients would like to take the risk of making the treatment decision, but
the majority feel like having a say (Tobin et al, 2002). A third option regards patients
that come to a decision about the treatment, based on information shared by doctor. An
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important point in all cases is to encourage the physician to transfer the knowledge in
a clear and non-biased way (Gafni et al, 1998). Other research, which was carried out
by Ritchie (1999), examines how qualitative research can add to patient-centred care.
It evaluates health care quality and highlights its two dimensions: the objective, which
is the technical dimension originated from the evidence, and the subjective, which is
the personal dimension as experienced by the service user. He argues that successful
offerings come about when these aspects mutually complement each other.
Additionally, many studies underline that health care providers should identify and
fulfil internal customers (employees) needs. For example, Bowen and Schneider
(1985) and more recently, Bellou (2010) agree that medical staff have an essential
responsibility to deliver high quality care and please patients, as they are part of the
service as viewed by the customer. Umashankar et al (2011), who analysed the
characteristics that influence internal innovation outcomes for customer service agents,
back up this viewpoint, stating that internal innovation benefits user satisfaction. What
is more, studies by Ordanini and Parasuraman (2011) and Umashankar et al (2011)
illustrate that service employees opinion throughout the design process advances
innovation outcome and front-staff contribution. In particular, it operates as a forceful
driver of service innovation volume and radicalness. It is noteworthy however, that
Melton and Hartline (2010) take a differing view. They carried out an empirical study
on customer and frontline employee involvement in new service development and
found (p. 411) that frontline employees are less effective than previously thought as a
source of new service ideas (and) firms should instead focus on incorporating those
personnel in the full launch stage to effectively promote and deliver the new service.
4.3.2.1 The Factors and the Benefits of Patient Involvement in Mental Health Care
Innovation
At some point, customer participation is supposed to lead to and enhance customer
satisfaction. Nevertheless, in health care, not all desires and preferences can be fulfilled,
as priorities have to be agreed. El-Guebaly et als study (1983) was the first that noted
that patient satisfaction is not always connected with treatment success. Even so, users
of psychiatric services have taken a more active role in their treatment and
hospitalisation over the recent years. Campbell (2001) noticed that until the early of
1980s, patients used to be passive recipients of their treatment, having no participation.
This is associated with Barnes and Wistows (1994) study that reported that after the
mid-1980s, mental health patients begun to influence the services they use. This is
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similar to the conclusion of Lammers and Happells study (2003), which examines and
debates the insights of mental health service users as regards their involvement in the
development, delivery, and evaluation of mental health services. They found that the
culture and methods by which mental health services are delivered have changed
significantly over the years. These changes took place in response to worries about and
condemnation of about the service quality that mental patients receive. The World
Health Organization (1990) stated that patients should be involved in the decisionmaking process with regard to their treatment. It has been mentioned in the literature
that mental health patients have not been treated with equal conscientiousness as other
kinds of patients (e.g. Lammers & Happell, 2003; Berger et al, 1996).
Although there are still many stakeholders (e.g. doctors, nurses, hospital managers)
who believe that service users have not much to contribute to decision-making on their
care (Bennetts et al, 2011). Campbell (2001) describes how many conditions have
changed in the last twenty years. Users have increased control over their care, over time,
and now, there are more possibilities for consumers to be involved in the decision
making process, though real involvement is still a work-in progress (Bennetts et al,
2011). There are special publications that inform patients about treatments and relatives
or advocates are shown to benefit the effectiveness and the quality of patients
involvement. For example, Victorian Mental Health Service (1999) reported that
enhanced patient involvement had led to noteworthy and optimistic alterations at the
stages of personal treatment, service planning, delivery, and assessment. It seems,
therefore, that people diagnosed with mental illnesses can make valuable contributions
to both mental health services and society.
Many studies support this viewpoint, with those by Tait and Lester (2005), Barnes
and Wistow (1994), and Peck et al (2002) providing detailed information about patient
participation. First, Wistow and Barnes (1993) distinguished user involvement in two
categories. The former seeks to create services that would be sensitive and responsive
to the needs and requirements of users to enhance their quality, while the latter aims to
empower users in decision making as regards the design, management, delivery, and
review of services. Service providers, however, should make sure that user involvement
would not be a stressful experience and the patient should be supported by appropriate
training and opportunities for preparation and debriefing (Barnes & Wistow, 1994). In
addition, Tait and Lester (2005), who reviewed the mental health literature, list a
number of gains and restrictions of user involvement in mental health services. Some
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of the most valuable benefits include: user involvement may increase the existing
limited understanding of mental distress; develop alternative approaches to mental
health and illness; be therapeutic and may encourage greater social inclusion. On the
other hand, the lack of information, financial and time costs, concerns over
representativeness and resistance to the idea of users, as experts appear to be the main
barriers of patient involvement. Finally, Lord (1989), who carried out a research to
appreciate the sources of understanding in participating in mental health services,
concluded that the aims of involving patients are generally to advance health outcomes,
raise satisfaction, and/or, reduce cost.
5. Cohen et al (2004) and Ritchie (1999) argue that customer contribution has a
positive influence on medical scientists' working practices, setting the basis for
exploiting patient-centred care.
6. Ford and Fottler (2000) have pointed out that involving users in health service
development allows organisations to provide an integrated offering that starts
before admission and is completed after discharge.
7. Ordanini & Parasuraman, 2011 and Umashankar et al, 2011 noted also that
service employees should also be involved in the design and development of
new health services. They found that their contribution is likely to increase the
quality of the new service and meet better the needs of the users.
8. Tait and Lester (2005) have found that user involvement increases the existing
limited understanding of mental distress; develops alternative approaches to
mental health and illness; and is therapeutic and encourages greater social
inclusion. This is likely to lead to new service opportunities aiming at
addressing users needs.
The research studies presented above support the use of customer orientation and
new service development as indicators for the identification of new service
opportunities. Another source of evidence supporting this idea comes from the data
collected from a set of interview questions for the company executives in the Research
Sections I and II. The questions below aimed to investigate whether and how those two
concepts lead to the exploitation of new service opportunites, and therefore to
organisational sustainability:
Question 15, Where did the concept of developing new services come from?
(existing customers, new customers, market research, always part of the plan?)
Question 16, How would you evaluate the coordination among people and
departments throughout the new service development process?
Question 26, Is there a formal method by which complaints, queries and poor
performance are fed into service development initiatives?
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There was an agreement that new services mainly come from the insights of
customers, and of employees, leading, at the same time, to the exploitation of new
opportunities. Likewise, data collected from mental service users in Research Section
III also show that involving patients in organisations operations and developments is
likely to increase the design of new offerings that address market gaps. The questions
below aim to explore this further:
Question 7, Would you like to participate in the way decisions are made for
your health?.
Here again, patients agreed that they feel productive when are engaged in hospitals
activities, which helps them improve their health issue. They are also keen in
participating in decision-making and in programmes that would make them feel better
and also help them overcome their problem. Therefore, it is clear that customer
orientation is a critical element in health service development and an indicator for the
identification of new service opportunities.
4.4
globalised environment, they need to create and sustain competitive advantages and be
continuously innovative, adopting new processes, creating novel ideas and developing
and launching successful new outcomes (Porter, 2004). New service development
activities are of vital importance, as they strengthen current business and provide new
business ventures. In particular, service organisations should be innovative as they thus
enhance the profitability of current offerings through cost reduction and sales growth.
Innovativeness also improves the loyalty of existing customers while attracting new
ones, and aids firms to expand their business, exploiting new opportunities that offer
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factors that govern the potential customer in making the purchase of the service (e.g.
Peppers & Rogers, 1995).
As regards health care services, health care organisations tend to focus more on the
expectations of their medical staff and third-party payers and less on their medical
consumers needs. However, patients have increased their influence on the performance
of health care organisations. They have become active participants in their health care
experience, as they have easier access to information and know more about their
alternatives. Todays experience is a holistic perception, initiated before admission,
with closure after discharge (Ford & Fottler, 2000). Organisations need to create a new
value for patients, understanding better their needs, and meeting these, both emotional
and physical. For this reason, customer orientation plays an important role, particularly
in service firms, because of heterogeneity, inseparability, intangibility, and
perishability. Although customers do not pay much attention to this interaction, service
firms should define their product-market orientation and place customers in the thick
of it, as many companies fail to meet their customers needs. This develops a creative
collaboration between a firms employees and customers, with feedback, suggestions,
and new ideas that emerge during their interaction.
In the next chapter, all key concepts (service innovation, corporate venturing, new
service development, and customer orientation) are presented along with the rationales
behind the development of the conceptual framrework. This chapter aims to describe
the relationships and the conceptualisations between the four concepts as well as to
present the rationale behind the utilisation of the models that come from the review of
the literature for the development of the conceptual framework, the new business model
and the propositions.
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Chapter V
Development of the Conceptual Framework
This chapter describes the development of the conceptual framework of the
research. Before proceeding with the discussion, Section 5.1 highlights the main
domains of knowledge used in this study. This section explains the development of the
conceptual framework and its components in order to provide a holistic understanding
of the various perspectives involved in the development of new services and
exploitation of entrepreneurial opportunities in the Greek health care industry. This
approach contributes to the discussions in this and in previous chapters of the study.
Sections 5.2 and 5.3 demonstrate the rationale for integrating the key concepts
identified from the litareture reviews in Chapters 3 and 4. Section 5.4 presents the
conceptual framework and Section 5.5 portrays the new business model and describes
the five propositions. Finally, Section 5.6 presents the implementation of both
conceptual framework and new business model for customer-oriented services in the
health care market.
5.1
and entrepreneurship (e.g. McFadzean et al, 2005; Zhao, 2005a), with some researchers
putting this down to definitional ambiguity regarding both concepts (McFadzean et al,
2005; Hornsby, 2002). On the other hand, many scholars have carried out studies on
customer involvement in service development processes (e.g. Greer & Lei, 2012; Sing
Wong and Tong, 2012).
The framework (Fig. 5.1) provides an illustration of the main groups of literature
that formed the basis for this study. Four theoretical concepts were adopted and studied:
Theory of Service Innovation; Theory of Corporate Venturing; Theory of New
Service/Product Development; and Theory of Customer Orientation. They are
classified into two groups (i.e. innovation & corporate venturing; new service
development & customer orientation) and are discussed in detail in the following
sections of this chapter.
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Theory of Service
Innovation
Theory of Corporate
Venturing
Entrepreneurial Innovation
Theory of New
Service/Product
Development
Theory of Customer
Orientation
5.2
Figure 5.2 A Holistic Definition of Entrepreneurship and Innovation (source: McFadzean et al, 2005)
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Figure 5.3 The Missing Link between Entrepreneurship and Innovation (source: McFadzean et al, 2005)
Figure 5.4 Linking Entrepreneurship With Innovation - Attitudes, Vision, and Actions (source:
McFadzean et al, 2005)
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innovation and entrepreneurship are dynamic and holistic processes that are not
restricted to the initial activity of a new undertaking.
This can be also viewed in De Burcharth and Ulhis (2011) recent study, who report
that radical innovation usually derives from new business ventures, so established firms
who hold a particular interest in developing advanced new products should take this
perspective seriously. The study by Herbig et al (1994) agrees, highlighting the
important connection between innovation and the creation of new ventures.
On the other hand, Zhaos (2005a, p. 36) research concludes that certain difficulties
are faced by organisations that choose to enhance their competitive advantages and
position themselves through innovation and entrepreneurship. The results of this study
underline the need to measure the outcomes of innovations and entrepreneurship, as it
is not easy to distinguish between these outcomes and the total outcomes of the
organisation. What is more, technological innovation may bring about job losses, lower
staff morale, and other staffing/human resources issues. This makes clear the
importance of recruiting competent employees and managing them well. Additionally,
elements such as risk-taking abilities, time and persistence are needed for a new offering
to be successful, while a formal business structure and an independent executive - such
as an innovation or entrepreneurship manager - are required to guide the whole process
correctly (see more details in Section 3.2 of Chapter 3).
Many studies conceptualise corporate venturing as the actions of individuals or
teams within organisations that lead to innovation of processes or products (e.g.
Antoncic & Hisrich, 2003; Walton, 2003). Therefore, the concepts of corporate
venturing and innovation have been recognised in the organisational sustainability and
growth literature. For example, the studies by Antoncic and Hisrich (2003) and Nielsen
et al. (1985) argue that corporate venturing includes innovative activities that generate
new products that sustain the competitive position of a company, while developing new
125
business activities that add value to the parent organisation. On the other hand, the same
studies claim that the parent organisation should provide all the necessary resources
(financial, knowledge, marketing, and so on) to avail, increasing its speed and levels of
innovation. Other studies hold the opinion that corporate venturing is better achieved
by large and established organisations (e.g. Gapp & Fisher, 2007; Zahra, 1996). They
are able to restructure through strategic renewal, based on gaining new capabilities from
smaller ventures. Equally, a study by Greene et al (1999) argues that corporate
venturing can prove an effective option for firms to gain knowledge and skills that often
lead to future revenue streams, although research by Tidd and Barnes (2000) reports
that, especially in life science industries, many organisations fail to differentiate their
strategic, financial, and operational goals, resulting in unsuccessful ventures. For more
details about the key factors that influence the success of service innovation and
corporate venturing in health care, please see Section 3.3, Chapter 3.
This section provides the theoretical background and the conceptualisations that
have been presented in the literature. This helps the researcher to base and build upon
those arguments, aiming at developing an integrated framework and a research design
that will help him to investigate further these concepts in the health care context.
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Figure 5.5 The Macro-Model of Entrepreneurship and Innovation (source: Shaw et al, 2005)
Figure 5.6 The Micro-Model of Corporate Entrepreneurship and Innovation (source: Shaw et al, 2005)
127
Figure 5.7 The Hypothetical System Model of Cultivating Corporate Entrepreneurship (Adapted from
Chen et al, 2005)
Some other studies focus on the linkage between individual and environment. For
example, Gartner (1985), Greenberger and Sexton (1988), Bygrave (1989) and some
128
others made studies that found that the interaction of the individual and the environment
is one of the most substantial parts of the corporate venturing process. Many of those
studies were based on Martins research (1984), which found that several features (e.g.
partial social alienation, psychological/physical predispositions, demonstration effects,
family factors, and precipitating events) create a moment in time for the individualorganisation. When this co-occurs with the identification of a new venture opportunity,
the access to financial support and a general supportive environment conclude in a
likely new venture. Likewise, the study by Hornsby et al (1993) aimed to describe a
model (Fig. 5.8) that explains how the individual-organisational characteristics that
cooperate with precipitating events led to successful and profitable new ventures. When
those characteristics cooperate with precipitating events, the decision to act
intrapreneurially is positive and this leads to the development and implementation of a
dynamic business plan. It is also important for the parent organisation to provide all the
necessary resources for the development of the new venture, while it is crucial to
transfer the appropriate knowledge and build the proper structure, helping the new
venture to overcome any difficulties.
Figure 5.8 An Interactive Model of Corporate Entrepreneurship (source: Hornsby et al, 1993)
129
This last section underlines the importance of both, external and internal,
environments of a company and their impact on organisations innovation and
entrepreneurial plans and activities. It also demonstrates that combining these two
concepts, firms are likely to explore and identify new opportunities. The above
arguments lead this research to include both concepts and consider them as critical
components of the conceptual framework below (see section 5.4).
5.3
130
Similarly, Jenssen and Aasheim (2010), who carried out a study examining how
organisational factors affect innovation and performance in small, knowledge-intensive
firms, argue that the success of product development depends on the level of market
contribution to the development process (see more details in Section 4.3 of Chapter 4).
Equally, the studies by Carbonell et al (2011), Ottenbacher, and Harrington (2010)
stress the importance of market responsiveness, which links innovation and marketcustomer demands, engaging close user-contact, comprehensive customer research, and
thorough understanding. On one hand, the former study argues that close customer
participation increases service advantage and speed to market, while lead-user
contribution augments the novelty of new offerings and service advantage even though
that affects market performance negatively. On the other, the latter research states that
companies should understand customers needs and respond to market changes,
developing differentiated offerings. Additionally, the studies by Gao and Chen (2010)
and Gronroos (2007) support that service users ask for quality, style and uniqueness, as
against standardised offerings, and therefore the design and development of a service
should be carried out by people who have a thorough understanding of the needs and
wishes of the consumers. In contrast, there might be cases where customers are required
to be involved in the decision-making process, but objections will be confronted. For
instance, although mental health workers are chary of user involvement in the new
service development process (Campbell, 2001), mental service users increasingly
contribute to the planning and to the development of new services with advocacy
projects, user councils and user-led movements (Barnes & Wistow, 1994). For more
details regarding the factors that influence patient involvement in mental health care,
please see section 4.3.2.1 in Chapter 4.
5.3.2 Conceptualising
New
Service
Development
and
Customer
Orientation
It has been clear in the strategic marketing literature that inputs of information about
actual and potential customers lead to successful and customised offerings (e.g.
Lundvall, 1988; Cooper & Kleinschmidt, 1988). Studies by Maidique and Zirger
(1984), Johne and Snelson (1988) agree that successful ideas usually come from the
market and not from the firm. This is also supported by many authors who argue that
customer orientation has a positive effect on adopting and developing successful new
services, which in turn benefits corporate performance (e.g. Han et al, 1998; Berthon
132
et al, 2004). Alam (2002, p. 254) carried out a study to explore user involvement in new
service development and identified six key objectives:
1. user involvement may help companies to develop and differentiate new services
that come closer to the customers needs and requirements;
2. service firms are able, in some cases, to reduce the overall service development
time when they involve their customers;
3. it is easier for the users who are involved in the development process to gain
information about the use and attributes of a new service;
4. service organisations can benefit from customers if they use them to diffuse the
new offering in the market place;
5. user participation may strengthen a companys public relations, which in turn
will help to win customers loyalty for the innovation and
6. customer involvement may assist a firm to maintain a long-term relationship
with its customers.
Many studies also highlight the importance of involvement in the service
development process, arguing that customers should play the role of partial employee
and share information with the firm, thus, mutual commitment, trust, adaptations, and
relationship management are essential for the development process to flourish (e.g.
Ritter & Walter, 2003; Svendsen et al, 2011). Many scholars add that user testing should
be part of every stage and a continuous and in-depth contact with leading customers especially in concept generation and testing stages - is likely to be a success factor (e.g.;
Martin & Horne, 1993; Von Hippel, 1988). Studies by Feldman and Page (1984),
Cooper and Kleinschmidt (1986) and de Brentani (1993) support this viewpoint,
reporting that new services need to be tested before and after their market launch, which
is a simple and a low cost process to eliminate failure. Moreover, the studies by Prahalad
and Ramaswamy (2000), Veryzer and de Mozota (2005) indicate that users are likely to
come up with suggestions for improvements during service testing, but the challenge to
involve customers requires interdepartmental cooperation, which, nevertheless,
enhances the users experience.
At the same time, many authors support the opinion that customers have a limited
ability to provide valuable input into the development process (e.g. Bonner & Walker,
2004; Christensen & Bower, 1996). For instance, Edvardsson and Olsson (1996) note
that firms should take into account the customers needs and wishes via an open
dialogue, but should not involve them in the service development process. Nambisan
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(2002) adds in his study that customers do not have a virtual and active role in the
development of new products, because of the poor connectivity between customers and
producers. In addition, other researches argue that the design and development of a new
product should be carried out only by professionals (e.g. Gales & Mansour-Cole, 1995;
McQuarrie & McIntyre, 1986). Contrary to this view, Magnussons research (2003)
argues that users provide more valuable and original ideas than do professionals.
However, despite such debate, customer involvement remains an underdeveloped
research area in the new service development process (Alam, 2002; Alam & Perry,
2002; Johne & Storey, 1998), and as Martin and Horne (1995) point out, direct customer
participation is rather infrequent.
This section provides the theoretical background and the conceptualisations that
have been presented in the literature. This helps the researcher to base and build upon
those arguments, aiming at developing an integrated framework and a research design
that will help him to investigate further these concepts in the health care context.
5.3.3 The Rationale for Utilising Models of Customer oriented New Service
Development in the Development of the Conceptual Framework
Customer participation in new service development is a relatively new area of
research. Several researchers have dealt with the benefits and limitations of customer
involvement in the new product or service development process, while a smaller
number have identified successful techniques that show how this could be better
implemented: Quality Function Deployment (Griffin, 1992); Consumer Idealised
Design (Cinciantelli & Magdison, 1993); Beta Testing (Dolan & Mathews, 1993) and
Leader User Analysis (von Hippel et al, 1999). However, Alam (2002) reports these
techniques as engineering driven, involving users at the design and the manufacturing
stage of the product development process; this is applicable mostly in construction and
engineering enterprises.
Many studies highlight that successful new services emerge from a dialogue
between provider and user (e.g. Witell et al, 2011; Hoyer et al, 2010). For example,
Witell et al (2011, p. 9) carried out a study to identify the differences between proactive
and reactive market research techniques during the development of new products. They
found that customer involvement creates value for businesses with activities in
which customers actively participate in the early phases of the development process by
contributing information about their own needs and/or suggesting ideas for future
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services that they would value being able to use. Likewise, Edvardsson and Olsson
(1996) describe a customer active paradigm that should be developed when formulating
and testing the service concept and implementing service processes. They focus on
service quality, involving customers in the development process. In this case, the
company is responsible for developing a service concept, taking into account the needs
of the users and offering a quality service using the service system, and for providing
the required resources for service development. Again, Cooper (1988, p. 248)
developed a systematic process model for new product development, putting
considerable emphasis on market orientation. He proposes that market orientation
should be a matter of routine in any new product process, as marketing inputs increase
product success. Thus, he suggests seven marketing activities that enhance the
efficiency of the development process:
1. preliminary market assessment to identify the market acceptance of the new
product concept;
2. market research to design the new product according to the needs and
preferences of the customers;
3. concept testing with users to acknowledge the reactions and intentions of
potential customers;
4. analysis of the competition;
5. tests with users to ensure good performance of the new offering;
6. market testing in a limited geographic area would show how the marketing mix
works and
7. full market launch, based on a marketing plan, providing the necessary
resources.
Alam (2002) performed a comprehensive research study involving business
customers/users in most of the ten stages of the new service development process. He
concluded that users benefit the process at all stages (Table 5.1), but the intensity of the
involvement depends on the special characteristics of each stage. This means that at the
initial stages of idea generation and screening and at the later stages of service testing,
test marketing, and commercialisation, customers should participate intensively. This
may be achieved by interviews with customers, user visits and team meetings, user
observation and feedback, focus groups, and so forth. However, Alam suggests that the
first two modes appear as the most ascendant in customer involvement. Recently, Hoyer
et al (2010) analysed consumer co-creation at different stages of new product
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development. Their study suggests that firms should exploit new technologies to create
value with customers in a more complete and professional manner. The studies by
Grewal et al (2006), Evans and Wolf (2005) and Hull (2004) take a similar viewpoint,
mentioning that new technologies, such as social media, can extend the width and
profundity of inputs, helping firms to share the development concept with customers
and ask for their contribution. Hoyer et als study (2010) adds that such technology can
be a useful tool for firms, as it lets product adopters send their feedback in less time
than with traditional techniques. This allows companies to understand relatively
quickly the causes of low repurchase rates and improve some features of the product
while it is on the market, aiming to decrease negative effects of the potential failure
(Dong et al, 2008).
1.Strategic planning
2. Idea generation
3. Idea screening
4. Business analysis
5. Formation of
cross-functional
team
6. Service design
and process/system
design
7.Personnel training
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8. Service testing
and pilot run
9. Test marketing
Develop marketing plan and test with the users; examine the
saleability of the new service; examine the marketing mix
options in different markets; limited rollout in the selected
market
10.
Commercialisation
Many studies raise this issue, mentioning that customer orientation, market
knowledge competence and user involvement programmes among others have been
positively linked to new product performance outcomes (e.g. Gupta & Wilemon, 1990;
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Figure 5.10 A Framework for Effective Customer and Frontline Employee Involvement in New Service Development
(source: Melton & Hartline, 2010)
Another rationale that puts customers at the centre of the new service development
process is the customer concept. The aim of this concept is to precipitate customers into
making the firm their first or sole choice. A study by Vandermerwe (2003) emphasises
that service organisations should not only develop and sell services, but also implement
a customer-focused strategy in order to become indispensable to the customer. Hence,
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companies should apply a proactive service innovation strategy to increase the selfreinforcing loop (Fig. 5.11), deterring competitors from exploring and exploiting
market gaps. The lock-on loop is based on shared information and collaboration
between firms and customers. This allows firms to offer more value to their customers,
considering always that their needs change over time. This leads to satisfied and loyal
customers, providing sustainable competitive advantages for the producer.
decreasing customers ability to express their needs and wishes to the product
development team. This requires tools and methods - such as face-to-face meetings,
joint problem-solving, and rich information channels - which are able to resolve this
ambiguity (Daft & Lengel, 1986). At the same time, low- embedded products do not
require high interactivity, as this leads to lower quality information. Highly interactive
processes lead to fewer customers offering input, which in turn leads to missed
customer requirements in the product development project. Daft and Lengel (1986) add
that in such conditions, more focused and less interactive methods should be used to
obtain customer information.
On the other hand, several studies claim that customer interactivity is not related to
customer information quality, because high customer involvement may reduce the
overall quality of information (e.g. Berthon et al, 2004; Bitner, 1997). Bonners study
(2010, p. 3) explains this, reporting that a highly interactive process requires more
team effort per customer, resulting in fewer customers contacted, as compared to a less
interactive process. Therefore, limiting the touch points in the market with an
interactive process might cause the product team to miss important customer
information (and) might add unneeded distractions and confusion. It has been clear
that customer involvement benefits the new service/product development process and
performance, as new service success depends on understanding and satisfying
customers needs. This leads to the conclusion that high new product performance is
achieved when high-quality customer information is used. Cheung and To (2011, p. 5)
expand on this viewpoint, stating that the level of co-production is a good moderator
that strengthens the positive link between customer involvement and perceived service
performance in terms of tangibles, reliability, empathy, and assurance.
This section (5.3.3) underlines the importance of customers and users in new service
development as well as the benefits and limitations of their involvement in
organisations innovation activities. It also demonstrates that combining these two
concepts, firms are likely to explore and identify new opportunities for customised
services, which is critical for the sustainability of the health care organisations, In
particular, those who operate within the mental health sector (for more details see
section 4.3.2). The above arguments lead this research to include both concepts and
consider them as critical components of the conceptual framework below (see section
5.4).
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5.4
Conceptual Framework
Research Context
Literature Review
Sections 5.2 and 5.3, as presented earlier in this chapter, concern the rationale of the
relationships among the main concepts in this study, and it has been aimed at
highlighting several issues regarding innovation and business growth in an attempt to
recognise multiple perspectives and to develop a well-founded conceptual framework.
The current literature concerning the concepts of service innovation, corporate
venturing, new service development and customer orientation as well as the health care
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industry as the research context of this study have been used for the development of the
conceptual framework below (Section 5.4.1).
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EUROMEDICA GROUP/
NEUROLOGICAL SERVICES
Competition in
Health Services
Service
Innovation
Corporate
Venturing
Identification of
entrepreneurial
opportunities
New Business Ventures
through the Development
Of Mental Health Services
Environmental
uncertainty in
Health Services
Customer
Orientation
Customised new
health service
opportunities
Figure 5.13 Conceptual Framework for New Service Development through Corporate Venturing In the Health Care Industry
5.4.1.1 The Key Driving Forces urging for Innovation and Business Growth
Figure 5.13 recognises that competition in the health care industry and
environmental uncertainty are the key external driving forces that require the
organisation to pursue strategies for growth. As has been shown in the research context
(see Chapter 2), the health service industry is now characterised by increased
competition and the growth of large enterprises offering a wide-ranging selection of
services. Consequently, this has led to a decrease in the number of smaller specialised
firms. The second driving force is the instability of the Greek health care industry. This
is the result of a number of factors; firstly, as Greek political power is frenetic in its lack
of longevity (with leading political parties, possessing power only for what is often a
very short time), policy regarding health care is continually changing. Secondly, there
are many problems regarding cash flow and payment delays by insurance funds, and in
turn for hospital funding and revenues. Lastly, great concern is felt by many Greek
citizens regarding hospital fees. It is important to mention that the conditions of
competition in the Greek private health care market and the political, business, and
social climate in Greek society are major forces pushing health care organisations to
seek innovation and to exploit every business prospect.
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144
5.5
145
Research Questions
Conceptual Framework
Research Context
Literature Review
Competition
Evolution of Medical
Science & Technology
Demographic
Characteristics
Industry
Characteristics
Socio-economic
Characteristics
New Business
Development
P1
Entrepreneurial
Opportunities
P2
Service Innovation in Business Development
P5
P3
Customer Contribution to Idea Generation
P4
New Service
Opportunities
Personalised
New Services
New Service
Development
Figure 5.15 The New Business Model
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147
Proposition 3: Involving patients in the idea generation process will produce a greater
number of new service opportunities.
There are studies that suggest that firms should become customer-oriented,
developing highly customised services that meet customers needs (e.g. Ford & Fottler,
2000; Wood et al, 2000). As regards health care, studies have shown that patient
involvement enhances health services, reduces complaints, and raises customer
satisfaction (e.g. Lord, 1989; Raju et al, 1995). In particular, it has been demonstrated
that mental health patients can benefit service planning, development and delivery
(Victorian Mental Health Service, 1999). The above discussions illustrate the
importance of customer participation in the new service development process, and this
forms the fourth key principle for the new business model. The following, fourth
proposition is linked with both the third and the fourth research questions. On one hand,
it explores the role of medical staff in involving mental service users in the development
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of new offerings, while on the other; it investigates how patients should contribute to
the development process, assuming that both contributions will tend to a successful
outcome:
Proposition 4: Involving mental health service users in the service development process
will enable health service firms to develop offerings that meet customers needs.
5.6
Business Model
Both the conceptual framework and the new business model are used to describe
the relationships between the key concepts of this study. They have also been used as
guidelines for creating the questionnaires (see Appendices 1, 2, 3) for the three sections
of the research (for more details, see the methodology chapter below). The questions in
the questionnaires represent the factors and the concepts in the conceptual framework
as well as they aim to validate the propositions that have been developed and presented
in Section 5.5.
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The three research sections involve discussion of these concepts and their effects
on organisational growth and sustainability that emerge from corporate venturing and
customer-oriented new services. They also include experts experiences and
recommendations about how these concepts can be implemented in practice. The results
may be used not only from the case organisation, but also from other organisations in
the health care industry in order to improve their ability to innovate and exploit
opportunites by using customers insights and knowledge.
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methods include continuous comparison of data received and model created throughout
the research study. The next chapter begins by presenting the research approach and
philosophy of this study, following by the research strategy. Here, the rationale for
employing face-to-face in-depth interviews is described and explained. In addition, the
development of a research framework based on existing literature, research questions,
and the conceptual framework presented above is illustrated. This research model
helped the researcher to form the three different sections for data collection and also
served as a guidance for the identification of the research instrument.
The next Chapter describes the research methodology of this study, explaining the
research approach, philosophy, and strategy as well as presenting the research design
of the three research sections.
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Chapter VI
Research Methodology
6.1
Introduction
So far, this study has presented the industry context, showing that intense
competition in the health care industry leads firms to innovative activities in order to
remain current and competitive. The area for growth was also identified; in particular,
the mental health care market in Greece. The review of the literature set the basis for
understanding the profound meaning of service innovation and the importance of a
service innovation strategy and process in determining the innovation goal as well as
the activities that should be adopted for the development of the new offering. Moreover,
the literature on innovation illustrated the significance of innovation activities within
the health care industry.
Additionally, the definition of corporate entrepreneurship and the exposition of the
value of corporate venturing in exploiting business opportunities and market expansion
have furthered the development and analysis of the service-provider related side of this
research. Furthermore, the review of the literature has helped the researcher to identify
the potentially major contribution of customer involvement in the new service
development process in order to develop new outcomes that fulfil users needs and
preferences. As regards the mental health industry, patient participation has been
reported as critical to the experience and the well-being of consumers.
Phased research is adopted as the research methodology with each phase
highlighting issues that need to be focused on in subsequent phases. The research
questions presented in Section 1.2.3 in Chapter 1 and the conceptual framework direct
the form of the three phases of the research design (see Figure 5.13). As Miles and
Huberman (1994) and Robson (1993) state, the conceptual framework which presents
the system of concepts, assumptions, expectations, and theories supporting the research
is a key part of the research design (c.f. Maxwell, 1996). In this study, the research was
designed as indicated in Figure 5.13. First, after the purposes of the study were stated,
the literature involved was reviewed and critiqued. Then the conceptual frameworks
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were generated. This led to the addressing of the research questions. Then, data were
collected and analysed based on the phase they were placed in.
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are very important as they can shed light to the contextual complexities and differences
in health care practice dynamics, influenced by the views, values, and beliefs of
participants and the power relations in health care settings. They can provide detailed,
descriptive reports on day-to-day practice and provide suggestions for improvements
or set new theoretical questions emerging from the ongoing research (Holloway, 2005).
Under these circumstances, evaluation is seen as the means through which to develop,
improve, and progress the project or programme evaluated. Patton (1999) states that the
focus is increasingly on its concurrent potential to inform and empower, a facet
particularly important amongst stakeholders at grassroots level. Qualitative research
methods are based on the premise of subjectivity and thus encourage the input from
different stakeholders (Taylor & Trujillo, 2001). However, in the context of medical
and scientific research, qualitative methods have been questioned for their subjectivity
and lack of factual, objective results. It is reported that medical researchers find it hard
to apply standards proposed by social scientists, which may be valid or useful in their
discipline, but do not necessarily count for generically valid scientific standards
(Chapple & Roggers, 1999).
To counteract the shortcomings of qualitative methods, researchers collect data
from a multiplicity of sources and perspectives, employing various data collection
methods. Making such methodological choices is subject to a number of factors: the
credibility and validity as well as the capabilities of the participants in the study. Davies
and Dodd (2002) suggest that such choices should be reflexive and responsive in order
to avoid procedures, which impose inhibiting controls. Patton (1999) stressed the
importance of continuous strategizing, adaptation, prioritising, and relevance in the
evaluation process. Pope and Mays (2008) suggest the following procedures to improve
validity: triangulation, respondent validation, clear detailing of data collection and
analysis, reflexivity and attention to negative cases. They also suggested the use of
detailed reports and sampling techniques as a means to increase relevance. Giacomini
et al (2009) have also emphasized the importance of clinical relevance.
Researchers use methodological triangulation, which is divided into two different
forms: intra-method triangulation and between-method triangulation. In the case of the
former, different strategies are adopted within the same paradigm, while the latter
involves testing the validity of a certain method by means of another qualitative
method. It is generally maintained that triangulation improves validity and reduces the
bias inherent in one method (e.g. Dootson, 1995; Perlesz & Lindsay, 2003). Whatever
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data collection methods are chosen, qualitative research involves a strategy of inductive
inference based on the analysis of statements made by the participants (Miles &
Huberman, 1994). This strategy follows the following steps: first, the interviews are
transcribed, and then the material is carefully examined several times and the
fragments, which are deemed as significant or meaningful, are classified fitted into
wider, generalised themes. At this final stage, it is useful to draw on the conclusions of
other studies - small or large scale, quantitative or qualitative - it can be either case.
Afterwards, the data elicited can be compared to relevant published data from other
studies (Schonfield & Farrell, 2009; Seale, 1999). By selecting a few representative
examples, the researcher can come to conclusions and produce generalised
assumptions, which go beyond the individuals under study as these conclusions
underline overarching themes and structures (Bourdieu, 1977; Giddens 1991).
The researcher when adopting qualitative research methods must assume a
reflective stance in assessing their role and involvement in any stage of their study. This
is of outmost importance in terms of the reliability and validity of their chosen research
methods and their way of implementation. Accounting for any bias or skewness in the
methodological approach adopted, reinforces the studys credibility and transferability
of findings (Van Maanen, 2011). The external validity of the research project results
depends on whether these can be applied to other settings. Researchers in qualitative
analysis should bear in mind that generalisations cannot be of the same scope as in
quantifiable sampling methods. The pursuit of qualitative analysis lies in the contextual
interpretation of textual material in specific settings.
This research study exploits the theory and research context to develop a research
design framework that directs the data collection process, followed by the comparison
of the findings with relevant literature to raise external validity. Apart from exploratory
interviews, other techniques of data gathering were also used in this research. As the
researcher was linked to the case organisation, he had the opportunity, for example, to
observe participating patients in their everyday life and have a physical presence in
hospitals facilities. This increased the construct validity of the research, as the
researcher was in a position directly to assess the responses of the interviewees. The
importance of face-to-face interviews and observation of respondents is highlighted by
Yin (2009). It should be mentioned here that the researcher holded the position of
Service Development Scientist in Euromedica Neurological Services. This allowed him
to talk to Euromedicas members of the board, other higher executives, senior medical
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complaints, and expectations. According to their statements, they found the experience
as empowering and therapeutic.
Indeed, reaching that level of cooperation and trust is vital for really meaningful
and insightful conclusions to be drawn from observation in natural settings.
Observational methods are meant to be designed to offer insightful and illuminating
records of naturally occurring behaviour within healthcare settings, which is hard to
achieve especially in case the researcher is not fully prepared. Observational methods
in social sciences involve recording behaviour and/or talk in a manner that is
systematic, detailed and feels unconstructive. Goffman (1961) apprehended this
research method, suggesting that the researcher should familiarise themselves with the
social group under observation. He stated that one should submit oneself in the
company of the members to the daily round of pretty contingencies to which they are
subject. In this way, the philosophy of observation is changing from control to care,
which can have dramatic effects on mental health research (Dodds & Bowles, 2001).
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the different social agents under study in specific social/interpersonal settings. It is also
an approach, which requires a rigorous and systematic reading and coding of the
transcripts, which enables for significant themes to emerge and then be classified into
generalised categories of description. Reproduction, the movement backward and
forward between theory and data, contributes to theory building based on systematic
exploration of underlying methods and mechanisms. The conclusion of an inductive
argument makes claims to conceptual knowledge beyond the confines of experience of
the individual study. The inductive approach is an established method of research
analysis in healthcare as it offers valuable insights into professionals and users
perceptions regarding the quality and context of care and identifies barriers to changing
healthcare practice.
The qualitative research instruments used for data collection in this study include
interviews with prominent members of the Euromedica Group, senior medical and
scientific staff, and managers. Semi-structured interviews with service users were also
included as well as some observation for evaluation and validation of their answers.
Semi-structured questions have the advantage of uncovering the interplay between
different perspectives, understandings, and meanings attached to the concept of service
user involvement by the various stakeholders involved in the process. However, this
type of interviewing may reduce the researchers control over the interview situation
and take a longer time to conduct and analyse, in addition to the difficulties of the
analysis process. Most of qualitative researches are interview based, therefore, an
outline of interview techniques and their application in medical setting is essential,
explaining the rationale for these techniques and showing how they can be used in
research kinds of questions.
6.1.2.1 Types of Interviews
Accordingly, there are different types of qualitative interviews, which will be
described though this study, in line with the way in which they differ from clinical
consultations and the practical guidance for conducting such interviews. During their
clinical work, practicing clinicians routinely interview patients. There is an issue about
whether simply talking to people constitutes a legitimate form of research. However, in
sociology and related subjects, interviewing is a well-established research technique
that is divided into three main types, those of structured, semi-structured, and in depth
interviews. The former consists of administering structured questionnaires.
Interviewers are trained to ask fixed choice questions in a standardised manner. An
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example of fixed choice question might be if the interviewee considers his health
excellent, good, fair or poor. It has to be mentioned that even though qualitative
interviews are often described as being unstructured, the term "unstructured" is
misleading, since no interview is completely devoid of structure as if it were, there
would be no guarantee of the quality of the data. In other words, the data gathered would
not have been appropriate to the research question.
Semi-structured interviews are characterised by a loose structure that consists of
openended questions, defining the area to be explored and from which either the
interviewer or interviewee may diverge in order to pursue an idea in more detail. In that
context, continuing with the previous example, the interviewee could be asked, what he
understands as good health and how he considers his health to be. Finally, in depth
interviews usually cover only one or two issues, but in much detail than the semistructured ones. Clinical and qualitative research interviews have different purposes.
However, the clinical task is to fit that problem into an appropriate medical category in
order to choose an appropriate form of management, even though the doctor may be
willing to see the problem from the patient's perspective.
The constraints that are entailed to most consultations are such that being a
qualitative research interview, the aim is to discover the interviewee's own framework
of meanings. The research task is to avoid imposing the researcher's structures and
assumptions, as they need to remain open to the possibility that the concepts and
variables that result by the research might be very different from those that might have
been initially expected. Additionally, the fact that any open-ended questioning needs to
be brought to a conclusion by the doctor within a short time, can be considered another
constraint. An example of a qualitative research conducted by Gantley et al (1993), who
interviewed mothers of newborns in different ethnic groups in order to understand their
child rearing practices and, by extension discover possible factors that contribute to the
low incidence of sudden infant death in Asian populations. However, qualitative
research can also open up different areas of research such as hospital consultants' views
of their patients or General Practitioners' accounts of uncomfortable prescribing
decisions.
6.1.2.2 Conducting Qualitative Interviews
Researchers conducting qualitative research try to be interactive and sensitive to the
language and concepts used by the interviewee. They also wish to keep the agenda
flexible, aiming to understand what is underlying the surface of the topic being
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discussed, explore what people say in as much detail as possible, as well as to discover
new areas or ideas that were not initially expected by the research. It is essential that
interviewers check that they have understood respondents' meanings instead of relying
on their own assumptions, taking into account that interviewees do not use medical
terminology in the same way that they do, and hence, there is obvious potential for
misunderstanding.
Patton (1999) said that good questions in qualitative interviews should be open
ended, neutral, sensitive, and clear to the interviewee, listing six types of questions that
can be asked, based on knowledge, opinion or value, behaviour or experience, feeling,
as well as those based on sensory experience and those asking about demographic or
background details. Most interviewees are willing to provide the kind of information
the researcher wants, however they need to be given clear guidelines about the amount
of details that is required, and it is generally accepted that is best to start with questions
that the interviewee can answer easily and then proceed to more difficult or sensitive
topics.
6.1.2.3 The Role of the Interviewer
The less structured the interview, the less determined and standardised are the
questions before the interview occurs. However, most qualitative researchers
conducting interviews will have a list of core questions that define the areas to be
covered. The order in which these questions are asked will vary, as will the questions
designed to probe the interviewees' meanings. Additionally, wordings cannot be
standardised as the interviewer will try to use the person's own vocabulary when
framing supplementary questions, as well as he might introduce further questions as he/
she becomes more familiar with the topic being discussed. Qualitative researchers,
especially in those cases where the interviewee knows that the interviewer is also a
doctor, need to consider how they are perceived by interviewees and the effects of
characteristics, such as class, race, sex, and social distance on the interview. The reason
becomes more intense when the interviewee is aware of the double role of the
interviewer, is that he or she, as a patient or a potential one, may wish to please the
doctor by giving the responses he/she thinks the doctor wants.
Due to the above, it is considered best not to interview one's own patients for
research purposes, and when this cannot be avoided, patients should be given
permission to say what they really think, and they should not be corrected if they say
things that doctors think are wrong. Interviewers are also likely to be asked questions
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transcribe, depending on the quality of the tape, which requires the costing of any
interview based study to include adequate transcription time.
6.1.2.5 Sampling Strategy
The process of identifying interviewees is determined by the purpose of the research
project. Statistical representativeness is not normally sought in qualitative research,
while sample sizes are not determined by hard and fast rules. On the contrary, they are
based on factors such as the depth and duration of the interview and what is feasible for
a single interviewer. Large qualitative studies do not often interview more than 50 or
60 people, although there are exceptions. Unlike clinicians conducting research in their
own workplace, sociologists conducting research in medical settings often have to
negotiate access with great care. Nevertheless, in any case, the researcher needs to
approach the potential interviewee, and present the purpose of the research, explaining
that a refusal will not affect future treatment. For the same purpose, an introductory
letter should be handed to the potential interviewees, describing what is involved, the
expected duration of the interview, clarifying that they will be conducted at interviewee
s' convenience and should give assurances about confidentiality. Finally, it is usually
preferable to interview people at home if take into account that the setting of an
interview affects the content.
6.1.2.6 Data Transcription
Transcripts of the above interviews were coded horizontally into major theme
categories. This strategy allows for the documentation of relationships between
emerging themes as well as similarities and differences across sub-groups (e.g. service
providers vs. individuals, medical professionals vs. the board of directors). The kind of
understanding gained through this strategy uncovers the complexity of conflicting
attitudes, values, and beliefs towards user inclusion in the context of changing practice
in the mental healthcare sector. This kind of understanding emerges through the
construction of major themes or categories from the raw data. Findings are the result of
setting the research objectives on the outset of the research project and arise directly
from the interpretation of the raw data. Inevitably, these findings are claimed to be
shaped by the assumptions and experiences of the researcher who makes the decision
of what is more or less important in the data. The credibility of these findings is tested
against the feedback from previous research.
The conclusions resulting from the coding have the following key features. They
are labelled according to their inherent meanings or specific features of the category in
162
which they fall. This classification presupposes a detailed descriptive and evaluative
account of the characteristics, scope, and limitations of each of the emerging categories.
Examples of text coded are provided to further exemplify and illustrate meanings,
associations, and perspectives associated with each category. Casual links between
different categories or other major themes are established in a hierarchical category
system, which assume commonalities or differences between categories or other casual
relationships. Generalisation of assumptions or categories provides the potential to
incorporate research findings into a wider theory or framework.
6.1.2.7 Rationale for Employing Face-to-Face In-depth Interviewing
The effectiveness, validity, and reliability of the research depend on the appropriate
selection of research methods and techniques. After considering the application of each
qualitative technique, in-depth interviews were considered appropriate for this study.
Firstly, the in-depth interview technique uses open-ended questions that allow the
interviewees to provide broader ideas. The researcher has more scope to understand the
perceptions and attitudes of different respondents. In addition, the researcher can deal
with the complexities, probe deeper for more important information, or even control
over the rate of missing data. To achieve the objectives of data collection, the researcher
can assist respondents during face-to-face in-depth interviewing (Robson, 2002;
Bernard, 2000). In addition, other data collection techniques, such as collage and word
association, can be used to facilitate the interview (Bernard, 2000). The researcher can
also judge the extent to which the interviewing is treated seriously (Robson, 2002).
Indeed, face-to-face in-depth interviews have the highest response rate and permit for
the longest interview period (Neuman, 2003; Saunders et. al., 2003). Advantages or
disadvantages of the in-depth interviewing are presented in Table 6.1.
Elite interviewing is one of the least widely referred to research methods in business
studies. As it is mentioned above, elite face-to-face interviews provide breadth and
depth of information about the background context of a research effort that may not be
feasible through other kinds of interviews (Gillham, 2000). The major difficulty in elite
interviewing lies in gaining access to an expert population and the limited time allowed
for the interviews.
Other techniques in Table 6.1 were not selected. The focus group technique is
advantageous as it has all experts in the same discussion table brainstorm each question.
However, it would have been hard to ensure the simultaneous availability of all these
top executives and hospital managers. In addition, some answers cannot be disclosed
163
to the public, as they may reveal classified information. The observation technique is
commonly used in behavioural studies and was considered appropriate for the Research
Section III. The other qualitative techniques in Table 6.1, such as word association,
sentence completion, and collages, can be used as facilitation tools in in-depth
interviews or the focus group. However, the researcher decided not to use these tools,
as the questions in the interview guide were deemed sufficient. It was concluded then
that the in-depth interviews and the questions in the interview guide were appropriate
for all the three sections of the study.
Description
Advantages
Success
between
others.
researcher.
Cannot
specific topics.
population.
researcher
and
Disadvantages
of
the
generalise
interview
to
the
places.
ethnography
the
techniques.
the
observation,
continuously
unnaturally.
technique,
researcher
participates
interested
activity
in
and
asks
they
will
act
Semi-Structured
Specific
open-ended
questions
Interviews
well-trained
same time.
Cannot
group
responses)
population.
Group
and
moderator
uses
encourages
the
generalise
to
the
164
Word
Association/
Sentence Completion
this technique.
Dependent
Collages
on
prepared
the researcher
Flexible response.
Dependent
on
the
Apperception
ambiguous picture.
Note: Modified from the table of common qualitative research tools by Zikmund and Babin (2007)
Research Context
Section I: Corporate
and Hospital related
Research (Elite indepth interviews)
Conceptual
Framework
Research Findings
165
As Yin (2003, p. 19) aptly remarks research design links the data to be collected
and conclusions to be drawn to the initial questions of the study it provides a
conceptual framework and an action plan for getting from questions to set of
conclusions. In addition, Maxwell (2005, p. 33), who studied qualitative research
design, states that the conceptual framework, the system of concepts, the assumptions
and theories, and the methods and sampling strategy that support and inform the
research, together constitute a key factor in determining the research design (Fig. 6.2).
Yin (2003) supports this viewpoint, mentioning that the researcher should
understand well the merits of the research prior to any field contact. He also developed
a typology of case study designs, which is based on the type of case study and the unit
of analysis (2009):
166
A case study approach was approved, as the focus of the research is to respond to
"what" and "how" questions. The researcher also wanted to include contextual
conditions, as they appear to be important to the phenomenon under study. Additionally,
a single-case (embedded) design was adopted. Although the research focuses on a
particular company, three of its hospitals (psychiatric) were under investigation, so
there were three units of analysis. Putting all these together, a qualitative type of
research was undertaken, following the conception of Rohrbeck and Gemnden (2011,
p. 234), who state, for research fields that are relatively new and about which the
knowledge is limited, a qualitative research design is recommended. This chapter
describes the design of the three different sections of the research. Firstly, lite in-depth
interviews with the top executives of the Euromedica Group were conducted to identify
organisations innovative and entrepreneurial activities as well as the role of the
customer in the service development process. Elite in-depth interviews were carried out
with the manager of every psychiatric hospital to discover their innovativeness: how
they conceptualise and manage patient participation in every day operations as well as
in new service development, and whether the hospitals adopt and implement the
corporate strategy. The total number of participants for this study group was 11.
Next, face-to-face semi-structured exploratory interviews with medical staff were
performed to identify, for example, the crucial matter of whether they believe that
patients can contribute something extra to the service innovation process or how they
understand their role in promoting the internal innovation process. What is more, those
interviews aim to illustrate, from the scientific point of view, how hospitals can increase
customer involvement in their innovative activity and obtain a different perspective on
the hospitals function. The total number of participants for this study group was 18, 6
interviewees from each hospital case.
Finally, face-to-face semi-structured interviews with selected patients from each
hospital were carried out to hear their own voice about the services they use or the
environment they live in. It is also important to understand patients perceptions about
the people (medical and nursing staff) who provide them treatment as well as whether
they participate in decision-making about their health, as well as whether they are
willing to take part in programmes in which they express their views on treatment. The
total number of participants for this study group was 30, 10 patients from each hospital
case.
167
Although each section of the research is independent, together they provide rich and
valuable information from quite different perspectives. Information that is combined
and contrasted gives answers to important questions: how patients should be involved
in the service development process; how Euromedica involves its customers in the
development of its health case services; what medical staff perceptions of customer
orientation are, and what role these perceptions play in the development of patient
oriented services. Consequently, it becomes apparent that a combination of
stakeholders views was required to gain a comprehensive understanding of the
development of new, customer-oriented health services and the exploitation of business
opportunities through corporate venturing. A total number of 59 interviews for all
Research Sections were conducted during the period of December 2010 to March 2011.
is possible, the open-ended nature of qualitative research means that these topics cannot
be avoided reliably (e.g. Richards & Schwartz, 2002; Holloway & Wheeler, 2009).
Exploitation
Feminist theorists, such as Sunar (1982), have debated the importance of power
relationships and the potential for research to exploit as well as exclude women
extensively. Others have argued that there is a power imbalance in the research
relationship, which is inevitable even when there is an intellectual and emotional
commitment between the researcher and the people being studied (e.g. Seidman, 2006;
Kincheloe & McLaren, 2002).
When a researcher is also a health professional, this power imbalance is exaggerated
in two ways, since the participant may feel pressurised or obligated to participate in
research because of a sense of duty, or because they depend on the good will of their
carers. Additionally, even though it is often assumed that a qualitative interview, which
allows the participant to speak in their own terms, can be therapeutic, the above feature
can also potentially result to exploitation and harm. If the interview becomes bemused
with a therapeutic encounter, a researcher may be inappropriately tempted to ask
sensitive questions and participants may reveal more information than they had
anticipated when deciding to take part to the study. These problems are more likely to
arise when one person fulfils the dual roles of researcher and health professional,
especially if they are directly involved in the care of the participant (Grbich, 1999).
Misrepresentation
The
theoretical
framework,
epistemological
commitments,
personal
risks seriously violating respect for participants' autonomy, which may also lead to
negative stereotyping.
The issues above are particularly relevant to health services research, as most
projects of this nature are designed to answer specific questions about the patients'
thoughts, perceptions and behaviour and, therefore, are strongly directed by
preconceived theories. Additionally, sampling strategies are often determined by these
theories, and participant characteristics, such as gender and socio-economic status,
which are considered significant, are embodied into the study design. Finally, there is
some evidence that the dynamics of the qualitative interview and the nature of data
collected can be affected by the researchers professional background (e.g. Grbich,
1999; Richards & Schwartz, 2002).
Identification of the participant by self or others
Throughout qualitative health services research, researchers collect large amounts
of data about interviewees' health and illness, their lifestyles and views about health
care, as well as information about members of their families and social groups, and if
identification occurs, it may potentially lead to serious harm such as prejudice and
retaliation to the patient or their wider social group. It is impossible to keep the
anonymity of the interview data at the stage of analysis. In addition, the identity of
participants will often be known to the person carrying out the transcription, since
interview transcripts contain multiple clues to the person's identity, such as their name,
employment details, place of residence and events, which have occurred in their
communities (Seidman, 2006). Even after the application of protocols that are supposed
to secure such anonymity, quotations, speech mannerisms and context may provide
enough information for participants to be identified by themselves or others, and it is
not always easy to predict which data will lead to identification (Fossey et al, 2002).
Inconvenience and Opportunity Cost
In addition to the serious potential risks described above, the inconvenience and
opportunity costs involved in participating in qualitative research are often
underestimated. As analyzed earlier in this study, most qualitative studies in the health
services involve in-depth interviews with participants, which normally last for at least
an hour and necessitate the interviewee travelling to a research centre or allowing the
interviewer into their home, and in some cases, the former will be asked to take part in
a second interview (Richards & Schwartz, 2002).
171
172
At the time of the interviews, the potential uses of the data are not always clear to the
research team, as it is in the nature of qualitative research that unexpected themes arise
during the analysis. Additionally, researchers may wish to archive interviews, which
could then be accessed for future research. In such cases, participants should be
informed and given the opportunity to withdraw permission for the use of their data.
Sufficient consent is obtained in qualitative research when participants are asked to
give very general consent at the beginning of the study, which, however, might diminish
the value of this consent or researchers can treat consent as an on-going process rather
than a one-off event. The British Sociological Association's Statement of Ethical
Principles stresses the necessity of involving participants when decisions are taken at
all stages of the research process, and also suggests that consent should not be regarded
as a once and for all event but as a process, subject to renegotiations over time. This
principle of involving participants in the design, implementation and propagation of
research is long established in sociology, as well as is increasingly recognised by the
academic medical community and funding bodies (e.g. Holloway & Wheeler, 2009;
Dewing, 2002). However, there are practical and ethical downsides to treating consent
as a process, as despite the small sample sizes of most qualitative studies, researchers
may consider re-contacting participants to be costly, impractical in cases where
participants and researchers who are geographically mobile, and most importantly, it
might be regarded as unnecessary harassment (Seidman, 2002).
There are also some special issues of consent arising in relation to qualitative health
services research, since in order to minimise the risk of exploitation and coercion, the
professional background of the researcher should be made clear to the participant,
particularly whether he or she is a health professional. Additionally, participants should
be informed that the research is not intended to be therapeutic or to be an attachment to
their medical care, as well as participants should be reassured that refusal to participate
would in no way endanger their health care (Grbich, 1999). It is important here to
underline that the above suggestions were taken into consideration and followed by the
researcher of this study.
Misinterpretation and Misrepresentation
Several measures can be employed to minimise the risk of misinterpretation, and
by extension, misrepresentation; respondent validation' refers to the process during
173
which researchers feedback the analysis to the participants before the findings are
published (Barbour, 2001; May & Pope, 2000). This practice has limitations and it has
to be treated as a process, instead of calling it a one off event. However, it involves
repeated contact with participants, which may be impractical and considered
harassment, just like treating consent as a process. Additionally, data obtained through
respondent validation are subject to the same process of interpretation as the primary
data, something that can be considered as the most fundamental objection (Easton et al,
2000).
It has to be mentioned that the risk of misinterpretation of data is highly increased
when a researcher is working in isolation (Easton et al, 2000). However, this risk can
be minimised by ensuring that trainee researchers are closely supervised and that
experienced ones have sufficient contact during the analysis with a co-worker who can
play the role of devil's advocate'. In addition to the above, researchers have to be aware
of and explicit about their possible biases by stating their theoretical approach to the
topic, and health professional researchers have to consider the ways in which their
personal and professional characteristics may have an impact on their interpretation of
data (Seidman, 2006).
Confidentiality
Qualitative studies collect large amounts of detailed personal information, which
are concealed by not only practical barriers, but also such contextual data, are often an
essential component of the analysis. There are some circumstances where participants
may not wish to remain anonymous, as identification with their expressed beliefs may
help participants to maintain ownership of the content and meanings of their narratives
(Baez, 2002). However, in most cases, qualitative health services research aims for
anonymity and confidentiality, and should use foolproof strategies for the secure
storage of tapes and transcripts, such as pseudonyms or initials that should be used in
transcripts and, where possible, alteration of other identifying details (Kaiser, 2009).
The failure to address these issues may result to the identification of participants and
make it easier to identify others through a process of elimination. As mentioned
throughout this study, there are detailed guidelines which exist for carrying out medical
research and that have been designed largely for use in relation to quantitative research.
Even though the ethical principles underlying both qualitative and quantitative
types of research are essentially the same, there is a number of special ethical issues,
which arise in relation to qualitative health services research. Researchers should
174
consider treating informed consent as a process rather than a one-off event, and they
should be aware that an interview might appear like a substitute of a therapeutic
encounter. Moreover, due to the possible confusion with a therapeutic encounter,
researchers should ensure that information and support for participants are available
when necessary. Extra care is required to ensure the anonymity of participants in
published work, since qualitative data by its nature is full of clues to participants'
identities (e.g. Easton et al, 2000; Miller, 2012). Additionally, the risk of
misinterpretation and misrepresentation can be minimised by ensuring that researchers
are adequately trained and supervised, and by encouraging reflexivity about the impact
of researchers' personal and professional characteristics might have.
Finally, in order to guarantee ethicality in qualitative health services research,
researchers, funding bodies, as well as reviewers should fully understand the scientific
basis and methodology of qualitative research. Of course, the possible disadvantages of
guidelines for qualitative research have to be taken into account, since they may be
over-prescriptive, inadequate or impractical (Grbich, 1999). However, it is obvious that
such guidelines are required for health services research, as many health services
researchers, unlike social scientists, are not trained in philosophical and political aspects
of research, so they might require more guidance on the ethical issues. Guidelines are
also required due to growing anecdotal evidence, both on a local and international basis
that researchers and ethics committees have difficulty judging the ethical soundness of
qualitative projects in health services research, and also because the actual risk to
participants is unknown, even though it is often assumed that involvement in qualitative
research is harmless (Miller, 2012). Research is needed in order to establish the risk to
participants in qualitative studies; it has been suggested that there is a need for a study
of researchers conducting qualitative research to determine the risks and rates of their
occurrence. Finally, further debate involving health professionals, social scientists and
ethicists is required, in order to establish ethical guidelines for qualitative research in
order to reach an agreement about what constitutes good practice (Baez, 2002).
The research tools (questionnaires) and patient approaches were designed and
evaluated in cooperation with medical experts of the Euromedica Group. It is also
important to add that the identity of all participants in the research remains confidential.
175
Designing: Refers to the methodological procedure and how it was planned and
prepared. The time schedule and the different steps were also analysed. This
step refers to the approach, the strategy, as well as the design of the research.
Analysing: Refers to the first part of the analysis that concerned the naming and
categorising of conclusions reached through the examination of data.
6.2
key shareholders were understandably preoccupied with the prospects of facing future
reduction budgets and expressed the intent to improve effectiveness without increasing
costs. The employees at Euromedica Group seem prepared to engage in the delivery of
customer-oriented services. There is an awareness on their part of existing ideas on
good practice and a great number of employee partcipants expressed willingness to
build on these. At board level though attitudes seem more sceptical about
acknowledgement and ownership of patients in service design and implementation.
Doyle (1999) suggests that researchers who undertake research in a setting where
they can understand participants and even identify their point of view are more likely
to gain a richer interpretation of their data. This process in qualitative research can result
in better rapport with participants and thus in more valid conclusions. To make sure
that participants feel comfortable about confiding about their role and contribution to
service processes within the particular care context, the researcher dedicated
considerable time to establishing an environment of unobstructive communication with
participants taking great care to listen to their views and feelings in a responsive and
176
settings. Providing the discourse context for service users creates opportunities for their
experiential knowledge to be heard, which can have profound influence on themselves,
carers, practitioners, and policy makers (LeFevre et al, 1996; Coleman, 1999).
Service users who were interviewed expressed in their majority their willingness
for further inclusion and active participation in day-to-day processes. It is well
documented in social mental health research that service users support the idea of a
more holistic and inclusive approach to implementing such services (Happell et al,
2003; Bailey, 2005). A substantial body of research has demonstrated the benefits and
positive outcomes from user service involvement (Lowes & Hulatt, 2005, Staley &
Minogue, 2006). Turner et al. (2003) demonstrated in their study that service users
support a whole systems approach in healthcare, benefits, transport and training and
employment opportunities. The benefit identified in the above papers on user service
involvement was the insight provided by users accounts when engaging in practice
situations. Happell et al (2003) and Khoo et al (2004) found medical practice to improve
under the introduction of user involvment schemes. Forrest et al (2000), Bennett et al
(2003), and Bailey (2005) indicated the challenges and conficts encountered in
curriculum development, recruitment, and assessment processes when the notion of
good practice between professional staff and user employees is different. Two surveys
conducted in service user involvement in psychiatrists training revealed the
psychiatrists reluctance to include service users in curriculum development or
selection processes.
Exclusion and stigmatisation are proved to have detrimental effects on individuals
sense of identity and integrity (Goffman, 1968). What is more, studies have shown that
those experience social or political prejudice can be at risk of mental health problems
(e.g. Sainsbury Centre for Mental Health, 2002; Social exclusion Unit, 2004). These
findings indicate that the social, cultural, political, and economical factors of exclusion
and stigma need to be considered in mental health research, something which clinical
approaches to mental health research and research methods have failed to do so.
Clinical approaches have contributed little to changing standardised treatments and
service responses. However, as social mental health research recognises the validity
and value of the diverse experiences of service users in the context of academic and
policy disources, service outcomes, which are increasingly more personalised, tailored,
and responsive begun to emerge. This studys in-depth interviews with the service users
in the hospitals reveal their awareness of their position within the hospital hierarchy,
178
their relationship with other stakeholders such as medical staff, nurses etc. What is more
telling is their perceived opression within the hospital setting as this is revealed in their
expressed discourse of oppression, discomfort, and subordination. This can be traced
both in the articulation of resistance, questioning of authority of those in charge of their
treatment, the expression of feelings of mistrust and resentement. A number of serviceusers followed along the lines of diving discourse of them versus us, identifying
non-service users (medical staff, nurses, managers etc.) as others, threatening, and
as unable to understand. Their concerns and their language use to describe these
concerns reveal a connection between mental distress and constraints and conflicts of
social meanings and social positions hidden beneath everyday perceptions and
experiences of the world. Their perceived subordination has a serious alienating effect,
which must not go unnoticed in mental health research. Many of the user service
participants revealed their sense of powerlessness through their silence, reluctance, or
inifference to participate in meaningful discussion about these issues.
It has already been established that the existing power and hierarchy structures
within the hospital settings of the Euromedica Group are still generally geared in favour
of medical professionals. Power sharing and authenitc communication is still resisted
by a number of professionals and organisation shareholders who oppose the validity of
user inclusion in decision-making processes. They support this view on the grounds of
users perceived incompetence to participate in professional structures. It seems that
they are emotionally unprepeared to engage in deep and meaningful debate about users
active inclusion and hold on to professional constructions of identity, power, and status.
This trend is more noticeable among executives and managers within the organisation.
On the contrary, medical and nursing staff demonstraterd higher levels of awareness of
the benefits of user involvement. They have demonstrated awareness of what consists
a good practice but remain largely confused as to how exactly such steps towards user
empowerment sould be implemented.
179
regularly used to describe this kind of research (Croot et al, 2011). In other words, when
a language barrier exists between qualitative researchers and their participants, the
research becomes a cross-language qualitative study that is characterised by unique
challenges related to language (Berman & Tyysk, 2011). Commonly, researchers
employ interpreters or translators to overcome that language barrier, and the way the
the former use the services of translators and interpreters in their study can affect the
results that are obtained from participants (Temple & Edwards, 2008).
Trustworthiness is a measure of a qualitative studys rigor, which is evaluated by
qualitative researchers by linking the trustworthiness of qualitative data to the
competence of the researcher orchestrating the study (Squires, 2009). A study by Tsai
et al (2008) about the development of culturally competent health knowledge showed
that in the case of cross-language qualitative research, inconsistent or inappropriate use
of translators or interpreters could threaten the trustworthiness of the study and
consequently, the applicability of the translated findings on participant populations.
Subsequently, using that standard with cross-language research, the way researchers
describe the role of translators in cross-language qualitative research reflects their
competence in addressing language as a methods issue. Several methods articles raising
the issue of cross language research have appeared since 2000, providing salient points
about difficulties related to cross-language research, however, no methodological
consensus has resulted from them (e.g. So & Best, 2010; Williamson et al, 2011).
Employing translators and interpreters provide language translation services. Even
though many use the terms without change, the two roles provide distinct services
(Temple & Edwards, 2008). For instance, when researchers need written documents
translated from one language to another - such as interview transcriptions or primary
and secondary sources - they employ a translator. On the contrary, they employ an
interpreter when translations to conduct an interview or focus group are required, as the
role of the interpreter provides oral translation services during an interaction between a
minimum of two people who do not speak the same language. Due to the fact that
different qualitative methods also require different roles for translators, researchers who
fail to systematically address the methodological issues that translators situate in a
cross-language qualitative research design can decrease the trustworthiness of the data
and, by extension, the overall rigor of the study (van Nes et al, 2010). Since the
translator and interpreter roles have been distinguished, in the following section of this
study several methodologically important issues for addressing language barriers
180
between qualitative researchers and their participants will be discussed. These include
maintaining conceptual equivalence, translator credentials, the translator or
interpreters role in the research process.
6.2.1.1 Equivalence of the Concept
Changes to language occur during the process of translation, as when a translator
performs a translation, they translate not only the literal meaning of the word, but also
the way the word relates conceptually in the context, which might be the sentence itself,
or the place where the person speaks it. The term 'conceptual equivalence' means that a
translator provides an accurate; both technically and conceptually, translated
communication of a concept spoken by participant in the study (e.g. Croot et al, 2011;
Squires, 2009). Consequently, when a poor translation occurs, the researcher may lose
the conceptual equivalence, or find the meanings of the participants words altered by
the way the translator performed the translation.
6.2.1.2 Credentials
For the above reason, it is obvious that the credentials of a person providing
translation services are important, as both credentials and experience will affect the
quality of translations produced by the translator and become especially crusial during
the qualitative coding and data analysis processes. Poorly translated concepts or phrases
will have a massive impact on the findings as they will change the themes emerged
from the analysis and may not reflect the actual words of the participant, threatening
the credibility and dependability of the cross-language study and form part of the
limitations of the study. Therefore, for research purposes, experts recommend that
translators or interpreters should have a minimum of sociolinguistic language
competence when providing translation service (Berman & Tyysk, 2011).
When translators or interpreters have this level of language competence, they
actually prove the ability to communicate between languages using complex sentence
structures, demonstrating a high level of vocabulary, in addition to the ability to
describe concepts or words in cases they do not know the actual word or phrase (e.g.
Squires, 2008). With this level of language competence, it can be ensured that translated
data is less likely to have errors related to translation. It is, therefore, ideal to employ
translators or interpreters to participate in a cross-language study possess certification
that come from a professional translators association, like the American Translators
Association, as they are credentialed individuals who have had their language
competency verified through a combination of educational and experiential criteria.
181
opt not to use a translator (Temple, 2008). For this reason, the investigator has to have
a high-level sociocultural competence and significant background knowledge about the
country or place of study. Nevertheless, in cases where the researcher plays both his
and the role of the traslator or interpreter, the literature recommends an independent
review to validate the technical and conceptual accuracy of the translation, in order to
ensure credibility and confirmability of data and findings translated by the former, and
by extension, to enhance the studys rigor (Temple et al, 2006). A certified translation
centre in Thessaloniki, which specialises in translating medical and health related
documents and terms, helped the researcher of this study to validate the translation of
the responses, enhancing the credibility of the research.
183
conclusions (Glesne & Peshkin, 1992). Therefore, it is obvious that the credibility and
reliability of qualitative methods depend largely on the skill, competence, and rigor of
the researcher doing the fieldwork. However, it might be also affected by things going
on in his/her life that might prove a distruction and may lead to prejudices and bias,
thereby providing invalid research and research that is not good. They need to ask
constantly themselves questions to ensure there are no interferences affecting their work
and lead to equal results. But, how should researchers reflexively evaluate ways in
which intersubjective elements transform their research?
The process of engaging in reflexivity is full of multiple trails as researchers
negotiate the swamp of interminable deconstructions, self-analysis and self-disclosure;
guidelines are offered by five variants of reflexivity, that involve introspection,
intersubjective reflection, mutual collaboration, social critique and discursive
deconstruction, each of which has a variety of opportunities and challenges (Ellis &
Bochner, 2000).
6.2.2.1 Introspection
According to Maslow (1966), there is no substitute for experience, pointing
researchers towards the value of self-dialogue and self-discovery. Those researchers
who begin their research with the data oftheir experience seek to embrace their own
humanness as the basis for psychological understanding (Walsh, 1995, p. 335). In this
case, researchers own reflecting, intuiting and thinking are used as primary evidence,
as believed by Moustakas (1990), who describes this process in terms of forming the
research question: The task of the initial engagement is to discover an intense interest,
a passionate concern that calls out to the researcher (p. 27). In different circumstances,
Moustakas (1990) describes heuristic research as the process of internal search through
which the researcher discovers meaning. In addition to examining ones own
experience and personal meanings for their own sake, insights may result from personal
introspection which then form the basis of a more generalised understanding and
interpretations, as reflections are assumed to provide data regarding the
social/emotional world of participants.
However, being preoccupied by ones own emotions and experiences can result into
misinterpreted or wrong findings. On the other hand, the researchers position can
become unduly privileged, blocking out the participants voice. Consequently, there is
a need to strike a balance, striving for enhanced self-awareness while eschewing navelgazing. Ultimately, reflexivity should be neither an opportunity to wallow in
184
187
rhetorical functions, while for this tradition they would notice that both participants and
researchers are engaged in an exercise of presenting themselves to each other.
Other post-modern researchers have focused on reflexive writing itself in terms of
textual radicalism. In that context, Lincoln and Denzin (1994) explain how textual
experimentation reflects a move towards a post-modern pluralism, which is needed to
be reflected in qualitative research. Accordingly, in the case explained above, there is
not one voice, but polyvocality; not one story but many talks, dramas, pieces of fiction,
fables, memories, histories, autobiographies, poems and other texts (p. 584).
Reflexivity to deconstruct gives post-modern researchers the opportunity to be creative
and powerfully thoughtful, provoking if they find a balance so as not to lose all
meaning. According to MacMillan (1996, p. 16), exposing the construction of a text
could be viewed as undermining the strength of its own position, since deconstruction
can clearly be applied to itself, with the researchers analysis deconstructing
(decomposing) before the ink has dried upon the page!.
6.3
customer orientation from the management perspective. All things considered, the role
and responsibility of top management is to deliberately create processes (regarding
innovation and corporate entrepreneurship) that are carefully cultivated and maintained
through cultural and structural design (Kemelgor, 2002, p. 70).
188
Research Context
Innovation &
Entrepreneurship
Literature
Development of the
propositions for Section I
Research Questions
for Research
Section I
Data Analysis
for Section I
Research Method
for Section I
189
Another study by Goldstein (2002) suggests that researchers should adopt lite
interviewing to seek information from a specific sample of officials (lites) to
generalise the outcome in connection with their characteristics or to search for
particular information. Therefore, researchers should be well-prepared, ask the proper
questions, establish a close relationship with participants, and work up the responses
accurately and consistently to make the analysis process straightforward and minimise
the inaccuracy contained in any interview data. What is more, researchers should be
receptive to the prospect that lite interviewees might have different professional
values, seniority, gender concepts, or culture. A study by Welch et al (2002a)
recommends that researchers seek balance in the interview process, exploiting this
opportunity to enhance communication and information exchange (Fig. 6.4).
Figure 6.4 Balancing Act by the Researcher in an Elite Interview (source: Welch et al, 2002a)
But how lites are defined? Giddens (1972) first described lites as a group of
people consisting of top executives of the organisation. More recently, a study by
Hornby et al. (2005, p. 495) indicated lites as a group of people in a society, etc. who
are powerful and have a lot of influence, because they are rich, intelligent, etc.
Likewise, Richards (1996, p. 199) define lites as a group of individuals, who hold, or
have held a privileged position in society and as such, () are likely to have had more
influence on political outcomes than general members of the public. On the other hand
Welch et al (2002b, p. 613) characterise the lite interviewee in international business
as an informant (usually male) who occupies a senior or middle management position;
has functional responsibility in an area which enjoys high status in accordance with
corporate values; has considerable industry experience and frequently also long tenure
with the company; possesses a broad network of personal relationships; and has
considerable international exposure.
190
questions
were
derived
from
the
innovation-management,
191
staff in innovation activity, the level, and type of market research undertaken on useroriented service development, and the management practices engaged when developing
new services. The key questions developed for discussion were about:
The tools and processes used to generate opportunities for service development;
The culture and the incentives for staff to identify and act on opportunities for
improvement;
The stimulus of growth and how this could help Euromedica to become more
innovative, developing new services and approaching new markets;
The number of services developed by Euromedica in the recent past and the plan
for the extension and evolution of their services;
The coordination among people and departments throughout the new service
development process;
The level of market assessment and the type of information obtained before any
investment is undertaken;
Whether there is room for customisation and judgement on the part of a service
provider;
192
Whether there are measures of customer satisfaction that the organisation uses
to improve its services.
INNOVATION
Activity, factors, and
business culture
Questions
1.
What are the internal factors that predispose Euromedica to
seek access to innovation?
2.
How and to what extent do external factors such as legislation,
social and economic, condition or stimulate favourable attitudes towards
innovation?
3.
Are adequate tools and processes used to generate
opportunities for product development?
4.
Does Euromedica do enough to create:
i)
A culture where continuous improvement is regarded as a
norm?
ii)
Incentives for staff to identify and act on opportunities for
improvement?
5.
How adequately or appropriately are the requirements of
customers taken into account in Euromedicas innovation strategy?
Sources
Adams et al (2006), Van Der
Panne et al (2003)
193
6.
Do you believe that customers can contribute something extra
to the service innovation process?
7.
How does Euromedica cope with failure in innovation? Does it
tolerate failure and learn from it? Or does it punish failure?
8.
What do you think is the role of the top executives in promoting
the internal innovation process?
9.
Do you believe that the stimulus of growth could help you
become more innovative, developing new services and approaching new
markets and why?
10.
Do you believe that the organisation and the structure of
Euromedica help you to implement innovative actions? If so, how does
this happening?
11.
Did Euromedica introduce any new or significantly improved
service in mental health sector?
12.
NEW SERVICE
DEVELOPMENT
Process, service
improvement and
evolution, and
coordination
CORPORATE
ENTREPRENEURSHIP
13.
How and to what extent has your service products changed
during the past 2 years?
14.
Does Euromedica have a plan for the extension and evolution
of its services?
15.
Where did the concept of developing new services come from?
(existing customers, new customers, market research, always part of the
plan?)
16.
How would you evaluate the coordination among people and
departments throughout the new service development process?
17.
Will you please describe the venturing and entrepreneurial
activity in Euromedica?
18.
What are Euromedicas venturing objectives?
Avlonitis et al (2001)
19.
How are entrepreneurial opportunities identified, evaluated
and selected by Euromedica?
20.
How does Euromedica encourage and support entrepreneurial
activity? How does recognise and reward innovative efforts?
21.
What preliminary market assessments occurred before any
investment was undertaken? (market research, market segmentation)
22.
Is there a clear idea of the type of information to be obtained
through market assessment?
23.
How much time and effort is spent in conducting
interdepartmental meetings to discuss market trends and developments?
Jaw (2010)
CUSTOMER
ORIENTATION
Market assessment,
customer relationships and
involvement, service
customisation, customer
satisfaction
24.
What type of relationship does the organisation have with its
customers?
25.
Is there an adequate process to track and respond to customer
queries and complaints? If so, does management get an up to date of the
status of complaints?
26.
Is there a formal method by which complaints, queries and poor
performance are fed into service development initiatives?
27.
Is there a robust mechanism to integrate the views of customers
into the service planning process?
Jimnez-Zarco et al (2011),
Kirca et al (2005)
Lado & Maydeo-Olivares
(2001), Matsuno & Mentzer
(2000)
Gouthier & Schmid (2003),
Grnroos (2007), Ernst et al
(2010)
Alam (2002), Carbonell et al
(2011)
Dolfsma
(2004),
Fitzsimmons & Fitzsimmons
(2000)
Cooper & Kleinschmidt
(1988),
Cinciantelli
&
194
28.
How much room is there for customisation and judgement on
the part of service provider?
29.
Please determine how Euromedica can increase customer
involvement in its innovative activity.
30.
Are there measures of customer satisfaction that you use to
improve your services?
Regarding the background information of each firm, the majority of the measures
used to assess the general background in Questions 1 and 2 were developed by adopting
firm related external and internal factors as suggested by Van Der Panne et al. (2003).
This study, suggests firm related factors are one of the four categories included in a
classification of factors that affect the innovativeness of an organisation. Subsequently,
this might depend on the satisfaction of relevant factors concerning the firms
background as well as the ecosystem that operates in.
Question 3 investigated whether the company uses adequate tools and processes to
generate opportunities for product development as suggested by Ali (1994) and Ali et
al (1995). These two studies report that the proper tools and processes lead to the
creation of opportunities for product development. Question 4 attempted to examine
whether there is a business culture that promotes innovation and acts on opportunities
for improvement as pointed out by Ahmed (1998). Question 5 aims to investigate
whether the case organisation takes customer requirements into consideration in order
to develop its innovation strategy. Several studies (e.g. Alam, 2006, 2002) have argued
that customers needs should be considered as key factors for innovation development.
Similarly, Question 6 aims to explore whether the executives in question consider
customers as key players of the innovation process, as Agarwal and Selen (2009), Alam
(2002), and Alam & Perry (2002) have pointed out. In addition, Question 7 takes the
arguments of Arbuss and Coenders (2007), and De Brentani (1995) that companies
should learn from failure instead of punishing it and, therefore, aims to explore whether
the case organisation tolerates failure and learns from it. Question 8 helps the researcher
to understand how executives perceive themselves in the promotion of the innovation
process as emphasised by Bantel and Jackson (1989). Question 9 adopts the arguments
of Ardishvili and Cardozo (1994) that the stimulus of growth guides companies to
become innovative and entrepreneurial, therefore, it aims to investigate whether
executives appreciate it as such factor. Questions 10 and 11 aim to explore whether
195
Euromedica has developed such structure and organisation that enable the
implementation of innovative actions and whether this has led to the development or
improvement of services in its mental health care division. Several studies (e.g.
Avlonitis et al, 2001; Beail, 2003) have noted that proper organisation and structure is
required for innovation development, particularly in the mental health sector.
The second part of the questionnaire aims to explore the new service development
activity and process of the Euromedica Group. Questions 12, 13, and 14 aim to show
whether the case organisation has developed and/or improved its services the recent
years as well as whether there is a plan for the extension and evolution of its offerings.
According to De Jong and Vermeulen (2003), Challans (2006) and others (e.g. Cowell,
1988; Johnson, 2000), those kind of questions give a good picture of the innovation
activity of a firm. Likewise, Question 15 aims to explore the source of the main ideas
for new services, as this is measurement tool of firms innovativeness as pointed out by
Storey and Hull (2010) and Calantone & Di Benedetto (1988). Finally, Question 16
investigates the level and quality of cooperation for service innovation among different
parties within the organisation. According to Bowers (1986) and Stevens and
Dimitriadis (2005), productive cooperation between people and departments has a
positive impact on the new service development process.
Following the second part, Questions 17 and 18 aims to examine the venturing
objectives and entrepreneurial activity of the Euromedica Group, as this would show
whether there is a linkage between service innovation and the entrepreneurial initiaves
of the firm (e.g. Henderson & Leleux, 2005; Narayanan et al, 2008). Similarly,
Questions 19 and 20 explore how entrepreneurial opportunities are identified and
evaluated by Euromedica and how it encourages, supports, and rewards such initiatives.
Many studies have shown that the evaluation process of business expansion
opportunities influences also the innovation activity of a firm as well as empolyees
quality of the contribution (e.g. Hornsby et al, 2002; Miles & Covin, 2002).
The last section of the questionnaire investigates the level of customer orientation
of the Euromedica Group. Questions 21 and 22 continue the goal of previous questions,
aiming to explore whether Euromedica gains knowledge and inputs from the market as
well as how it assesses the opportunities before any investments take place. According
to many authors, the information and initial assessment of any type of innovation is
required and determines the successfulness of the effort (e.g. Jimnez-Zarco et al, 2011;
Kirca et al, 2005). Similar to Question 16, Question 23 aims to examine the amount of
196
time and effort that is spent in interdepartmental meetings regarding market trends and
developments. Several studies have pointed out that such activities are critical for the
development of offerings that will meet market needs (e.g. Lado & Maydeo-Olivares,
2001; Matsuno & Mentzer, 2000). Moreover, Question 24 explores the type of
relationship between the case organisation and its customers, because studies have
proved that the good relationship between the two parties influences positively the
development and promotion of innovations (e.g. Grnroos, 2007; Ernst et al, 2010).
Questions 25 to 27, 29 and 30 aim to investigate whether a process, and/or a formal
method and/or a mechanism is used by Euromedica to respond to customer queries and
incorporate them into the service planning process, increasing customer involvement in
its innovative activity. Many authors have argued about the importance of such tools
and procedures that track complaints as well as integrate customer views into the
innovation process (e.g. Carbonell et al, 2011; Cheung & To, 2011). Finally, Question
28 explores whether there is flexibility on the part of the service provider, as several
studies have pointed out the importance of customisation in the service offerings,
especially in the mental health sector (e.g. Alam & Perry, 2002; Gao & Chen, 2010).
6.3.3.2 Validation Process of the Survey Instrument with the Item-Objective
Congruence (IOC) Index
The validation of the questionnaire was completed using the IOC technique and
pilot tests. There were two main stages performed [adapted from Weir (2005)] to
validate the questionnaire as presented in Table 6.3 below. During the validation
process, the IOC index was 0.85. The first draft of the questionnaire (40 questions) was
revised, and ten questions were finally rejected. After the completion of the two stages
in the quality control process in Table 6.3, the English version of the complete
questionnaire was completed as shown in Appendix 1.1 (the Greek version of the
questionnaire is presented in Appendix 1.2).
Table 6.3 Stages in the Quality Control Process of the Survey Instruments
Stage 1: A Priory Validation
Test Specifications of the Constructs
Literature Review
Needs Analysis (based on the reviews)
First Draft
Items Setting
Small Piloting (1st)
IOC index (experts judgement for content and
construct validity)
Stage 2: A Posteriori Validation
Pilot Study
Piloting (2nd)
Estimating Reliability
197
Main Study
the study entails interviewing a pre-defined and visible set of actors, the researcher may
be in a position to identify the particular respondents of interest and sample those
deemed most appropriate.
Table 6.4 Participant List for Research Section I
Firm/Organisation
Position
Euromedica Group
Chairman
Euromedica Group
Euromedica Group
Euromedica Group
Director of Quality
Euromedica Group
Euromedica Group
Euromedica Group
Thermaikos Hospital sa
Hospital Manager
Galini Hospital sa
Hospital Manager
Castalia Hospital sa
Hospital Manager
has reference to the procedure of summarising, selecting, coding, and categorising the
information to direct it towards essential aspects of the questions under consideration.
By data displays, Miles and Huberman (1994, p. 91) describe a visual format that
presents information systematically, so the user can draw valid conclusions and take
needed action. In other words, it refers to the process of organising and collecting the
data with a distinct focus and aims that lead to conclusion drawing and action.
Conclusion drawing and verification includes interpretation of the information
gathered, formation of patterns, and detection of rationalisation. It also relates to the
emergence of meanings responding to the research questions (Miles & Huberman,
1994; Sarantakos, 2005).
Figure 6.5 Components of Data Analysis: Interactive Model (source: Miles & Huberman, 1994)
The data collected for Section I were subjected to qualitative analysis by the
researcher. Analysis of relevant literature and documentation, along with the findings
of the interviews conducted in Section I, allowed for the creation of a new conceptual
approach to organizational strategy in this study (see Section 5.4).
Data analysis was performed throughout by a broad and thorough procedure as set
out by Creswell (2007). At the early stage of the qualitative analysis of Research
Section I, interviews were transcribed to produce manuscript that could be used to
generate coding categories and test theories. Before transcriptions were coded, each
transcript was examined carefully to enable a thorough understanding of its value. A
guide to themes then emerged, using a category system for data reduction and coding
in line with both the initial theoretical framework and the conceptions that had been
developed by the interviewees. The next step followed the process employed by
Lindgren and O'Connor (2011), who classified interview data and organised them
200
thematically to compare organisation, operation and strategy among case study sites as
well as participants viewpoints. This systematic process concerns the description of
managerial practices, the interpretation of decisions and actions, as well as the search
for patterns and correlations among data (Lindgren & O'Connor, 2011). Likewise, the
study by Pope et al (2002, p. 149) reports, when conducting this coding analysis the
researcher gives consideration to the actual words used, the context, the internal
consistency, the specificity of responses that is more based on one's own experiences
of respondents, and the big ideas beneath all detailed information.
As regards conclusion drawing and data verification, one would apply the notion of
Rohrbeck and Gemnden (2011), who recommend that a researcher should follow the
theoretical framework, identify and assess rival explanations and make a case
description.
6.4
results of this Section, together with the review of the relevant literature, added to the
development of the conceptual framework (See Chapter 5.4). The stages of the research
process for this Section are shown below (Fig. 6.6).
Research Context
Patient Involvement in
New Service
Development Literature
Research Question
for Research
Section II
Research Method
for Section II
Data Analysis
for Section II
Conceptual
Framework
Figure 6.6 Stages of the Research Process for Research Section II
202
Position
Castalia Hospital sa
Castalia Hospital sa
Castalia Hospital sa
Psychologist
Castalia Hospital sa
Occupational Therapist
Castalia Hospital sa
Social Worker
Castalia Hospital sa
Galini Hospital sa
Galini Hospital sa
Galini Hospital sa
Psychologist
Galini Hospital sa
Occupational Therapist
Galini Hospital sa
Social Worker
Galini Hospital sa
Thermaikos Hospital sa
Thermaikos Hospital sa
Thermaikos Hospital sa
Psychologist
Thermaikos Hospital sa
Occupational Therapist
Thermaikos Hospital sa
Social Worker
Thermaikos Hospital sa
203
6.5
health service users in developing services (e.g. Wensing & Elwyn, 2003; Marshall,
1996). The importance of their contribution to decision-making is also recognised
(Ritchie, 1999). A study by Green and Britten (1998) reports that qualitative studies
examine the attitudes, beliefs and preferences of practitioners and patients in an effort
to understand central clinical issues that cannot be responded to by experimental
methods, such as the reasons for patients following or abandoning health treatments
(Kuper et al, 2008). Another study by Telford et al (2002) underlines that customers
should be involved at almost every phase of the development and implementation of
health research projects in order to express specific needs and assist the development
of customer-focused care. Likewise, a study by Ritchie (1999) concludes that
practitioners should encourage user participation and researchers should engage them
in research processes.
A research by Grypdonck (2006) illustrates the contribution of qualitative research
in chronic illness cases, awareness of its findings helps healthy people, including
professionals, to understand how people with chronic illness feel or how they strive to
deal with it. This is well-founded in psychiatric research, where several methods should
be employed to identify the views of patients and collect relevant data (Wensing &
Elwyn, 2003; Brown & Lloyd, 2001).
204
Research Context
Patient Involvement in
New Service
Development Literature
Research Question
for Research
Section III
Research Method
for Section III
Data Analysis
for Section III
Conceptual
Framework
Figure 6.7 Stages of the Research Process for Research Section III
206
treatment and in customer-initiated tasks (Tobin et al, 2002). The aim of the questions
is twofold. First, to identify whether patients are capable of and interested in
participating in innovative processes that will provide them with new offerings and
enhanced service quality and second, to let patients assess the staff and condition and
quality of services. Following Patons suggestion (1987), early questions were prelusive
and easy to answer, while later ones were about more sensitive issues. Topics covered
including:
Level of care;
Questions
1.
Was it your choice to be treated; If so, was it your choice to be
treated in this hospital?
2.
Do you find someone on the hospital staff to talk to about your
worries and fears?
3.
Do you have confidence and trust in the way doctors treating
you?
4.
Would you trust the doctors of the hospital to discuss a
personal matter?
5.
Do you get answers that you can understand when you have
important questions to ask a doctor?
in hospital staff
Level
of
communication
Patients
participation
6.
In your opinion, are there enough nurses on duty to care for
you in hospital?
7.
How do you feel when engaged in clinical activities?
in
8.
Would you like to participate in the way decisions are made
for your health?
9.
Are you willing to participate in a particular programme in
which patients expressed about their treatment?
10.
work?
Sources
Bank & Millward
(2000), Beail
(2003)
Barnes & Bowl
(2001), Bowl (1996)
Ingvarsdotter et al
(2012)
Barnes & Wistow
(1994)
Bennett & Baikie
(2003),
Forrest
(2000)
Campbell (1996),
Goffman (1961)
Dodds & Bowles
(2001), Goffman
(1968)
Barnes & Wistow
(1994), Bennetts et
al (2011), Borg et al
(2009)
Barnes & Wistow
(1994), Bennetts et
al (2011), Borg et al
(2009)
Berger et al (1996)
207
and
11.
What do you think of the services provided to patients?
In particular on:
i)
The way of nursing patients (wounds, sores, etc.);
ii) The way of caring for hygiene (bath, shaving, laundry, etc.);
iii) The method of administration of drugs (even hours, checking
on patients, etc.);
iv) The way of boarding patients
12.
how?
13.
Have you ever been asked about the services you use? If so,
Coleman (1999)
Gillard et al (2010),
Lammers &
Happell (2003)
Gillard et al (2010),
Madianos (2002)
Dodds & Bowles
(2001), Goffman
(1968)
hospital
infrastructure
Productivity of patients during
their residence in the hospital
14.
How do you criticise the infrastructure of the hospital
(condition of the building, surroundings, facilities, etc.)?
15.
Do you feel productive during your residence in the hospital?
According to Bank and Millward (2000) and Beail (2003), there are many cases of
mental patients who either do not recognise their health issue or do not choose the centre
for their hospitalisation. Therefore, the first question is introductory and acted as a filter
for the researcher to understand whether the interviewee appreciated their health issue.
Furthermore, Questions 2 to 4 were related to confidence and trust on the part of the
patients to hospital staff. Studies have shown that those are critical elements for the
participation of service users to the any activity of the hospital (e.g. Barnes & Bowl,
2001; Ingvarsdotter et al, 2012). Likewise, Question 5 aims to explore the level of
communication between doctors and patients, which is also important for the latters
participation (Bennett & Baikie, 2003; Forrest, 2000). Question 6 examines the level of
care provided in the case hospital units. According to Campbell (1996) and Goffman
(1961), the adequate number of nursing staff, providing quality care and good
communication to patients has a positive influence in patients involvement. Questions
7 to 10 aim to investigate whether patients are willing to participate in clinical activities
and decision making, with several studies putting that as the cornerstone of the
successfulness of such initiatives and plans (e.g. Bennetts et al, 2011; Borg et al, 2009).
Similarly, Questions 11 and 12 examine the service provision quality, with studies also
highlighting its importance as a factor that affects patients willingness to contribute to
service development initiatives (e.g. Bellali & Kalafati, 2006; Hampshire, 2000).
Questions 13 and 14 are related to patients perception regarding staff behaviour and
hospitals infrastructure. Staff behaviour and the infrastructure of the setting (e.g.
condition of the building, surroundings, facilities, etc) have been reported also as
208
important factors that affect the enthusiasm of mental service users in participation in
innovation or other activities (e.g. Gillard et al, 2010; Gillard et al, 2010). Lastly,
Question 15 aims to explore whether the patients feel productive during their residence
in the hospital. Dodds and Bowles (2001) and Goffman (1968) have argued that patients
who feel active and productive are more likely to participate and ask for new initiatives
that would improve their health condition and living standards.
aim of the analysis is to identify, explore, and further compare the data collected by all
types of participants so that real and valuable answers for the research questions may
emerge(Brown & Lloyd, 2001).
6.6
with the research questions and conceptual framework mentioned in the previous
chapters. The research design in this study consists of three sections. The first is related
to corporate and hospital research, aiming at collecting data from the organisations
executives and the managers of the hospitals. In-depth elite interviews with 11
executives and hospital managers were employed to answer the first two research
questions: What is the role of the customer (and of the market) in the development of
health services in Euromedica Group? and How does Euromedica Group exploit
service innovation to engage in corporate venturing? Well-designed tools for
collecting data result in reliable research outputs. The questionnaire was validated by
the consulting supervisor and by experts using the IOC index. In this study, the
researcher used the interview guide to collect the data. Then, the collected data were
analysed following three different stages: data reduction and coding, data organisation
and classification, and data verification and conclusion drawing (Lindgren & O'Connor,
2011; Rohrbeck & Gemnden, 2011).
The second research section involves the medical staff and aims to collect data
about the involvement and their perceptions regarding patient contribution in new
service development. Semi-structured exploratory interviews with 18 members of the
three hospitals medical staff was conducted to answer the third research question:
What are medical staffs perceptions of customer orientation and what role do they
210
211
Chapter VII
Qualitative Data Analysis of Senior Executives
This chapter opens the analysis section of the present research study. It explores the
results of the lite in-depth interviews performed with top executives - members of the
decision-making team - of the Euromedica Group. This chapter aims to illustrate the
innovative activity of the Group, the tools and processes employed to develop new
health services, the entrepreneurial model used by Euromedica to expand its operations,
and the strategy for customer involvement in developing new offerings. In addition, it
aims to address the research propositions, questions, and objectives specified in Chapter
6.
A series of strategic issues linked to the process of new service development,
venture creation and customer orientation were investigated in this chapter, including:
the factors that force the company to be innovative; the coordination among people and
departments throughout the new service development process; the business culture and
the incentives for staff to identify and act on opportunities for improvement; the
processes to track and respond to customer queries; and the methods that fuel service
development
initiatives.
Managerial
perspectives
regarding
entrepreneurial
opportunities within the health care industry and customer orientation in health services
provision were also examined.
To answer the first two research questions (see section 1.2.3), the elite in-depth
interviews were employed as a technique. The results of those interviews, conducted
with 8 senior executives of the Euromedica Group and another 3 hospital managers (see
Chapters 8, 9, and 10), were then examined to deal with the research questions. The
results from the interview data were analysed and categorised into four categories
innovation, new service development, corporate venturing, and customer orientation
based on the conceptual framework. These findings are presented in the following
sections.
The first research section was led by the first two research questions (RQ1 & RQ2).
Figure 7.1 illustrates that the propositions that emerged from those two research
questions guided to the collection of data from two different sources - the executives of
the Euromedica Group (part 1) and the hospital managers (part 2). The researcher
212
213
Objectives
Background information that aim to present the internal
and external factors that affect innovation
12.
How many new services did you introduce last year?
13.
How and to what extent has your service products changed
during the past 2 years?
14.
Does Euromedica have a plan for the extension and evolution
of its services?
15.
Where did the concept of developing new services come from?
(existing customers, new customers, market research, always part of the
plan?)
16.
How would you evaluate the coordination among people and
departments throughout the new service development process?
17.
Will you please describe the venturing and entrepreneurial
activity in Euromedica?
18.
What are Euromedicas venturing objectives?
19.
How are entrepreneurial opportunities identified, evaluated and
selected by Euromedica?
20.
How does Euromedica encourage and support entrepreneurial
activity? How does recognise and reward innovative efforts?
214
21.
What preliminary market assessments occurred before any
investment was undertaken? (market research, market segmentation)
22.
Is there a clear idea of the type of information to be obtained
through market assessment?
23.
How much time and effort is spent in conducting
interdepartmental meetings to discuss market trends and developments?
24.
What type of relationship does the organisation have with its
customers?
25.
Is there an adequate process to track and respond to customer
queries and complaints? If so, does management get an up to date of the
status of complaints?
26.
Is there a formal method by which complaints, queries and poor
performance are fed into service development initiatives?
27.
Is there a robust mechanism to integrate the views of customers
into the service planning process?
28.
How much room is there for customisation and judgement on
the part of service provider?
29.
Please determine how Euromedica can increase customer
involvement in its innovative activity.
30.
Are there measures of customer satisfaction that you use to
improve your services?
The in-depth elite interviews were conducted with top management executives and
hospital managers of the Euromedica Group in order to further understand and present
the innovative and entrepreneurial activities of this organisation. The data collection
employed content analysis in order to allow categorisation into four groups, as
mentioned in previous sections. Below, the analysis of the data of those four groups is
conducted, starting with the innovation activity of the case organisation and the role of
patients and then describing the health service development process. It follows the
analysis of the companys entrepreneurial model and finally, the customer involvement
in the health service innovation is discussed.
7.2
and the role of patients in general. As it can be seen below, the role of top executives in
promoting the internal process of innovation is examined as well as whether the
organisation and structure of Euromedica helps its employees to implement innovative
actions. The analysis starts with the factors that predispose or stimulate innovation and
continues with the examination of the business culture.
215
216
context, it is not easy to integrate innovative actions, so legislation usually does not
push for innovation: rather the opposite.
As regards the economic factors, many participants argue that, especially in the last
decade, businesses that operate in Greece had benefited from the good economic
climate and from easy credit; people could spend more easily than today. Other than
that, both Directors of Corporate Development and Quality argue that economic factors
influence innovative activity only in relation to whether it is costly, i.e. the cost of
developing an innovation or the motivation required. However, an innovative activity
is not always costly. As regards social factors, participants responded that they affect
the company as it operates in the area of health care, which is the sovereign good for
people. Therefore, Euromedica cannot be callous, but must show social awareness at
unit level and at group level through its social responsibility programme. The Chairman
characteristically stresses that the objective of Euromedica is to help people in need
through innovative ideas and actions and the result of this assistance is financial gain.
Euromedica
follows
four-step
process:
concept,
design,
implementation, and evaluation. Ideas usually come from the continuous monitoring of
217
developments in the industry and the needs that arise. Later, ideas are evaluated and
priced. Sustainable ones are adopted and others that may not be viable or profitable but
confer prestige are categorised as such. In such cases, those ideas that seem to create
no significant negative effects are approved. There is also a strategic planning
committee and, along with the management team, they arrange regular meetings to
develop and improve services. In addition, a special body to plan future investments
exists (see Section 7.3.2). It is also found that the company attempts to establish a
culture where top executives solve problems and develop ideas based on a model of
growth and innovation. This approach works well and transfers knowledge from
managers and supervisors to the remaining staff.
In addition, Euromedica tries to create a culture of continuous improvement,
encouraging employees to suggest new ideas for diversifying its services and enhancing
quality. The CEO of Euromedicas Neurological Services stated, The Company aims
to develop a labour culture where everyone can create, grow, and feel proud of working
here. According to the Vice-Chairman, there are three types of incentives in such
cases. First is the moral reward, where the directors of hospitals have to motivate staff
to contribute, with new ideas, to the company's growth. Second, there is a financial
reward as a bonus for success and overall effort, and finally, institutional rewards when
employees get promotion according to their performance in relation to the needs of the
company. Nonetheless, the Chairman highlights that the company mainly prompts and
expects high officials (e.g. doctors, managers etc) to present new proposals, business
ideas, and investments. Incentives for other staff are usually designed to encourage
adoption and implementation of the new development. However, there are respondents
who note the absence of such actions. Medical and Nursing Directors answer that no
such incentives in fact exist and the Director of Patients Services and Admissions
mentions, The Company has no executives who are motivated towards improving.
There are no incentives to personnel and the general economic climate does not help
at this time.
218
views and novel ideas from customers. These are the main driving force even in
strategic moves, such as creating a new unit or a new service. The market requirement
(e.g. doctors, patients, etc.) and the development of medical science are the factors that
impel the acceptance and integration of innovation within health care industry firms.
The Quality Director explains that Euromedica has developed customer service
departments for patients and relatives in every hospital unit. We consider customers
complaints or claims so as to improve our services, she adds.
Still, top executives of the Euromedica Group support the opinion that patients may
contribute and should be involved in the process of developing and improving the
accommodation/residential services, and rather less the medical methods. According to
the Chairman, patients can contribute to innovation management and not to
innovation acceptance or implementation. As regards medical services, doctors are
those who decide on and follow scientific rules and developments. This is also
supported by both the Nursing Director and the Director of Patient Services and
Admissions. However, the CEO of Euromedica Neurological Services responds that in
mental health services we hear carefully what our patients have to say about their
treatment.
219
However, it seems that there is room for improvement regarding the participation
of the scientific staff in fostering innovation. The Director of Medical Services states
that the role of physicians should be more decisive, while the Director of Patient
Services emphasises that the administration should develop a more fruitful cooperation
with them. Nevertheless, there appears an elastic reaction to unsuccessful innovation
movements. Following a well-known Greek saying, Euromedica prefers sometimes to
take wrong decisions than to take none. This emerges from the response of the ViceChairman that even the best business plans may prove to be erroneous and fail. The
point is to learn from your mistakes and improve. In line with this, other executives
mention that there are times where the performance of an investment has been
overestimated or seems to have significant short-term benefits only. In such cases,
failure is analysed to prevent recurrence. The firm follows proper procedures to analyse
innovation prior to the implementation and commercialisation stages.
220
of the Greek economy. According to the Vice-Chairman, though, efforts are being made
to complete projects in progress. Additionally, the Group's growth in various sectors of
health care is very important. As seen in Chapter 2, Euromedica has developed units
and services in all health care disciplines, such as diagnostic centres; outpatient clinics;
general clinics; specialised clinics, e.g. obstetric, psychiatric, oncology; and
rehabilitation centres. Therefore, growth, both geographically and in services provided,
remains the main stimulus for the Euromedica Group. Moreover, health care services
in Greece and other Southeast European countries have not developed to the extent they
could have, or have developed elsewhere in Europe. Thus, Chairman underlines that it
is important, through innovation, to get to the new market segments first.
7.3
coordination dynamics within Euromedica. It aims to explore the level of new service
development within the last two years, the source of ideas for new services as well as
the level of coordination among people and departments throughout the development
process. The sector of mental health care and the presence of Euromedica is examined
below as well as the evolution of services and the strategic plan for expansion.
221
222
223
7.4
presence, providing a range of health services. Another key element in the companys
entrepreneurial model is its collaboration with doctors. For example, physicians, and in
some cases other investors from the local market, participate in the ownership structure.
The company is keen to develop such cooperation, because local investors support the
investment knowing the market, the community, the culture of the area, and so on. This
creates a combination of forces and knowledge. Usually, the number of such investors
is commensurate with the nature of the project. The ownership structure of such
partnerships varies. Ideally, Euromedica prefers to hold 50% of shares, but in some
cases, legislation stipulates that doctors must own the majority of shares. Nevertheless,
the company might own more in cases where the percentage of 50% cannot be met by
other investors. The Chairman emphasises, this method of development offers
significant competitive advantages, contributing to the consolidation and secure
expansion of the company.
Euromedica also operates in many fields of health care that have an independent
parallel development. There are times where physicians call for the development of a
facility or service and then the company tries to homogenise, implant common
monitoring procedures, and integrate these within a context of development and
planning. The Director of Corporate Development explains that the peculiar business
model of Euromedica is ongoing, as it has derived from rapid growth through
accumulation of forces and multiple investments. In mental health services, the
company follows the same model, using the experience and economic contributions of
psychiatrists, psychologists, and physicians who aim to establish a hospital in their
community.
224
225
Analysis and discussed in company meetings. The Board of Directors' decisions are
based on economic criteria and competitiveness. Each investment, however, requires
time for data collection. The Vice-Chairman states that, when developing a diagnostic
centre for example, usually a few months are required for data collection, assessment
and decisionmaking. On the other hand, when the company establishes an oncology
(cancer) hospital, the procedure is clearly more demanding and time-consuming.
7.5
and service customisation initiatives that have been carried out by Euromedica. It also
explores whether adequate processes, tools and mechanisms have been used to track,
respond and integrate customers opinions in service development efforts. Additionally,
the level of customer involvement is analysed below.
226
227
Nonetheless, there is a printed form in all units, which is given to patients to assess
all stages of the provided service, i.e. quality of accommodation and food, staff
behaviour, a record of any complaints or suggestions. Those forms are collected then
processed by the unit, and the rating is monitored over time. Thus, the level of operation
of each unit is revealed, with the scope for improvement and growth potentials.
Notwithstanding, in mental health clinics no such tools have yet been adopted. Still, as
mentioned by the Vice-Chairman and CEO of Euromedica Group, there is doubt about
such actions in Greek society and unfortunately, only a small number of patients
complete the assessment leaflet. Furthermore, the Chairman points out that customers,
either of hospitals or of other centres, do not usually participate in filling in
questionnaires. Therefore, there is a pertinent instruction to the managers and heads of
departments to interact with customers. Yet, he stresses that people who reach a health
facility usually experience a health issue and therefore are not in a suitable mood or
would not patiently share their thoughts.
However, there is no official method in which complaints and suggestions from
patients feed initiatives for developing new services. At hospital level, there is an
informal process through the cooperation of managers, so that patients' complaints may
fuel initiatives that meet their needs. The CEO of Neurological Services indicates, The
low performance and initiatives for service development are set out differently in each
unit and are activated as based on its management team. The firm has not yet
developed a specialised mechanism to incorporate the views of customers into the
process of designing new services. As mentioned above, the suggestions from patients
and physicians are discussed in regular meetings where top executives and managers
take the actual decisions. That is about all.
Overall, the respondents' answers maintain that the company makes efforts to
evaluate its services rather than customise them. There is no central policy within
Euromedica to determine detailed rules for adjusting. However, as indicated by the
Chairman, heads of the units are fairly autonomous in the management of everyday
life and incidents. Moreover, according to Vice-Chairman, the company collaborates
with external evaluation advisers, who identify the effectiveness of both services and
staff. The results point to either the improvements that need to be made or the adoption
of successful and profitable operations by the other units of the Group.
228
7.6
Summary of Findings
A summary of the findings can be seen below in Table 7.2.
Table 7.2
Questions
1.
What are the internal factors
that predispose Euromedica to seek
access to innovation?
Evolution of technology; enhanced quality of the service offerings; the need to remain
competitive and have additional revenue from different sources in a time of crisis.
2.
How and to what extent do
external factors such as legislation,
social and economic, condition or
stimulate favourable attitudes towards
innovation?
3.
Are adequate tools and
processes used to generate opportunities
for product development?
229
4.
Does Euromedica do enough
to create:
i)
A culture where continuous
improvement is regarded as a norm?
ii)
Incentives for staff to identify
and act on opportunities for
improvement?
5.
How
adequately
or
appropriately are the requirements of
customers taken into account in
Euromedicas innovation strategy?
6.
Do you believe that customers
can contribute something extra to the
service innovation process?
7.
How does Euromedica cope
with failure in innovation? Does it
tolerate failure and learn from it? or
does it punish failure?
8.
What do you think is the role
of the top executives in promoting the
internal innovation process?
market researches in order to be acquainted with the needs of customers, the state of the
competition, and other important information that helps the firm take appropriate
decisions. Reports on industry or employment published by consultancy firms
complement the information required. All hospital units have questionnaires for service
users from which useful conclusions are drawn for service development and/or
improvement. Euromedica follows a four-step NSD process: concept, design,
implementation, and evaluation. A strategic planning committee along with the
management team arrange regular meetings to develop and improve services.
Euromedica tries to create a culture of continuous improvement, encouraging employees
to suggest new ideas for diversifying its services and enhancing quality.
Three types of incentives have been used: moral rewards, financial rewards, and
institutional rewards. The Chairman highlights that the company mainly prompts and
expects high officials (e.g. doctors, managers etc.) to present new proposals, business
ideas, and investments. Incentives for other staff are usually designed to encourage
adoption and implementation of the new development.
The company is open to views and novel ideas from customers. It considers them as the
main driving force even in strategic moves, such as creating a new unit or a new service.
The market requirement and the development of medical science are the factors that
impel the acceptance and integration of innovation within health care industry firms.
Euromedica has developed customer service departments for patients and relatives in
every hospital unit.
Patients may contribute and should be involved in the process of developing and
improving the accommodation/residential services, and rather less the medical methods.
There appears an elastic reaction to unsuccessful innovation movements. There are times
where the performance of an investment has been overestimated or seems to have
significant short-term benefits only. In such cases, failure is analysed to prevent
recurrence. The firm follows proper procedures to analyse innovation prior to the
implementation and commercialisation stages
The role of managers in the innovation process of a hospital is critical, as they are aware
of the unit and areas needs. Every manager is responsible for promoting solutions and
bringing forward ideas for innovation. The role of top executives is the most important
in promoting the internal innovation process. There are those who push for a decision to
be taken, for an innovative activity, or for an innovative investment to be made. If
executives do not give support to the suggestions of physicians and patients, then no
proposal will proceed to the next stage. However, there is room for improvement
regarding the participation of the scientific staff in fostering innovation. The role of
physicians should be more decisive and the administration should develop a more fruitful
cooperation with them.
One of the companys main goals is to integrate many innovative ideas, resulting in its
strategic growth. Therefore, growth, both geographically and in services provided,
remains the main stimulus for the Euromedica Group.
9.
Do you believe that the
stimulus of growth could help you
become more innovative, developing
new services, and approaching new
markets and why?
10.
Do you believe that the The views of participants are ambiguous. Some defend the organisation and the
organisation and the structure of structure of the firm in implementing innovative actions, while others claim that there
Euromedica help you to implement is room for improvement.
innovative actions? If so, how does this
happening?
NEW SERVICE DEVELOPMENT: Process, service improvement and evolution, and coordination
11.
Did Euromedica introduce any The company has not introduced any new services to the industry. The aim is to develop
new or significantly improved service in the sector as is, as it falls short in Greece, in both infrastructure and in the manner of
mental health sector?
providing services.
12.
How many new services did Euromedica Group has run a series of new units - diagnostic centres, rehabilitation
you introduce last year?
centres, and a cosmetic medicine centre in the previous year. Further, new practices,
technologies and surgeries within existing clinics have been developed.
As regards mental health services, several attempts have been carried out to unlock this
sector, either by developing activities beyond the clinics by or using experts,
occupational therapists and psychologists, to provide new services and bring alternative
forms of engagement for patients.
230
13.
How and to what extent has
your service products changed during
the past 2 years?
14.
Does Euromedica have a plan
for the extension and evolution of its
services?
Health services have changed considerably over the past 2 years, by both increasing the
number of units and by expanding its business into two sectors, that is, mental health
care, and physical rehabilitation. Moreover, the existing units have introduced a number
of new departments and services, updated their equipment, and developed new
treatments. In addition, molecular biology was added recently.
There have also been several other improvements, i.e. establishing an integrated
computer system that helps hospitals organisation, customer management offices, and
others. As regards mental health care, great importance is given in establishing new open
structures that will reintegrate patients into society
The growth of the company is designed in line with the range and quality of public sector
services, the structure of the private sector, and the services provided in each area. As
regards mental health care, the company has developed a medium-term development
programme, establishing 10 hospitals in an equal number of geographic locations.
The ideas for such programmes come from the companys executives, associate doctors,
competition, and market research. Initiatives usually come from unit managers, who are
responsible for the development, or doctors who will introduce a new idea. Comments
and suggestions by customers also play an important role.
15.
Where did the concept of
developing new services come from?
(existing customers, new customers,
market research, always part of the
plan?)
16.
How would you evaluate the The views of participants are ambiguous. Many issues arise between hospitals staff and
coordination among people and those in the central offices. This constitutes a constraint on the introduction of new
departments throughout the new service actions. Furthermore, the model of Euromedica has a peculiarity. The units are
development process?
independent and often do not work together, but develop an internal competition.
CORPORATE ENTREPRENEURSHIP: Business model, venturing activities, entrepreneurial opportunities
17.
Will you please describe the Euromedica is interested in having a wide geographic presence, providing a range of
venturing and entrepreneurial activity in health services. A key element in the companys entrepreneurial model is its
Euromedica?
collaboration with doctors.
The peculiar business model of Euromedica is ongoing, as it has derived from rapid
growth through accumulation of forces and multiple investments. In mental health
services, the company follows the same model, using the experience and economic
contributions of psychiatrists, psychologists, and physicians who aim to establish a
hospital in their community.
18.
What
are
Euromedicas Business development goals of the group define the geographical spread of services,
venturing objectives?
achieving maximum population coverage and development across all sectors of health
care. Overall, the goal for Euromedica is to create a Pan-Hellenic Health Group, which
would operate at all levels of health care in major regional capitals, gain a strong position
in rehabilitation centres and therapeutic tourism in tourist areas, and be able to expand
into neighbouring countries.
In the field of mental health, the goal is to develop a network of 10 hospitals,
geographically distributed to respond to increasing needs. In addition, primary care is to
be developed so that mental patients can be treated from the beginning of the illness until
their reintegration into society.
19.
How
are
entrepreneurial There is a group of Board members, which is responsible for developing business in
opportunities identified, evaluated and Greece and abroad. The financial analysis department examines the financial data of the
selected by Euromedica?
target units and prepares business plans for new ones. The legal department verifies the
legality of the establishment and operation of units and their assets. Eventually, the
Board takes the final decisions on entrepreneurial ventures.
20.
How
does
Euromedica The firm encourages its partners-investors to provide new ideas for investment in order
encourage and support entrepreneurial to develop the operations of the company and gain a larger market share.
activity? How does recognise and The organisation seems to encourage the participation of doctors through economic
reward innovative efforts?
benefits and support for entrepreneurship by large percentage holdings and roles in
organising the business.
CUSTOMER ORIENTATION: Market assessment, customer relationships and involvement, service customisation,
customer satisfaction
21.
What preliminary market The company benefits from the international literature on health services, studying the
assessments occurred before any trends and relationship between provision and demand. A second component is the
investment was undertaken? (market conditions in the region under discussion, utilising the company's experience from
research, market segmentation)
similar investments. Additionally, the firm seeks to learn from its competition and
associate doctors, who usually express their requirements prior to the implementation of
an investment, as they are well aware of local market needs. The initial step is the
scientific evaluation of an innovation. Second is an appreciation of the number of
231
22.
Is there a clear idea of the type
of information to be obtained through
market assessment?
23.
How much time and effort is
spent in conducting interdepartmental
meetings to discuss market trends and
developments?
24.
What type of relationship does
the organisation have with its
customers?
25.
Is there an adequate process to
track and respond to customer queries
and
complaints?
If
so,
does
management get an up to date of the
status of complaints?
26.
Is there a formal method by
which complaints, queries, and poor
performance are fed into service
development initiatives?
27.
Is there a robust mechanism to
integrate the views of customers into the
service planning process?
28.
How much room is there for
customisation and judgement on the part
of service provider?
29.
Please
determine
how
Euromedica can increase customer
involvement in its innovative activity.
30.
Are there measures of
customer satisfaction that you use to
improve your services?
7.7
possible incidents that can be served by this investment and, afterwards, a business plan
is developed based on the pricing and cost of the investment, that shows whether it will
be viable.
The first element to explore is whether there is sufficient number of customers-patients
as well as the economic background of the area in question.
Information is often required about local needs, competition, and infrastructure for
business development initiatives.
Interdepartmental meetings are conducted to review developments and market trends.
Firstly, the problems of the units are discussed as well as the local competition.
Thereafter, regular meetings are organised with executives and managers, discussing the
progress of all units, industry developments and the firms positioning, suggestions for
development/improvement, etc.
The company maintains tight and daily contacts with physicians, giving incentives for
cooperation, attending medical conferences, and organising relevant events.
Additionally, the relationship with patients begins and finishes inside the hospital and is
maintained by offering superior quality.
Authorised individuals are designated in hospitals to specialise in customer service,
being responsible for responding to patients questions or fulfilling their special
requirements, identifying difficulties and ensuring their resolution.
The hospital manager is responsible for providing solutions in other cases where major
concerns are recorded. In addition, associate physicians who refer patients to
Euromedica reflect on the services provided and then the company receives feedback,
availing itself of an excellent relationship with these physicians.
There is no official method in which complaints and suggestions from patients feed
initiatives for developing new services. At hospital level, there is an informal process
through the cooperation of managers, so that patients' complaints may fuel initiatives
that meet their needs.
The firm has not yet developed a specialised mechanism to incorporate the views of
customers into the process of designing new services. The suggestions from patients and
physicians are discussed in regular meetings where top executives and managers take
the actual decisions.
The company makes efforts to evaluate its services rather than customise them. There is
no central policy within Euromedica to determine detailed rules for adjusting.
Respondents agreed that the corporation should increase patient involvement in new
service development and venturing activities by establishing a partnership with a
specialised organisation, which shall contact patients who used its services or by
adopting practices and methods for customer involvement to enhance quality and meet
special requirements of patients and families.
There are no particular tools that are used to measure customer satisfaction. Overall,
customer participation in new service development activities is poor, even though the
company recognises its importance.
Conclusion
Following the objectives of the present research, the analysis of the first phase
focused on how the senior management of the Euromedica Group perceives innovation
and entrepreneurial activity as well as the importance and contribution of customers. It
is remarkable that, in general, the responses of participants were based on the same
background and were assimilable. Only in a few cases were there dissimilar views on
the same topic. The main points that provide answers to the research questions are
summarised below.
232
233
Chapter VIII
Qualitative Data Analysis for Thermaikos Hospital
This chapter explores the operation of Thermaikos Hospital and the conditions for
patient involvement in day-to-day care. It falls into two parts. The first investigates the
opinion of administrative and medical staff regarding the factors that determine
innovative activity, the tools and processes applied for new service development, the
contribution of customers, and the role of executives and medical personnel in the
innovation process, customer involvement in new health service development, as well
as others. The second part examines the perspective of customers regarding the
hospitals operation and infrastructure along with their level of enthusiasm for being a
part of the service development process.
Similar to the previous chapter, several strategic issues are linked to the innovation
strategies and new service development processes as well as patients perspective and
willingness to participate in such activities. To enrich the answer of the first two
research questions, the researcher interviews the managers of the three case hospitals.
This chapter demonstrates and analyses the answers that were taken from the first case
hospital: Thermaikos Hospital. The results from the interview data were analysed and
categorised into four categories innovation, new service development, corporate
venturing, and customer orientation based on the conceptual framework. These
findings are presented in the following sections.
In this case, the three research sections were led by the research questions. Figures
8.1 and 8.2 illustrate that the propositions that emerged from the RQs guided to the
collection of data from three different sources - the manager (part 1), the medical staff
(part 2), and the patients (part 3). The researcher gained insights from those three
subgroups of participants on customers involvement in new service development and
on exploitation of service innovation for corporate venturing. Those insights and the
combination of answers and different perspectives led to the mapping of the key
findings.
234
8.1
managers (see section 7.1), the participants consisted of three groups, with the hospital
manager (1 participant), medical staff (6 participants), and patients (10 participants)
covering the wide range of interviewees for Thermaikos Hospital. As it was described
in Section 7.1, this used expert sampling, a form of purposive sampling for medical
staff, while stratified sampling was used to identify the right type of patients (e.g.
McKeown et al, 2010; Ghauri, 2005).
Table 7.1 in the previous chapter illustrates the questions that was also used for
hospital managers and describes the objectives of each question. Similarly, Table 8.1
displays the objectives and the role of each question that was used to interview medical
staff. As it was mentioned in Section 6.5.3, the questionnaire included some of the same
questions used in the interviews with hospitals administrative staff. The aim of this
action was to collect a similar kind of information, but from different perspectives - that
235
of administrative and medical staff in order to make comparisons. This tool aims to
collect data regarding the hospitals innovation activity, new service development
process and the level of patient participation in hospital activities and initiatives (for
more details see Section 6.5.3 and Appendix II).
Likewise, Table 8.2 presents the questions that were used to collect data regarding
the position and intentions of patients within the hospital to participate in new service
development programmes and other similar activities. The aim of the questions is
twofold. First, to identify whether patients are capable of and interested in participating
in innovative processes that will provide them with new offerings and enhanced service
quality and second, to let patients assess the staff and condition and quality of services
(for more details see Section 6.6.3 and Appendix III).
Table 8.1
Questions
1.
Are adequate tools and processes used to generate opportunities
for product development?
2.
Does Euromedica do enough to create:
i)
A culture where continuous improvement is regarded as a
norm?
ii)
Incentives for staff to identify and act on opportunities for
improvement?
3.
Do you believe that patients can contribute something extra to
the service innovation process?
4.
How does the hospital cope with failure in innovation? Does it
tolerate failure and learn from it? or does it punish failure?
5.
What do you think is the role of the medical staff in promoting
the internal innovation process?
6.
Did Euromedica introduce any new or significantly improved
service in mental health sector?
Objectives
To explore whether the company uses proper tools and
processes, leading to the creation of opportunities for
product development
To examine whether there is a business culture that
promotes innovation and acts on opportunities for
improvement
7.
How many new services did the hospital introduce last year?
8.
How and to what extent have your service products changed
during the past 2 years?
9.
How would you evaluate the coordination among people and
departments throughout the new service development process?
10.
What type of relationship does the organisation have with its
patients?
11.
Is there an adequate process to track and respond to customer
queries and complaints? If so, does medical staff get an up to date of the
status of complaints?
12.
Is there a formal method by which complaints, queries and poor
performance are fed into service development initiatives?
13.
How much room is there for customisation and judgement on
the part of service provider?
236
14.
Please determine how the hospital can increase customer
involvement in its innovative activity.
15.
Are there measures of customer satisfaction that you use to
improve your services?
Table 8.2
Questions
1.
Was it your choice to be treated; If so, was it your choice to be treated in this
hospital?
2.
Do you find someone on the hospital staff to talk to about your worries and fears?
3.
Do you have confidence and trust in the way doctors treating you?
4.
Would you trust the doctors of the hospital to discuss a personal matter?
Objectives
To investigate the confidence and trust
of patients in hospital staff
5.
Do you get answers that you can understand when you have important questions to
ask a doctor?
To
explore
the
level
of
communication between doctors and
patients
To explore the level of care
To examine patients participation in
clinical activities and decision making
6.
In your opinion, are there enough nurses on duty to care for you in hospital?
7.
How do you feel when engaged in clinical activities?
8.
Would you like to participate in the way decisions are made for your health?
9.
Are you willing to participate in a particular programme in which patients
expressed about their treatment?
10.
Do you think that patients should be employed in hospitals work?
11.
What do you think of the services provided to patients?
In particular on:
i)
The way of nursing patients (wounds, sores, etc.);
ii) The way of caring for hygiene (bath, shaving, laundry, etc.);
iii) The method of administration of drugs (even hours, checking on patients, etc.);
iv) The way of boarding patients
12.
Have you ever been asked about the services you use? If so, how?
13.
How do you criticise the conduct of staff to patients?
14.
How do you criticise the infrastructure of the hospital (condition of the building,
surroundings, facilities, etc.)?
15.
Do you feel productive during your residence in the hospital?
237
8.2
Patients
This section examines the hospitals innovation activity and the role of patitents in
service development initiatives. The factors that encourage innovation as well as the
tools that are used for new service development are explored below among other issues,
such as organisational structure, entrepreneurial activities, and customer orientation.
238
8.2.4 The Role of the Top Executives and Scientific Personnel in Promoting
Innovation Process
The manager supports that top executives and scientific personnel, design and foster
innovation, mentioning that their role is critical, as these are those who develop ideas
and determine the method of implementation. However, this view is supported only by
the manager. Scientific staff who participated in the research hold a different viewpoint
and acknowledges that the voice is unheard; there is scepticism from a part of the
administrative staff, some of whom prefer to support the existing order. Nevertheless,
the hospital treats failure with clemency in an attempt to be innovative. The aim is to
gain knowledge from such experiences, to improve the hospitals operation and
procedures. There may be penalties, however, for example in cases of omission, the
manager said.
8.2.5 The Structure and the Stimulus of Growth for Thermaikos Hospital
The manager argues that the stimulus of growth significantly helps the hospitals
innovative activity, resulting in new groups of patients. Better organisation and
enhanced structures are required for the hospital to proceed to the development of new
services. This is somewhat difficult to achieve at this point in time, he adds.
8.3
in the mental health care market in the last two years. The director explains that the
problems of the past and the current financial crisis do not leave room for growth.
239
240
does not implement any processes that would reward such efforts. The manager reports,
Regular discussions take place within the hospital, both with the medical staff as well
as with patients and relatives. My role is to hear everyone and then I keep those that I
consider important and viable at the time of discussion. I also keep notes about
suggestions that could open opportunities for growth in the near future. The
management team is always interested in and encourages medical staff to participate
in discussions regarding hospitals operations and development.
As regards recognition and rewarding, it comes out that there is room for
improvement. The hospital managers notes, Even though we listen to what our
stakeholders have to say, we have not adopted any official process that would promote,
encourage, and reward the participation of, let us say, patients or employees. I think
that we could be in a better position than where we are today, in terms of recognition
and rewards for innovative efforts.
242
243
managed yet to get to where we want, the manager adds. The psychologist suggests a
regular discussion with patients or the distribution of a questionnaire to those who are
responsible for patients care (doctors, nurses, etc), including questions about their
nutrition, hygiene and service provision in general. The purpose of such action would
be to gain useful information and ideas for new offerings. The social worker adds that
such actions should be adopted to reduce passivity and turn patients towards the
community. The head of the nursing service agrees, adding that, at times, irregular
actions take place. Finally, it is evident that no measures of customer satisfaction are
applied to service improvement.
8.6
Hospital
It is worth noting that in most cases, patients answered questions in one word, even
though the questions were open-ended and the research pursued a deeper
understanding. First, it was important to recognise whether patients agreed to be treated
at this hospital. According to their responses, it appears that many would not like to be
hospitalised at all, as they did not acknowledge their health problem. Only two of the
respondents were willing to enter this hospital and follow treatment. Two others
accepted their mental health issue, but it was their family who had proposed admission
to this hospital. The administration, however, informed the researcher that many
patients are committed to hospital by court order. Summary information with regard to
demographic and social characteristics can be found in Table 8.3 below.
10
Gender
Male
Male
Female
Male
Female
Male
Male
Male
Male
Female
Age
52
40
43
53
70
61
53
75
52
38
Years of
hospitalisation
12
10
13
10
15
Primary
School
High
School
High
School
High
School
High
School
Primary
School
High
School
Undergraduate
Degree
High
School
High
School
Education
244
8.7
Table 8.4
Questions
1.
What are the internal factors
that predispose Themaikos hospital to
seek access to innovation?
2.
How and to what extent do
external factors such as legislation,
social and economic, condition or
stimulate favourable attitudes towards
innovation?
246
3.
Are adequate tools and
processes
used
to
generate
opportunities
for
product
development?
4.
Does Euromedica do enough
to create:
i)
A culture where continuous
improvement is regarded as a norm?
ii)
Incentives for staff to
identify and act on opportunities for
improvement?
5.
How
adequately
or
appropriately are the requirements of
customers taken into account in
hospitals innovation strategy?
6.
Do
you
believe
that
customers/patients can contribute
something extra to the service
innovation process?
7.
How does Euromedica cope
with failure in innovation? Does it
tolerate failure and learn from it? Or
does it punish failure?
8.
What do you think is the role
of the top executives/medical staff in
promoting the internal innovation
process?
9.
Do you believe that the
stimulus of growth could help you
become more innovative, developing
new services, and approaching new
markets and why?
10.
Do you believe that the Better organisation and enhanced structures are
organisation and the structure of required for the hospital to proceed to the
Thermaikos hospital help you to development of new services.
implement innovative actions? If so,
how does this happening?
NEW SERVICE DEVELOPMENT: Process, service improvement and evolution, and coordination
Hospital Manager
Medical Staff
11.
Did the hospital introduce
any new or significantly improved
service in mental health sector?
12.
How many new services did
you introduce last year?
The hospital has not introduced any new or improved service in the mental health care
market in the last two years.
The problems of the past and the current financial crisis do not leave room for growth
247
13.
How and to what extent has
your service products changed during
the past 2 years?
14.
Does Euromedica have a
plan for the extension and evolution of
its services?
15.
Where did the concept of
developing new services come from?
(existing customers, new customers,
market research, always part of the
plan?)
16.
How would you evaluate the
coordination among people and
departments throughout the new
service development process?
There is no short-term plan for the expansion of operations or the development of services.
The hospital tries to address some internal issues and survive, overcoming the crisis.
18.
What are the hospitals
venturing objectives?
19.
How are entrepreneurial
opportunities identified, evaluated and
selected by the hospital?
The manager answered negatively to the questions that regard the hospitals venturing
objectives. He reported that it is Euromedica who sets out the goals.
There are several ways to identify entrepreneurial opportunities, such as by eavesdropping
the market or by involving stakeholders in the development process.
As regards medium-term planning, there are only thoughts and ideas, which mainly
originate from existing customers and the hospitals vision.
20.
How
does
Thermaikos Thermaikos provides the necessary time to employees to share their views and suggestions
encourage and support entrepreneurial concerning hospitals operations, but does not implement any processes that would reward
activity? How does recognise and such efforts.
reward innovative efforts?
CUSTOMER ORIENTATION: Market assessment, customer relationships and involvement, service customisation,
customer satisfaction
Hospital Manager
Medical Staff
21.
What preliminary market Market research is a daily, open process. However, decisions about the course of the hospital
assessments occurred before any are taken by Euromedica and therefore the manager considers that his role is complementary
investment was undertaken? (market to decision-making and executive to decision implementation
research, market segmentation)
22.
Is there a clear idea of the Market assessment is carried out by Euromedicas bodies. Therefore, hospitals
type of information to be obtained management team has ignorance about the kind of information that should be obtained
through market assessment?
through market evaluation.
23.
How much time and effort is No departmental meetings are held to discuss market trends, but only informal discussions
spent in conducting interdepartmental among hospital executives with reference to developments in the mental health sector.
meetings to discuss market trends and
developments?
24.
What type of relationship The relationship between the hospital and its The hospital tends to operate near
does the organisation have with its customers is based on sound service provision, capacity. This proves a good relationship
customers?
as they appear to choose this hospital unit to with patients. Also, deinstitutionalisation
tackle their problem if they relapse. This is moving very slowly in Greece, so some
creates a trusting relationship over the years.
patients have spent their entire lives in the
hospital. In those cases, an interpersonal
and even a kind of "family" relationship
have been developed.
248
25.
Is there an adequate process
to track and respond to customer
queries and complaints? If so, does
management get an up to date of the
status of complaints?
26.
Is there a formal method by
which complaints, queries, and poor
performance are fed into service
development initiatives?
27.
Is there a robust mechanism
to integrate the views of customers
into the service planning process?
28.
How much room is there for
customisation and judgement on the
part of service provider?
29.
Please
determine
how
Euromedica can increase customer
involvement in its innovative activity.
30.
Are there measures of
customer satisfaction that you use to
improve your services?
Table 8.5
Questions
1.
Was it your choice to be treated; If so, was it your
choice to be treated in this hospital?
Service Users/Patients
Many patients would not like to be hospitalised at all, as they did not
acknowledge their health problem.
2.
Do you find someone on the hospital staff to talk to
about your worries and fears?
3.
Do you have confidence and trust in the way doctors
treating you?
4.
Would you trust the doctors of the hospital to discuss
a personal matter?
5.
Do you get answers that you can understand when
you have important questions to ask a doctor?
6.
In your opinion, are there enough nurses on duty to
care for you in hospital?
7.
How do you feel when engaged in clinical activities?
Nearly all of them believe that staff is close to them and takes an
interest in discussing their worries and fears.
Patients have confidence and trust in doctors.
8.
Would you like to participate in the way decisions
are made for your health?
9.
Are you willing to participate in a particular
programme in which patients expressed about their
treatment?
10.
Do you think that patients should be employed in
hospitals work?
11.
What do you think of the services provided to
patients?
In particular on:
i)
The way of nursing patients (wounds, sores, etc.);
249
ii)
13.
14.
How do you criticise the infrastructure of the
hospital (condition of the building, surroundings, facilities,
etc.)?
16.
8.8
Conclusion
The main points that provide answers to the research questions are summarised
below.
. It has become rather clear in this research that nearly every mental health patient
could in fact communicate needs and desires if approached with the proper technique
(see Section 4.2.2.3). Indeed, a few members of staff strongly believe that service users
should contribute to the development of new offerings, resulting in a more patientoriented process. On the other hand, it does emerge that the administration attempts to
consider customers views to facilitate quality health services. It seems, therefore, to be
a confusion among administration and medical staff about the role of customer in new
service development (RQ1) as well as the role and willingness of medical staff in
developing patient oriented services (RQ3). It is also comes forward that there is no
strategic plan for the expansion of services, nor is market assessment performed by the
hospital. However, Thermaikos Hospital maintains tight relationships with service
users, while lacking, nonetheless, organised procedures and appropriate tools for
keeping details about customer requirements and complaints. Thus, it comes forward
that this unit does not utilise innovation in order to expand its services, showing also
that it does not engage in corporate venturing activities (RQ2).
The second part of the chapter explores customers opinion regarding their
experiences within the hospital and their involvement in the service development
process. Many agree that people should feel useful, dynamic, and productive, and
therefore suggest they be employed in hospital work. It is worth mentioning, however,
that in some cases there were different approaches among patients. A few prefer to
250
manage their health issue with minimum assistance from doctors. The above illustrate
a poor willingness of patients to be involved in a service development process,
preferring only to use new services that are designed and developed by doctors (RQ4).
The next chapter continues the analysis of the second case hospital: Castalia
Hospital.
251
Chapter IX
Qualitative Data Analysis for Castalia Hospital
This chapter investigates the functioning of Castalia Hospital in addition to the
prerequisites for patient involvement in care. This chapter also comprises two parts.
The first examines the views and attitudes of executives and scientific staff, with
reference to the aspects that influence innovation activity, the instruments, and
procedures employed for developing new services, the role of the workforce in any
innovation process, as well as patient participation in service development. The second
part explores the patients' perception of the hospitals activity and infrastructure in
conjunction with their interest in being involved in service development.
As the three chapters of cases follow the same analysis approach, here again the
strategic issues are linked to the innovation strategies and new service development
processes as well as service users perceptions and enthusiasm to join in such activities.
This chapter reveals and examines the answers that were taken from the second case
hospital: Castalia Hospital. The results from the interview data were analysed and
categorised into four categories innovation, new service development, corporate
venturing, and customer orientation based on the conceptual framework. These
outcomes are presented in the next sections.
In this context, the three research sections were led by the research questions.
Figures 9.1 and 9.2 illustrate that the propositions that emerged from the RQs guided
to the collection of data from three different sources - the manager (part 1), the medical
staff (part 2), and the patients (part 3). The researcher gained insights from those three
subgroups of participants on customers participation in new service development and
on exploitation of service innovation for corporate venturing. Those insights and the
combination of responses and different viewpoints headed to the mapping of the key
findings.
252
9.1
Similar to the approach that was used for Thermaikos Hospital (see section 8.1), the
participants consisted of three groups, with the hospital manager (1 participant),
medical staff (6 participants), and patients (10 participants) covering the wide range of
interviewees for Castalia Hospital.
Table 7.1 in Chapter 7 illustrates the questions that was also used for hospital
managers and describes the objectives of each question. Similarly, Table 8.1 in the
previous chapter displays the objectives and the role of each question that was used to
interview medical staff. This tool aims to collect data regarding the hospitals
innovation activity, new service development process and the level of patient
participation in hospital activities and initiatives (for more details see Sections 6.5.3
and 8.1, and Appendix II).
253
Likewise, Table 8.2 presents the questions that were used to collect data regarding
the position and intentions of patients within the hospital to participate in new service
development programmes and other similar activities (for more details see Sections
6.6.3 and 8.1, and Appendix III). Below, the analysis is shown, starting with the
innovation activity of Castalia Hospital and the role of patients, followed by the
development of health services within the hospital. It follows the analysis of customer
orientation in health service development and this chapter ends with describing and
analysing the insights of patients regarding their readiness to contribute to hospitals
service development.
9.2
Patients
This section aims to analyse the innovation activity, the business culture as well as
the factors that stimulate or hinder innovation within Castalia hospital. Below, the tools
and processes for new service development are presented along with the role of
executives and medical staff in promoting innovation. Finally, the role of customers in
the innovation process is described.
254
to society. Still, it is worth noting the difference in responses as regards the incentives
given to staff to identify shortcomings and present ideas for improvement. Half of the
respondents answered that incentives for improvement are provided, with the social
worker indicating that the medical staff is regularly informed on how to address
illnesses. The other half, including the Director of the unit, do not consider themselves
as highly motivated or that staff is sufficiently informed to act appropriately.
9.2.4 The Role of the Top Executives and Scientific Personnel in Promoting
the Innovation Process
Responses vary and are of particular interest regarding the role of top executives
and scientific personnel in promoting innovation. Participants agree that staff play a
determining role as they promote and reassess innovative services. The physician states
that the workforce is the driving force behind any attempt to innovate, while the social
worker notes that staff should keep up-to-date and adopt innovations to maximise their
efficiency. The psychologist states that everyone who utilises their own knowledge
seeks to improve and to promote new ideas in order to enhance the operation of the
clinic. The psychiatrist proposes certain actions to set the framework for the
development of new services:
sought. Failure is the beginning of all subsequent efforts to improve and progress,
she adds. Similarly, the Director argues that failures are permitted when a service is
under construction or jointly developed. Shortcomings are likely to be penalised,
however, when an attempt was made individually without the approval or consent of
the supervisor.
9.2.5 The Structure and the Stimulus of Growth for Castalia Hospital
The manager believes that the stimulus of growth could help them become more
innovative, developing new services and approaching new markets, resulting in an
economic return. Castalia hospital could save resources, labour hours, and materials for
the development of innovative services if it adopted better organisational and
functioning systems.
9.3
examines the strategic plan for the expansion of services within Castalia as well as the
level of coordination among people and departments throughout the innovation process.
256
9.4
of our customers, who will choose and follow Castalia in its next entrepreneurial
initiatives.
9.5
section. The relationship of the hospital with its customers is analysed. This section also
discusses whether methods, processes, and tools for customer involvement are used.
258
259
argues that the hospital could also promote alternative types of employment, such as
part-time work outside the hospital, while the social worker reports that hospital could
increase patients involvement by setting rewards or other incentives. The psychiatrist
goes a step further, saying that the hospital should encourage patients to make their own
proposals for innovation and improvement. The analysis so far indicates that the
scientific personnel communicate with patients and are aware of their needs and desires.
Patients also communicate through expression and discussion groups. Therefore, the
psychiatrist' suggestion above already applies and does not constitute a method for
widening patient involvement. Additionally, the nursing and scientific staff encourage
patients to participate in innovative activities, though they approach novel offerings
with caution. It also comes forward that no appropriate tools are used for measuring
patient satisfaction, but only informal discussions with practitioners.
9.6
in detail their views about the living environment, and sharing their opinions regarding
their contribution to developing new services. It is important to note that many
respondents chose this hospital to address their health problem. Two of them
underlined, it is a good hospital. I did not like the other two where I stayed.
Information regarding demographic and social characteristics can be seen in Table 9.1
below.
Table 9.1 Demographic and Social Characteristics of the Respondents
Patients/
Variable
10
Gender
Female
Male
Male
Male
Male
Male
Male
Male
Male
Male
Age
50
39
59
54
50
58
49
48
64
60
Years of
hospitalisation
Primary
School
High
School
Undergraduate
Degree
High
School
Primary
School
Primary
School
High
School
Primary
School
High
School
High
School
Education
male patient, who has spent six years at the hospital, says that he talks to the
psychiatrist, but prefers to discuss his worries with relatives. Many participants reported
that they get comprehensive responses from doctors, noting that the staff is willing to
explain. Still, a female patient, who has spent eight years in the hospital, said,
Explanations are difficult to understand sometimes. Nevertheless, participants
appear to have confidence and trust in the way doctors treat them. One reported, I trust
medical staff, for the reason that they are willing and responsible.
Furthermore, patients mostly declared that there are enough nurses on duty to care
for them in hospital, though two of them would like to see more, especially over the
weekend. Further, participants seem to agree that their nursing service is satisfactory,
underlining that nursing staff treat patients and their needs with responsibility and strive
for the best. Similarly, they consider the method of administration of drugs acceptable,
with regularity and stability. One also stresses that there is adequate control over
whether patients have taken their medication. There is a similar picture for basic
hygiene care (baths, shaving, laundry, etc.), it being mentioned that there is a good and
organised service, although a few people would prefer it to be more frequent. Likewise,
many are pleased with the board and lodging, assessing it as organised and prompt.
Others state that there is room for improvement, wishing to see more fruit in the diet
and more waiters in service.
What is more, patients evaluate the behaviour of staff positively, as proper,
responsible, and patient. One notes the kindness and friendliness of staff, mentioning
that they make every effort to keep patients happy, while another highlights, It is a
hard work. There is fortitude on the part of staff and good relationships with patients.
A good number of the participants trust the hospitals doctors to discuss personal
matters, reporting that they feel comfortable with them. There are a few, though, who
declare that it depends on the doctor, as they do not trust all of them. Finally, patients
evaluate the infrastructure of the hospital as suitable to meet their principal needs,
stating that it has been improved and maintained well. Nonetheless, many say that more
chairs and tables should be added in the courtyard, shaded areas should be extended,
and a site for physical activity should be created.
261
again. Two of the respondents, however, offered more thoughtful answers, indicating,
I feel that am a responsible person and deserve respect. I find myself through those
activities and I consider myself there as a useful and capable person. In addition,
nearly everyone would like to participate in the way decisions are made about their
health, mentioning that it would be nice to express themselves, even if this already
happens to some extent within expression groups. Only one, a female patient, 50,
responded that she does not feel able to be involved in such activities. It is however
remarkable that they have never been asked about the services provided. A female
service user, who has lived eight years in the hospital, reveals that this is the first time
someone has asked for her opinion. Apart from that, it becomes apparent from the
research that patients are willing to participate in a particular programme in which they
would be able to express their views on their treatment. Most of them answer that they
would like to share their beliefs with those responsible for their health condition and
would be keen to talk about how service offerings could be enriched. A male patient,
who has spent the last six years in the hospital, adds that this attempt would bring them
even closer to staff and doctors.
Respondents also identify a need to be employed on the hospitals work, its
everyday tasks. They recognise that this would help them to overcome their deficiencies
and to recover. A male service user reported that both work and group activities
facilitate patients' putting behind them their concerns and escaping from the confined
space of the hospital. One argued that engagement in such activities makes people feel
useful and both patients and staff benefit, while another disagreed, stating that work
does not help patients, as most of them are not in a position to offer much, as a result
of their health condition. Finally, only two participants do feel productive during their
residence in the hospital. One noted that he expresses himself through work and
activities and the other stressed that he feels capable while participating in activity
groups (i.e. construction, puzzles, handicrafts, etc.). It is worth noting, though, that most
of the patients involved in the research feel quite unproductive and bored in the hospital.
Only one male patient, who has spent nine years in the hospital, said that although he
is not productive, he does not have any need to be so.
9.7
A summary of the findings can be seen below in Table 9.2 and Table 9.3
262
Table 9.2
Questions
1.
What are the internal factors
that predispose Castalia hospital to
seek access to innovation?
2.
How and to what extent do
external factors such as legislation,
social and economic, condition or
stimulate favourable attitudes towards
innovation?
3.
Are adequate tools and
processes
used
to
generate
opportunities
for
product
development?
4.
Does Castalia do enough to
create:
i)
A culture where continuous
improvement is regarded as a norm?
ii)
Incentives for staff to
identify and act on opportunities for
improvement?
5.
How
adequately
or
appropriately are the requirements of
customers taken into account in
hospitals innovation strategy?
6.
Do
you
believe
that
customers/patients can contribute
something extra to the service
innovation process?
7.
How does Castalia cope with
failure in innovation? Does it tolerate
failure and learn from it? Or does it
punish failure?
8.
What do you think is the role
of the top executives/medical staff in
promoting the internal innovation
process?
9.
Do you believe that the
stimulus of growth could help you
become more innovative, developing
new services, and approaching new
markets and why?
10.
Do you believe that the
organisation and the structure of
263
14.
Does Castalia have a plan for
the extension and evolution of its
services?
15.
Where did the concept of
developing new services come from?
(existing customers, new customers,
market research, always part of the
plan?)
16.
How would you evaluate the
coordination among people and
departments throughout the new
service development process?
18.
What are the
venturing objectives?
The entrepreneurial goals of Castalia are to expand its services into other sectors of health
care, i.e. rehabilitation sector, and also develop a small network of primary mental health
care settings that will cover the needs of the wider region.
Market research is conducted to identify the need and assess how this need is met. Following
this, industrial reports show which sectors will continue growing in the near future.
Coordination among people and departments There is cooperation and willingness for
throughout the process of developing new self-improvement and development.
services is advantageous.
Coordination is good, but additional effort
There is an exchange of views between heads is needed to promote those new services.
of departments on a weekly basis; discussions
are followed up in monthly executive meetings
to define further actions
CORPORATE ENTREPRENEURSHIP: Business model, venturing activities, entrepreneurial opportunities
Hospital Manager
17.
Will you please describe the The entrepreneurial model of Castalia appears to be based on the demand-led provision
hospitals
venturing
and concept. that the hospital explores opportunities that emerge from the requests of customers
entrepreneurial activity?
or doctors.
hospitals
19.
How are entrepreneurial
opportunities identified, evaluated and
selected by the hospital?
20.
How
does
Castalia
encourage and support entrepreneurial
activity? How does recognise and
reward innovative efforts?
264
22.
Is there a clear idea of the
type of information to be obtained
through market assessment?
23.
How much time and effort is
spent in conducting interdepartmental
meetings to discuss market trends and
developments?
24.
What type of relationship
does the organisation have with its
customers?
25.
Is there an adequate process
to track and respond to customer
queries and complaints? If so, does
management get an up to date of the
status of complaints?
26.
Is there a formal method by
which complaints, queries, and poor
performance are fed into service
development initiatives?
27.
Is there a robust mechanism
to integrate the views of customers
into the service planning process?
28.
How much room is there for
customisation and judgement on the
part of service provider?
29.
Please
determine
how
Euromedica can increase customer
involvement in its innovative activity.
30.
Are there measures of
customer satisfaction that you use to
improve your services?
patients and relatives feel quite satisfied by the The relationship with patients is optimal
quality of services.
and maintained through daily contact.
This everyday engagement with patients and Continuous communication is carried out
their relatives facilitates the provision of the through doctors daily visits to patients
services that every customer needs.
wards,
regular
sessions
with
The relationship between the hospital and its psychologists and psychiatrists and
customers is interactive.
frequent updating of relatives.
There is no adequate process for monitoring customer queries and complaints. Patients
informally express their opinions and make comments to psychologists and the
administration of the hospital is then informed in all cases.
No formal process exists by which complaints and customer queries might prompt creation
of new services.
Table 9.3
Questions
Service Users/Patients
1.
Was it your choice to be treated; If so, was it your
choice to be treated in this hospital?
2.
Do you find someone on the hospital staff to talk to
about your worries and fears?
Patients feel safe and confident enough to share their concerns with
medical staff. One observes that there is always someone available
to talk to and, another replies that everyone is eager to assist.
Participants appear to have confidence and trust in the way doctors
treat them
A good number of the participants trust the hospitals doctors to
discuss personal matters, reporting that they feel comfortable with
them.
Patients get comprehensive responses from doctors, noting that the
staff is willing to explain.
3.
Do you have confidence and trust in the way doctors
treating you?
4.
Would you trust the doctors of the hospital to discuss
a personal matter?
5.
Do you get answers that you can understand when
you have important questions to ask a doctor?
265
6.
In your opinion, are there enough nurses on duty to
care for you in hospital?
7.
How do you feel when engaged in clinical activities?
8.
Would you like to participate in the way decisions
are made for your health?
9.
Are you willing to participate in a particular
programme in which patients expressed about their
treatment?
10.
Do you think that patients should be employed in
hospitals work?
11.
What do you think of the services provided to
patients?
In particular on:
i)
The way of nursing patients (wounds, sores, etc.);
ii) The way of caring for hygiene (bath, shaving,
laundry, etc.);
iii) The method of administration of drugs (even hours,
checking on patients, etc.);
iv) The way of boarding patients
12.
Have you ever been asked about the services you
use? If so, how?
13.
14.
How do you criticise the infrastructure of the
hospital (condition of the building, surroundings, facilities,
etc.)?
17.
9.8
Conclusion
The main points that provide answers to the research questions are summarised
below.
As regards the first part of the chapter, responses point out that administration tries
to establish a culture where constant improvement would be considered as a norm, but
no sufficient tools and processes are employed to develop new offerings. In fact,
executives and medical personnel gave dissimilar answers regarding motivations given
to staff to generate new ideas and detect deficiencies. Some responded that incentives
are offered, while others stressed the opposite, considering themselves as lowmotivated employees. Therefore, it appears not to be clear the role of medical staff in
the development of patient oriented services (RQ3). Further, everyone agrees that the
266
role of executives and medical staff is critical in advancing innovative activity. They
conclude that the workforce of the hospital determines any effort and that staff should
adopt innovation to enrich and expand the business operation. The above show that
both customers and medical staff play a key role in service development, with doctors
supporting the participation of patients in the process (RQ1 and RQ3).
Additionally, it is clear that some market assessment takes place, gathering
information about current demand for mental health services and customer
requirements for new outcomes; no regular meetings, however, are conducted to
recognise market trends and industry developments. The above description shows that
the hospital utilises innovation to expand and improve its offerings, but there are no
plans to engage in corporate venturing activites (RQ2). Finally, the scientific personnel
already provides a number of approaches / activities through which service users could
increase their involvement in the hospitals innovative activity, such as hours of creative
work, part-time employment, scientific discussion groups, and so on. This provides
alternatives of mental service users contribution in the service development process and
shows that medical staff is positive to patients participation in such processes (RQ3
and RQ4).
The second part of the chapter has related the standpoint of patients and their
contribution to new service development. It is important to note that patients seem to
have a strong will to join a programme in which they will be able to share their thoughts
about treatment. This also illustrates how patients could be involved in new service
development (RQ4).
The next chapter continues the analysis of the second case hospital: Galini Hospital.
267
Chapter X
Qualitative Data Analysis for Galini Hospital
Similar to the previous two analysis chapters, this one explores the operation of
Galini Hospital as well as the requirements of patients regarding their treatment. This
chapter has two parts. The first investigates the opinions and approaches of
administrative and medical personnel as regards their position in the service
development process, the contribution of patients to this, the tools and processes
adopted to implement development, and the characteristic factors that affect innovative
activity. The second part examines the patients perspective regarding Galinis
operation and infrastructure, along with the level and nature of their enthusiasm for
participation in the development of new service offerings.
A series of strategic issues linked to the process of new service development,
venture creation and customer orientation were also examined in this chapter.
Managerial perspectives regarding entrepreneurial opportunities within the health care
industry and customer orientation in health services provision were investigated. This
chapter analyses the answers that were taken from the third case hospital: Galini
Hospital. The results from the interview data were analysed and categorised into the
same four categories innovation, new service development, corporate venturing, and
customer orientation based on the conceptual framework. These outcomes are
presented in the next sections.
In this framework, the three research sections were led by the research questions.
Figures 10.1 and 10.2 illustrate that the propositions that emerged from the RQs guided
to the collection of data from three different sources - the manager (part 1), the medical
staff (part 2), and the patients (part 3). The researcher gained insights from those three
subgroups of participants on patients contribution to new service development and on
exploitation of service innovation for corporate venturing. Those insights and the
combination of responses and different views headed to the mapping of the key
findings.
268
Likewise, Table 8.2 (see Chapter 8) presents the questions that were used to collect
data regarding the position and intentions of patients within the hospital to participate
in new service development programmes and other similar activities (for more details
see Sections 6.6.3 and 8.1, and Appendix III). Below, the analysis is presented,
beginning with the innovation activity of Galini Hospital and the role of patients,
followed by the development of health services within the hospital. It follows the
analysis of customer orientation in health service development and this chapter finishes
with the description and analysis of the perceptions of patients regarding their
enthusiasm to participate in service development.
270
have proven to be of reduced efficiency and duration. Still, the scientific staff notes
that there are incentives and rewards that are associated with working performance.
10.2.4 The Role of the Top Executives and Scientific Personnel in Promoting
Innovation Processes
The manager acknowledges that the role of top executives in promoting internal
innovation process is fundamental, as they govern the progress of innovative action and
rectify any deficiencies. Moreover, the psychologist points out that the role of scientific
personnel is critical, as they facilitate the creation and promotion of new ideas and the
implementation of decisions. Equally, the pathologist argues that medical staff, usually,
start implementing an innovative action, then, along with other executives, monitor its
progress and make the necessary corrections.
Furthermore, this hospital seems to avoid condemning less-successful attempts if
these were designed to improve and develop services. In cases where the outcome is
other than the expected, an assessment identifies errors and omissions. The Director
underlines that the aim is to gain knowledge for future actions - to learn from mistakes.
Similarly, a psychologist notes that failures have been observed in those cases where
different techniques and personalised services were applied to patients. Sometimes, the
result is not the best possible. In such cases, the hospital staff tries to gain knowledge
to avoid similar mistakes in future. Nevertheless, the scientific coordinator and
psychiatrist states, Punishment does not exist. Still, innovation is not our top priority.
10.2.5 The Structure and the Stimulus of Growth for Galini Hospital
Director explains that organisation and structure in themselves have no value, but
are variables that may, at any time, be redefined by administration to point in the desired
direction. Rather, an essential characteristic of this unit is the direct and continuous
271
272
considering both internal and external factors (social, economic, legal etc.). The ideas
for new services arise from developments in science; existing and potential patients;
medical staff; information on what happens in other structures, and any changes in the
legal context.
their ideas and the additional work that they had to carry out. There are several types of
rewards, i.e. financial bonuses, institutional promotion, etc.
274
resolution process is provided, yet there is no formal tool, or procedure, by which the
opinion of patients would be considered in the development of new services. Neither is
a mechanism used to incorporate the views of customers into the process of designing
new services. Only informal meetings among departments are conducted to discuss
such issues. Nevertheless, the manager indicates that there are thoughts of adopting
such a tool.
It is important to note, however, that there is considerable disagreement among
participants as regards the customisation of services. The medical staff highlight the
importance of customisation in mental health care services and mention that
personalisation of services to patient needs takes place. A psychologist argues that
customisation is needed, because there are many patients with different characteristics
and requirements that need to be addressed. In contrast, the manager of the hospital
appears to be rigid, noting that once a service is designed and developed, it should be
given to all patients, as developed for each treatment stage in the same way, as planned,
without differentiation. The design of a service incorporates the rules of medical
science and therefore any adjustment should be carefully considered, he adds.
10.5.2.3
275
10
Gender
Male
Male
Female
Male
Male
Female
Female
Male
Male
Male
Age
45
32
57
62
48
51
36
49
40
58
Years of
hospitalisation
15
11
13
High
School
High
School
Primary
School
High
School
Primary
School
Primary
School
High
School
Primary
School
Primary
School
High
School
Education
276
share personal matters. Similarly, respondents assess the infrastructure of the hospital
as suitable. One reports hospital has a nice yard and nice colours in the wards, raising
the morale of patients. Nonetheless, there are a few suggestions regarding the
hospitals facilities and surroundings. A patient notes that they would like bigger area
for smoking, while another answered that there are difficulties, e.g. stairs, that should
be reconsidered in future improvements.
277
Table 10.2
Questions
1.
What are the internal factors
that predispose Galini hospital to seek
access to innovation?
2.
How and to what extent do
external factors such as legislation,
social and economic, condition or
stimulate favourable attitudes towards
innovation?
3.
Are adequate tools and
processes
used
to
generate
opportunities
for
product
development?
4.
Does Galini do enough to
create:
i)
A culture where continuous
improvement is regarded as a norm?
ii)
Incentives for staff to
identify and act on opportunities for
improvement?
5.
How
adequately
or
appropriately are the requirements of
customers taken into account in
hospitals innovation strategy?
6.
Do
you
believe
that
customers/patients can contribute
something extra to the service
innovation process?
7.
How does Galini cope with
failure in innovation? Does it tolerate
failure and learn from it? Or does it
punish failure?
No specific tools are used for the development and improvement of new services and that
the procedures in fact adopted here are informal.
8.
What do you think is the role
of the top executives/medical staff in
promoting the internal innovation
process?
9.
Do you believe that the
stimulus of growth could help you
become more innovative, developing
new services, and approaching new
markets and why?
10.
Do you believe that the
organisation and the structure of
Castalia hospital help you to
the administration of the hospital seeks to establish a culture in which continuous service
improvement is considered as a norm. The Director stresses that the proper mind-set is
established through regular meetings, immediacy of communication from the lowest to the
highest level and continuous assessment.
The scientific staff notes that there are incentives and rewards that are associated with
working performance.
The requirements of customers are taken into
most serious consideration in the innovation
strategy of the hospital.
There is still room for improvement regarding
their contribution to the development of new
services.
This hospital seems to avoid condemning lesssuccessful attempts if these were designed to
improve and develop services. In cases where
the outcome is other than the expected, an
assessment identifies errors and omissions. The
aim is to gain knowledge for future actions - to
learn from mistakes.
The role of top executives in promoting internal
innovation process is fundamental, as they
govern the progress of innovative action and
rectify any deficiencies.
278
implement innovative actions? If so, and dedication needed to achieve the desired
how does this happening?
result.
NEW SERVICE DEVELOPMENT: Process, service improvement and evolution, and coordination
Hospital Manager
Medical Staff
11.
Did the hospital introduce
any new or significantly improved
service in mental health sector?
12.
How many new services did
you introduce last year?
13.
How and to what extent has
your service products changed during
the past 2 years?
Galini has introduced three new groups of services within the previous year. One new set
of services is associated with activity groups.
Additionally, the hospital has adopted experiential psychotherapies, a new service offered
by qualified staff, which involves outpatients who follow some form of treatment, but need
not be hospitalised. There has also been developed a psychosocial rehabilitation service,
based on regular and customised clinical and psychosocial investigation of a patients
capabilities and needs.
Services are routinely monitored in terms of efficiency and satisfaction, and then improved.
There are times where small changes lead to complete transformation of a service.
New programmes for some patient groups have been added, such as cognitive programmes
for those with dementia; excursions; autonomy groups; etc.
14.
Does Galini have a plan for
the extension and evolution of its
services?
15.
Where did the concept of
developing new services come from?
(existing customers, new customers,
market research, always part of the
plan?)
16.
How would you evaluate the
coordination among people and
departments throughout the new
service development process?
hospitals
Expand its business to cover areas in mental health care that are still unexploited, by
developing a network of small units in the region that will provide primary health care
services for mental patients.
19.
How are entrepreneurial Entrepreneurial opportunities are identified by market research and evaluated by
opportunities identified, evaluated and Euromedicas executives, doctors and hospitals management team. They decide which
selected by the hospital?
opportunities worth exploring according to the needs, the competition, and the current
economic situation.
20.
How
does
Castalia By allowing stakeholders to take initiatives for growth. In some cases, they allow associate
encourage and support entrepreneurial doctors to lead and invest in an effort, providing the necessary administrative and financial
activity? How does recognise and support. In addition, Galini recognises innovative efforts by rewarding employees for their
reward innovative efforts?
ideas and the additional work that they had to carry out.
CUSTOMER ORIENTATION: Market assessment, customer relationships and involvement, service customisation,
customer satisfaction
Hospital Manager
Medical Staff
21.
What preliminary market The manager of Galini hospital indicates that
assessments occurred before any for an investment plan, they consider
demographic conditions, look for appropriate
279
25.
Is there an adequate process
to track and respond to customer
queries and complaints? If so, does
management get an up to date of the
status of complaints?
26.
Is there a formal method by
which complaints, queries, and poor
performance are fed into service
development initiatives?
27.
Is there a robust mechanism
to integrate the views of customers
into the service planning process?
28.
How much room is there for
customisation and judgement on the
part of service provider?
29.
Please
determine
how
Euromedica can increase customer
involvement in its innovative activity.
30.
Are there measures of
customer satisfaction that you use to
improve your services?
There is no formal tool, or procedure, by which the opinion of patients would be considered
in the development of new services.
Service Users/Patients
1.
Was it your choice to be treated; If so, was it your
choice to be treated in this hospital?
2.
Do you find someone on the hospital staff to talk to
about your worries and fears?
3.
Do you have confidence and trust in the way doctors
treating you?
4.
Would you trust the doctors of the hospital to discuss
a personal matter?
Many of the patients replied that they cannot find anyone from the
hospital staff with whom to discuss their worries and fears.
A small number of patients mentioned that they have no confidence
and trust in the way doctors treat them.
There appears to be a relationship of trust among doctors and service
users, as patients note that they share personal matters.
280
5.
Do you get answers that you can understand when
you have important questions to ask a doctor?
6.
In your opinion, are there enough nurses on duty to
care for you in hospital?
7.
8.
Would you like to participate in the way decisions
are made for your health?
9.
Are you willing to participate in a particular
programme in which patients expressed about their
treatment?
10.
Do you think that patients should be employed in
hospitals work?
11.
What do you think of the services provided to
patients?
In particular on:
i)
The way of nursing patients (wounds, sores, etc.);
ii) The way of caring for hygiene (bath, shaving,
laundry, etc.);
iii) The method of administration of drugs (even hours,
checking on patients, etc.);
iv) The way of boarding patients
12.
Have you ever been asked about the services you
use? If so, how?
13.
14.
How do you criticise the infrastructure of the
hospital (condition of the building, surroundings, facilities,
etc.)?
18.
They get comprehensible answers from medical staff when they have
important questions to ask.
Although most of the service users believe that there are enough
nurses on duty to care for them, a considerable number deem the
opposite.
Patients feel good when they participate in hospital activities.
Most respondents agree that they are keen to contribute to decisionmaking about their health treatment.
Respondents want to participate in an actual programme where their
opinion about their therapy would be communicated.
Participants considered that mental health service users should
undertake hospital work. They point out that this would be beneficial
to patients health, as they would have something creative or
constructive to do.
Respondents reported that nursing care is quite acceptable, even
though some indicate scope for improvement. Similarly, the way
nurses care for patients hygiene is adequate, only one participant
reporting otherwise. The same applies to the method of drugs
administration, as respondents reported themselves satisfied. As
regards diet, many note that the food is acceptable, but further
improvements to the variety of meals should take place.
Many participants report that they have never been asked about the
services they use. This contrasts with the picture provided by hospital
staff, who mentioned that they want to know what patients think in
order to meet their needs. Indeed, a number of patients noticed that
there are in fact such discussions within expression groups.
The majority of the participants offer positive feedback on the
behaviour of staff, mentioning the good communication. Still, a few
stress that some times the nursing staff behave strictly and bad
attitudes are punished.
Respondents assess the infrastructure of the hospital as suitable.
Nonetheless, there are a few suggestions regarding the hospitals
facilities and surroundings.
Many patients do not feel productive throughout their residence,
despite their interest and participation in the activities of the hospital.
10.8 Conclusion
The main points that provide answers to the research questions are summarised
below.
As regards the first part of the chapter, it emerges that appears that customer needs
are taken into account in Galinis innovation strategy, but patients do not contribute
further to new service development. Staff recognise their own importance in adopting
and promoting innovation, as they generate ideas, design new outcomes, and monitor
the development process. Besides, it happens that the administration of the unit is not
harsh on failures, choosing rather to gain knowledge and improvement from such
281
incidents. Those findings illustrate the importance of both customers and medical staff
in new service development, providing insights regarding the role of patients in the
process as well as the perception of medical staff in patient involvement (RQ1 and
RQ3). It is also clear that innovative initiatives lead to new offerings, such as new
activity groups, cognitive programmes for those with dementia, experiential
psychotherapies, and others. Accommodation services have also been upgraded. In
contrast, it emerges that there is a problematic issue with respect to the level of
cooperation between employees, many respondents noting that there is room for
improvement and people should work together to increase success. The above findings
show that there is no interest from the hospital to utilise innovation in order to engage
in corporate venturing activities (RQ2).
Additionally, both administration and medical staff propose numerous ideas for
further customer involvement: development of relevant activities; occupational therapy
groups enhancing patients socialisation; participation in hospital work; etc. The above
present a contrast between the importance of patients in service development and the
tools and processes that are used to achieve this. It is noteworthy that even though the
administration considers customers as an important stakeholder, it has not adopted
mechanisms to integrate them in new service development. Therefore, it is not clear in
this case how mental service users could be involved in the service development process
(RQ4). The next chapter discusses and summarises the key findings of the three sections
of research.
282
Chapter XI
Discussion of the Key Findings of the Three Research Sections
This chapter summarises the main findings of the three areas of the primary
research. Following the conceptual research framework, the innovation activities and
venturing objectives of Euromedicas psychiatric hospitals are reviewed. Then the level
of customer-orientation within Euromedica and its mental health hospitals is examined,
as well as the opinion and requirements of patients regarding their contribution to the
development of new services. Finally, Figure 11.1 illustrates the major parameters that
affect the firms innovation and entrepreneurial activity, either positively or negatively.
283
capability for informed choices they could otherwise exercise. It is a denial of their
potential to participate as active and meaningful partners. What is more, in statements
such as patients are invited to review the quality of their services upon completion of
their treatment implies a limited role bestowed on them which is more about
evaluating existing policies rather than being encouraged to participate in planning and
development. The view that appropriate decisions about planning are made by those
appointed to do so implies a hierarchical structuring within the organisation and thus
leaves little space for user involvement, if any. When medical and management staff
do express a positive view about user involvement, their discursive construction of such
a model reveals confusion and uncertainty. They do express a positive assumption that
patients should take an active role in the management of their care but do not seem
confident in suggesting specific notions of user involvement or clear implementation
concepts.
Training programmes are important in helping mental health professional staff
develop the capabilities necessary in adopting in their everyday practice based on the
patient empowerment theory. It is clear in the present study that there is a mixture of
responses from mental health care staff regarding service-user involvement in all areas
of mental health. A number of them indicated a reluctance in accepting patients
contributions as a necessary part for effective practice. It becomes evident that a vital
part of training should be about addressing the cultural and social factors within
organisation structures in mental health that obscure the efforts towards user
involvement. The distribution of power within organisational structures needs to
change to acknowledge patient empowerment in decision-making processes.
It is evident that the organisations approach to organisational performance relies
on the practical understanding of market operations, start-up financing, ICT-based
integration services, skills-based training, and careful employee selection. The
organisation as many others in the mental health sector in Europe presents an
authoritative model of business development. This means high ratios of psychotherapy
staff and business experts. Its internal structure is geared towards offering few
opportunities for user service involvement. At the same time, there is an effort observed
to coordinate services across various departments and units to deliver improved care
outcomes. Euromedica is aiming at two different approaches to innovation: 1) through
product innovation which refers to the introduction of new types of goods and services
for the external market and 2) through process innovation, which refers to the
287
enhancement of internal production processes for goods, and services. It seems that
Euromedica has so far invested heavily in product innovation, which has generated
incremental revenues for the company. Process innovation is still underdeveloped. It
could however, improve the internal capabilities of the organisation.
Patient involvement in evaluation of services still follows a silo mentality and is
routinely pursued through the dissemination of leaflets and questionnaires to patients.
It is a fact that when healthcare providers do not promote a systematic approach to
include users insights in decision making mechanisms, then the sharing of information
and the delivery of care can become challenging. This attitude may be explained on the
grounds of medical professionals and business executives scepticism about mental
health users adeptness to participate in such processes.
The Euromedica Group has created opportunities for the se-called disruptive
innovations. The group has entered new markets, delivered added value to stakeholders
through the provision of new, improved services and have created new players in the
market. The company is looking for opportunities to further its disruptive innovation
efforts by allocating money to venture funds. Their new diagnostic and treatment
offerings are an example of a non-disruptive structural innovation. The clinics and
medical centres of Euromedica are efficient, cost-effective and have generated
significant interest in consumer markets across the country. Information technology is
a key driver of innovation in the Euromedica group, adopting breakthrough technology
in medical devices, procedures, and treatments. Nonetheless, less focus has been given
to innovations in networking and communications synergies.
The opinions of experts (executives - Research Section I - and doctors Research
Section II see Chapter 6) and findings from the documentary research (see Chapter 2)
are taken into consideration in order to answer the first three research questions: RQ1 What is the role of customer (and of the market) in the development of services in
health care organisations?, RQ2 - How do mental health care providers exploit
innovation in services so as to engage in corporate venturing?, RQ3 - What are
medical staffs perceptions of customer orientation and what role do such perceptions
play in the development of patient-oriented services?
Following this, the opinion of patients (Research Section III - see Chapter 6) and
findings from the literature review regarding mental service users involvement in new
service development (see Chapter 4) are considered to answer the fourth research
288
question: RQ4 How should mental health service users be involved in the service
development process?
Tables 6.2 and 6.6 in Chapter 6 present the measurement items for the three
research sections, including the subjects to be measured as well as the sources of those
questions. Likewise, Tables 7.1, 8.1 and 8.2 in Chapters 7 and 8 show the objectives of
every question that was used to interview the top executives of the Euromedica Group
as well as the medical staff and service users. Finally, Tables 7.2 in Chapter 7, 8.4 in
Chapter 8, 9.2 and 9.3 in Chapter 9, and 10.2 and 10.3 in Chapter 10 summarise the
findings of top executives, medical staff and service users in the Euromedica Group and
its three mental health hospitals.
The administration of the Euromedica Group states that several tools are used by
the company to identify the needs of customers and assess the health care market, (i.e.
management information systems and questionnaires). However, those tools have not
been adopted by the psychiatric hospitals, as managers recognised that they do not use
appropriate tools that help the development of new offerings. Even though no official
processes for the development of new services are adopted, both executives and hospital
managers stressed that a basic and informal process of four steps is followed (i.e. idea
generation; service design; service development, and final service evaluation). Then,
disagreement emerges between administration and scientific personnel as regards
incentives for development. Top executives and hospital directors argued that the
company attempts to develop a business culture where everyone could undertake
initiatives to enhance service quality, meet customer requirements, decrease operating
costs, generate new ideas for expansion, promote service products, and develop
beneficial relationships with the community. On the other hand, medical and nursing
staff complained that no such actions take place and the firm is far off its targets.
Respondents agreed, however, that the role of top executives and medical personnel is
critical regarding the adoption of innovation and the reinforcement of the service
development process. Still, there is scope for improvement, as many highlighted that
there are gaps regarding staff participation in the decision-making process and their
cooperation with administration. Nonetheless, it has been found that the firm is not
rigorous about efforts that fail. It prefers to gain knowledge from such events, to
improve its assessment techniques and increase the chances of success for future
attempts.
Additionally, an argument arises with reference to the companys organisation and
structure. Some executives argue that the firm has built a system where innovation
flourishes without constraints. Most respondents, however, believe that further actions
should come about to upgrade organisations structure and attain better outcomes. In
any case, participants argued that the stimulus of growth advances innovative activity
and Euromedica has proved, through its course, that the entrepreneurial goal is to
expand its operations in every sector of the health care industry and beyond countrys
borders as well as developing novel services that fulfil customers growing needs. The
latter is particularly important for the firm, as the administration underlined that
customers, together with other stakeholders, guide the organisations innovation efforts.
Therefore, Euromedica engages customers requests in its innovation strategy and
290
develops services that serve the needs of patients, taking into consideration their
demands. Still, the management team argued that patients are able to play a role in the
enhancement of hospitals residential services but not in the development of medical
ones. Hospital managers underlined that only some of mental service users are in a
position to contribute to the development process. However, there were respondents
who stressed that in psychiatric centres, there is no such culture and organisation as
might care about customers desires and integrate these into the service development
process. The above analysis illustrates well that the current structure and organisation
of the Euromedica Group do not work in favour of either business development or new
service development. It becomes also clear in the analysis of the findings that there is
no central and specific plan for innovation, being a negative factor for innovation
development.
291
It also emerges that hospital managers are quite autonomous in making decisions
regarding the expansion of offerings, whether creating a new department or developing
a novel service, aiming to better meet the needs customers and enhance service quality.
In addition, Euromedica promotes entrepreneurial ideas that seem to have both caring
and financial return, encouraging investors/doctors to hold more than half of the new
investments shares, increasing its economic contribution where necessary and
organising the new business, using its knowledge and experience in the health sector.
Apart from that, the company rewards both executives and scientific personnel for
successful innovation efforts, offering economic bonuses, business prospects, and
project funding. Overall, it comes forward that Euromedica exploits service innovation
to engage in venturing activities, as every investment is undertaken so as to:
expand the firm's activities to address potential customers, increasing its target
group.
292
294
patients agreed that they should be employed in the everyday work, functioning of the
hospital, as this would be beneficial for their health and make them feel useful and
creative. The above analysis shows the positive effect and describes clearly patients
strong willingness to contribute to new service development.
Industry Characteristics
Evolution of Medical
Science & Technology
Co mpetition
Patients Needs
Service Quality
New Business
Development
Socio-economic Characteristics
Customer Requirements
Political Characteristics
Business Culture
New Service
Development
Customer Involvement
Experience
Patients willingness to
contribute
Note:
Positive effect
Negative effect
Figure 11.1 Illustration of the Major Attributes That Affect Innovation and Entrepreneurial Activities
296
297
this study, which found that users behaviour improves when they are involved in such
processes as they feel that they benefit themselves.
Table 11.1
Comparing
Research Findings
with
Literature
Review
Service Innovation
Casual
relationship
between the
key
concepts and service
innovation
is
confirmed
Organisational innovation
Business culture
Organisational structure
Risk-taking policy
Corporate venturing
Business
development
strategy
Strategic change and renewal
Proactiveness and risk-taking
strategy
Intangible resources
Business development
Knowledge-based
value
creation
Casual
relationship
between the
key
concepts
and
organisational
innovation
is
confirmed
Casual
relationship
between the
key
concepts
and
corporate venturing is
confirmed
Casual
relationship
between the
key
concepts and internal
resources
and
internationalisation is
confirmed
Casual
relationship
between the
key
concepts and external
Hipp et al (2000)
Fitzsimmons and Fitzsimmons (2008)
Blumentritt et al (2005)
Tether (2003)
Rohrbeck and Gemnden (2011)
Duncan and Breslin (2009)
Chaharbaghi and Newman (1996)
Knox (2002)
Cumming (1998)
Galanakis (2006)
Fitzsimmons and Fitzsimmons (2008)
Thakur et al (2012)
van der Panne et al (2003)
Bernstein and Singh (2006)
Den Hertog et al (2010)
Agarwal and Selen (2009)
Varadarajan (2009)
Ireland et al (2003)
Oke (2007)
Crawford (2006)
de Brentani (1993)
Edgett (1994, 1996)
Edvardsson et al (1995)
Johnson et al (2000)
Menor and Roth (2007)
Avlonitis et al (2001)
Cooper et al (1994)
Agarwal and Selen (2009)
Oke (2001, 2007)
Tidd et al (2005)
Internal resources
Creation
of
knowledge
Business growth
systemic
Casual
relationship
between the
key
concepts
and
innovation
and
innovation
management
is
confirmed
298
Naidu et al (1999)
Ritchie (1999)
Wood et al (2000)
Tobin et al (2002)
Ford and Fottler (2000)
Raju et al (1995)
Gafni et al (1998)
Lammers and Happell (2003)
Wistow and Barnes (1993)
Patient Involvement
Customer Orientation
Business
growth
and
prosperity
Customer satisfaction and
loyalty
Generation of opportunities
Cost reduction and sales
increase
Value creation
Market synergy
Customers needs
Customer observation
Experimentation
Selective partnering
Customer value
Customer satisfaction
Service quality
Customer empowerment
Consumer co-creation
Patient-focused NSD
Users behaviour
Patient satisfaction
Patients motivation
Organisational improvement
Service environment design
Knowledge transfer
networks
and
knowledge acquisition
is confirmed
Casual
relationship
between the
key
concepts and NSD is
confirmed
Casual
relationship
between the
key
concepts and customer
orientation
is
confirmed
Casual
relationship
between the
key
concepts and patient
involvement
is
confirmed
Table 11.2
Questions
1.
What are the internal factors that predispose
Euromedica to seek access to innovation?
2.
How and to what extent do external factors
such as legislation, social and economic, condition or
stimulate favourable attitudes towards innovation?
Legislation, finance, and social factors appear to hinder firms that operate
in the Greek health care industry. In particular, regulations change too
often, the business environment is fluid, the financial crisis deters
innovation, and meeting social factors does not offer commensurate
economic outcomes
3.
Are adequate tools and processes used to
generate opportunities for product development?
Several tools are used by the company to identify the needs of customers
and assess the health care market, (i.e. management information systems
and questionnaires). However, those tools have not been adopted by the
psychiatric hospitals, as managers recognised that they do not use
appropriate tools that help the development of new offerings.
Top executives and hospital directors argued that the company attempts to
develop a business culture where everyone could undertake initiatives to
enhance service quality, meet customer requirements, decrease operating
costs, generate new ideas for expansion, promote service products, and
develop beneficial relationships with the community. On the other hand,
4.
Does Euromedica do enough to create:
i)
A culture where continuous improvement is
regarded as a norm?
ii)
Incentives for staff to identify and act on
opportunities for improvement?
299
5.
How adequately or appropriately are the
requirements of customers taken into account in
hospitals innovation strategy?
6.
Do you believe that customers/patients can
contribute something extra to the service innovation
process?
7.
How does Euromedica cope with failure in
innovation? Does it tolerate failure and learn from it? Or
does it punish failure?
8.
What do you think is the role of the top
executives/medical staff in promoting the internal
innovation process?
medical and nursing staff complained that no such actions take place and
the firm is far off its targets.
Euromedica engages customers requests in its innovation strategy and
develops services that serve the needs of patients, taking into consideration
their demands.
Patients are able to play a role in the enhancement of hospitals residential
services but not in the development of medical ones. Hospital managers
underlined that only some of mental service users are in a position to
contribute to the development process.
The firm is not rigorous about efforts that fail. It prefers to gain knowledge
from such events, to improve its assessment techniques and increase the
chances of success for future attempts.
The role of top executives and medical personnel is critical regarding the
adoption of innovation and the reinforcement of the service development
process. Still, there is scope for improvement, as many highlighted that
there are gaps regarding staff participation in the decision-making process
and their cooperation with administration.
9.
Do you believe that the stimulus of growth
could help you become more innovative, developing
new services, and approaching new markets and why?
300
19.
How are entrepreneurial opportunities
identified, evaluated and selected by Euromedica?
30.
Are there measures of customer satisfaction
that you use to improve your services?
Table 11.3
Questions
1.
Was it your choice to be treated; If so, was it
your choice to be treated in this hospital?
Service Users/Patients
Many patients who participated in the research would have preferred not to
be hospitalised, as they appear not to accept their health problem. Few were
those who acknowledged the need to be treated and even fewer were those
who chose hospitalisation.
301
2.
Do you find someone on the hospital staff to
talk to about your worries and fears?
3.
Do you have confidence and trust in the way
doctors treating you?
4.
Would you trust the doctors of the hospital to
discuss a personal matter?
5.
Do you get answers that you can understand
when you have important questions to ask a doctor?
6.
In your opinion, are there enough nurses on
duty to care for you in hospital?
7.
How do you feel when engaged in clinical
activities?
8.
Would you like to participate in the way
decisions are made for your health?
9.
Are you willing to participate in a particular
programme in which patients expressed about their
treatment?
10.
Do you think that patients should be
employed in hospitals work?
11.
What do you think of the services provided to
patients?
In particular on:
i)
The way of nursing patients (wounds, sores,
etc.);
ii) The way of caring for hygiene (bath, shaving,
laundry, etc.);
iii) The method of administration of drugs (even
hours, checking on patients, etc.);
iv) The way of boarding patients
12.
Have you ever been asked about the services
you use? If so, how?
13.
How do you criticise the conduct of staff to
patients?
14.
How do you criticise the infrastructure of the
hospital (condition of the building, surroundings,
facilities, etc.)?
19.
It is remarkable that in two hospitals, patients had never been asked about
the services provided.
Participants argued that the behaviour of staff is appropriate and courteous;
they therefore feel comfortable discussing a personal matter or sharing their
thoughts.
Respondents also viewed positively the facilities of the hospitals (i.e.
condition of the buildings, surroundings, amenities etc.). There were some,
however, who reported that further improvements should be carried out
regarding mobility, entertainment, and recreation.
Patients appear not to feel productive throughout their residence, despite
their interest in the activities of the hospitals.
In Chapter 12, the contribution and conclusion of this study are presented. The
implementation of all significant factors is also recommended.
302
Chapter XII
Conclusion, Contributions, and Implications
Competition is particularly intense in the private health services sector. Following
a period of significant business developments and upheavals that led to major
investments, acquisitions and mergers, agreements and strategic alliances, big
businesses and organised groups now enjoy competitive advantages over their smaller
counterparts. The business of a private medical centre is associated with its reputation
(its name), its infrastructure (buildings, medical equipment, and scientific staff), its
geographic location and accessibility, the quality and speed of services, cooperation
with insurance bodies, and flexibility in pricing policy. The large groups now provide
a wide range of services, focusing their strategy on four key pillars, namely:
a) geographical coverage;
b) provision of a full range of medical services;
c) technological and scientific development and
d) expansion into new foreign markets.
All these confirm the first proposition that entrepreneurial opportunities will
emerge, and that intense competition in the health care market leads to further business
expansion. This gives half an answer to the first research question, on the role of
competition in the development of new health services, and this can be verified from
the conclusion of chapter 2. It also comes to light that the evolution of medical science
and technology and the evolving needs of patients also trigger business development.
Additionally, it appears that health care organisations tend to focus more on the
requirements of doctors and third-party paying clients and less on the medical needs of
patients. However, patients have increased their participation in the operation of health
care institutions. They actively participate in their health care, having access to
information and to alternative solutions. Consequently, the purpose of the present study
was to investigate the influence of user involvement on new service development and
how outcomes of this can enhance a firms entrepreneurial activity. On one hand the
aim of this study was to advance previous service-innovation theory by associating it
with entrepreneurship theory, while on the other, it sought to extend previous
knowledge regarding the benefits of customer participation in new health service
303
304
Those research research questions are answered in the following subsections of the
chapter.
306
Euromedica, as many argue that it has organisational weaknesses and its structure lacks
efficiency.
At the same time, participants acknowledged that innovation is the key to the longterm growth and economic performance of enterprises, which is emphasised by the
studies of Eisingerich et al (2009); van der Panne et al (2003) and Cottam et al (2001).
Many studies agree and underline that customers should be actively involved in the
design and development process through specific procedures, taking into account their
needs and requirements (e.g. Fuchs & Schreier, 2011; Kandampully, 2002; Svendsen et
al, 2011).
308
and methods should be embraced by the firm, which rather implies that customers do
not yet participate in new service development.
A study by Berry and Mirabito (2010) suggests that health services must be adapted
to individual patients, considering their medical needs. The hospital-patient relationship
should be recognised as a key element in whether service users experience and respond
to the treatment (Ong et al 1995). It is also important to stress that participants agree on
and suggest various ways in increasing the presence and participation of patients in
hospitals innovative activity. This answers the first part of the third research question,
verifying that medical staff hold a positive attitude towards the participation of patients
in the new service development process. Research by Peck et al (2002) agrees that
patient involvement includes interaction between individual users and practitioners,
management of local services, and services planning.
It seems that patients are increasing their presence and participation in hospitals
innovative activity. Nevertheless, a study by Barnes and Wistow (1994) underlines that
service providers should support patients by offering adequate training and
opportunities for preparation and debriefing, as well as ensuring that user involvement
will not be a stressful experience. Another study by Raju et al (1995) adds that hospitals
must collect and use information in order to reduce customer complaints, enhance
customer satisfaction, and meet customer needs. The above arguments give an answer
to the fourth research question, illustrating how mental service users should be involved
in the service development process. However, it is obvious that none of the hospitals in
the case study uses any of these: tools to assess customer satisfaction; processes to
identify and respond to customer queries; methods through which complaints activate
development initiatives; mechanisms in which the opinions of customers enter the
process of planning new services. Still, many respondents noticed that an organised
effort would have significant outcomes for patients. This confirms the fifth proposition,
as it therefore becomes clear that a significant number of growth opportunities will be
identified when the health care organisation exploits entrepreneurial opportunities by
developing customer-oriented new mental health services.
309
choose the treatment, relying on their choices. There are few cases where patient and
doctor come to a decision together - so-called shared decision-making and it is
apparent that there are zero cases where patients take decisions about treatment based
on the information given by doctors (Charles et al, 1997).
Patients confirmed that there is enough nursing staff and argued that their behaviour
is appropriate; they therefore feel comfortable discussing a personal matter or sharing
their thoughts. This is supported by the studies of Bowen and Schneider (1985) and
Ottenbacher and Harrington (2010), who claim that services must be provided by
trained staff who not only offer and create the service, but actually form a part of that
service in the customers view. Therefore, employees needs should also be identified
and met. Bellous study (2010) adds that the medical staff has the substantial
responsibility for providing high quality care. In addition, respondents appear to enjoy
the hospitals facilities. This is important, because the study by Ottenbacher and
Harrington (2010) argues that services must be provided in easy and pleasant settings.
Patients said that enjoy participating in activities as these enhance their treatment
and help them to overcome their problem. It is obvious that patients should participate
in decision-making regarding their treatment, as increased patient involvement has led
to significant changes in levels of personal care, service planning, delivery, and
evaluation (e.g. World Health Organization, 1990; Victorian Mental Health Service,
1999). Nevertheless, the study by Barnes and Wistow (1994) found that userinvolvement, on one hand aims to create services tailored to and responsive to the needs
and requirements of customers, to enhance quality, and on the other, to empower users
in decision-making for planning, management, delivery, and review of services. It also
reveals that a large number of those stakeholders were keen to participate in making
decisions. They acknowledged that this would be particularly beneficial for the
development of treatment and so for their psychological condition. Tait and Lester's
(2005) study agrees that users are experts on their illness and may have differing but
equally important views about their illness and care.
Furthermore, respondents expressed excitement about joining a programme in
which they will express their beliefs and perceptions about treatment; they are eager to
contribute in service improvement. A study by Wood et al (2000) suggests that
healthcare companies should focus on new approaches, such as customer-orientation
and patients' satisfaction. Organisations should create a new value; patients should
understand their needs and both their emotional and physical needs should be met.
310
However, there is so far a limited understanding of those needs and a lack of strategic
direction for the exploitation of this knowledge (Duncan & Breslin, 2009). Tait and
Lester (2005) added that user involvement could increase the current limited
understanding of mental distress and foster social inclusion. Overall, the analysis by
Ford and Fottler (2000) concluded that the mental health units should identify the
customer key drivers, encourage participation of clients, develop a customer-centric
culture, select, train, and motivate employees to focus on the customer, and design an
attractive interface. Nevertheless, in the field of health, not all wishes and preferences
can be met. El-Guebaly et al (1983) underlined that patient satisfaction is not always
associated with treatment success. Then again, Tait and Lester (2005) listed a number
of restrictions on user participation in mental health services (i.e. lack of information,
financial and time constraints, concerns about representativeness and resistance to the
idea of users as experts).
build the appropriate structure and develop the culture across the organisation that will
promote entrepreneurship and innovation and encourage employees to undertake the
new business. However, findings revealed that Euromedica has not promoted such
actions. Many respondents highlighted that there are gaps regarding the participation of
staff in the decision-making process and their cooperation with administration. Indeed,
few were those who advocated that the firm has built a system where innovation
flourishes without constraints. Most respondents believe that further actions should
come about to upgrade the organisations structure and attain better outcomes. It
becomes apparent that Euromedica lacks a particular plan and a proper procedure to
run its innovation activities and this might well hinder or obstruct the execution of its
growth plans. Therefore, it should develop a strategic plan for the implementation of
service innovation. It is evident that innovation strategy provides a clear direction for
dealing with strategic issues - such as selecting the markets to enter and the skills to
develop - and focuses the effort of the entire organisation on a common innovation goal
(Lester, 1998; van der Panne et al, 2003; Oke, 2007). Euromedica should also focus on
internal and external resources to expand its operations into new markets/sectors and
explore business opportunities in order to improve its competitive positioning. All this
evidence answers the second research question, highlighting that Euromedica does not
do much to exploit service innovation in corporate venturing activities.
It also appears that Euromedica does not regard patients or mental health service
users in particular, as capable of contributing to the service development process. It is
argued that they can only be a factor in improving the hospitals residential services.
This illustrates their role in the process, giving an answer to the first research question.
What is more, it becomes apparent that there is no culture and organisation that pays
attention to their needs and integrates these into the service development process. There
is neither flexibility for customisation nor adequate tools, processes and methods to
track and respond to customer complaints that would trigger growth initiatives. For that
reason, many noted that an organised effort on the part of the company would have
superior results for patients. This is supported by the literature as a number of studies
note that firms should make efforts and plans to appreciate customers needs and
accomplish those needs by developing specific services (e.g. Berthon et al, 2004; Saxe
& Weitz, 1982). Other studies also recognise that customer-oriented businesses enhance
customer satisfaction and deliver better service quality (e.g. Kelley et al, 1990; Hartline
et al, 2000). Therefore, health care organisations should focus on new approaches to
312
313
the exploitation of entrepreneurial opportunities and the development of new customeroriented services. This research also shows that patient involvement is necessary in
identifying and developing new services. It proves that linking patients to idea
generation and service development stimulates a greater number of new service
opportunities and enables firms to develop customised new health service offerings. In
other words, patients presence and participation boost innovative activity.
Overall, medical and nursing staff in Euromedica hospitals demonstrated an
advanced understanding of the concept of user involvement and were positive towards
the idea of enhancing user involvement in mental health care services. They were more
resistant though to the idea of involving mental health patients in the planning and
design process of such services, which might imply a degree of disbelief in patients
capability to affect creatively such processes. One of the doctors suggested, Doctors
and nursing staff should continue the same pattern of conduct and communication with
patients as it is successful and functional. Patients have not expressed major complaints
or dissatisfaction after all. This lack of acknowledgement of the need to increase user
involvement at the level of policymaking can be attributed to the lack of visibility, voice
and credibility within mental health communities and which gravely impedes
implementation and promotion of service user inclusion in practice (Woodhouse,
2010). It is well documented in the literature that there is a difference in the opinions
expressed by professionals and what actually happens in practice (Summers, 2003;
Campbell 2001). Many of them appear to be dismissive of the contributions of service
users due to their perceived inability or unwillingness to articulate their needs and
expectations. This view became a finding consistent among managers and senior staff
even though studies in mental health indicate that through appropriate staff training,
user encouragement and support, service users develop an interest to participate in
formal procedures. They seem to be able to overcome feelings of intimidation,
stigmatization and exclusion.
Senior scientific and managerial staff seem to contribute to the disparities in mental
health care provision due to a belief that they are superior in the chain of command
within healthcare organisations (Stromwall et al., 2011; Roberts, 2000). This was
evident in our analysis too. This mentality can hinder efforts towards greater user
inclusion as it is based on the principles of servitude and dedication with a rigid
hierarchy which breeds authoritarian beliefs (Hampshire, 2000, p. 10). However, the
organisation within the Euromedica hospitals is more flexible and autonomous across
314
made without serious input from users. Nonetheless, service users in their majority
expressed a vivid interest in participating in procedures, holding the belief that their
empowerment could help their recovery and identified inconsistencies within the
current system of service provision. A study by Simpson & House (2002), which was a
review of the international research into user involvement in mental health services,
indicated major benefits for users despite significant methodological weaknesses in
most of the studies.
One of the driving main contributions of this research paper is the conceptual
framework that provides other researchers with the foundations upon which they can
built their future research efforts. This paper begins with the definitions of healthcare
innovation and a thorough and deep explanation of how innovation works in healthcare
sector. The conceptual framework is then carefuly developed which articulates the main
intervening variables that influence the so-called innovation in modern healthcare
systems in Greece. Based on the introductory definition of healthcare innovation, all
main dimensions of healthcare innovation along with the process of healthcare
innovation and the conceptual framework are presented among others in the study. This
paper aims to contribute and help researchers to address several questions regarding
innovation in healthcare sector. If the concept of healthcare innovation can be clarified,
become clearer and explain as it should then it may become easier for health
policymakers practitioners and doctors to evaluate and adopt new services in ways that
recognize, encourage, and provide priority to truly valuable, effective and high
sophisticated healthcare innovations. This approach is driven by qualitative research
and uses design philosophy to identify all innovation opportunities, and apply design
skills to propose effective solutions with measurable end user value. According to other
studies, it has proved relevant in other business processes including strategy and new
product and service development, and has successfully supported both short and longerterm innovation.
316
Propositions
Intense competition
Reputation, infrastructure, geographic
location, speed and quality of services,
and cooperation with the insurance
funds are the main factors that lead
health care companies to seek access to
innovation
and
to
business
development.
RQ2:
How
does
Euromedica
Group
exploit
service
innovation to engage in
corporate venturing?
P5:
A
significant
number
of
growth
opportunities will be
identified when the health
care organisation exploits
entrepreneurial
opportunities
by
developing
customeroriented new mental
health services
317
318
of innovative and entrepreneurial capabilities. Some less important concepts that would
have made the framework more complicated were not deemed worthy of inclusion,
such as coopetion between business units, knowledge sharing processes and capabilities
and marketing efficiencies. The studys scope is limited and some further factors (or
variables) have been omitted from the framework, such as environmental,
technological, social, legal, etc. that also influence the innovative activity of a firm.
319
320
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Appendices
Appendix 1
Appendix 1.1 Semi-structured interview questions for Senior Executives for
Research Section I (English Version)
Innovation
1. What are the internal factors that predispose Euromedica to seek access to
innovation?
2. How and to what extent do external factors such as legislation, social and economic,
condition or stimulate favourable attitudes towards innovation?
3. Are adequate tools and processes used to generate opportunities for product
development?
4. Does Euromedica do enough to create:
i) A culture where continuous improvement is regarded as a norm?
ii) Incentives for staff to identify and act on opportunities for improvement?
5. How adequately or appropriately are the requirements of customers taken into
account in Euromedicas innovation strategy?
6. Do you believe that customers can contribute something extra to the service
innovation process?
7. How does Euromedica cope with failure in innovation? Does it tolerate failure and
learn from it? Or does it punish failure?
8. What do you think is the role of the top executives in promoting the internal
innovation process?
9. Do you believe that the stimulus of growth could help you become more innovative,
developing new services and approaching new markets and why?
10. Do you believe that the organisation and the structure of Euromedica help you to
implement innovative actions? If so, how does this happening?
11. Did Euromedica introduce any new or significantly improved service in mental
health sector?
New Service Development
12. How many new services did you introduce last year?
13. How and to what extent has your service products changed during the past 2 years?
14. Does Euromedica have a plan for the extension and evolution of its services?
367
15. Where did the concept of developing new services come from? (existing customers,
new customers, market research, always part of the plan?)
16. How would you evaluate the coordination among people and departments
throughout the new service development process?
Corporate Entrepreneurship
17. Will you please describe the venturing and entrepreneurial activity in Euromedica?
18. What are Euromedicas venturing objectives?
19. How are entrepreneurial opportunities identified, evaluated and selected by
Euromedica?
20. How does Euromedica encourage and support entrepreneurial activity? How does
recognise and reward innovative efforts?
Customer Orientation
21. What preliminary market assessments occurred before any investment was
undertaken? (market research, market segmentation)
22. Is there a clear idea of the type of information to be obtained through market
assessment?
23. How much time and effort is spent in conducting interdepartmental meetings to
discuss market trends and developments?
24. What type of relationship does the organisation have with its customers?
25. Is there an adequate process to track and respond to customer queries and
complaints? If so, does management get an up to date of the status of complaints?
26. Is there a formal method by which complaints, queries and poor performance are
fed into service development initiatives?
27. Is there a robust mechanism to integrate the views of customers into the service
planning process?
28. How much room is there for customisation and judgement on the part of service
provider?
29. Please determine how Euromedica can increase customer involvement in its
innovative activity.
30. Are there measures of customer satisfaction that you use to improve your services?
368
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370
Appendix 2
Appendix 2.1 Semi-structured interview questions for Medical Personnel for
Research Section II (English Version)
1. Are adequate tools and processes used to generate opportunities for product
development?
2. Does the hospital do enough to create:
i) A culture where continuous improvement is regarded as a norm?
ii) Incentives for staff to identify and act on opportunities for improvement?
3. Do you believe that patients can contribute something extra to the service
innovation process?
4. How does the hospital cope with failure in innovation? Does it tolerate failure and
learn from it? Or does it punish failure?
5. What do you think is the role of the medical staff in promoting the internal
innovation process?
6. Did Euromedica introduce any new or significantly improved service within the
past 2 years?
7. How many new services did the hospital introduce last year?
8. How and to what extent have your service products changed during the past 2 years?
9. How would you evaluate the coordination among people and departments
throughout the new service development process?
10. What type of relationship does the organisation have with its patients?
11. Is there an adequate process to track and respond to customer queries and
complaints? If so, does medical staff get an up to date of the status of complaints?
12. Is there a formal method by which complaints, queries and poor performance are
fed into service development initiatives?
13. How much room is there for customisation and judgement on the part of service
provider?
14. Please determine how firm can increase customer involvement in its innovative
activity.
15. Are there measures of customer satisfaction that you use to improve your services?
371
372
Appendix 3
Appendix 3.1 Semi-structured interview questions for Patients for Research
Section III (English Version)
1.
Was it your choice to be treated; If so, was it your choice to be treated in this
hospital?
2. Do you find someone on the hospital staff to talk to about your worries and fears?
3. Do you get answers that you can understand when you have important questions to
ask a doctor?
4. Do you have confidence and trust in the way doctors treating you?
5. In your opinion, are there enough nurses on duty to care for you in hospital?
6. How do you feel when engaged in clinical activities?
7. Would you like to participate in the way decisions are made for your health?
8. What do you think of the services provided to patients?
In particular on:
i) The way of nursing patients (wounds, sores, etc.);
ii) The way of caring for hygiene (bath, shaving, laundry, etc.);
iii) The method of administration of drugs (even hours, checking on patients,
etc.);
iv) The way of boarding patients
9. Are you willing to participate in a particular programme in which patients expressed
about their treatment?
10. Have you ever been asked about the services you use? If so, how?
11. How do you criticise the conduct of staff to patients?
12. Do you think that patients should be employed in hospitals work?
13. Would you trust the doctors of the hospital to discuss a personal matter?
14. Do you feel productive during your residence in the hospital?
15. How do you criticise the infrastructure of the hospital (condition of the building,
surroundings, facilities, etc.)?
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374