How Dutch

Hospitals Make
Value-Based
Health Care Work
The Boston Consulting Group (BCG) is a global management consulting firm and the world’s
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Santeon is a Dutch hospital group of seven leading teaching hospitals. Our member hospitals
work together intensively in measuring and comparing outcomes, costs, and relevant process
indicators. One in eight patients in the Netherlands visits a Santeon hospital for care and
treatment. The reach and extent of our care provision, plus our national coverage, are a good
basis for achieving our objective to add more value to the treatment of patients by continuous
improvement of care.
HOW DUTCH HOSPITALS
MAKE VALUE-BASED
HEALTH CARE WORK
In less than two years, seven hospitals in the Netherlands
have substantially improved health outcomes while
delivering better value.

June 2018 | The Boston Consulting Group

CONTENTS

3 INTRODUCTION

5 THE SANTEON VBHC MODEL

Three Foundations of Success
Implementing VBHC in Patient Groups

1 2 THE IMPACT OF SANTEON’S MODEL

The Breast Cancer Group
The Hip Arthrosis, Lung Cancer, Prostate Cancer, and CVA Groups

1 6 SEVEN KEY LESSONS FOR OTHER HOSPITALS

1 9 FOR FURTHER READING

2 0 NOTE TO THE READER

2 | How Dutch Hospitals Make Value-Based Health Care Work

 INTRODUCTION

S anteon, a Dutch network of seven leading teaching hospitals,

has achieved reductions of nearly 30% in unnecessary inpatient
stays and up to 74% in the rate of reoperation due to complications in
breast cancer patients. Santeon achieved these results in a year and a
half, not merely by meeting protocols or guidelines—its member
hospitals have been doing that for a long time—but by emphasizing
transparency and making value delivered to patients the core of its
strategy.

The key to Santeon’s success was the implementation of a structured,

value-based health care (VBHC) approach. In 2015, BCG started work-
ing with Santeon to make VBHC a reality at its hospitals. After an ini-
tial design phase, Santeon began implementing VBHC in March 2016
among five patient groups: breast cancer, prostate cancer, lung cancer,
cerebrovascular accident (CVA), and hip arthrosis. Implementation in
each group consists of four stages:

1. Use a multidisciplinary team to define the right metrics to improve

outcomes.

2. Share and learn internally, and then initiate a strict and simultane-
ous cadence of improvement cycles within the member hospitals.

3. After a few internal cycles to validate and stabilize the process and
data, share results externally to accelerate improvements.

4. Engage with patients and payers to move toward value-based

contracting.

The breast cancer group was the first to reach the third stage. After
defining a short list of key metrics for outcomes, costs, and process in-
dicators (stage 1), Santeon began sharing data within and among its
seven hospitals to foster internal learning in a safe environment
(stage 2). Now, following the completion of three improvement cycles,
the results are being shared with the outside world on a hospital-
by-hospital basis (stage 3). Those results are very impressive indeed.
In addition to the figures noted above, Santeon achieved, on average,
a reduction of more than 15% in lumpectomy reoperation rates after
positive margins, with one hospital achieving a reduction of about
60% (from 11% to 4%).

Other Santeon patient groups show similar signs of improvement, al-

though they are not yet at a sufficiently advanced stage for the results
to be published externally. Still, the variation observed in the metrics

The Boston Consulting Group • Santeon | 3

 data among the hospitals for the other patient groups is comparable
to that seen in the breast cancer group and clearly indicates the po-
tential for improvement (for 30% of the metrics, Santeon found that
the highest and lowest scores varied by a factor of between two and
five, indicating significant improvement potential in those domains).1

In this report, we share Santeon’s successes in implementing VBHC,

describe how the hospital group has made the transformation work,
and offer a number of key lessons for other providers whose ambition
is to put value for patients at the center of their approach to health
care.

Note
1. Based on international BCG experience, this level of variance is not uncommon; it
is often much higher. (Elsewhere in this report we cite variance factors of four to
thirty-six.) What is uncommon is for such variance to be made visible like-for-like for
complete sets per patient group, and to be acted upon as Santeon does.

4 | How Dutch Hospitals Make Value-Based Health Care Work

 THE SANTEON VBHC
MODEL

S anteon is a cooperative of seven top-

performing Dutch hospitals that together
account for 11% of the nation’s hospital care
across the Netherlands and do not directly
compete with one another. (See Exhibit 1.)

volume, employ approximately 29,000 Santeon embraced the VBHC concept in 2012
people, and generate €2.9 billion in annual and between 2015 and 2017 worked with BCG
revenues. Santeon represents a unique effort on various projects to put VBHC at the core of
by hospitals that have joined forces to its collaboration model. Santeon is now wide-
increase the quality and efficiency of patient ly recognized in the Netherlands and beyond
care. The hospitals are widely dispersed as a VBHC pioneer and a driving force and

Exhibit 1 | The Santeon Network

7 Martini
well-respected Dutch teaching hospitals Hospital

€2.9 billion
annual revenue (combined)
OLVG
Hospital Medisch
29,000 Spectrum
employees St. Antonius Twente
Hospital
Canisius
11% Wilhelmina
of national hospital volume Hospital
Catharina
Hospital
Two-time
winner of the Value-Based Health Care Prize Maasstad
Hospital

Sources: Santeon hospitals annual reports; BCG analysis.

The Boston Consulting Group • Santeon | 5

 partner in the movement toward a more val- Santeon hospitals share an ambition to
ue-based health care system. (See the sidebar “realize better outcomes for patients faster
“The Promise of Value-Based Health Care.”) together” via transparency on health
outcomes and costs. They also committed
to a long-term VBHC agenda: start with a
Three Foundations of Success few patient groups to develop and test a
Santeon’s success is based on three impera- methodology and then expand it to
tives that it established before it began imple- include 20 to 25 patient groups by 2020.
menting VBHC around patient groups:
•• Establishment of a VBHC Model.
•• A Shared Ambition and Long-Term Santeon designed and implemented the
Commitment to VBHC. The boards and same VBHC model in all seven of its
medical leadership of each of the seven hospitals so that it could benchmark and

THE PROMISE OF VALUE-BASED HEALTH CARE

Value-based health care aims for the best enormous, given the large variations that
patient outcomes for every euro spent. exist among providers in treatment
Many articles have described the concept decisions, cost of care, and patient out-
since Michael E. Porter and Elizabeth comes. The exhibit below shows the
Olmsted Teisberg introduced it in Redefining differences in outcomes among hospitals at
Health Care: Creating Value-Based Competition the national level. Similar variations among
on Results (2006). VBHC makes the delivery hospitals are found across treatment areas
of improved health outcomes for the same and geographies.
or lower cost the primary objective of
global health systems. The potential for In many industries, a difference in costs or
improvement in health care value is quality of 5% to 10% between competing

Practice Variation Leads to Highly Variable Outcomes

4x variation in bypass surgery mortality (United Kingdom)

6x variation in emergency readmissions after hip surgery (United Kingdom)
9x variation in complication rates from radical prostatectomies (Netherlands)
12x variation in mortality after gall bladder surgeries between median and worst clinics (Germany)
12x variation in mortality after coronary artery bypass grafting between best 5% and worst 5% clinics (Germany)
18x variation in reoperation rates after hip replacement between best 10% and worst 10% clinics (Germany)
20x variation in mortality after colon cancer surgery between best 10% and worst 10% clinics (Sweden)
33x variation in infections of central vein catheters between best 10% and worst 10% clinics (United States)
36x variation in complications after cataract surgery between best 10% and worst 10% clinics (Sweden)
Sources: International Consortium for Health Outcomes Measurement (ICHOM); Peter Lee and Atul Gawande,
“The Number of Surgical Procedures in an American Lifetime in 3 States,” Journal of the American College of
Surgeons, 2008.

6 | How Dutch Hospitals Make Value-Based Health Care Work

leverage the network’s combined exper- •• The Right Infrastructure and Gover-
tise efficiently. Multidisciplinary clinical nance. Santeon established a central
teams organized around patient groups infrastructure and governance system to
develop an aligned view across the seven promote the VBHC model. First, it
hospitals on the 15 to 20 metrics that installed a central team comprising a
define value for each group. They then set VBHC program manager and a few data
up improvement cycles of six months each analysts to support the local multidisci-
that establish a strict, simultaneous plinary teams. This team ensures align-
cadence for the teams in each hospital to ment across the seven hospitals, provides
follow. Hospitals develop and execute quality control, and helps local teams
improvement initiatives locally, with input prepare and manage meetings. Second,
on data and best practices shared among VBHC became a key element in the
them. governance of both the Santeon group

organizations typically triggers major while facing ever-increasing pressure from

improvement programs by the trailing rising costs and a high registration burden
organization. Among hospitals worldwide, around process metrics, guideline adher-
the differences in cost and quality can ence, and reimbursement administration.
range from 400% to 3600%! The failure to
act on such large disparities reflects what More and more health care organizations
Porter calls the “pre-industrial nature of recognize the potential of VBHC and are
health care.” moving toward a value-based way of
working. Implementing VBHC is not merely
The VBHC approach emphasizes the a project; it transforms hospitals into
systematic measurement of health out- learning organizations that provide care
comes and of the costs involved in deliver- around patient groups, based on transpar-
ing them to specific subpopulations—for ency in their outcomes and costs per
example, to all patients who suffer from a medical condition.
particular disease or condition, such as
colon cancer, or who share a similar risk
profile, such as the multimorbid elderly.
Teams composed of clinical specialists use
this data on outcomes and costs to devise
customized interventions that, over time,
will improve the ratio of positive outcomes
to costs for each patient group.

Focusing on the objective of improving

health care value, VBHC has the potential
to deliver better health outcomes at lower
costs than are currently achievable by most
health care systems around the world.
VBHC also improves patients’ access to
suitable care, identifies significant innova-
tions in treatment and care delivery, and
offers major new public- and private-sector
business opportunities for health care
organizations. VBHC promises to be a
solution for hospitals that aim to deliver
the best possible care for their patients

The Boston Consulting Group • Santeon | 7

 and each individual hospital. For example, coordinate discussions among the seven
VBHC is now a standard topic on the hospitals. (See Exhibit 2.) Supported by a
agenda at board meetings, and the boards few central resources, one hospital takes
are responsible for making overarching the lead in developing a scorecard identi-
decisions regarding investment, prioritiza- fying 15 to 20 key outcome, cost, and
tion of the rollout of patient groups, and process metrics relevant to its patient
other matters. Third, a handbook was group. (See Exhibit 3.) It’s important for
developed to codify the VBHC model, hospitals to be pragmatic about these
ensure uniformity, and provide guidance scorecards, leveraging existing registries as
to stakeholders. The handbook describes much as possible and starting with
the process and goal of each step within metrics for which data are readily avail-
every improvement cycle, the roles and able (refining them over time if neces-
responsibilities of the participants in each sary). For outcome metrics, Santeon uses
cycle, the formats to use, and strict rules the International Consortium for Health
about data quality and the sharing of data Outcomes Measurement (ICHOM) indica-
internally and externally. tor sets as much as possible. (See the
sidebar “ICHOM’s Global Standards for
Health Outcomes Measurement.”) For cost
Implementing VBHC in Patient metrics, it identifies the biggest cost
Groups buckets for a patient group and the most
Prepared with a shared ambition, a working important cost drivers to track. Santeon
model, and the necessary infrastructure, San- adds process metrics only when they are
teon began rolling out VBHC for the first pa- critical for patients (such as the duration
tient groups early in 2016. The VBHC team of the period of high uncertainty between
for each patient group has a clear path to fol- diagnosis and the determination of a
low, consisting of four stages: treatment plan). Patients play a central
role in defining all metrics related to the
•• Organize multidisciplinary teams and outcomes and processes that matter most
define the metrics. VBHC implementa- to them.
tion within a patient group starts with
forming a multidisciplinary team at each •• Share results internally and implement
member hospital. Three core members are a standardized improvement cycle for
the driving force of each team and each patient group. When teams and

Exhibit 2 | The Breast Cancer Group Multidisciplinary Team at Each Hospital

Core team of three . . . One or two patients . . . Other relevant care

providers along the breast
cancer patient journey . . .

. . . serves as the driving force behind . . . provide input on what is . . . provide input and work on
the multidisciplinary team important to patients improvement initiatives

• Medical lead (breast surgeon) • Nurse

leads the content, including metrics • Nurse practitioner
• Project leader • Oncologist
leads the process
• Pathologist
• Data analyst • Plastic surgeon
collects and analyzes data
• Pharmacist
• Radiologist
• Radiotherapist

Source: Santeon hospitals.

8 | How Dutch Hospitals Make Value-Based Health Care Work

Exhibit 3 | Breast Cancer Group Scorecard

Category Indicator

• Five-year survival rate, unadjusted (%)

• Repeat operations after a positive margin (%)
• Repeat operations after postoperative complications (wound infections
and postoperative bleeding) (%)
• Unplanned admission, deviation from treatment plan and/or heart failure
Outcomes after systemic therapy (%)
• PROMs: Quality of life (well-being, functioning, pain, etc.)
• PROMs: Specific symptoms as a result of treatment (breast, arm,
vasomotor)
• Local relapse within five years after the first operation (%)

• Nursing days per patient (number of days)

• Primary breast-conserving operation without hospitalization (%)
Costs • Operating-room time per patient (minutes)
• Outpatient clinic consultations, per patient (number)
• Additional diagnostic activities (MRI, PET, CT, MammaPrint), per patient
• Use of expensive medicines

• Duration from referral to first clinic visit

• Duration from first clinic visit to diagnosis (AP report)
• Duration from diagnosis (AP report) to discussion of the treatment plan
Processes
• Duration from discussing the treatment plan to starting treatment
• Dedicated contact person who supervises the patient and is known to
the patient (%)

• Percent of patients per treatment option (e.g., breast-conserving, direct

Treatment mix reconstruction)

Source: Santeon hospitals.

Note: PROMs = patient-reported outcome measures.

scorecards are in place, teams embark on could create unwarranted delays. As soon
the improvement cycle: a continuous as a team seems to be performing better,
feedback loop that involves collecting it makes sense to look at it more closely
data, analyzing data, identifying areas for and share approaches. Confidential
improvement, and implementing improve- sharing lets the teams gain familiarity
ment initiatives. (See Exhibit 4.) A safe with the new way of working and ap-
learning environment is critical at this proaching data, highlights areas where
stage. Therefore, data and results from the improvement is possible, and allows time
first three six-month improvement cycles to make the first round of improvements
should be transparent only among and validate the comparability of data
member hospitals and not yet shared with before going public.
external parties. Teams use this data not
to judge one another but to form hypothe- •• Share results externally to inspire
ses regarding potential improvement others and accelerate the improve-
initiatives and develop best-practice ments. The teams know that the aim is to
sharing on the basis of observed, clinically share the data externally after three
relevant differences. These differences are improvement cycles. This can encourage
not necessarily statistically significant; other hospitals to measure and share the
making that a prerequisite to taking action same metrics, providing the health care

The Boston Consulting Group • Santeon | 9

 ICHOM’S GLOBAL STANDARDS FOR HEALTH OUTCOMES
MEASUREMENT
The International Consortium for Health most to patients. The organization also
Outcomes Measurement (ICHOM) is a supports health care providers worldwide
nonprofit organization cofounded in 2012 in implementing and measuring these
by Michael Porter of the Harvard Business outcomes in practice, which ultimately
School, Martin Ingvar of the Karolinska places patients at the center of health care
Institute, and The Boston Consulting delivery, and in the process drives up the
Group. The consortium’s mission is to quality of care and reduces costs.
transform health care systems worldwide
by measuring and reporting patient As of May 2018, ICHOM had collaborated
outcomes in a standardized way. with 658 working group members repre-
senting 44 countries and had published 23
ICHOM convenes global teams of physician standard sets (9 more are in the pipeline).
leaders, outcomes researchers, and patient The exhibit below illustrates ICHOM’s
advocates to publish standard sets, which standard set for breast cancer.
define the outcome measures that matter

ICHOM’s Standard Set for Breast Cancer

Source: International Consortium for Health Outcomes Measurement.

10 | How Dutch Hospitals Make Value-Based Health Care Work

 Exhibit 4 | Santeon’s Improvement Cycle

Analysts in each hospital extract data from

Establish
Develop several sources for the indicators on the
multidisciplinary
scorecard scorecard. To align data, analysts from different
team hospitals meet weekly and discuss exact codes
and definitions for extraction.

Central data analysts coordinate between the

lect data an
Col tions ( d iden hospitals, help perform analyses, and present
ia 2m
var on tif
th
the materials for Santeon-wide discussion.

y
s)
The core teams (medical lead, data analyst, and
im pr project lead) from the different hospitals meet
The multidisciplinary team meets again to discuss the observed variation: Is variation
ov e m e n t
I m p le m (2 m

on ve n s a n d
in its own hospital. The medical lead due to differences in data registration or

th m e n t s
discusses the hypotheses regarding best collection, patient mix, treatment choice, or
practices with the rest of the execution? They also share best practices.

ti o
en

multidisciplinary team and identifies one

s

ria
After the central meeting, the multidisciplinary
va
t

s)
or two actions per cycle to implement,

o
on

pr
ze m team meets in its own hospital to further
with the entire team’s agreement. th
s) A n a l y tif y i m discuss the possible drivers of observed
The cycle then begins anew, and the iden (2 variation relevant to its own hospital. As a result
team analyzes the results of the of this discussion, medical professionals from
improvement efforts in the next data the different hospitals sometimes reach out to
collection round. each other to share best practices.

Source: Santeon breast cancer team.

community with an even broader pool of providers to reap any direct financial
data to learn from. In addition, sharing benefit when they improve the quality of
results externally can accelerate improve- the health care that they deliver. Santeon
ment initiatives. Santeon collects its data is working with health insurers in the
in an outcome database, which provides Netherlands to move toward value-based
researchers with a rich pool of data that contracting, and it recently became the
they can use for future research, with the first health care organization in the
aim of publishing scientifically and country to announce such contracts for
statistically significant results over time. breast cancer, with three insurers.1

•• Move toward value-based contracting.

Leveraging transparency around health
outcomes, the appropriateness of care,
and the long-term effects of treatment for Note
contracting with health insurers or public 1. Santeon partnered with the Dutch private health
insurer Menzis to cofinance the first period of imple-
payers is the logical next step. Today, menting value-based improvement cycles in its
many hospitals still receive reimburse- hospitals.
ment for care on the basis of volume
rather than value. This makes it harder for

The Boston Consulting Group • Santeon | 11

THE IMPACT OF SANTEON’S
MODEL

E vidence that Santeon’s VBHC ap-

proach is working is emerging from the
breast cancer group, which has already
between the lowest and highest percent-
ages of reoperations due to positive
surgical margins (which indicate that
reached the external transparency stage, as some cancer cells may remain) after
well as from the other four patient groups lumpectomy. CWZ, which had the highest
(hip arthrosis, lung cancer, prostate cancer, percentage of such reoperations, analyzed
and CVA), which have not yet reached that possible causes and implemented three
stage. corrective measures: using echography
during surgery to gain more certainty
about having removed all cancer cells,
The Breast Cancer Group improving communication between
Santeon’s multidisciplinary breast cancer surgeons and pathologists on the defini-
teams, the first to complete three improve- tion and risks of a positive margin, and
ment cycles, recently revealed their first re- more explicitly discussing whether
sults externally.1 Exhibit 5 shows a selection reoperation is the most sensible response
of the improvements that Santeon achieved to instances of positive margins. Data
within about a year and a half. The breast collection one year later (in the third
cancer teams will closely monitor these re- improvement cycle) showed an impressive
sults in future improvement cycles to ensure reduction in reoperation rates due to
lasting impact. They will also continue to positive margins at CWZ. The team will
identify and implement new improvement continue to closely monitor this indicator
initiatives to increase the value of care for in future improvement cycles to ensure a
breast cancer patients. Each of the seven hos- lasting impact.
pitals discovered practice areas where it could
learn from others—as well as teach others— •• Reoperations due to postoperative
to improve patient outcomes. Here are just a complications after lumpectomy
few examples: dropped by 27% across Santeon and at
St. Antonius Hospital declined by more
•• Reoperations due to positive surgical than 70%. Although complication and
margins fell by 17% across Santeon and reoperation rates were low in all member
at Canisius-Wilhelmina Hospital (CWZ) hospitals, a factor-4 variation between the
declined by more than 60% (from 11% lowest and highest percentages of reoper-
to 4%). In the first improvement cycle, ations after postoperative complications
Santeon observed a factor-4 variation led the teams to investigate improvement

12 | How Dutch Hospitals Make Value-Based Health Care Work

 Exhibit 5 | Initial Breast Cancer Results

Reoperation after positive Reoperation after Lumpectomy day cases

margins (%) complications (%) (versus inpatient) (%)

–2.7x –3.9x 2.2x

+18%
–64% –74%
66 +115%
11.0 –27%
3.1 56
–17% 2.6 43
6.0 1.9
5.0
4.0 20
0.8

Santeon Canisius- Santeon St. Antonius Santeon Medisch

average Wilhelmina average Hospital average Spectrum
Hospital Twente
Cycle 1 Cycle 3

Sources: Data from Santeon hospitals and NABON Breast Cancer Audit, Netherlands Comprehensive Cancer Organization; Santeon and BCG
analysis.

opportunities. The safe, confidential could go home on the day of surgery. First,
setting established by Santeon’s VBHC some patients were not aware in advance
model enabled the St. Antonius Hospital of the expected discharge date; when it
breast cancer team to compare the was made clear that they could go home
outcome scores of individual surgeons. on the day of surgery if there were no
The team found that one outstanding complications, patients were able to adjust
performer used much more intensive their arrangements accordingly. Second, at
wound flushing during surgery. St. Anto- hospitals that employed full anesthesia
nius surgeons who then adopted this followed by morphine, patients were often
practice saw an immediate reduction in unable to go home on the day of surgery.
complication rates, and data from the But at hospitals that relied on locoregion-
third improvement cycle confirmed the al (nerve block) anesthesia, patients could
improvement, showing a 74% decline in go home with over-the-counter pain
reoperation rates after complications. relievers on the same day, with no addi-
tional negative effects. Changes that give
•• Santeon reduced the number of days in preference to locoregional anesthesia
the hospital for lumpectomy patients when appropriate increased the number
by increasing the number of day cases of day cases within six months.
by 18% on average, and Medisch Spec-
trum Twente doubled its day case
(versus inpatient stay) rate. Data The Hip Arthrosis, Lung Cancer,
collected in the first cycle indicated that Prostate Cancer, and CVA Groups
day case treatment percentages for The VBHC teams in Santeon’s other four ini-
lumpectomy, which the teams expected to tial patient groups are now either finalizing
be around 85%, in fact ranged from 20% to the second improvement cycle or have started
79%. After testing several hypotheses, the third. (Santeon also recently started the
including correlations with age and home first improvement cycle for patient groups fo-
situation, the teams found that two factors cused on kidney disease, colorectal cancer,
had a direct effect on whether patients and childbirth.) Consistent with VBHC princi-

The Boston Consulting Group • Santeon | 13

 ples to protect a safe and open learning envi- cancer team discovered that the best-per-
ronment, data sharing at these early stages is forming hospital, rather than letting
restricted to internal teams and cannot yet be doctors continue a drain when they were
disclosed in this report. Nevertheless, some unsure if it had done its work, used
anonymized examples offer a preliminary pressure-testing equipment and pre-
view of select initiatives launched to improve scribed the pressure at which a drain can
outcomes, costs, and processes. be removed. A Santeon-wide protocol is
now under development.

VBHC principles establish Member hospitals are reducing costs by elimi-

nating practices that do not contribute to bet-
and protect a safe and open ter outcomes:

learning environment. •• Hospitals are adopting best practices in

patient flow management for hip
arthrosis patients to reduce unneces-
Member hospitals are making changes to im- sary preoperative days in the hospital.
prove outcomes for patients. The hip arthrosis team’s first improvement
cycle revealed differences in the number
•• To improve postoperative outcomes in of preoperative days among the Santeon
lung cancer patients, one hospital hospitals. Most Santeon hospitals admit
changed its approach to biopsies. The the majority of their hip surgery patients
lung cancer team found that postoperative on the day of surgery. Some, however,
complication rates, lengths of stay, and admit patients a day in advance for blood
surgery durations all varied by nearly a tests. Orthopedic surgeons discussed this
factor of two. At one hospital with unfa- disparity—and a solution that other
vorably high rates on all these metrics, the hospitals use to overcome it—at a semi-
team undertook a local improvement annual VBHC meeting. The solution is
initiative. It found that, as standard now being implemented at one hospital.
practice, other Santeon hospitals took
diagnostic biopsies preoperatively (in- •• Fewer postoperative X-rays are being
stead of performing intraoperative frozen taken in hip arthrosis patients, follow-
sections), and patients in these hospitals ing a finding that some photos did not
reported reduced uncertainty going into contribute to better health outcomes.
surgery. As a result, the advantages of Variation by a factor of three in the
preoperative diagnostic biopsies versus number of X-ray photos taken per patient
frozen section, which had previously been motivated the teams to compare the
debatable, were now deemed sufficient to extent of diagnostic imaging throughout
justify changing protocols. Over the next the patient journey at different member
cycles, the lung cancer team will closely hospitals. The hospital where the largest
monitor the impact of the new approach. number of photos were taken was unique
in taking them in the recovery room
•• To reduce complications and postoper- immediately after surgery, despite the
ative lengths of stay in lung cancer absence of any observable differences in
patients, hospitals are testing new health outcomes. On the basis of this
drain protocols and equipment. The finding, the hospital stopped taking these
longer a patient has a drain, the higher unnecessary X-rays, which lowered costs
the risk of infection, which can extend the without jeopardizing outcomes.
length of stay at the hospital. Member
hospitals observed variations in complica- Member hospitals are changing processes to
tion rates and lengths of stay, and subse- improve the patient experience:
quently found a factor-2 variation in the
timing of drain removal, as well as •• For prostate cancer patients, the new
differences in drain protocols. The lung standard calls for inviting a family

14 | How Dutch Hospitals Make Value-Based Health Care Work

 member or caregiver to appointments patient experiences across Santeon
where diagnostic results are discussed. hospitals, the VBHC teams found that
This measure was implemented following hospitals that held more frequent dis-
a suggestion by a patient—a member of charge discussions tended to provide more
the VBHC team—who had received an accurate and up-to-date briefings to their
unexpected terminal diagnosis without a patients, whose hospital stays were
family member or partner present. He shorter. One hospital is therefore prepar-
considered this the most undesirable way ing to switch from twice-weekly to daily
to receive such impactful news. The meetings.
hospital subsequently changed its policy
and invites family members and caregiv- In light of the proven benefits for both pa-
ers to all diagnostic result appointments, tients and clinicians, Santeon plans to roll out
whether the results are positive or value-based health care to 20 to 25 additional
negative. patient groups by 2020.

•• For CVA patients, one hospital is

working to improve patient communi-
cation regarding the expected length of
stay by increasing the frequency of Note
discharge discussions in the wards. 1. For more details about the breast cancer results, see
Santeon’s report at https://issuu.com/santeon/docs/
Patients on the VBHC team asked for breast_cancer_2017_care_for_outcome.
better and timelier communication about
the inpatient stay. Comparing data and

The Boston Consulting Group • Santeon | 15

SEVEN KEY LESSONS FOR
OTHER HOSPITALS

S anteon’s experiences with VBHC

already offer a number of valuable
lessons for any hospital that is trying to
tic or who are already implementing
VBHC in isolation. Give the VBHC
champions a platform. This will generate
improve health care quality while maintain- enthusiasm for the VBHC approach and
ing or lowering overall costs: lay the groundwork for expansion into
more complex areas.
•• Develop a common understanding of
value and ensure long-term commit- •• Build a safe learning environment, and
ment. Medical specialists, patients, and keep up the pace toward transparency.
external stakeholders unite around a A period of internal data sharing only
shared ambition to create transparency helps VBHC participants gain confidence
and improve health care outcomes at in comparing outcomes and testing
similar or lower costs. An outspoken improvements. Maintain the focus and
long-term commitment and a willingness momentum by emphasizing the prospect
to “make it real” are essential to achieving of external communication and, ultimate-
lasting change. ly, active cooperation around value with
external stakeholders, including insurers.

Value-based health care •• Have medical professionals take the

lead, and provide them with process
puts patient value at the core support. To build on their expertise and
intrinsic motivation, let medical specialists
of decision making. lead team discussions and select the
relevant metrics. Nonmedical tasks
require an investment in extra resources
•• Start small, be pragmatic, and create a to manage the project, facilitate processes,
snowball effect. Aim for a smooth start drive improvement initiatives, and
with a scorecard based on existing quality provide data and analyses.
standards for a limited number of promis-
ing conditions. Prioritize based on clear •• It’s about the patient—and must be
criteria. For example, begin with condi- implemented with the patient. VBHC
tions that have clear improvement puts patient value at the core of decision
potential and a fair amount of good data making. To emphasize this perspective
available, with doctors who are enthusias- and foster the right mindset among all

16 | How Dutch Hospitals Make Value-Based Health Care Work

 participating professionals, every Santeon solution, but it leads to groundbreaking
VBHC team has one or two patient and continuous improvements. It requires
members. Santeon has gained valuable a real change effort from all involved—an
insights from their points of view, and effort that is well worth the investment,
patients indicate that they appreciate according to Santeon’s medical profession-
seeing the results of their participation. als. (See the sidebar “Health Care Profes-
(See the sidebar “Patients See the Direct sionals Embrace This Way of Working.”)
Impact of Their Contributions.”) The VBHC approach appeals to the
intrinsic motivation of medical profession-
•• Improve locally, and learn from others. als, because it focuses on what matters
The local VBHC teams in each hospital most to patients, and the impact of efforts
are responsible for prioritizing and execut- to improve is clearly apparent.
ing improvement initiatives. They use
data from other hospitals as points of Value-based health care is poised to trans-
reference and comparison. Santeon form the health care industry, improve pa-
hospitals benefit from coordinated data tient outcomes, lower health care costs, and
collection across seven hospitals, but dramatically improve the patient experience.
hospitals that are not (yet) collaborating By creating transparency around differing ap-
in a network can use publicly available proaches to care, comparing outcomes, and
data and international benchmarks, or changing protocols accordingly, providers are
start their own data-sharing alliances. The gaining new insights into the ways specific
only prerequisite is that definitions be treatments improve the health of patients. As
aligned. For this, ICHOM can provide a the data on outcomes continues to grow and
very useful starting point, as it has defined national registries become richer and more
global standards for many disease areas. robust, the VBHC model will only become
more compelling.
•• It’s hard work and moves one step at a
time, but it’s absolutely worth it.
Implementing VBHC is not a quick-fix

PATIENTS SEE THE DIRECT IMPACT OF THEIR

CONTRIBUTIONS
VBHC teams engage directly with patients “Breast cancer patients now find soft facial
in order to understand the outcomes that tissues to dry their tears in the waiting
matter most to them. In many cases, room of the breast cancer outpatient clinic.
patients’ suggestions for improvement can This is the first impact I saw after sharing
be adopted quickly. my experiences with the value-based
health care team.” — patient of breast cancer
“Awaiting the results of mammography, at VBHC team
home, is a most horrible period filled with
insecurity. Sharing this in the VBHC team
led to tangible impact: mammography
results are now communicated on the same
day.” — patient of breast cancer VBHC team

“All patients are now actively encouraged

to bring a second person to consultations
at the prostate outpatient clinic. This
change was implemented based on my
recommendation.” — patient of prostate
cancer VBHC team

The Boston Consulting Group • Santeon | 17

 HEALTH CARE PROFESSIONALS EMBRACE THIS WAY OF
WORKING
VBHC allows doctors to share best working or not. More contact about the
practices and learn from one another in a content. A practical way to mold our
safe and supportive environment. The profession together. Looking at the num-
focus is always on delivering better quality bers more often and making plans for a
for patients while maintaining or lowering new process. And adjusting the process
overall costs. faster.” — Ron Koelemij, oncological surgeon,
St. Antonius Hospital
“This is an unbelievably good concept.
Although it takes time, it is much more “This way of working stimulates us to
motivating than the other ways we have to improve ourselves. We discuss recognizable
look at data and deal with quality indica- practical situations, and you have a
tors. By learning from each other, we can conversation partner you know well. It
really improve care for our patients. That helps; it makes it easier to talk to each
gives me a lot of energy and I definitely other. You have the feeling of forming some
recommend working like this to my kind of a club that is less anonymous,
colleagues.” — Yvonne van Riet, breast which makes talking easier.” — Luc Strobbe,
surgeon, Catharina Hospital surgeon, Canisius-Wilhelmina Hospital

“For me, the power of collaboration is in

directly getting feedback if something’s

18 | How Dutch Hospitals Make Value-Based Health Care Work

 FOR FURTHER READING

The Boston Consulting Group offers Health Care’s Value Problem— The Value-Based Hospital: A
many reports and articles on value- and How to Fix It Transformation Agenda for
based health care that may interest A report by the BCG Henderson Health Care Providers
senior executives in the industry, Institute, October 2017 A report by The Boston Consulting
including the following. Group, October 2014
Value in Health Care: Laying the
Foundation for Health System Competing on Outcomes:
Transformation Winning Strategies for Value-
A joint report by the World Economic Based Health Care
Forum and The Boston Consulting A Focus by The Boston Consulting
Group, April 2017 Group, January 2014

The Boston Consulting Group • Santeon | 19

NOTE TO THE READER

Acknowledgments For Further Contact Wouter van Leeuwen

This report was codeveloped by the Douwe Biesma Partner and Managing Director
Santeon Hospitals and The Boston CEO, St. Antonius Hospital BCG Amsterdam
Consulting Group. We thank the Chair, Santeon Hospital Group [email protected]
many hospital leaders, medical [email protected]
professionals, data analysts, and
patients whose contributions made Pieter de Bey
it possible. The following Director, Santeon
individuals, in particular, [email protected]
contributed to writing and review:
Douwe Biesma, Pieter de Bey, Jan Willem Kuenen
Leonique Niessen, and Annemarie Senior Partner and Managing Director
Haverhals of Santeon and Jan BCG Amsterdam
Willem Kuenen, Wouter van [email protected]
Leeuwen, Bente Jorritsma,
Josephine Linthorst, and Amy
Strong of BCG. We are also grateful
to Katherine Andrews, Gary
Callahan, Kim Friedman, Abby
Garland, and Ron Welter for editing,
design, and production.

20 | How Dutch Hospitals Make Value-Based Health Care Work

© The Boston Consulting Group, Inc. 2018. All rights reserved.

For information or permission to reprint, please contact BCG at:

E-mail: [email protected]
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