Implementing new technologies for complex care: The role of embeddedness factors in team learning

• DOI: http://doi.org/10.1002/joom.1034
• Author: Merieke Stevens,Jan Schaik
• Published date: 01 January 2020
• Date: 01 January 2020

RESEARCH ARTICLE

Implementing new technologies for complex care:

The role of embeddedness factors in team learning

Merieke Stevens

1

| Jan van Schaik

2

1

Department of Technology & Operations

Management, Rotterdam School of

Management, Erasmus University,

Burgemeester Oudlaan 50, 3062 PA

Rotterdam, The Netherlands

2

Department of Surgery, Leiden University

Medical Center, Albinusdreef 2, 2333 ZA

Leiden, The Netherlands

Correspondence

Merieke Stevens, Department of Technology

& Operations Management, Rotterdam

School of Management, Erasmus University,

Burgemeester Oudlaan 50, 3062 PA

Rotterdam, The Netherlands.

Email: mstevens@rsm.nl

Handling Editors: Lawrence Fredendall,

Anand Nair, Jeffery Smith and Anita Tucker

Abstract

Bearing the rising health care costs of our aging global population is one of the

most urgent challenges society is facing. We study the implementation of new

medical technologies as one way to increase the effectiveness of care, particularly

in the area of aortic disease—a condition that affects an increasing number of

patients globally. Our research focus is the implementation of complex endo-

vascular treatment techniques by a multidisciplinary aortic treatment group, in

addition to their traditional open treatment of aortic disease. We find that relational

and cognitive embeddedness factors support team learning, which in turn enables

the team to achieve its self-set goals of treating more patients; offering more tailor-

made care; and providing endovascular treatment in emergency situations. At the

end of our data collection period, the first steps toward the team's ultimate goal of

offering patient-centered care were also taken.

KEYWORDS

technology implementation, team learning, health care, embeddedness, medical suppliers, longitudinal study

1|INTRODUCTION

In modern industry,harmony among people in

a group,as in teamwork,is in greater demand

than the art of the individual craftsman.

Taiichi Ohno, founder of the Toyota Production

System, (1978)

Implementing new technologies in health care is a difficult

and complex task. The Dutch Ministry of Health, Welfare and

Sport found that avoidable deaths increased in 2015–2016

compared to 2011–2012 only in academic hospitals (Langelaan

et al., 2017). The report suggests that a contributing factor was

insufficient cooperation and communication between different

specialists in various disciplines, during treatments where the

physicians' technical skills were important (Klopotowska,

Schutijser, Bruijne, & en Wagner, 2016). We examine the

challenge of new technology implementation by focusing on

how embeddedness factors impact team learning using an in-

depth case study approach of one medical group.

Our study took place at the Leiden University Medical

Centre (LUMC), one of the eight university hospitals in the

Netherlands. More specifically, we looked at how open recon-

struction of complex aortic disease by members of the vascu-

lar surgery and thoracic surgery departments is supplemented

(and later partly substituted) by endovascular reconstruction

of complex aortic disease by the endovascular treatment team

(ETT) composed of members of the vascular surgery and the

interventional radiology departments. All treatment decisions,

however, continue to be taken by the Aorta Group, which

brings together members of the vascular surgery, thoracic sur-

gery, and interventional radiology departments.

Cardiovascular disease is one of the leading causes of

global mortality and morbidity. According to the World

Received: 1 December 2017 Revised: 14 March 2019 Accepted: 4 May 2019

DOI: 10.1002/joom.1034

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original

work is properly cited.

© 2019 The Authors. Journal of Operations Management published by Wiley Periodicals, Inc. on behalf of The Association for Supply Chain Management, Inc.

112 J Oper Manag. 2020;66:112–134.wileyonlinelibrary.com/journal/joom

Health Organization (WHO), it was responsible for an esti-

mated 17.7 million deaths worldwide in 2015, which is 31%

of all deaths. Between 2005 and 2015, cardiovascular

disease accounted for the majority of the global health care

burden and ranked first in disability-adjusted life years lost

(Global Burden of Disease Study, October, 2016).

Cardiovascular disease thus represents a major economic

burden in terms of direct costs (e.g., hospitalizations, rehabilita-

tion services, physician visits, drugs) as well as indirect costs

(e.g., loss of workforce productivity) associated with disability

due to morbidity and mortality. What is more, increased life

expectancy and obesity rates are likely to increase the cost of

cardiovascular disease even further. Therefore, we consider

vascular treatment as an important topic of study. Our research

focuses on a team that provides low-volume, high-complexity

care, which differentiates our work from earlier studies into

high-volume, high-efficiency care.

The ETT aims to master the new technology in order to

(1) be able to treat more patients; (2) provide care that is better

tailored to each individual patient; (3) apply the new treatment

in emergency cases; and ultimately, (4) provide more patient-

centered care by involving patients more actively into their

own care path. In our case study, we found evidence for 1–3,

while during the final stages of our study, initial steps were

taken with regards to 4. We find that embeddedness contributes

to the ETT's ability to learn the new technology.

Embeddedness consists of three types of factors: structural,

relational, and cognitive (Sting, Stevens, & Tarakci, 2019).

Structural factors refer to the operational integration of different

organizations—mostly buyers and suppliers (Carey, Lawson, &

Krause, 2011; Cousins & Menguc, 2006). We studied an

intraorganizational team, which by being part of the same orga-

nization, by definition is structurally embedded. Relational and

cognitive embedding, however, do not automatically follow

from structural embeddedness. Relational embeddedness con-

sists of mutual trust, friendship, and goodwill and is enabled by

frequent, informal communication, and repeated interactions

(Uzzi, 1996, 1997). Cognitive embedding consists of shared

culture, norms, procedures, meaning, and understanding

(Lusch & Brown, 1996; Nahapiet & Ghoshal, 1998) and often

has both structural and relational embedding as its source.

Relational embedding and particularly its sub-dimension trust

became recognized during the 1990s as a main factor in Japa-

nese automotive firms' ability to manage the increasing complex-

ity and depth of exchange with suppliers needed at the time

(Dyer, 1996). We are interested in whether the increasing com-

plexity of medical treatments and depth of exchange between

different specialists can be supported by similar factors.

After completing the first round of our data analysis in

2017, the Ministry of Health, Welfare, and Sport published a

report about avoidable death and injury in Dutch hospitals.

It was found that this was particularly linked to treatments

whereby technical skills of the physician, as well as simulta-

neous treatment by multiple specialists, are important

(Langelaan et al., 2017). A follow-up study found that insuf-

ficient cooperation and communication between different

specialists amplified problems (Klopotowska et al., 2016).

These findings suggest that the role of team embeddedness fac-

tors in new technology implementation require further study.

While a vast body of the literature discusses embeddednes s at

the inter-organizational level, it is less often applied to teams

(for an exception in a health care setting see Reagans, Argote, &

Brooks, 2005). We argue that this is a missed opportunity, as

relational and cognitive factors of embeddedness can enable

team learning, as we find in our case.

Because the process we investigate is complex and under-

studied, we adopt an in-depth case study approach covering all

68 complex open aortic treatments and 46 complex endo-

vascular treatments conducted by the members of the Aorta

Group during the four-year period between July 2013 and June

2017—a consecutive series of 114 treatments (see Table 1).

2|THEORETICAL BACKGROUND

The positive relation between innovation on the one hand, and

interactions between team members on the other hand, is well-

known in the literature (Clark & Fujimoto, 1991; Gladstein,

1984). Likewise, the positive effect of including multiple per -

spectives and rich data when solving a problem is widely

accepted (MacDuffie, 1997). Also in a health care setting, there

is overwhelming evidence for the importance of teamwork for

health care outcomes. For example, Edmondson, Bohmer, and

Pisano (2001) found that the successful implementa tion o f a

minimal invasive technology for cardiac surgery depends

on the medical specialists' ability to also act as skilled team

leaders who could create an environment conducive to

team learning. Edmondson, Higgins, Singer, and Weiner

(2016) and Nembhard and Edmondson (2006) found that

psychological safety in particular was important to enable

learning in a health care team setting. Nembhard and

Edmondson (2006) further underscored the importance of

leader inclusiveness to team functioning, while Edmondson

et al. (2001) suggest that hospital management should

TABLE 1 Treatments in our sample

Open repair Endovascular repair Total

2013 17 1 18

2014 14 4 18

2015 15 6 21

2016 5 16 21

2017 17 19 36

TOTAL 68 46 114

STEVENS AND VAN SCHAIK 113