Lluvia de ideas

When looking at how these stakeholders react to each other and how they look at the opinions of others, what stands out is the important role of the specialist. When consulting GPs, it is often mentioned that there are two stakeholders that can shape the opinion of a general practitioner: the NHG, the scientific GP organization that develops the guidelines and advises on the newest technologies, and the specialist. The NHG itself also consults experts before approving any new technology and communicating this to all connected member GPs. Therefore, from the GP perspective, the specialist is the stakeholder with the most influence in the acceptance of the technology. This can also be seen in the initial start of the screening as in 2004 a questionnaire among GPs from Amsterdam (response rate 32%) showed that only half of them were of the opinion that a national screening was necessary, while 92% of gastroentologist were in favour of the screening (Terhaar sive Droste et al., 2006), essentially pushing the decision. From a governmental perspective, the NZa always employs and consults experts before developing or advising any new medical technology or innovation. When looking through the perspective of the insurer, it became clear that an insurer will only cooperate with a company in the development of a new solution, when that solution has already proven its functional validity and when a care professional “ambassador” is connected to the project28_{. Even more so, an insurer will only listen}

to the plea for the value of a new solution when this plea is coming for a care professional, a company won’t be listened to. In addition, to acquire the necessary scientific proof of the practical validity of the solution, specialists must be involved to establish and guide the (clinical) validation study.

Another key issue, is a concept known as ‘not invented here’29_{. This concept entails that sometimes care}

professionals are not willing to accept a new innovation, even though it has proven its effectiveness, solely because of the reason that they specifically were not included in the development of the solution. This has been mentioned in multiple workshops and conversations with experts (See Appendix 2). In other words, without a specialist, it is a near impossible feat to get the solution accepted by the relevant stakeholders in the system. Which is essential for the successful implementation of the solution, as literature has shown that “the resistance and low level acceptance by healthcare providers are among the main factors for failure” (Haslina Mohd et. al., 2005).

28 _{Workshop Risk management & ISO 14971, 25-10-2018, TechMed Centre, Enschede. ‘Wie gaat dat betalen?’, 26-11-2018, Hotel theater} Figi, Zeist.

29 _{Workshop Risk management & ISO 14971, 25-10-2018, TechMed Centre, Enschede.} Figure 8. Technology acceptance.

As has been mentioned in the introduction of this chapter, the most well-known method for the identification of stakeholders is a stakeholder power grid (Mitchell et al., 1997). This grid places stakeholders on multidimensional grid along the axes of legitimacy, power, and urgency. Power is the stakeholder’s power to influence the firm and gain access to means to impose its will in the relationship. Important to notice is that this power is transitory; it can be acquired and lost. Legitimacy can be described as “a generalized perception or assumption that the actions of an entity are desirable, proper, or appropriate within some socially constructed system of norms, values, beliefs, and definitions” (Suchman , 1995: 574). Power combined with legitimacy establish authority, with which is stakeholder has the power to impose its will and the legitimacy to do so. Urgency can be defined as the “degree to which stakeholder claims call for immediate attention” (Mitchell et al., 1997, p.876).

Figure 9. Stakeholder typology (Mitchell et al., 1997).

These stakeholder attributes are variable and dynamic: they can (and will) change over time). The most common shift will be from dominant stakeholders moving to the definitive category (Mitchell et al., 1997). Additionally, these attributes are “socially constructed”, i.e. perceived and not objective (Mitchell et al., 1997, p. 868) and the stakeholder might not even beware of possessing one or more of these attributes. The most common stakeholders that hold two or more attributes should be closely monitored during the lifetime of the system. First, the dominant stakeholders. These posses both the power and legitimacy attribute which ensures their influence on the company. Generally, it can be expected that formal mechanisms will be in place that operate this power and legitimacy, acknowledging the relationship between the stakeholder and the firm (Mitchell et al., 1997). Second, the dependent stakeholders. These can be characterized by their lack of power whilst having legitimacy and which claims are urgent. Their dependency can therefore be explained as they will need other stakeholders to actualize their claims. To satisfy these stakeholders, the company must either by willing to cooperate and act on their claims or be subject to powerful other stakeholders, responding to the claim. Third, the dangerous stakeholders. These stakeholders combine power with urgency but lack the legitimacy for their claims, and pose therefore a threat to the organisation. Mitchell et al. (1997) would like to add that the depicting these stakeholders as ‘dangerous’ developed some discomfort, however, the authors were more concerned with the “failure to identify” these stakeholders as that would “result in missed opportunities for mitigating the dangers”. Last, the definitive stakeholders which posses all three attributes and their claims, therefore, should be prioritized above all others. Managers of a company are obligated to closely monitor these stakeholders and act appropriately.

Two power grids will be defined: one for the development process and one for the implementation process, as the processes differ significantly in which stakeholders are involved and how their relationships are established. The stakeholders that were considered are all parties mentioned in the analysis of the Dutch medical system and the regulatory process. To estimate their position on the grid, a short analysis of the three attributes for (almost) all stakeholders will be discussed. The overall goal of this research project is to find a strategy that will allow for the successful development and implementation of the system. Therefore, the goal of this exercise is to estimate the influence of stakeholders on that development and implementation process. To define the level of power a look will be taken at how much influence the stakeholder can impose on either the development or implementation process. To define the level of legitimacy, an assessment will be made based on previously gained knowledge that will describe the desirability and properness of the stakeholders claim. The level of urgency will be analysed based on previously gained knowledge and can best be depicted as the amount of trouble the company will get in to when not acting on a claim immediately (e.g., sanctions, fines, disqualifications, etc.). Using this method, it shall become clear which stakeholders pose a threat to the development of the system and which relationships must be established. Additionally, this understanding will be the basis of determining the road of implementation of the system (Part IV) of which the options will be discussed in the next chapter. In both the development and implementation grid, the user as a stakeholder is excluded. This is due to the fact that the user is the only stakeholder which is undefined as well as ‘moving’: susceptible to significant changes. As has been mentioned before and will be discussed in Part III Chapter 11, no current target group exists: a target group must be designed for this solution. Therefore, providing a detailed analysis of the target group during this research project will not provide any more insight as this group might change significantly.