Although the partial studies of this thesis are connected to each other in order to find answers to the main research question and all sub questions, each part can also be read separately. PART 2, 3 and 4 have a similar structure. The first chapter in each part describes the findings from literature, which is then reflected upon in the light of the data obtained from practice in the second chapter.
The first part (1) of this thesis describes the context of hospital real estate. People who are unfamiliar with the Dutch healthcare system can find background information in chapter 2 on changes in legislation and regulation during the period 2004 until 2012 and the impact on hospital real estate. Chapter 3 analyses trends in the hospital sector related to accommodation decisions. This chapter presents an existing model that has been made applicable to the healthcare sector and tested by a case study of the Gelre Hospital in Zutphen.
In PART 2, chapter 4 describes literature on Corporate Real Estate Management and how existing models can be aligned to models of organisational management. In this chapter, the Rotterdam Eye Hospital is used as an explorative case study. Chapter 4 results in a meta-model on the alignment of CREM to organisational management.
This meta-model is tested for its applicability in chapter 5 by an ex-post analysis of the initial phase of the Maasland Hospital in Sittard.
PART 3 studies the state of the art of the added value of real estate from CREM literature in chapter 6 and makes this concept applicable for the hospital sector in chapter 7. Empirical results of the interviews on hospital real estate added value are described in chapter 7.
PART 4 first explores possible architectural and urban design analysis methods and how these drawing techniques can be applied to assess added values in the design phase. These drawing techniques are visualised in chapter 9 in a case study of the Deventer Hospital.
PART 5 concludes this thesis by reflecting on the practical insights and implications of this research for both the hospital sector and Corporate Real Estate Management in general. In chapter 10 the social relevance of this research is discussed by presenting the design of the toolbox with models and instruments to support real estate decisions regarding hospitals. Chapter 11 summarizes the answers to all research questions and reflects on the scientific relevance and the added value of this thesis to the literature on Corporate Real Estate Management.
Part 1 Context
Design Value Context
Manage
2 3
4 5
6 7
8 9
10 11
1
2 Dutch hospitals in transition
What is the impact of the changing legislation and regulations on the accommodation choices of hospitals in the Netherlands?
Abstract
Purpose: This chapter discusses the political context in which hospitals have to make decisions about their accommodation strategy. To this end, this chapter is a retrospective of the period from 2004 to 2012 which involved the transition from a centrally directed real estate budget system with ex-ante testing of building plans into a performance based and output driven finance system.
Literature study: Literature review of the Dutch healthcare system and regulations on hospital real estate investment.
Empirical research: An analysis of 111 internet news publications of a professional journal in the Netherlands during the period 2004-2012 that informs hospital boards and CEOs of new developments in hospital real estate regulations and discusses the responses from the healthcare sector.
Findings: The analysis of the hospital sector shows that recent changes in the political context have resulted in hospitals determining their own strengths and opportunities and realising their new responsibility for the risks and threats associated with recovering the real estate investment costs. Another important lesson is that it is important that the government provides a clear policy during the period in which the responsibility for real estate is transferred to private parties. The transfer of responsibilities and risks should also imply a fair assessment of the current value of the hospital building and access to loans and venture capital. As a consequence, the influence of various external stakeholders changes. The decrease of the government’s direct influence on investment decisions and the related capacity of healthcare institutions means an increasing influence of the health insurance companies in purchasing healthcare (capacity) and the banks in the financing of accommodation investment. Deregulation of the construction standards gives hospital CEOs the opportunity to determine themselves the organisational goals which have to be attained by the accommodation. Due to the removal of the review of construction plans, hospital managers are also responsible for assessing whether these values are incorporated into the design. This requires (1) a management model in which accommodation is linked to the organisational strategy;
(2) an understanding of real estate added values and; (3) opportunities to test these values in the design of new hospitals.
Introduction
Governmental regulation and legislation is part of the general context in which hospitals have to make decisions about investments in accommodation.
Understanding both the past and current healthcare legislation and planning systems is therefore relevant for any accommodation investment decision made by a hospital.
Although much has been written on this subject, a comprehensive overview of all the rules and regulations and the consequences for hospital organisations regarding accommodation decisions is missing. This chapter aims to explain healthcare
legislation in relation to real estate in the Netherlands and gives insight into the role of government in accommodation decisions made by hospital organisations alongside the consequences of this governmental regulatory role for individual hospital organisations making real estate decisions in a constantly changing context. Firstly the former and new healthcare system in relation to accommodation investment in the Netherlands is described and positioned within international trends in healthcare systems in developed countries. In addition, the transition period from the former system to the new regulated market system with deregulated healthcare accommodation decisions is analysed. Three important moments in this transition period are: the first announcement of the new legislation in 2004; the first of January 2008 when the new law for hospital accommodation came into force and 2012, intended as the end of this transition period. The analysis of this period shows how governmental regulations have influenced the accommodation decisions of individual hospitals during this transition period. This description shows the political context in which hospitals have had to make accommodation choices.
The analysis of this specific period reveals a timeframe in which a lot of former certainties ceased to exist. This can be regarded as an example for many other sectors who since 2008 have also been coping with new realities as a result of the credit crisis, the recession and financial crisis. Not only hospitals, but also organisations in other sectors and even society as a whole, are coping with a totally new context in which individual organisations still have to make long term accommodation investment decisions.
Whereas this chapter gives a retrospective of the transition period, chapter 3 describes the trends in the hospital sector based on reports with future explorations until 2025.
The accommodation choices on the organisational level are further analysed in PART 2 and PART 3 of this thesis.