Transitioning three innovation projects in Transumo programme
6.3 Predevelopment of the Transition Programme in Long-term Care (2006)
6.3.1 How Transition Management became the central steering approach (September 2006)
In September 2006, the potential of a Transition Management approach in the care sector was fi rst presented by DRIFT10 at a meeting organised by the Working Group Innovation. The working group was responsible for advising a Board of Directors from the Ministry of Health, Welfare and Sports and the care sector organisations about implementing the AWBZ covenant 2005-2007. However, two years after the completion of the covenant, the resources for innovation in the care sector had not yet been allocated, because the Working Group Innovation was still searching for an adequate approach.11 When DRIFT presented the Transition Management approach, the Working Group Innovation, and several innovative care institutes which also attended this meeting, immediately recog- nised the potential of Transition Management for the long-term care sector (Box 6.1).
7. Since November 2007 the national client advisory body LOC-LPR and Zorgverzekeraars Nederland also participated in the Working Group Innovation.
8. To broaden the central innovation theme from the Ministry, in 2006 the Working Group Innovation had formulated 4 innovation themes which provided possible directions for the transition experiments: (1) prevention and redefi ning care demand, (2) social and societal support systems, (3) remote care and (4) ef- fi cient management. Just before the second round of the transition experiments the Ministry decided that the transition experiments should also focus on “logistics” and “small-scale” (within the 4 themes).
9. Quote from the Ministry “The programme originated from the necessity to address the future labour problems. For this purpose innovation is an important instrument. The theme of this programme has fur- ther evolved to sustainable care, a term that covers the scope more adequately, since it is not only about providing more quantitative care with the same amount of labour, but also about qualitatively better (sus- tainable) care.” (Source: Presentation Ministry VWS, Instruction meeting, April 2, 2007)
10. The presentation was conducted by Jord Neuteboom (DRIFT), elaborating upon the TM theory as it was being developed by prof. Jan Rotmans (DRIFT) and others. Jord Neuteboom started working at DRIFT in 2006 to take up the challenge of both stimulating a transition in the care system and providing a basis for conducting dedicated research to understand and infl uence this transition.
11. A previous eff ort by SenterNovem to develop a programmatic approach failed because it did not gain the support and confi dence of the Working Group Innovation. This was related to a too early focus on the care providers, a lack of expertise in the care sector, a lack of expertise on Transition Management and a too large distance between SenterNovem and the Ministry ofHealth, Welfare and Sports.
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Following up this meeting, a consortium12 of Ernst&Young, CC care advisors and DRIFT was commissioned to develop an action plan for a Transition Programme in Long-term Care. It was agreed that in this programme Transition Management would be used as a central steering approach.13 Within DRIFT, Jord Neuteboom (a senior consultant whose main task at DRIFT is stimulating a transition in health care) was leading the intensive process of preparing the programme action plan, together with the other consultants and the Working Group Innovation members, while making continuous connections to diff erent researchers at DRIFT14, who were further developing the Transition Manage- ment concepts and tools.
6.3.2 Preparing the programme action plan (September - December 2006)
During the preparation of the programme action plan numerous decisions were made with regard to how the Transition Management approach would be applied in the long- term care sector. Three important decisions involved: (1) starting with transition experi- ments instead of developing a sustainability vision in a transition arena, (2) selecting a
12. To commission a consortium instead of one organisation was perceived by the Working Group Innova- tion as an ‘innovation’ as well (Source: presentation Eugenie van Es, Open Learning Meeting, November 11, 2008). The consortium was actually a compromise between the Ministry, who preferred Ernst&Young, and care sector organisations, who had a fi rst interest in DRIFT, and suggested to balance the fi nancial expertise of Ernst&Young with the care expertise of CC Care Advisors.
13. Initially the Working Group Innovation (WGI) requested the two consortium partners E&Y and CC to work out the new approach, and DRIFT to monitor this process and to evaluate its transition aspects. How- ever, the three organisations took the initiative and proposed the WGI to work out jointly an integrated Transition Management approach, in which DRIFT provided the methodological TM tools and instruments. This proposal was accepted by the WGI and created a conceptual and organisational framework for the three organisations to work jointly on the programme, and later onwards in the execution and implementa- tion phases. This phase also helped the persons working in the three diff erent organisations to get to know each other, while sharing and combining their diff erent expertise and elaborating this into a tailored TM approach for the care sector. (Van den Bosch and Neuteboom, forthcoming)
14. The DRIFT researchers who were directly involved in the Transition Programme in Long-term Care in- clude: Jan Rotmans, Roel van Raak and Suzanne van den Bosch. Mattijs Taanman was indirectly involved in monitoring this transition programme (Taanman, forthcoming).
The core of the Transition Management approach: a new approach for steering (not a trick or panacea)
changing the care sector from within using outside support: small sheltered experiments with visionary thinking and practical acting
in small steps with a long-term focus resulting in a societal movement
Box 6.1: Possibilities of Transition Management in the care sector (Source: DRIFT presentation, AWBZ
limited number of experiments and (3) focusing on transition experiments instead of diff erent types of experiments.
Initially, DRIFT suggested a double track approach in which a transition arena would be a starting point for formulating a project portfolio and transition experiments. Start- ing with a transition arena (Van Raak, forthcoming) was explained as being important for thoroughly analysing the persistent problems in the care sector, for developing a strong vision on a sustainable care sector, for building up trust and belief in change, and for strategically infl uencing existing societal and administrative/political networks. Following up the transition arena, DRIFT suggested that transition experiments could be set up to provide practical “transition spaces”, which were explained as:15
Aiming at societal challenges/paths
High potential contribution to transition process
High risk (in terms of chance of failure/risky) regarding the applicability in the cur- rent situation
Ideally consisting of a mix of innovation types (Box 6.2)
Involving diff erent perceptions: (societal) experiment versus project (participants) However, during the process of preparing the programme action plan, it was decided that instead of starting the programme with setting up a transition arena, the fi rst pri- ority was to set up transition experiments. This decision was strongly infl uenced by the Ministry of Health, Welfare and Sports and the care sector organisations, who felt pressure to quickly spend the 90 million euros for innovations, as agreed in the AWBZ covenant 2005-2007. Because the implementation of this covenant had been delayed, they wanted to give an immediate impulse to innovations in long-term care, by “devel- oping good ideas, implementing innovations and rewarding innovative care institutes”. A transition arena process, with a focus on integrated problem analysis and visioning, did not meet their interests for the short term.16 Furthermore, they were not interested in another “steering group”. The consortium of DRIFT, Ernst&Young and CC Care Advisors not only lacked support for developing a transition arena, but also lacked capacity and funding.
With regard to the allocation of resources to experiments in long-term care, an initial idea of the care sector organisations was to support all their member care institutes with a relatively small amount of money. However, the consortium convinced them that this would be a waste of money which would only lead to incremental innovations and
15. Source: DRIFT presentation, AWBZ meeting September 4, 2006.
16. Because the budget had to be spent within a few years, a conventional ‘top-down’ transition man- agement approach that starts with a transition arena would have taken too much time. Furthermore, the Ministry had already defi ned the main problems (e.g. labour problems) and had already developed a vision (including the four innovation themes). A ‘bottom-up’ TM approach that starts with transition experiments better fi tted the context (e.g. interests, aims, time perspective).
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would not stimulate fundamental changes. The approach was therefore focussed on selecting a limited number of experiments, which fi tted the idea of supporting frontrun- ner care institutes with initiatives that could really make a diff erence.
The fi rst draft of the action plan proposed an approach that distinguished between various types of experiments17, in which ‘transition experiments’ would fulfi l only a small part (Box 6.2). However, eventually it was decided that all experiments would be supported under the heading of ‘transition experiments’ because ‘optimisation experi- ments’ and ‘innovation experiments’ were already supported by the ZonMW programme (section 6.2.2).
6.3.3 Action plan of Transition Programme in Long-term Care (January 2007)
The fi nal action plan of the Transition Programme in Long-term Care was rapidly realised by CC Care Advisors, Ernst&Young and DRIFT in December 2006. Because of the failed previous attempts to implement the AWBZ covenant 2005-2007, the action plan strongly
17. This distinction was an elaboration of the table with classical innovation experiments and transition experiments (Chapter 3), and added ‘optimisation experiments’ which would be mainly aimed at a better implementation of existing innovations.
Experiments in long-term care (AWBZ sectors) Types: Aspects: Optimisation experiments Innovation experiments Transition experiments
Starting point Working more eff ectively
and effi ciently:
realising and diff using optimisations
Realising same objectives in diff erent way. Initiating innovations and making ready for market
Societal challenge: demonstrating fundamentally diff erent structure & culture
Nature of problem Practical/technological
and diff usion
Diff erent domains, inter-organisational, institutional barriers
Uncertain and complex: end goal and pathways are changing, part of societal debate
Perspective Highly short-term: 1-2
years
Short-term and medium- term: 5-10 years
Long-term: 10 – 20 years
Method Solution driven
application
Testing and demonstration
Exploring, searching and learning
Learning First order learning about
applications
First order learning (individual)
Second order learning (collective)
Involved disciplines One or a few A few Many
Actors Professionals, managers,
end users
Professionals, managers, end users, engineers, etc.
Multi-actor alliances (across society)
Management context Classical project
management
Programme management Transition management (visions, arenas, paths)
Box 6.2 Three diff erent types of experiments (Source: Draft action plan Transition Programme in Long-
recommended to keep up the current speed and start with the Transition Programme before a defi nitive political decision about the portfolio of transition experiments would have been made. The action plan suggested starting immediately in February 2007 with a multi-phase approach:
– a pilot phase to build up the project organisation and start the fi rst transition ex- periments (recruited and selected based on a top-down “push” strategy)
– a follow-up phase to prepare a broad tender open to all AWBZ care institutes (“pull” strategy).
The underlying idea of the pilot phase was to start off a minimum of 3 to 5 ‘pilot’ transition experiments, which would demonstrate to the Ministry and care sector organisations that a Transition Management approach was possible. The action plan contained many explicit Transition Management concepts (e.g. persistent problems, societal transition challenge, transition arena, deepening, broadening and scaling-up) and stated that: ”The core of the programme encompasses the development and execution of transition experiments, executed by frontrunners and innovative parties, which are selectively and directly supported in such a way that the entire care sector can learn from this.”
At the beginning of February 2007, the Ministry and directors of the care sector organisa- tions formally agreed upon the action plan, which kicked off the Transition Programme in Long-term Care. From this moment onwards the consortium of CC Care Advisors, DRIFT and Ernst&Young cooperated as a ‘Programme Team’ to develop and manage a portfolio of transition experiments in long-term care.
Refl ection on Predevelopment of Transition Programme in Long-term Care (2006)
The action plan can be regarded as a ‘milestone’ in the scientifi c and practical development of Transition Management (TM), and specifi cally the TM instrument transition experiments. Before 2007 the care sector was still an unexplored domain within TM research and practice. Moreover, the care sector did not have a history of radical innovation and therefore the implementation of the TM approach was a break-through in the innovation culture of the sector.
The realisation of the Transition Programme in Long-term Care was the result of both strategic action and contingency. It fi rst required strategic actions from the Working Group Innovation, including the development of innovation themes (which was mainly stimulated by the care sector organisation Actiz) that broadened the narrow focus of the Ministry on ‘la- bour productivity’. The implementation of Transition Management was the result of strategic actions of DRIFT, which aimed to understand and infl uence the transition to a sustainable care system. To realise these aims, DRIFT could make use of various (partly contingent) oppor- tunities. First, the AWBZ covenant provided political commitment and resources to set up a large innovation programme in health care. Secondly, the Working Group Innovation was in
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search of an adequate approach, after the failed attempt of SenterNovem to develop such an approach. Thirdly, SenterNovem had already written a report about TM for the Ministry, but because of their lack of TM expertise they could not convince the Ministry. These opportunities together enabled DRIFT to come into contact with the Working Group Innovation (including the Ministry) and convince them about the value of TM for the care sector (based on DRIFT’s scientifi c expertise and practical experiences in other sectors, such as the energy sector).
The resulting consortium of DRIFT, Ernst&Young and CC Care Advisors was also partly contingent (and not based on the theoretical TM model). However, this consortium provided an opportunity to combine the expertise on TM processes of DRIFT with the expertise on care substance of CC Care Advisors, and the expertise on fi nancial and organisational aspects of Ernst&Young. Hence, this consortium was unique and an experiment in itself.