diffusion and adoption of innovations in danish public ... · title: diffusion and adoption of...

Master’s Thesis in Medicine with Industrial Specialization, Medical Market Access

What innovation characteristics are perceived important in the diffusion and adoption process of advanced medical equipment in Danish public hospitals

| By Claus S. von Arenstorff

31-05-2018 DIFFUSION AND ADOPTION OF INNOVATIONS IN DANISH PUBLIC HOSPITALS

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School of Medicine and Health (SMH)

Medicine with Industrial Specialization

Medical Market Access (MMA)

University of Aalborg

Frederik Bajers Vej 7

9220 Aalborg

Denmark

Master’s thesis

Project period: February – May, 2017

Project group: 10009

Written by: Claus S. von Arenstorff

Supervisors: Jeppe Vangsgaard Sabrina Storgaard Sørensen

Pages: 79 (incl. appendix) Word count: 30.166 (incl. appendix) Submission date: May 31

st 2018

Abstract

Title: Diffusion and adoption of innovations in Danish public hospitals

Background: Diffusion and adoption of innovations in public hospitals is a complex process, where many stakeholders

must be taken into account. With the theoretical framework proposed by Everett Rogers, this thesis aim to elucidate

important innovation characteristics that can explain the diffusion and adoption process of innovations in Danish

public hospitals. Two innovations - The leksell gamma knife, and the da Vinci surgical robot, is used to elucidate

important innovation characteristics from decision managers.

Method: A literature search was conducted to obtain information about the two innovations, and what characteristics

they have. They were evaluated on the relative advantage, compatibility, complexity, trialability and observability.

Interview with four decision managers were conducted, in order to confirm or reject the findings made.

Results: The leksell gamma knife have a significantly slower diffusion and adoption compared to the da Vinci. The

difference may partly be caused by a greater complexity and high cost which doesn’t justify its relative advantage.

Furthermore, the da Vinci has a great appeal to doctors in more than one way, which may play a key role.

Conclusion: In terms of highly advanced surgical equipment it was found; the relative advantage is the most important

characteristic. Especially increased patient care, and appeal to doctors. Both the complexity and observability may

play an important role, due to the political influence asserted into the public Danish hospitals. Compatibility and

trialability was found to be less significant, although it is factors decision managers do consider and take under

consideration prior to taking a decision.

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Table of content:

1. Introduction Page 4

2 Problem Statement Page 5

2.1 Structure of the project Page 6-7

3. The included innovations Page 8

3.1 Leksell Gamma Knife Page 8-9

3.2 Da Vinci Surgery Systems Page 10-11

4. Background Theory Page 12

4.1 Introduction to innovation theory Page 12

4.2 Diffusion of innovations and adaption Page 12-14

4.3 Characteristics of health care innovations Page 14

4.3.1 Relative Advantage Page 14-15

4.3.2 Compatibility Page 16

4.3.3 Complexity Page 16-17

4.3.4 Trialbility Page 17-18

4.3.5 Observability Page 18-19

4.4 The innovation-decision process Page 19

4.4.1 Knowledge Page 20

4.4.2 Persuasion Page 21

4.4.3 Decision Page 21

4.4.4 Implementation Page 21-22

4.4.5 Confirmation Page 22

4.5 The Danish public hospital sector Page 22-23

5. Methods Page 24

5.1 Research design Page 24

5.1.1 Literature search Page 24-25

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5.1.2 Interview Page 25-26

6. Results Page 26

6.1 Adoption of the innovations Page 26-28

6.2 Findings from literature search Page 29

6.3 Findings from interview Page 29-33

6.3.1 Rated perception of innovation dynamics Page 34

7. Discussion Page 35-40

8. Conclusion 1

9. References Page 42-48

10. Appendix Page 49

10.1 Appendix 1 – Letter of consent Page 49

10.2 Appendix 2 – Interviewguide Page 50-51

10.3 Appendix 3 – Transcription of Interview 1 Page 52-59




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1. Introduction

This thesis focuses on the association between innovation characteristics and innovation adoption in the

Danish hospital sector. When introducing an innovation for a public organization like a hospital, three major

influencers can affect the innovation adoption – organizational characteristics, decision maker

characteristics and innovation characteristics. This interrelation is illustrated in figure 1.

Figure 1 - The interrelation between innovation characteristics, decision maker characteristics, organizational characteristics and innovation adoption.

Organizational innovation researchers argue that innovation adoption is a response to changes in

organizational characteristics. This could be an increase in patients, which calls for innovation to treat more

patients, or treat them faster with the same quality of care. Or innovative solutions that can complement

an inexpedient composition of employees, or reduce the need of coveted qualifications. If there is a need

for the innovation from an organizational point of view, the probability of successful innovation adoption is

greatly increased. However, due to other influencers it is not a matter of course. Decision makers and their

characteristics possess great power when it comes to reject or acquire an innovation. A study shows that

personal characteristics among decision makers play a crucial role when it comes to innovation adoption.

(2) Examples of personal characteristics are education, gender and attitude towards innovations. The

characteristics of the organization and the decision makers seem mostly out of hands of the business. What

are in the hands of the business though are the innovation characteristics. The innovation characteristics

often described are relative advantage, compatibility, complexity, trialability and observability. These were

first introduced by Everett Rogers, during his work with the diffusion of innovations theory. (1) Over time

there have been several attempts to develop general scales for measuring the influence of innovation

characteristics on the adoption process, Rogers though argue that no such unifying framework exists.

However, within a highly specific context, already existing innovations can provide information about

preferable characteristics for future innovations (2). In this thesis two already implemented innovations in

the Danish health care sector will be studied in order to elucidate preferable characteristics for future

innovations. The two innovations are Da Vinci Surgical Robot and Gamma Knife.

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2. Problem Statement

The aim of this project is to elucidate which innovation characteristics have the highest influence on

adoption of innovations in the Danish health care system. To answer this, the following problem statement

has been deduced:

It is known from the literature, that no unifying framework of innovation characteristics exists. However,

within a specific context, characteristics of successfully implemented innovations can be used for indicative

purposes. The specific context is not defined anywhere in the literature, so it may be up to an individual

interpretation of when it is specific enough. I interpret advanced surgical equipment as a specific context,

which leads me to the selection of the included innovations in this study. The included innovations are the

Leksell Gamma Knife and the Da Vinci Surgical Robot, which both are technical advanced innovations used

for surgical purposes.

This framework can be used by anyone who wants an innovation adopted by the Danish hospitals, but may

be of much greater interest to those who invent, manufacture and sell equipment similar to those included

in the study. Great resemblance between a future innovation and included innovations, the more usable

will the findings of this study be, hence the specific context of the innovation.

With a foundation in two existing innovations, how do the perception of

innovation characteristics influence the diffusion and adoption process, and

what characteristics are emphasized in the context of highly advanced

surgical equipment in Danish public hospitals.

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2.1 Structure of the project

The purpose of this chapter is to give the reader a general understanding of the report, and its structure.

Figure 2 has been made to give a visual illustration of the overall report.

In the beginning an introduction gives the reader a brief understanding of the theories used, the aim of this

report, and more specifically what it will concern. The project aims to elucidate important innovation

characteristics that can predict diffusion and adoption of innovations in the Danish health care system,

which the problem statement will describe. To do so, two already implemented innovations will be

examined. The two innovations are the gamma knife, and the Da Vinci Robot. During the introduction, a

general description of both innovations is made, which serves the reader with a general understanding of

the innovations.

During the theoretical part of the report, the reader will be introduced to fundamental innovation theory.

Everett Rogers will be the primary source of information for this chapter, and his theory about diffusion of

innovations. As a part of the theory section, the innovation characteristics: Relative advantage,

compatibility, complexity, trialability and observability will be described in reference to the two

innovations. To describe them in that context, a literature search for both innovations is performed.

To complement the findings in the literature, several semi-structured interviews are conducted with

members of different buying units at different Danish hospitals. On model X, the blue part describes the

theoretical research (which is done for both innovations), and the green part describes the experimental

research (which is also done for both innovations).

At the end of the report, the findings from both the theoretical research and the experimental research, is

brought together to elucidate which innovation characteristics are emphasized in the context of highly

advanced surgical equipment, and what is the perception of innovation characteristics from a buying unit

perspective.

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Figur 2 – A visual illustration of the report. Two innovations (Gamma Knife and Da Vinci Robot) is used in order to find innovation characteristics with impact on the diffusion and adoption process. The methodology in this study is literature search, and a semi-structured interview will be conducted in order to support the findings made in the literature.

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3. Included innovations

3.1 Gamma knife

The gamma knife (also known as Leksell Gamma Knife (LGK)) is a creation of Lars Leksell, a Swedish

professor and neurosurgeon, and Börje Larsson, a Swedish professor of physical biology. The LGK uses a

technique called stereotactic radiosurgery, where highly-focused beams are aimed at a specific defined

area inside the brain to cause a lesion. The very first LGK was invented in 1968, as a result of decades of

research into the art of performing non-invasive intracranial surgery. However, that model is nothing like

the models available today. Originally the LGK was invented to treat functional neurological disorders,

where it can benefit the patient to have specific parts of the brain damaged. As medical imaging techniques

improved dramatically during the 80s, it became possible to target intracranial arteriovenous

malformations and tumors with the LGK, which to this day remain a purpose of the LGK. (3) That sparked

the adoption of the innovation, which begun in 1984 with the installation of gamma knife systems in UK

and Argentina. In 1987 the first patient was treated in the U.S, and in 1995 the first gamma knife was

installed in Denmark. (4, 5) In 2012 LGK number 500 was manufactured, resulting in an installation base of

300 systems worldwide (6). The closest competitor to the LGK is the LINAC (linear accelerator), which like

the LGK is a radiation therapy.

The LGK functions by emitting up to 201 precisely focused beams of cobalt-60 gamma radiation. The beams

are emitted from different directions, into an exact spot inside the patients’ brain. A visual illustration can

be found on Image 1. The beams are single handedly not powerful enough to cause any significant damage,

as they move through the tissue. But when they’re all collectively aimed for the exact same spot, they are

able to cause great damage to that spot, while surrounding tissue remain largely unharmed. (7) The

procedure is typically performed under local anesthesia. However, patients unable to cooperate such as

kids and mentally ill may be put under full anesthesia. A special frame is then placed around the head of

the patient, and attached with screws to keep the head of the patient in place. The main function of the

special frame is the in-built technology. It provides the LGK with a three-dimensional coordinate system,

which divides the brain of the patient into small segments. Imaging techniques are then performed, e.g. MR

or CT, to get the exact location and size of the desired target. Imaging results are then sent to the software

of the LGK. Beams can now be emitted to a very precise location inside the three-dimensional coordinate

system, because of the special head frame. During the treatment, the software gives input to an advanced

robotic technology that moves the patient with submillimeter increments, in order to effectively treat

targets with different shapes and sizes. (8)

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Image 1 (29), a visual illustration of how the gamma knife functions. A patient is placed on a board, which goes into a machine. Inside the machine 201 gamma rays will be precise aimed at a spot inside the brain, in order to remove it.

If the target is below four centimeters in size, it is treatable in one session. This goes for the majority of

treatments performed. A treatment can take anywhere from minutes to several hours depending on the

shape and size of the target, but usually takes 30 to 60 minutes. The most common conditions treated with

LGK are arteriovenous malformations and brain tumors – both benign and malignant. Indications for LGK

usage are small tumors, deeply situated tumors that can’t be reached by standard surgery, and patients not

suited for traditional open-brain surgery, e.g. elder or weak patients who can’t undergo full anaesthesia.

Gamma knife is currently the preferred method of choice, when it comes to removal of small intracranial

tumors. (9)

During treatment a multidisciplinary medical team consisting of a radiation oncologist, a medical physicist,

a neurosurgeon, a nursing crew, a radiation therapist and possibly an anesthesiologist takes care of the

patient. All medical professionals attending, except the anesthesiologist, have typically received special

training in the LGK. It is a requirement, that at least one member of the medical team is an “authorized

user”, and have control of the treatment console during the entire length of the procedure. To become an

“authorized user” one must attend a special course giving theoretical and practical knowledge about the

LGK. The course will take four weeks to complete, and continuous training will be needed to keep up with

new upgrades. (10)

Because the LGK have been reinvented since the launch of its first model, multiple models are today

available. Each model has different properties and usability, but the emphasis of this project will be put on

the Leksell Gamma Knife Perfexion. The perfexion model, is the model with greatest resemblance to the

first models, and is the flagship of gamma knifes. The acquisition cost of the perfexion model is $3.2 million

USD, and an additional cost of $675,000 USD for installation and software. Additional cost of yearly

maintenance is typically 0.5% of acquisition cost, which is approximately $20.000 per year. (11, 12)

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3.2 Da Vinci Surgical Systems

The Da Vinci Surgical System (from now on Da Vinci) is a creation of the American company Intuitive

Surgical. The Da Vinci innovation is a result of two other innovations merging. One of the innovations is the

master-slave robotics technology, where a robotic arm controlled by a human is used to move objects. The

master-slave technology was developed during the 50s and 60s. The other innovation is the medical

procedure laparoscopy. Laparoscopy is a minimal invasive surgical procedure, where a surgeon makes a

small hole in the skin, and inserts the surgical instruments necessary to perform the procedure including a

small camera for visual guidance (a laparoscope). This surgical procedure was greatly improved, and met

general acknowledgement, during the late 80s. The merging of the master-slave robotics technology and

modern laparoscopy gave rise to the Da Vinci – a computer-assisted surgical robot responding to inputs by

surgeons to perform precise, delicate and complex surgical procedures with minimal invasions. (13)

In 1999 Da Vinci was introduced to the market, and received quickly widespread attention and

acknowledgement, after FDA approved it in 2000 – the first robot to be FDA approved. Five years should

go, before the technology had reached Denmark. The first medical procedure performed in Denmark on a

Da Vinci was found to be a prostate cancer procedure in 2005 (14), and is now considered a fixture in most

Danish surgical departments. As of December 2017, 4271 Da Vinci robots were installed worldwide

performing a total of 850.000 procedures in 2017. (15)

The Da Vinci consists of two vital components – the tower, and the console. The tower consists of four

robotic arms, holding up to four surgical instruments needed for the procedure. One of these instruments

is a small 3D camera, used for visual guidance inside the patient. The tower is placed in direct relation to

the patient, in order to be able to perform the procedure. The tower is connected to the console with a

cable, in order to make latency literally none existing. At the console a surgeon, responsible for performing

the procedure, is sitting in a comfortable chair. At his disposal is a high resolution 3D image for visuals, as

well as handles and foot pedals to control the arms. With available pedals, the surgeon can adjust the

power of the robot arms, to give a very high precision when needed. The medical staff attending a Da Vinci

procedure is equivalent to the medical staff attending a conventional laparoscopy procedure. Only

difference is the capabilities and preferences of the surgeon. One must be trained to do conventional

laparoscopy, or trained to perform Da Vinci procedures. An overview of the operating room during a Da

Vinci procedure is illustrated in image 2. (16) The procedures eligible to be performed on a Da Vinci is

equivalent to procedures performed with conventional laparoscopy. That includes cardiac surgery,

colorectal surgery, gynecologic surgery, head and neck surgery, thoracic surgery, urologic surgery and many

kinds of general surgery such as cholecystectomy or appendectomy. (17)

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Image 2 (31), a visual illustration of how the operation room could be arranged.

The main advantages of the Da Vinci system opposed to conventional laparoscopy are: Better ergonomics,

better visibility and better handling of instruments. During some procedures, the better handling of

instruments implies decreased blood loss, slightly decreased mortality rate (0.097%) and fewer days

admitted compared to conventional laparoscopy surgery. The disadvantages of the Da Vinci are longer

operative time, a complex installation process and a high acquisition cost. Especially the high acquisition

cost is considered a prohibitive factor for some hospitals, when it comes to acquiring the Da Vinci. But

when the cost of the procedure and admission is considered, the Da Vinci is found to be a cost-effective

solution by some studies, compared to both conventional laparoscopy and open surgery (18, 21). The

admission time for Da Vinci surgery is averaging 4.9 days, for conventional laparoscopy 6.1 days. The

median cost of performing a procedure on Da Vinci is found to be $30,540 while the cost of conventional

laparoscopy is found to be $34,537. (18, 19) However, other studies find the exact opposite – which is the

Da Vinci is not cost-effective to acquire and use (22, 23). The results of cost-effective analysis in this field

are susceptible to how many patients are included, and which procedures are used in the calculations, as

some procedures are more cost-effective to perform on the Da Vinci than others.

The acquisition cost of acquiring a Da Vinci ranges from $0.5M - $2.5M. Instruments and accessories range

from $700 – $3,500. Typically instruments for the Da Vinci can only be used a certain amount of times,

ranging from one to a hundred procedures, which shall be calculated as an ongoing cost. The service

contract ranges from $80,000 to $170,000 per year. The average Da Vinci typically cost between $1.5M and

$2.2M. (15, 20)

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4. Background Theory

4.1 Introduction to innovation theory

There are different types of innovation. An innovation may typically be thought of as either an incremental,

substantial or a radical innovation (24). That is the three levels of innovation (25). Incremental innovations

are typically small, but important improvements and features added to a product to enhance its value and

give a competitive advantage compared to similar products in the market (25). Substantial or semi-radical

innovation is a greater change to the product than what is seen in incremental innovations. Typically

substantial innovation involves a degree of change in business model and technology (25). Radical

innovation is the highest level of innovation, and involves a great change or an invention of a completely

new demand. Radical innovations possess the capability to disrupt a market, eliminate existing industries or

force them to transform and adapt in order to survive. (25)

Researchers have previously presented different theories related to innovation research. The Austrian born

economist Joseph Schumpeter, who is believed to be one of the first in the field of innovation research,

argued that market power and economic changes, was based on innovation and entrepreneurial activities.

Instead of dumping prices and cutting margins, companies should focus on rethinking the business model

and rethinking the product portfolio. Any new profitable improvements made, is according to Joseph

Schumpeter innovation. (26) While that definition is considered very wide, other researchers such as

Amabile et al. defines the term innovation more narrowly – “innovation is the successful implementation of

creative ideas within an organization” (27). Everett Rogers who will lay the theoretical foundation of this

paper defines innovation as: “Innovation are a broad category, relative to the current knowledge of the

analyzed unit. Any idea, practice or object that is perceived as new by an individual or other unit of adoption

could be considered an innovation available for study.” (1)

With those three definitions in mind, all of the included innovations for this thesis pass on the definition.

However, whether or not they are implemented successfully within the health care organization can be

brought up for discussion.

4.2 Diffusion of innovations and adoption

Diffusion of innovations is a theory presented by Everett Rogers. The theory aims to explain how, why and

at what rate new innovations spread throughout a social system (1). The social system could for an instance

be health care organizations. Rogers define diffusion as “the process by which an innovation is

communicated over time among the participants in a social system.” If an innovation is indispensable, and

possesses some great characteristics, the participants of a social system will be more likely to communicate

its findings to friends and colleagues, and that is how the knowledge of an innovation spread to adopters

over time. Once people are informed about the innovation, they have to decide whether or not to adopt it.

Rogers call this rate of adoption, and define it as “the relative speed with which an innovation is adopted by

members of a social system.” Adopters can be seen as both people or organizations in the social systems,

who decide to acquire the innovation. Rogers have made five distinguished categories of adopters, based

on their willingness to adopt an innovation:

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Figur 3 (1). The diffusion of innovations based on adopter characteristics according to Everett Rogers.

Innovators are the first group of people, who are willing to acquire a brand new innovation. The innovators

typically have liquidity to make risky investments, and a great willingness to take risks. Of the five

categories, the innovators are typically the youngest in age, and have a high social class. The majority of

innovators are males, who have a close social connection to the innovative part of their industry. The

connections typically arise from meetings at fair trades, through reading scientific research papers, and just

in general being aware of new tendencies in the industry. According to Rogers the Innovators only consist

of approximately 2.5% of a target population, but they are of great importance to get proof of concept,

which will help acquire early adopters. (1)

Early adopters are the second fastest group of people, who are willing to acquire a new innovation. Like

the Innovators, early adopters have financial liquidity to make risky investments, although their willingness

to take risks is lower than Innovators. It is not uncommon for early adopters to observe the group of

innovators for risk assessment. Early adopters are typically young in age, have a high social status, an

advanced education, and are socially forward compared to late adopters. Early adopters are of great

importance for the innovation diffusion process. Due to a high degree of opinion leadership, early adopters

have great capabilities of spreading the knowledge of an innovation throughout a social system. (1)

Early majority is a large group of people, where both the diffusion and adoption process takes notably

longer time, compared to the previous two groups. The diffusion process is slowed down due to lack of

opinion leadership, which results in minimal communication related to the innovation carried out

throughout the social system. Adoption of an innovation is for the early majority contingent on successful

use by either the innovators or the early adopters, and preferably someone they know from their network.

People in this group typically have above average social status, are less affluent and possess an educational

level below innovators and/or early adopters. (1)

Late majority is a large group of people, who will adopt an innovation on ly after seeing a majority of the

population acquiring it. Knowledge about new innovations typically hit the late majority group long time

after launch. Combined with a general skepticism towards new innovations, the late majority group

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contributes to a slow diffusion and adoption process. People in this segment are generally a bit older than

the previous groups, less educated and are less affluent. People from the late majority typically mingle

with people from early and late majority, showing little opinion leadership. (1)

Laggards are the last group of people to adopt an innovation. People in this group typically have an

aversion to changes, and are afraid of implementing technology they don’t fully understand and

comprehend. Laggards typically prefer to do things, as they always have been done. Furthermore the

laggards are likely to have the lowest social status, socializing with very few people – primarily family. In

general this group of people have very little to none opinion leadership. Laggards have the oldest average

age, and possess the lowest level of education among all adopters. (1)

In order to have a successful diffusion of an innovation, it is important to target the right kind of people

from the beginning. Different characteristics the innovations possess can benefit the diffusion process, and

the rate of adoption. These characteristics were first time introduced by Rogers. These characteristics will

be discussed in the following chapter.

4.3 Characteristics of health care innovations

The purpose of looking into the innovation characteristics is to categorize potential adopters

perceptions of the innovation, for an instance; how does it look, how does it feel, is it easy to use and

how beneficial is it to acquire. Such perceptions will naturally form the intentions of potential

adopters, and will ultimately be what they rely on when making a final decision of whether or not to

acquire an innovation. Rogers have derived five characteristics based on his research, which lay the

foundation of this theoretical framework. The five characteristics are: Relative advantage,

compatibility, complexity, trialbility and observability. (1)

4.3.1 Relative advantage

The relative advantage of an innovation describes the more potential value adopters can obtain from

acquiring the innovation, compared to alternative solutions. Rogers define relative advantage as: “…

the degree to which an innovation is perceived as being better than the idea it supersedes.” (1) A

relative advantage can for an instance be of economic character (i.e. low acquisition cost, or low

running cost), social character (i.e. prestige in community, or greater appeal to job seekers) or

performance character (i.e. treat patients better, or treat patients faster with same level of quality)

just to name some. Anything that can be perceived as an advantage compared to the existing situation,

can be considered a relative advantage. (28) Needless to say, one innovation may have many relative

advantages, but only those perceived as relative advantages by the decision makers affect the

intentions of adoption in a positive direction.

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Relative advantages of the Da Vinci

According to the company behind the Da Vinci, Intuitive Medical, there are several relative advantages

to their product. The relative advantages stated by Intuitive are typically compared to either

conventional laparoscopy, open surgery or both. The relative advantages are:

Decreased variability in surgeon performance.

Better opportunities to train procedures, and become better surgeons.

Better comfort for the surgeon during a surgery.

Better intracavitary vision during surgery.

Better patient care (reduced length of admission, reduced complications, fewer readmissions

and lower infection rates). (15)

All relative advantages stated above are of a performance character. It is known from the literature

that the Da Vinci is superior to open surgery both in terms of patient care and economy. However,

compared to conventional laparoscopy, there are mixed results. Some results point in favor of using

the Da Vinci, and some in favor of using conventional laparoscopy. The Da Vinci has better

performance when it comes to certain procedures, while conventional laparoscopy remains the

dominating method when it comes to other procedures (30). Some procedures doesn’t have a

difference in performance, but is likely a matter of preference from the surgeon to determine

technique used. We also know from the literature, that the Da Vinci can both be cost-effective and

not. It depends on the circumstances, and the setting in which the Da Vinci is implemented. If there

are enough procedures to be performed, and the procedures are highly suitable for the Da Vinci, it will

most likely be cost effective in that scenario. (30, 32)

Relative advantages of LGK

As mentioned in the introductory section about LGK, the alternative to LGK is in most cases the LINAC.

LINAC possesses the ability to carry out radiosurgical treatments similar to the LGK. If the hospital has

a need for radiosurgical equipment, LINAC would likely be the second option for intracranial

procedures. Therefore the relative advantage of the LGK is compared to the LINAC. The primary

relative advantages of the LGK are:

High accuracy in delivering radiation, which spares surrounding tissue. The LINAC gives 2-6x

higher dose to normal brain tissue, than the LGK.

Higher precision in targeting.

Session duration time is shorter. (33)

The relative advantages of the LGK reflect the performance of the innovation, which can lead to better

patient care. However, a retrospective comparative study with a total of six studies found no

difference in the clinical outcomes between the LGK and the LINAC (34). It is speculated though, that

the more damage the LINAC inflict on surrounding tissue, can show up in a study with a longer time

horizon. Shorter session duration time can also be of an economic character. Choosing the LGK

opposed to the LINAC, hospitals can treat more patients with same quality of care. A cost comparing

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study between the LGK and the LINAC concludes the LGK is the most favorable alternative, if the

hospital has a larger number of patients (>200 p.a.) (35).

4.3.2 Compatibility

Rogers define compatibility as: “… the degree to which an innovation is perceived as consistent with

the existing values, past experiences, and needs of potential adopters.” (1) Compatibility describes the

ability of an innovation to fit directly into a setting, without further actions of the adopter. This can for

an instance be the ability to coexist with other already existing equipment. If the innovation depends

on other technology, or other technology depends on the innovation, it is important for the diffusion

and adoption process, that these technologies is compatible and can coexist without further cost for

the adopters. (28)

Compatibility of Da Vinci

A lot of modern compatibility issues arise when two independent systems need to communicate with

each other. That is not the case with the Da Vinci. The Da Vinci is a complete system, consisting of a

surgeon console and a tower. No interactions with other systems are made, or needed, which

essentially makes the Da Vinci a “plug-n-play” solution for surgeons. But, if surgeons don’t like the

properties defined in the software, they cannot alter it. The software used is proprietary, and can only

be edited by Intuitive Surgical. However, it is very rare any surgeon may want to alter these settings.

The compatibility of the Da Vinci is generally not considered a prohibitive factor for adoption. (36)

Compatibility of LGK

When using a LGK, imaging services must be performed prior to the actual procedure. In the Gamma

Knife Perfexion, imaging services can be performed at a MRI or CT scanner. Imaging results will be sent

to the Gamma Knife planning computer system, where doctors can precisely aim the beams based on

the location of the target. The MRI or CT scanner performing the imaging services does not need to be

of a specific brand or modality. When an imaging service is performed, the output will be images in a

specific file type, which the gamma knife planning computer system will be able to read. Newer

models of the gamma knife, such as the Gamma Knife Icon have in-built imaging services. (8, 37)

4.3.3 Complexity

Rogers define complexity as: “… the degree to which an innovation is perceived as relatively difficult to

understand and use.” (1) The complexity of an innovation is negatively related to the rate of adoption,

while simplicity is positively related to the rate of adoption. An innovation considered easy to

understand, and easy to use, is more likely to have a positive diffusion and adoption process (28). But

as highly complex innovations are common in the health care sector, it can be argued that it doesn’t

affect the diffusion and adoption process as much as it would in other industries. When new

equipment is introduced to the health care market, both doctors and nurses are aware of the learning

process it includes. Furthermore, both doctors and nurses are used to read, learn and absorb new

information, which makes them great candidates for complex innovations. It is very likely though, it

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may slow the diffusion and adoption; since time must be spend from adopters, to learn the

innovations. (38)

Complexity of Da Vinci

The Da Vinci is a very complex piece of engineering. It took many years to develop, consists of more than

2700 parts, and contains more than 1.1 million lines of software code. But even though it is a very complex

machine, it is relatively simple to understand and use. The Da Vinci innovation aim to replace conventional

laparoscopy procedures, which is a procedure all most surgeons are familiar with. With that in mind,

surgeons can easily understand the usage and functionality of the Da Vinci. A Dutch study shows the main

source of training comes from the manufacturer (intuitive surgical), and/or local courses with an

experienced colleague. A majority of the population in the study (p=56), expressed to have received only 5

hours of basic training or even less. Most of the training is carried out after a learning-by-doing principle, on

real life human beings, with an experienced surgeon as a supervisor. In the study though, all surgeons with

no exception had experience with laparoscopy procedures. (39) To me, that indicates the Da Vinci is an

innovation, that is both easy to understand and easy to use.

Complexity of LGK

The LGK is a very complex innovation, both to understand and to use. The LGK is based upon an

advanced biophysics principle, where radioactive gamma beams are aimed at a target. In order to

understand how the beams are emitted, one might need a degree in physics to completely

understand. How the emitted beam affects the cells in the brain, one might need a degree in medicine

to understand. In order to understand the LGK, and decrease uncertainty for this innovation, the

decision-making group should be of a multidisciplinary origin. Furthermore, it is an advanced machine

to use, and takes a four weeks course to get authorization to use it. But the entire team working on the

OR, needs to be educated on the LGK, and receive special training on the matter. The complexity of the

LGK is also reflected in the installation process. From beginning of installation, to beginning of

commissioning, it typically takes about 4-5 weeks. To install the equipment, specialized technicians

must be brought in. (40)

4.3.4 Trialability

Trialability is the ability to try out an innovation in a smaller scale, to test it out before making a total

commitment to the innovation. If the innovation can be tested with minimal investment and no risk,

more people are intrigued to test it out. If an innovation has a high trialability, it greatly influences the

diffusion and adoption rate in a positive direction. Especially early adopters perceive trialability as

important, since it is their opportunity to test the innovation out in practice. Late adopters and

laggards tend to move from trial to full-scale much quicker, because they can see how the early

majority have implemented the innovation. (1)

Trialability of Da Vinci

There are different opportunities available for the potential adopter, to test and try the innovation

before adopting. Intuitive surgical is constantly evolving their training applications, which include a full-

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scale demo edition, where a surgeon can sit at the console and navigate the handles and pedals, like

he would in real life surgery. Instead of a real patient though, the doctor can only see a software made

illustration of how it would look. In this way, the doctor can get a feeling of the mechanics. However,

to get an idea of how the innovation will function in practice, the minimum of one complete system

must be acquired.

Trialability of LGK

The LGK have a very low trialability. In order to test this innovation on a department, the entire system

must be acquired. But it is not enough to acquire a LGK, the department must also have imaging

technology compatible with the LGK available, as it needs imaging services in order to emit beams with

high precision. The smallest quantity of trialability the LGK can match, is one complete system with a

compatible imaging device.

4.3.5 Observability

Rogers define observability as: “… the degree to which the results of an innovation are visibile to

others.” (1) If another possible adopter easily can understand the relative advantage the new

innovation brings, by just observing, it will increase both diffusion and adoption rate. In order to

contribute to a positive rate of adoption, the observed results must be positive and understandable.

Observability may be a particularly important characteristic in the health care sector. It is known from

the literature that hospitals tend to look at other hospitals, for suggestions to improve hospital

performance and patient care (41, 42).

Observability of Da Vinci

The relative advantages of Da Vinci propose reduced length of admission, and fewer readmissions. In

Denmark it has become a well-known problem, that some hospitals are overcrowded from time to

time. The Danish media like to make a fuss out of it, and find a scapegoat (43, 44). If the Da Vinci truly

do reduce length of admission, and cause fewer readmissions, it will imply fewer patients in the

hospitals where the Da Vinci is used. Some may see the correlation, and pick up the Da Vinci as a tool

to reduce overcrowding in hospitals. It will depend though, on how efficient the Da Vinci is in that

matter. According to the studies found, a conclusive statement can’t be made on the matter (18), and

more research is needed on the topic.

Another observable advantage the Da Vinci possesses is the better comfort for the surgeon.

Procedures performed in an operation room may take very long time, and may force the surgeon to

stand in bad positions over a longer time. A study determined to examine the correlation between

surgeons having bad posture during an operation and experienced pain. The study found 80% of the

surgeons in the study to have pain on a regular basis. 46% of those having pain, stated the posture was

the reason. Almost 7% of the population said they had been on sick-leave, as a direct result of pain

caused by bad posture during surgery. With the Da Vinci these numbers may possibly be reduced, and

more surgeons will be available in the workforce. (43)

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Last but not least, some sources (81, 82) points towards Da Vinci being an expensive marketing

gimmick. Some people perceive the Da Vinci as a marker for hospital willingness to develop on existing

procedures to become better. A perception of the newest technology will beat old technology or old

procedures feed this attitude. This leads to two distinct paths: Patients with this attitude, are more

likely to choose hospitals with Da Vinci opposed to hospitals without Da Vinci. Executives and surgeons

are likely to adopt the Da Vinci to maintain their professionalism and pride. Medicine, and especially

surgery, is a very proud and respectable craft. Nobody in this industry likes to be perceived as “being

behind times” or a laggard.

Observability of LGK

The observability of the LGK can appear in different ways, based on the relative advantage it offers. In

Denmark most hospitals are under governmental control, and patients are sometimes referred to another

hospital in another region, if that hospital possesses the ability to perform highly specialized procedures.

The LGK can perform highly specialized procedures. In the introductory part of the LGK, we established the

perception of the LGK is to be a golden standard treatment for intracranial arteriovenous malformations

and cerebral metastasis. Adjacent regions may start referring their patients with those conditions, if they

do not have an LGK themselves, due to the golden standard perception of the LGK.

4.4 The innovation-decision process

The decision to adopt an innovation doesn’t happen instantaneously. Especially in the hospital sector,

where individuals in the decision-unit is responsible for purchasing technologically advanced, and expensive

equipment on behalf of others. Time and contemplation is a must to evaluate the impact an adoption or

rejection of the innovation may or can have. Rogers have described that as the innovation-decision process,

which is a five-step model representing the process a decision-unit goes through. The five stages are

(1)knowledge, (2)persuasion, (3)decision, (4)implementation and (5)confirmation. This model is important,

because it can provide information about the process potential adopters go through: How much time does

it take to adopt/reject an innovation, at what stage in the innovation-decision process do potential

adopters adopt/reject, and what kind of information-seeking does potential adopters perform in order to

decrease uncertainty about the innovation. The model is depicted visually in Figure 4. (1)

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Figure 4 (46). A visualization of the innovation-decision process.

4.4.1 Knowledge

The knowledge stage begins when the decision-unit first time gains knowledge about the innovation. The

decision-unit may have the innovation presented to them by a sales representative, maybe they read about

it in a magazine, or it is introduced to them by friends or colleagues or at an exposition. The amount of

information given to the decision-unit at this stage is often very limited and the amount of knowledge can

be categorized into three groups: Awareness-knowledge, how-to-knowledge and principles-knowledge.

Awareness-knowledge is typically a superficial knowledge about the innovation, giving enough information

to answer what it is. How-to-knowledge is a more technological description of the innovation, giving the

potential adopter an understanding of how it is functioning. Principles-knowledge serves the potential

adopter with the underlying foundation of knowledge leading to why the innovation works.

The importance of which type of knowledge served to what kind of adopter is not without significance, and

can lead to rejection of an innovation based on misunderstandings or lack of knowledge. The superficial

awareness-knowledge typically requires potential adopters to search for deeper understanding themselves.

This can be done through literature or through a social network. Anyhow, it requires adopters to

individually take action. To take action, adopters must generally speaking have some level of higher

education and a pro-innovation attitude. How-to-knowledge naturally requires adopters to have some sort

of technical understanding, in order to fully comprehend the innovation and its possible capabilities.

Principles-knowledge requires the adopter to have an understanding of the surroundings, in which the

innovation is put to use. Typically the most suitable recipient to principles-knowledge, is a person with a

combined theoretical and practical knowledge, who can understand the innovation and imagine how it will

be put to use. The risk of delivering principles-knowledge to inappropriate candidates can lead to misuse

and misunderstanding of the innovation. (1)

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4.4.2 Persuasion

When an individual have gained knowledge about an innovation, the next stage is the persuasion stage. In

the persuasion stage, the potential adopters seek out information on the subject, in order to form an

attitude towards the innovation. The term persuasion in this case does not imply an action performed by an

agent in order to convince someone about something. Persuasion in this context refers to the

interpretation of the information found, which leads to either a favorable or an unfavorable attitude

towards the innovation. Especially information about the innovation characteristics play an important role

in forming the attitude, not to mention the source of this information, how it is delivered and how it is

interpreted.

The attitude is often assumed to pave the way for the decision; to reject or adopt an innovation. However,

this is not always the case. Innovations with a favorable attitude can still be rejected. Similarly can

innovations with an unfavorable attitude be adopted. External pressure on a decision-unit, can lead to

adoption of innovations with an unfavorable attitude. An example of such is the pressure from e.g. the

government, society or management to treat more people faster and more efficiently. Such pressure can

lead to adoption of an innovation with an unfavorable attitude, but a hope that it might function above

expectations, and relieve some of the external pressure.

All innovations possess some degree of uncertainty. How does it perform in a specific setting, what are the

long term consequences of adopting and so on. In order to decrease the uncertainty, a potential adopter

might search for innovation-evaluation information during the end of the persuasion phase, or in the

beginning of the decision phase. Innovation-evaluation information serves the potential adopter with a

better gut feeling when it comes to taking a decision. (1)

4.4.3 Decision

According to Rogers, the decision phase is initiated when the decision-unit starts engaging in activities

where a decision is assumed to be made. The decision can either be to adopt the innovation, or reject the

innovation. Adoption of an innovation is a decision to acquire, and make full use of the innovation, within

the boundaries of what is possible in the organization. Rejection is a decision to not adopt the innovation.

As mentioned in the persuasion chapter, innovation uncertainty plays a large role in the innovation-

decision process. To further confirm the innovation-evaluation findings, most individuals will proceed with

implementing the innovation on a partial basis, or in a small-scale trial presupposed a continued interest.

Partial implementation, or small-scale trials are according to Rogers still a part of the decision process, as a

decision to make full use of the innovation haven’t been made yet, and discontinuance as described in

figure 4 is still a possibility. (1)

4.4.4 Implementation

The implementation phase begins, when the innovation is put into use. Right up until this moment, the

entire innovation-decision process has been a mental exercise, where potential adopters imagine and

conceptualize the implementation of the innovation, and complications that may arise. But at this stage of

the process, the innovation will be put into practice, and unforeseen complications may arise. This can lead

to more questions, more information seeking and possibly a demand for technical assistance. How the

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company reacts to these demands from the adopter can be of great importance, and can possibly lead to

discontinuance if the adopter feels dissatisfied.

During the implementation a re-invention can take place. Re-invention is a utilization of the innovation in

different ways than originally planned. The re-invention is carried out by adopters, and can be the result of

a deliberate action or coincidences. The deliberate re-invention is typically a response from an individual

with a profound knowledge in the field, who sees opportunities to perform a task easier or better with the

aid of the innovation. The coincidental re-invention can take place, when the innovation is misused or

misunderstood. This can especially take place in hospitals, because the people who go through the

innovation-decision process aren’t the same people who are bound to use the innovation on a regular

basis. Innovations that are very complex and process-oriented get re-invented in a higher degree than

innovations that are not.

The implementation phase doesn’t end at a specific time, or after a certain amount of time. It ends when

the innovation becomes a regular part of the adopters’ ongoing operations. For some individuals,

implementation is the final stage in the innovation-decision process. For others, there is yet another phase

called confirmation. (1)

4.4.5 Confirmation

Confirmation is a phase some adopters go through, but not all. The purpose of this phase is to reinforce the

decision made by seeking more information, hence the name confirmation. If new information comes up, it

can either be in harmony or disharmony with the previous decision made (to adopt or reject). If it is in

disharmony, it may change both knowledge and attitude of the adopter which can result in discontinuance

or late adoption. (1)

4.5 The Danish public hospital sector

The Danish health care model is closely similar to the health care model used in England, with a foundation

in the Beveridge model. All permanent residents in Denmark can freely use any service offered by the

Danish hospitals. The services are like in England paid from general taxation. The public hospital sector in

Denmark is approximately five times bigger than the privatized hospital sector, measured on patients

treated per year (47, 48). All public hospitals in Denmark are administered by their respective regions.

Denmark is divided into five regions, which can be seen on image 3. Each region is, among others,

responsible for running the hospitals in their area, and is led by a democratically elected council called the

region council. The region council is responsible for hiring hospital executives, make a budget and enforce

political decisions (49). In each region there is only one purchase department, acting like a joint purchase

department for all hospitals in the area. The majority of all hospital purchases are made through the joint

purchase department in their region.

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Image 3 (67). Illustration of how Denmark is divided by regions. In each region a political council is in charge for all the public hospitals in that area, called the region council. The region council in each region has set up central organizations to maintain

key functions for all hospitals in that area, such as purchase. Purchases from all hospitals in the region is made from a centralized purchasing department, typically located at the largest hospital in the region.

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5. Methods

5.1 Research design

The used research design for this study is based on a sequential exploratory mixed methods research

design, but is not a pure sequential exploratory mixed methods research design. A mixed methods research

design involves combining qualitative and quantitative research. However, that is not exactly what I have

done. But the research design I have chosen to use, have the highest resemblance with the sequential

exploratory mixed methods research design.

The exploratory design is an approach, where the researchers make two separate data collections, where

one type of data can help to develop the other. The design begins qualitatively followed by a quantitative

data collection. Thus, from initial qualitative results, it is evolving and identifying variables for a quantitative

data collection to support the qualitative results. An exploratory design can either be concurrent or

sequential. In concurrent studies, both the qualitative and quantitative data collection is performed at the

same time. In sequential studies, one method is performed before the other. (50)

In this study, a qualitatively data collection is first performed – the literature search. Based on the literature

search, I evolved a deeper understanding of the topic. The deeper understanding was used for the second

part of the research design. But instead of a quantitative data collection, which would be considered

normal in a sequential exploratory mixed methods research design, I conducted several semi-structured

interviews. The decision to make semi-structured interviews was made, because of the ability to divert and

bring up new questions during the interview. In a structured interview, the researcher has a set of

questions which must be rigorously followed. In a semi-structured interview, an interviewguide is prepared

with different topics of interest, but the informant can be asked to clarify and explain in a higher degree. At

the end of the interview, a set of survey-like questions have been prepared, giving it a touch of quantitative

data collection. The initial questions in the interviewguide are made with the purpose of getting knowledge

and information from the informants, while the final survey-like questions are made with the purpose of

getting quantifiable data to support or reject the initial findings made in the literature search.

5.1.1 Literature search

To gather information for this study, a literature search was conducted. The aim of the literature search

was to obtain data about the two innovations, in order to comment on their innovation characteristics. A

secondary outcome of the literature search was to obtain the necessary knowledge, in order to construct

an interview guide for the semi-structured interview.

The literature search was conducted in PubMed, EBSCO and on Google. The used search terms can be

found in table X. Each search term is marked with a quotation symbol (“). The plus sign (+) indicate use of a

Boolean operator, to add a second search term. The Boolean operator, and a second search term, was

necessary in order to narrow down the search result. On PubMed the search term “da vinci surgical

system” alone returned 1628 results, while “gamma knife” returned 17490 results. On EBSCO “da vinci

surgical system” returned 777 results, while the term “gamma knife” returned 3742 results. When

combined with a Boolean operator, the search returned significantly less results. In cases where the result

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was still considered high (in this study >199 is considered high), the first 10 pages (200 studies) was

screened for relevancy. Screening consist first and foremost of reading the title. If the title were deemed

relevant, the abstract was skimmed. If the study was still deemed relevant, it would be saved for possible

later usage.

For the literature search on Google, the same search terms and procedure was used. Google does not

support the use of Boolean operators, but support the usage of symbols instead. By using the quotation

symbol to mark search terms, and the plus sign to add search terms, the same result can be achieved as

using a medical database. On Google the first 3 pages were screened for relevancy under each search term.

In this case, the screening process consisted of reading the metatitle and the metadescription. All relevant

websites was saved for later.

Search terms used in the literature search

Search terms used related to the Da Vinci “da vinci” + “cost comparison” “da vinci” + “cost-effective” “da vinci” + “cost-benefit” “da vinci” + “experience” ”da vinci” + ”advantage”

”da vinci” + ”assessment”

Search terms used related to the LGK “leksell gamma knife” “gamma knife” + “cost comparison”

“gamma knife” + “cost-effective” “gamma knife” + “cost-benefit” “gamma knife” + “experience” ”gamma knife” + ”advantage”

”gamma knife” + ”assessment” Table 1 - Search terms used in the literature search

Databases used in the literature search including articles found and used

Database Relevant articles found Articles used in the report

PubMed 27 16

EBSCO 15 4

Google 12 6 Table 2 - Amount of literature found and used during the literature search

5.1.2 Interview

In the following section the chosen interview form, themes in the interview and the selection of informants

will be explained.

The interview is a highly relevant form of method in this case. The problem statement indicates a search for

opinions and preferences among a specific population – the decision managers at Danish public hospitals.

In order to obtain the most precise information about that matter, it has been decided to go straight to the

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source. The chosen interview-form has been decided to be a semi-structured interview. The semi-

structured interview has an informal character, and is a combination of a casual conversation, and a

structured interview. The semi-structured interview is often used, when the interviewer only have one shot

to obtain the interview, and want as much information as possible from the informant. Furthermore, it is

often used when the informants have more knowledge than the interviewer in the area of interest, and the

interviewer doesn’t want to constrain the informant in his answers. (51) To maintain control of the

interview, and ensure important questions are asked, an interviewguide is prepared prior to the interview.

The very first questions of the interviewguide is of introductory character, and primarily serve the purpose

of breaking the ice, and get a conversation going. The rest of the questions are arranged in themes. Three

themes were identified for this interviewguide: The da Vinci robot, the Leksell Gamma Knife and perception

of innovation characteristics.

A minimum of five interviews was desirable in order to cover all regions described in section 4.5. One

interview from an informant from Region Nordjylland, one interview from an informant from Region

Midtjylland and so on until all regions was covered. It was important all regions were covered, in order to

understand what characteristics are emphasized in Danish hospitals, and not only hospitals in e.g. Region

Nordjylland. Besides, there can be differences in the perception of innovation characteristics among

decision managers in different regions. It was decided to target the purchasing department, as they are

responsible for executing the purchase of both Da Vinci’s and LGK’s. In order to schedule the interviews,

emails were sent to all five purchase departments at the end of April 2018. With no answers, a follow-up

email was sent one week later – in the beginning of May 2018. Two interviews were scheduled, and

obtained in week 20 2018. After an additional follow-up by phone two more interviews were scheduled and

obtained in week 21 2018. Only four interviews were conducted, as nobody at Region Sjælland was

available to be interviewed. All four participants were employed in the purchasing department.

All interviews were conducted in Danish, made over the phone, recorded with the app TapeACall, and later

transcribed. It was decided to use standard transcription, because laughs and pauses wasn’t considered

important for the essence of the interview. All interviewees gave oral consent to being recorded, and to be

a part of the report. All informants requested complete confidentiality about their names. Instead of

assigning fictive names, it was decided in compliance with the informants to display the jobtitel.

Interviewguide and letter of consent can be found in tappendix.

6. Results

6.1 Adoption of the innovations

Year Installed Da Vinci’s in the world Installed LGK’s in the world

1970 0 1 (52)

1984 0 3 (52)

1987 0 5 (53)

1991 0 20 (54)

1995 0 63 (55)

1996 0 X

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1997 0 X

1998 0 X

1999 12 (66) 124 (56)

2000 28 (66) X

2001 50 Units (68) 153 (57)

2002 152 Units (69) X

2003 315 Units (69) X

2004 X 202 (58)

2005 394 Units (71) 220 (59)

2006 546 Units (71) X

2007 800 (73) 257 (60)

2008 X

2009 1390 (74) 269 (61)

2010 X

2011 1676 Units (75) 282 (62)

2012 2462 Units (76) 300 (6)

2013 2976 Units (77) 310 (63)

2014 3101 Units (78) X

2015 X X

2016 3729 Units (79) >300 (64)

2017 4271 Units (80) >328 (65) Table 3 - Amount of installed LGK's and Da Vincis worldwide (Installed base)

Image 4 - Development of Da Vinci install base worldwide

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Image 5 - Development of LGK install base worldwide.

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Image 6 – Development of both Da Vinci and LGK install base worldwide.

6.2 Findings from literature search

In this section the findings made during the literature search, with greatest significance to answering the

problem statement are briefly covered. For a more elaborate review of the findings go to section 4.3 in this

report.

The relative advantage of both innovations is found to be centralized around better treatments. Both

Intuitive Surgical and Elekta claim their product will result in a better outcome for the patient, but research

on the subject can’t endorse the statements without regards. The findings indicate Da Vinci can imply

better patient care in certain procedures (such as prostatectomy), while conventional surgical techniques

would be preferable in other procedures (primarily due to increased cost of using the Da Vinci). The Da

Vinci differs from the LGK by having a high focus on the medical professionals using the innovation. The Da

Vinci claim to decrease variability in surgeon performance, offer better training opportunities and provide

better comfort to the surgeon during a medical procedure.

The compatibility of both the Da Vinci and LGK haven’t been found to be an important characteristic in

terms of rejecting or adopting the innovation.

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Both innovations are complex, and require training before use. The Da Vinci has been found to be intuitive

and easy to learn. The LGK have been found to have a steep learning curve, compared to medical

equipment in general. The functions of the Da Vinci can easily be explained to a non-surgeon, while the

functions of the LGK are difficult to explain to a non-surgeon.

The trialability is considered low for both innovations. In both cases it requires the adoption of an entire

system to test it out in practice, which involves an economical commitment in the million-dollar scale.

Intuitive Surgical can offer surgeons to try a simulator, which can give an indication to the surgeon of

whether or not they like the innovation, and can imagine them using it for performing procedures on a

daily basis.

Three circumstances where the results of adopting the Da Vinci can be observable, has been identified in

the literature. One is the ability to reduce length of admissions for patients. A second is the ability to

prolong the worklife of a surgeon. Some surgeons struggle with musculoskeletal pain caused by bad

posture during conventional surgery. The Da Vinci may possibly increase worklife of surgeons, thus

increasing the active workforce of surgeons. Third circumstance is where people perceive the Da Vinci as a

status symbol and as an indicator of hospital willingness to develop on existing procedures to become

better. It can become prestige to own a Da Vinci. That may imply an increased satisfaction with the

hospital, its management and its doctors from the general population.

6.3 Findings from interview

In this section the most important findings from the interviews related to answering the problem

statement are summarized. The interviews in their full extent have been transcribed and can be found in

the appendix.

When informants were asked about what influenced the decision to adopt the Da Vinci or the Gamma

Knife the answers were quite similar:

It is evident from the interviews, that the entire process of adopting an innovation, such as the Da

Vinci or the LGK, to the Danish public health care sector is a complex process. It involves many

different committees, with representatives in the committees having different professional

Danish: ”.. Det er simpelthen så forskelligt jo. (...)

det er forskellige kriterier der vurderes efter.”

– Informant 3, Birgitte Fjeldgaard

English translation: .. It is so different. (..) There are

different criteria’s to be assessed.”

- Informant 3, Birgitte Fjeldgaard

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backgrounds to cover the greatest aspect possible of the innovation. It is therefore incredibly difficult

for one person to justify what and why the decision was made to adopt the innovation. However,

when the question is approached differently, the informants have no problem highlighting some

important aspects, which were evaluated during the decision process. Especially the relative

advantage, and the subcategories economy, social and performance were mentioned and seemed to

be of great importance in relation to the decision.

Informant 1, Lars Hansen said the following about the Da Vinci:

The relative advantage, or more correctly, the missing relative advantage is obviously of great concern.

Lars Hansen here comments on the economical character and the performance character. Similar to

the findings made during the literature search, the performance (increased patient care) of the Da

Vinci is found to be questionable in the eyes of the adopters. However, several the social character

were identified by Lars Hansen during the interview. First of all, he supported the literature findings

about the Da Vinci prolonging worklife of surgeons by providing better comfort:

Danish: ”en af årsagerne til at det

tilbagevendene er til drøftelse er: punkt 1, at det

er dyrt at anskaffe og drifte, og punkt 2, et er

meget svært at finde evidens på at det rent

faktisk gør en forskel for patienten.”

- Informant 1, Lars Hansen

English translation: ”one of the reasons this is a

recurrent subject to discuss is: 1, the acquisition

cost and running cost is high, and 2, it is very

difficult to find evidence saying it actually does a

difference for the patient.”


Danish: ”den største fordel ved robotter, det er, at man

kan levetidsforlænge, undskyld udtrykket, hvad er det

det hedder, klinikerne. Altså lægerne der står og

operere.”


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And he identified a new relative advantage, also of social character, which couldn’t be identified during

the literature search: The ability to recruit new doctors to the hospital, because of the Da Vinci. Other

hospitals in the region approach Lars, because they need a Da Vinci to their hospital saying it is vital to

attract qualified and competent personnel:

The majority of the informants did not know much about the LGK. The reason why, is because the

purchase of the LGK’s were made outside of the purchase department, and without their involvement.

However, informant 2, a strategic purchaser had some experience in the field of LGK’s. It was

mentioned, that they have decided to go with LINACS instead of Gamma Knifes, because they believe

that technology is improving so rapidly the gamma knife technology may become redundant in the

future.

The following was said:

English translation: ”the greatest advantage of

robots, is the fact that you can prolonge worklife,

sorry the expression, of what is it, the clinicians.

The doctors who stand and operate.”


Danish: ”Det er også noget vi skal ha’, blandt andet

for at kunne rekruttere personale, men også for at

udvikle det faglige område.”


English translation: ”That is also something we need,

among others to recruit personnel, but also to

develop the professional area.”


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When Informant 2 was asked about, if the possible redundancy of the gamma knife technology can

explain the reluctance of potential adopters to adopt the innovation, he said he believed the price to

be a bigger issue:

Danish: ”Spørgsmålet er, om det (red. LINACS) i

virkeligheden er ved at overhale sådan noget som gamma

knife indenom. Altså med stereotaktiske behandlinger,

som er der hvor gamma knife har sin helt store excellence.

Spørgsmålet er om man er ved at nå så langt med de

konventionelle linacs, at man faktisk gør den teknologi

(red. Gamma knifes) overflødig. Vi har jo for eksempel

besluttet os for ikke at købe nogen gamma knife.

- Informant 2, Strategisk Indkøber

English translation: ”The questions is, if the (red. Linacs) in

reality is overtaking something like gamma knife.

Pointedly with stereotactical treatments, which is where

gamma knife have its great excellence. The questions is if

the conventional linacs will make the technology (red.

Gamma knife technology) redundant. For an instance, we

have decided not to buy any gamma knife.

- Informant 2, Strategic Purchaser

Dansk: ”Nej altså, jeg tror for gamma knifes vedkommende

handler det i høj grad om pris.


English translation: ”No, i think in the case of gamma

knife, it is very much a matter of price.


34

6.3.1 Rated perception of elucidated innovation dynamics

At the end of every interview, each informant was asked to give the characteristic a rating from 1 to 10

based on perceived importance in the decision phase. The characteristics were based on the findings of the

Da Vinci and the LGK made during the literature search. Region Sjælland did not participate in this rating, as

they were unable to get in touch with.

Innovation dynamic Nord Midt Syd Sjælland Hovedstaden Avg. Score

Economy related to the innovation 7 10 9 X 6 8/10

The innovation is from a well-known brand

4 2 2 X 2 2.50/10

Well documented research can support the claims of effect

8,5 9,5 9 X 8 8.75/10

The innovation is better in terms of patient care than alternative

8,5 10 9 X 10 9.375/10

The innovation is wanted by doctors or nurses

9 10 10 X 9 9.5/10

The innovation is wanted by patients

5 5 3 X 7 5/10

The innovation can coexist with existing equipment

9 10 6 X 5 7.5/10

The innovation is easy to use and easy to understand

6 7 6 X 7 6.5/10

The innovation can be tested in small scale (reduced commitment)

5 6 6 X 8 6.25/10

The innovation imply better reputation

8 8 8 X 8 8/10

Table 4 - Rated perception of innovation dynamics, based on findings made during the interviews

Arranged after perceived importance for successful diffusion and adoption, starting with dynamic

perceived most important:

Innovation dynamic Score The innovation is wanted by doctors or nurses 9.5/10

The innovation is better in terms of patient care than alternative 9.375/10 Well documented research can support the claims of effect 8.75/10

The innovation imply better reputation 8/10 Economy related to the innovation 8/10

The innovation can coexist with existing equipment 7.5/10 The innovation is easy to use and easy to understand 6.5/10

The innovation can be tested in small scale (reduced commitment) 6.25/10 The innovation is wanted by patients 5.0/10

The innovation is from a well-known brand 2.5/10 Table 5 - The rated dynamics arranged after perceived importance, starting with the dynamic perceived most important.

35

7. Discussion

The theoretical framework “Diffusion of innovations” proposed by Everett Rogers, was first time published

in 1962. The initial ideas of Rogers were originally based on farming equipment, which may raise a question

about the relevancy of using his framework on highly advanced surgical equipment, or in today’s health

care industry in general. In the initial phase of this thesis, different studies in the health care sector utilizing

the diffusion of innovations theory were read. (83, 84) Overall the conclusion is the framework is suitable in

the health care sector to evaluate how innovations diffuse and adopt. This claim was supported during the

work with the thesis as well. Ten questions were made and asked during the interview, in order to obtain

adopters perception of certain innovation dynamics. The dynamics were elucidated based on Rogers’

relative advantage, compatibility, complexity, trialability and observability of the Da Vinci and LGK found

during the literature search. One informant said:

Completely independent, and without any knowledge of Everett Rogers, a decision manager at region

Hovedstaden came up with a set of principles for internal use, to evaluate private innovation projects.

Those principles had a significant resemblance to the five innovation characteristics proposed by Rogers,

Dansk: ”Jeg synes faktisk det er nogle rigtigt gode spørgsmål du kom

med her til sidst. De minder rigtigt meget om noget jeg selv skrev

sidste vinter noget vi kalder ”De 7 bærende principper”. Og det er 7

principper der skal kunne tikkes af, for at vi som region siger: Ja, det

her private innovationsprojekt, det er noget vi gerne vil putte penge i.

Og mange af de spørgsmål du stillede før, de kan faktisk kobles

direkte på de her 7 bærende principper. F.eks. med økonomi, klinisk

relevans, skalerbarhed og sådan. Det er lidt sjovt.”


English translation: ”I actually think it is some really good questions

you brought up here at the end. They remind a lot of something I

wrote last winter we call “The 7 bearing principles”. And that is 7

principles that must be checked off, before we as region say: Yes, this

private innovationproject, is something we would like to put money

in. And actually many of those questions you asked before, they can

be linked directly to these 7 bearing principles. For an instance with

economy, clinical relevance, scalability and such. It is a bit funny.”


36

which makes the foundation of this project. That indicates to me; the theory proposed by Rogers still is very

much applicable in today’s world. Furthermore, Rogers’ (1) was the foundation of the work made by Mary

Cain and Robert Mittman “Diffusion of Innovation in Health Care” (28), where the innovation

characteristics are discussed in a health care setting. The work by Mary Cain and Robert Mittman was,

together with Rogers, the literary foundation of section 4.3 about innovation characteristics. However,

Mary Cain and Robert Mittman doesn’t call it innovation attributes, or innovation characteristics, but

innovation dynamics. A dynamic can be recognized as a factor that can stimulate, or change a process

within a system. In this case Mary Cain and Robert Mittman described ten dynamics, where four of them

were directly based on the theory made by Rogers. The remaining six are probably the reason why it have

been decided to call them innovation dynamics, and not innovation characteristics, because they are not

directly related to the innovation, but more an influencing factor that can help the innovation diffusion and

adoption process. One dynamic that was recognized as very important in the case of LGK and Da Vinci was

the eight dynamic described by Cain and Mittman; Opinion Leaders.

Opinion leaders are considered credible and respected sources of information. Selection of opinion leaders

is a subconscious process, based on knowledge, attitude, authority and beliefs. Many different opinion

leaders exist, but common to all opinion leaders is the ability to exert influence on others’ decision-making

(85). Opinion leaders in the health care sector are typically individuals, such as well-respected researchers,

and governmental organizations such as the FDA. The opinion leaders have been recognized as key actors

in the diffusion of innovations (28), which also apply to the LGK and the Da Vinci. The LGK have a very slow

diffusion, but in 1987 the first machine in the USA was installed in Pittsburgh – the fifth worldwide. That

becomes an important development in the diffusion of the LGK, due to the research material published

from the University of Pittsburgh Medical Center. It was considered of high quality, honest and believable.

(52, 53). Prior to the installation of LGK in Pittsburgh, the amount of research published about the gamma

knife was scarce. In 1989 followed a FDA approval of the LGK (86). The combination of these two opinion

leaders vouching for the LGK is considered a great influencer to the diffusion. From 1970 to 1987 a total of

five systems were installed worldwide. In 1991, just four years later that number had been increased to 20,

and in 1995 a total of 63 systems had been installed worldwide. The same findings can be made in regards

to the Da Vinci. Since 1998, more than 7,000 peer-reviewed publications have been published (87), and the

FDA approved it in 2000 (88). According to the findings of this study well-documented research is very

important aspect of adopting an innovation. In section 6.3.1, the informants rated it 8.75 on a scale from 1

to 10. That indicates well-documented research is the third most important dynamic, out of all ten asked

dynamics. Informant 4 made a great quote in regards to this finding. When asked about perceived

importance of evidence to support the claims made by the manufacturer on a scale from 1 to 10 she says:

37

Another important aspect of diffusion and adoption is likely to be the complexity of the innovation. The

perceived importance “only” scored 6.5 out of 10, which placed it as the 6th most influential dynamic

among the included dynamics. However, I think the perceived complexity of the innovation may play a

larger role, than what the informants express. During the interviews it became apparent, that the decision

to adopt an innovation to Danish public hospitals is a result of a long and complex process. In the case of

highly advanced surgical equipment, which is considered very expensive, a doctor must first and foremost

apply for the equipment. That application is handed in to a committee responsible for that specific

department, and operates under a budget. That committee typically has a chairman who is a doctor,

accompanied by members with different professions – such as a represent from the purchasing

department, and a technician. That committee will go through the innovation-decision process described in

section 4.4. If it is decided the innovation may be a good idea to adopt, but the price is too expensive to fit

under budget, it will be send to a new committee. That committee is called the apparatus committee, and

has a budget each year to acquire equipment, which can’t be covered by the budget allocated to the

department itself. There is one apparatus committee in each region, which covers all hospitals in that

region. The budget of the apparatus committee varies from region to region, and is determined by the

politicians. When the application arrives at the apparatus committee, they get knowledge about the

innovation, and the innovation-decision process is started over again. The apparatus committee in e.g.

Region Nordjylland (which is the smallest of the regions) only has approximately 40-50 million DKK each

year in budget (approx. 7 million USD). In the apparatus committee a selection of doctors, economists,

engineers and such is sitting. If the innovation is very expensive, the apparatus committee will typically do a

business case on the acquisition, which will be presented for the hospital executives. If the hospital

executives, together with the apparatus committee, estimate the overall costs to exceed what is

reasonable to spend, the innovation can naturally not be acquired. But if the benefits of acquiring the

innovation are deemed great enough, the application can be send from the apparatus committee to the

region council (described in section 4.5). The region council, which consists of 41 elected politicians, is now

imposed to take a decision of whether or not the budget for the apparatus committee should and can be

increased, in order to acquire the innovation. The decision to adopt an innovation has now become a

political decision. In the region council a voting may take place, where each of the 41 members will vote for

Dansk: ”Det er vigtigt. Specielt når vi indkøber nye ting, som

vi ikke allerede har på sygehuset. Så forsøger vi altid at finde

så god dokumentation som muligt. Og det er både fra

forskningsartikler, men også hvad andre sygehuse har gjort

sig af erfaringer. Jeg vil sige 9.”

- Informant 4, Indkøber

English translation: ”It is important. Especially when we

acquire new stuff we don’t already have on the hospital.

Then we always try to find as good documentation as

possible. And that is both research articles, but also

experiences made from other hospitals. I’ll say 9.”

- Informant 4, Purchaser

38

or against. Each vote is equal and independent. That means the 41 politically elected members individually

will go through the innovation-decision process. Members who might not be the best fitted individuals to

evaluate a highly complex health care innovation. We know from the innovation-decision process, that the

first of all serving the right knowledge to the right people is important. The 41 people in the region council

are most likely served the same material, hence served the same knowledge. If the knowledge doesn’t suit

a specific council member, a negative attitude towards the innovation may already have occurred. In the

next stage, the persuasion stage, potential adopters seek information on the subject in order to form an

attitude towards the innovation. If the information found is too difficult to understand, or if the innovation

in general is too complex, the formed attitude is most likely negative. This goes for all committees

evaluating the innovation. For every time a new committee is evaluating the innovation, the chances of

adoption decrease. The same problem wouldn’t occur, if the innovation was very cheap, because it will not

have to go through all mentioned committees. It would most likely be acquired by the department

committee, and purchased with funds from the department budget. Bear in mind some regions may have

minor differences in the structure of their organization, but this is a general depiction based on findings

made in the interviews.

Findings made during the literature search indicate the LGK is perceived as more complex than the Da Vinci.

As seen in section 6.1, the LGK have a significantly slower adoption. Whether or not the complexity is

accountable for that, or it is just a matter of supply and demand remain unknown. It is likely though, the

complexity of the LGK act as a barrier for successful diffusion and adoption, considering the context just

mentioned, and the fact that Europe has the lowest market penetration for LGK’s, mainly due to budget

restrictions imposed by medical authorities (56).

According to the findings in section 6.3.1, the two dynamics were perceived significantly more important

than the others, when it comes to diffusion and adoption of innovations. The two dynamics are the

innovation is wanted by doctors or nurses (scored 9.5/10), and the innovation is better in terms of patient

care than the alternative (scored 9.375/10). These findings are in conformity with findings from a Brazilian

study, where the object was to find drivers of the technology adoption in healthcare. The Brazilian study

elucidated from the findings, that the increased patient care is vital in order to make the hospital consider

the innovation. In order to maintain the system, and avoid discontinuance of the innovation, the doctors

had to like the system. (72)

An unforeseen finding is the fact, that what the patients want isn’t considered to influence the decisions

process a whole lot. The focus is first and foremost to give the patient a good treatment, and make the

work environment good and sustainable. Informant 1 says:

Dansk: ”Det er klart, vi lytter til hvad vores patienter fortæller os, men man

skal også huske på, at de ikke har faglige kvalifikationer til at vurdere en

ehm, altså forstå mig ret. Der bliver lyttet til forslag, det gør der bestemt,

men når vi skal tage en beslutning tænker vi ikke på hvad patienten synes

eller mener. Men forstå mig ret, patienterne er altid i fokus.

Informant 1, Lars Hansen

39

Sources point towards the exact opposite attitude in American hospitals, due to the structure of the health

care system. American hospitals have a higher degree of competition among each other, and need

equipment perceived as top notch in order to attract customers (patients). This is because the American

health care system is based on a Bismarck inspired health care model, where a vast majority of the

hospitals are privately owned institutions fighting for profitability. Acquisitions made by hospitals in the

U.S. do not only need to deliver a good treatment, but also a great perception of the hospital, in the eyes of

the patient. This has been recognized as one of the facilitators for buying Da Vinci’s in the U.S., one study

says: “The reason the hospital purchases the robot is because medicine is competitive” (70). This was

recognized by Intuitive Surgical who launched a direct-to-consumer marketing strategy, in order to create a

need for the Da Vinci in the general population. With an Intuitive Surgical induced patient-perception of the

latest technology is the greatest technology, more and more patients started asking for robotic surgeries in

the U.S. (82), which forced more and more hospitals to buy it in order to maintain customers. Through

marketing, Intuitive Surgical has been able to create a demand for robotic surgery, and a perception of

robotic surgery can provide the best treatment possible. Some surgeons even believe the Da Vinci to have

raised the stature, and given them credibility in their craft (70), even though the evidence to support a

better patient-outcome remains scarce.

It is known, that the Danish health care sector look abroad for inspiration on how to provide better health

care, and among others often look at the U.S. (89, 90). It is not impossible the perceived qualities of the Da

Vinci have travelled across the Atlantic, and been a contributing factor for the diffusion and adoption

process of Da Vinci in Denmark. According to the findings in the interviews, two of the major influencers for

adoption the Da Vinci seemed to be the perceived prestige of owning a Da Vinci, and the increased surgeon

comfort during surgery.

That may lead weaknesses in this study. Perhaps the diffusion and adoption of the Da Vinci is a result of

great marketing efforts, and not really desirable innovation characteristics. Furthermore, it was not

possible to retrieve information about how many Da Vinci’s or LGK’s there were adopted to the Danish

public hospitals. Therefore the worldwide installed base was found in literature for each of the innovations.

An assumption had to be made, that the trend of installed systems worldwide had to be somewhat similar

to the trend in Danish public hospitals.

Some other major weaknesses in this study are based on the study design itself. Innovation studies are

typically qualitative studies, where behavior and opinions of a target group are examined. The preferred

method of choice for innovation studies are typically interviews and surveys (2). The reliance of expert

opinions is inevitable, but has the lowest methodological power according to the hierarchy of scientific

evidence. When performing interviews, bias is almost inevitable. All the interviews were performed over

English translation: ”Clearly, we listen to what our patients tell us, but one

should remember, patients do not have the qualifications to estimate ehm,

don’t misunderstand me. There will be listened to proposals, definitely, but

when we make a decision, we do not consider what the patient think or

mean. Do not get me wrong, the patients are always in focus.


40

phone, which meant the body language and nonverbal cues of the informant couldn’t be read, and isn’t

included in the transcription. That will result in nonverbal bias in the study. Another significant bias, is the

non-response bias. All informants without exception failed to answer the question: “What factors

influenced the decision process”. The missing response is most likely a combination of many factors coming

together: It is a very difficult and complex question, all informants were very busy and had barely time for

an interview, and the answer to that question is very long. In order to elucidate some important factors, or

dynamics, a set of prepared questions was asked. That led to a new bias, the confirmation bias.

Confirmation bias occurs when a researcher search for information, that can either confirm or disprove

preexisting beliefs. When a question was asked, such as: “How important is it the innovation is compatible

and can coexist with existing equipment on the hospital?” a hypothesis of compatibility importance was

either confirmed or disproved. It would be much greater, if the informant said freely, and without getting

influenced, that compatibility is a factor in terms of adoption of the equipment. Due to the inexperience

from the researcher to conduct qualitative studies, anchoring bias cannot be excluded. Anchoring bias is a

tendency to rely too much on the first information given, and not ask further questions about the subject.

Prior to the study a theoretical foundation was established about qualitative studies, in order to conduct

the interviews, but practical experience in the art of performing interviews was limited.

41

8. Conclusion

It is evident from the findings made in section 6.1 that the LGK have a very slow diffusion and adoption

compared to the Da Vinci. Four years after the Da Vinci was introduced to the market, it already had a

higher installed base compared to LGK, even though the LGK had been on the market for more than three

decades. Both through the literature search, and confirmed in the interviews, the most important

innovation characteristic is the relative advantage. Rogers divide the relative advantage into three

subcategories; economic character, performance character and social character. Both innovations have a

weak economic character and are considered very expensive. This was found for both innovations to be a

prohibitive factor for diffusion and adoption. Both innovations claim to have a good performance

character, by increasing quality of treatment given to the patient. This character is without a doubt of great

importance in terms of diffusion and adoption, as it was rated the second most important among all

interviewed decision managers (rated 9.5/10). For the LGK no social character was found, while Da Vinci

seemed very strong in this subcategory. There was found to be an element of prestige in owning a Da Vinci,

it have the possibility to decrease sick-leave at surgeons by providing better comfort, and maybe in

correlation to that, it is a great tool to attract surgeons to the hospital. Overall a lot of social character was

found in the Da Vinci innovation, which all is positively viewed by the doctors. It was found in section 6.1,

that the overall most important dynamic for innovation adoption is, that the innovation is wanted by

doctors and nurses. Perhaps the social character of the Da Vinci plays the largest role in terms of innovation

diffusion and adoption.

Neither compatibility nor trialability was found to be of great influence, when it comes to diffusion and

adoption of innovations in Danish public hospitals. Both systems are individually almost completely

independent of other systems. Generally speaking, it is a relatively important charateristics which the

decision managers do consider (rated 7.5/10), but in the case of Da Vinci and LGK it doesn’t play a key role

in the decision.

The complexity of the innovation was rated 6.25 out of 10 from the decision managers. It plays a role, but it

isn’t a key component in the decision process, according to the interviews. The argument is; if the relative

advantage (primarily patient care) is very good, the complexity doesn’t play a role. There are competent,

highly educated people employed at the Danish hospitals perfectly capable of assessing highly complex

innovations. However, as described in the discussion section, it is not unlikely the decision to adopt an

innovation may end up being indirectly taken by politicians. Particularly if the innovation is so expensive it

may exceed the budget. In that case, the complexity may be very important, as the politicians are

democratically elected people with all sorts of background, and perhaps not fitted to evaluate highly

complex medical innovations. In the literature search, a big difference between the LGK and the Da Vinci

was the perceived complexity. The LGK is perceived very difficult to use and understand, while the Da Vinci

is a complex innovation perceived very easy to use and understand. The difference in adoption pattern

between the LGK and the Da Vinci is not unlikely to be somewhat partly caused by the perceived

complexity.

The observability is likely to play a key role for innovation adoption in Denmark, primarily due to the

political influence. In the interviews it was discovered that Directors want to look good in front of the

politicians, and politicians want to look good in front of the public. All so they can get reelected.

42

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49

10. Appendix

10.1 Appendix 1 – letter of consent

Samtykkeerklæring

Jeg giver hermed samtykke til deltagelse i et interview, som omhandler opfindelser på sygehuse, og hvilke

egenskaber en opfindelse kan have for at bidrage til en bedre optagelse.

Dette interview handler om beslutningsenheden på et sygehus, særligt beslutningsenheden der har taget

en beslutning om at anskaffe og anvende en Gamma kniv og en Da Vinci Robot.

Jeg er informeret om, og indforstået med at:

Interviewet vil blive brugt i forbindelse med et 10. Semester afsluttende kandidat projekt, på

uddannelsen Medicin med Industriel Specialisering ved Aalborg Universitet.

Interviewet bliver optaget og transskriberet, for at kunne udgøre en del af rapporten.

Interviewet kan gøres anonymt efter ønske, så min identitet ikke kan spores via noget navn læst i

rapporten. I tilfælde af jeg ønsker anonymitet tildeles jeg et pseudonym.

Interviewet er frivilligt, og jeg kan til enhver tid trække mig, eller lade være at svare på spørgsmål.

Ønske om anonymitet?

Såfremt der er ønske om at tilbagetrække denne erklæring, så ingen eller dele af udtalelser ikke længere

må anvendes, skal der tages kontakt til kontaktperson Claus von Arenstorff.

Dato og underskrift: ________________________________________________________________

Kontaktperson: Claus von Arenstorff Mail: [email protected] Telefon: 28150153

JA NEJ

mailto:[email protected]

50

10.2 Appendix 2 - Interviewguide

Interviewguide

Introducerende spørgsmål:

Vil du starte med at fortælle lidt om dig selv og din rolle på sygehuset?

Da Vinci Robotten:

- Hvem sidder i sådan en beslutningsenhed? (antal, jobtitler)

- Ved du hvor fra idéen til at anskaffe en Da Vinci kom? (Læge? Sundhedsstyrelsen? Sælger?

Direktion?)

- Hvad sker der typisk i løbet af sådan en beslutningsprocess? (Research?)

- Hvad kan være afgørende faktorer for, at man netop vælger at købe en Da Vinci Robot?

Gamma kniv:

- Hvem sidder i sådan en beslutningsenhed? (antal, jobtitler)

- Ved du hvor fra idéen til at anskaffe en Gamma kniv kom? (Læge? Sælger? Sundhedsstyrelsen?

Direktion?)

- Hvad sker der typisk i løbet af sådan en beslutningsprocess? (Research?)

- Hvad kan være afgørende faktorer for, at man netop vælger at købe en Gamma kniv?

Opfølgende spørgsmål:

Er der nogen der har det sidste ord i en beslutningsenhed?

Hvem har mest ”magt” i en beslutningsenhed? Hvem ville det være mest hensigtsmæssigt at opsøge i

forsøget på at få en ny innovation integreret på et dansk hospital? (Indkøbschef, innovationschef, direktør,

afdelingslæge, afdelingssygeplejerske?

51

Innovations egenskaber:

Her nævnes nu nogle egenskaber en opfindelse kan have. Du skal nævne på en skala fra 1 til 10 hvor vigtig

en egenskab det er i forhold til at blive udbredt i den danske sundhedssektor.

1 = Slet ikke vigtigt

5 = Gennemsnitligt vigtigt

10 = Meget vigtig

Egenskab Skala (fra 1-10)

Hvor meget kigger i på det økonomiske aspekt i en innovation?

Opfindelsen er fra et anerkendt brand

Der er forskning som understøtter producentens påstand

Produktet er giver patienten bedre behandling end alternativet

Produktet er efterspurgt blandt læger og sygeplejersker

Produktet er efterspurgt blandt patienter og pårørende

At det kan snakke sammen med eksisterende IT løsninger

At innovationen er både let at forstå, og let at bruge

At man kan teste opfindelsen af i en lille skala først (f.eks. 1 enhed)

I hvor høj grad er det vigtigt, at folk (andre end læge og sygeplejerske) kan se nytten af opfindelsen (f.eks. politikere og patienter)

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10.3 Appendix 3 – Transcription of interview 1

Interview 1 – Lars Hansen, Kontorchef Indkøb & Medicoteknik, Region Midtjylland

Interviewer: Goddag Lars, du taler med Claus. Jeg har hørt en lille fugl synge om, at du gerne vil bruge lidt

tid på at besvare nogle spørgsmål jeg har.

Informant: Jamen det vil jeg gerne.

Interviewer: Super super. Jeg ved ikke om du har hørt fra dine kollegaere hvem jeg er, nu har jeg jo snakket

med et par stykker af dem, som der har sendt mig videre til dig.

Informant: Nej, ikke andet end at jeg snakkede med en af dine medstuderende her I forrige uge tror jeg det

var.

Interviewer: Oka…….

Informant: Og så er din henvendelse på en eller anden måde endt hos Susanne, som er min sekretær, og

det er så det det har gjort at vi har fået formøblet det her i stand her. Eller samtalen i stand her.

Interviewer: Ja, lad mig lige kort fortælle lidt om hvad det egentligt går ud på det her så. Jeg læser industriel

medicin på Aalborg Universitet, og det her er mit kandidat speciale. Det her interview handler en del om

beslutningsenheden på et sygehus, og sådan hele den process der sådan foregår omkring

implementeringen af opfindelser på sygehuse. I mit projekt her kigger jeg specifikt på Da Vinci robotten og

Gamma knive..

Informant: Jeg kender ikke rigtigt noget til gamma knive. Jeg har hørt om den. Jeg har faktisk lige været

oppe og jagte hende som jeg mener der har været involveret i det på et tidspunkt her hos mig, hun var der

så desværre ikke. Men gamma kniv tror jeg ikke har fyldt ret meget hos os, for det er noget der ligger i den

kliniske afdeling, og vi har ikke rigtigt været involveret i det. Så det vil jeg gerne lade være med at kloge mig

på hvad der lige er sket der.

Interviewer: Okay, helt i orden, men inden vi kommer for dybt ind i interviewet har jeg en samtykke

erklæring jeg er nødt til at skal læse op for dig.

Informant: Okay.

Interviewer: Nu har jeg lige fortalt kort hvad projektet handler om. Interviewet bliver optaget, så det kan

bruges i mit kandidat projekt, og det håber jeg du er okay med.. ?

Informant: Det, det har ingen altså.. det helt fint. Det bestemmer du.

Interviewer: Yes, okay. Det kan også gøres anony...

Informant: Er det dig der bipper sådan?

Informant: Det ved du ikke?

Interviewer: Øhh, jeg er ikke helt med.

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Informant: Ja, det bipper sådan.

Interviewer: Det ved jeg faktisk ikke lige, jeg kan ikke høre noget bip.

Informant: Nå.

Interviewer: Men altsåååå, interviewet kan gøres anonymt hvis det er noget du ønsker. Så bliver du tildelt

et fiktivt navn i rapporten, så ingen kan genkende ud fra navn.

Informant: Det er ligemeget, det bestemmer du.

Interviewer: Okay, jamen så lad os starte. Jeg vil gerne høre om du ved noget omkring hvem der sidder i

sådan en beslutningsenhed for da vinci robotter? Om det er noget du har kendskab til?

Informant: Ja, altså det er jo ekstremt komplekst....

Interviewer: Jeg tænker især på hvem der sidder, altså jobtitler og sådan – er det læger, økonomer eller

hvem sådan sidder og vurdere sådan?

Informant: Ja altså, jowjow, det skal jeg nok lige vende tilbage til. Men selve det hvordan tager vi

beslutninger, der kan man sige der er jo rigtigt rigtigt mange svar på det. Nogle gange er det meget

rationelt og struktureret, og andre gange er det jo ildsjæle der bliver involveret i et eller andet, og der så

formår at få skabt en eller anden situationer hvor det bliver højt prioriteret igås, fordi nogen mener der er

fremtid i det eller hvad der nu ellers kan være ik’. Så der er altså rigtigt mange svar omkring det, men det

tror jeg også godt du er klar over.

Interviewer: ja, det er meget komplekst det her.

Informant: Det er kompleks. Og nogen gange lidt ustruktureret, og oven i købet på et lidt tyndt grundlag

der måske bliver truffet beslutninger. Men lidt mere tilbage til robot kirugien, så kan man jo sige, at vi har

jo arbejdet med robot kirugi i rigtigt mange år i region midt. Jeg tror vi fik den første robot – ja det var i

nullerne i hvert fald.

Interviewer: Ja, så vidt jeg har fundet ud af, så kom de vidst til Danmark omkring 01/02.

Informant: Ja, det var vidst i 02 vi fik den første på hvad er det det hedder afdeling K. Men, men altså så kan

man jo sige, vi har fået robotter efterfølgende, og lige pt har vi 5 robotter i regionen. Og det er, det er hvad

skal man sige, et emne som tilbagevendende er til drøftelse. Og en af årsagerne til at det tilbagevendende

er til drføtelse er punkt 1, at det er dyrt at anskaffe og drifte, og punkt 2 det meget svært at finde evidens

på at det rent faktisk gør en forskel for patienten. Der er forholdsvis meget fokus i robot området lige i

øjeblikket. Som du måske ved, så har der jo været igennem mange år – altså tilbage til nullerne, har der jo

været monopol på området. I og med, at der kun har været én leverandør. Det er ret interessant nu, fordi

der er flere levenrandører der viser sig i markedet, uden at der er nogen der sådan rigtigt er kommet på

banen endnu med. Altså, flere leverandører har udstyr, og vi har også været ude og se det I Italien og flere

forskellige steder, men altså der er ikke nogen klinisk drift af det i Danmark lige på nuværende tidspunkt. Så

der er nogen der står lige på spring – et par stykker faktisk. Og det er jo interessant. Monopol bryder vi os

ikke om jo. At der kun er én leverandør. Så det vil være bedre hvis der kommer lidt mere konkurrence. Både

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på økonomien, men også på fagligheden kan man sige. Altså kvaliteten af det produkt der nu er. I region

midt, hvis du ligesom spørger om beslutningsprocesserne, så vil jeg sige at vi har nogen helt overordnet det

kan jeg måske lige vende tilbage til, men helt overordnet har vi nogle centrale midler sat af i regionen til

medicoteknisk udstyr.

Interviewer: Ja

Informant: Og så kan man sige, at det er jo alles kamp mod alle kan man sige. Hvor det er et spørgsmål om

at klinikerne ansøger om udstyr, og så skal det så prioriteres. Og det er jo så der det bliver lidt ufordrende

at der ikke er evidens for robotkirugi. Fordi så er der ikke vægten omkring den faglige kvalitet og den

patientmæssige værdi i det, den er forholdsvis begrænset. Og det er jo ikke så godt når man i forvejen skal

kæmpe om for få penge.

Interviewer: Ja, så det er primært læger der tager det her intiativ til at få den implementeret kan man sige?

Informant: Ja, altså alt det udstyr – eller 90% af det udstyr vi snakker om, det bliver initieret af at der er

nogen læger der søger om udstyret.

Interviewer: Ja, okay.

Informant: Og det kan være udstyr som er ny teknologi. Det kan være udstyr som er en vigtig udskiftning af

det eksisterende udstyr. Og når vi snakker udskiftning af eksisterende udstyr, så kan det også være os (Red:

Indkøb & Medicoteknik, Region Midtjylland) som serviceorganisation, og som dem der ved noget omkring

driften af udstyr, der påpeger at nu er der brug for at få skiftet det og det udstyr. Men altså, det starter

sådan set med at det er læger der, i hvert fald typisk læger, der det kan også være sygeplejersker, men altså

og indenfor laboratorieområdet er der selvfølgelig også andre kategorier, men det er klinikerne der ansøger

om udstyret.

Interviewer: Efter de har ansøgt, hvem er det så der behandler sådan en ansøgning?

Informant: Jamen så er der det vi kalder et årshjul. Hvor klinikken, eller afdelingen. Nej, klinikerne ansøger

om udstyret, og så går der en prioritetsprocess igang hvor det i første omgang er et spørgsmål om at den

enkelte afdeling prioritere udstyret. Og derefter er det det enkelte sygehus der skal lave deres

prioritesliste, og når vi snakker det store udstyr som en gamma kniv og en da vinci robot vil være, som

koster over en million, så er det også regionen hvor vi sådan set laver en prioritering på tværs af regionen.

Og altså man kan sige som sagt det er klinikerne der ansøger om tingene, men det er os der som afdeling

(Red: Indkøb & Medicoteknik, Region Midtjylland) har ansvaret for hele den her prioriteringsprocess, og

også styrer økonomien efterfølgende. Og vi har også indstillingen omkring hvad der skal prioriteres, men så

er det vores det der hedder lederforum for økonomi, og det vil sige alle hospitalsdirektørerne og det er den

direktør der nu har sundhedsområdet der sidder for bordenden, hvor man så prioritere de her ting. Så det

kører som sådan et årshjul, hvor når vi kommer til Oktober, så har vi styr på prioriteringer for det næst-

kommende år. Og vi har cirka sådan i runde tal 200 millioner om året at prioritere indenfor. Og som sagt,

der er jo, der er altid mange flere ansøgninger, det vil sige der er ansøgninger for næsten det dobbelte af

hvad vi har penge til.

Interviewer: Ja, okay.

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Informant: Og det er jo der, hvor man så kan sige, så for at vende tilbage til robotten, det er jo så der hvor

man så kan sige, der indgår det at skifte fra almindelig kirugi åben kirugi til robot kirugi, der skal det indgå i

den prioritering. Hvis det ikke er sådan, for det har der også været en del gange, at der er nogen fonde der

sådan set bevilger udstyret, det er især på universitetshospitalet, så kan man sige at vi skal have råd til at

tage imod den donation, for det koster jo noget i efterfølgende drift igås.

Interviewer: Ja.

Informant: En ehm.. Altså der er lidt forskel på hvilket indgreb, men det koster minimum 10.000 pr. Indgreb

man laver på robot mere end det ellers vil koste.

Interviewer: Er det knivene der skal på armene, eller hvor ligger den større udgift?

Informant: Ja, altså det er primært instrumenterne og det er tiden og det er ressourcer og det er

forbrugsvarer. Altså vi har lavet flere beregninger på det, og det løber sig op i omkring 10.000 mere kroner

pr. Operation. Og det udfordrer vi selvfølgelig leverandørene på fordi, hvis det her sådan rigtigt skal batte

noget, så skal det gap mellem åben kirugi og ehm, eller traditionel kirugi bragt ned og så robot, det skal vi

have bragt ned. Kan man sige. Ja, lige nøjagtigt omkring robot kirugi, det er som sagt det er der en del fokus

på i vores region lige nu, fordi der er kun to hospitaler der har robotter, og de tre andre hospitaler står på

spring og siger ligesom: Det er også noget vi skal ha’, blandt andet for at kunne rekruttere personale, men

også for at udvikle det faglige området.

Interviewer: Så det er også et godt middel til at rekruttere nye læger til regionen, eller hospitalerne måske,

sådan en robot der?

Informant: Det tror jeg stadigvæk det er. Og det har i hvert fald været det, kan man sige. Tidligere. Ja, altså,

det har været en måde at rekruttere på. At der et billede på faglig udvikling, at man havde mulighed for at

operere i begrænset omfang på robot. For det har været i et begrænset omfang at man har gjort det, på

grund af økonomien.

Interviewer: Noget af det, som jeg bl.a. har læst lidt om i forbindelse med det projekt her, det er bl.a. at

robotten muligvis kan reducere sygedage hos læger, fordi der er nogen der f.eks. får ondt i ryggen og så

videre ved at lave bestemte procedurer. Er det noget som..

Informant: Ja, altså ja. Det er noget vi har fokus på. Og hvis man skal skære det helt ind til benet, så er der

måske næsten nogen *utydeligt* siger at det er den største fordel der er ved robotter, det er, at man kan

levetidsforlænge, undskyld udtrykket, hvad er det det hedder, klinikerne. Altså lægerne der står og operere.

Interviewer: Ja.

Informant: Men altså, vi har to faglige grupper der arbejder med det her I regionen – altså det vil sige, der

er klinikerne, der står og arbejder ved robotterne, eller står på operationsgulvet. Og så er vi indenover med

noget teknisk ekspertise og sådan. Og vi har faktisk også en professor på det her område i regionen, og han

er så formand for den her faglige gruppe. Men i og med at der er så meget økonomi i det, og prioritering i

det, så er der også en ledelsestung afdeling eller jeg mener udvalg med de lægefaglige direktører på

hospitalerne i en styregruppe om man vil. Styregruppe kalder vi det, men det er jo en styregruppe for hvad

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skal man sige hvordan det her skal håndteres i region midt. Og det går, altså det går lidt trægt kan man sige.

På grund af de ting jeg lige har nævnt.

Interviewer: Ved du circa hvor lang tid sådan en beslutningsprocess kan tage – snakker vi noget lignende et

halvt år, et år eller..

Informant: Nej altså, sådan kan man ikke se på det. Lige nu står vi mere i en process hvor man kan sige vi

har besluttet at vi vil have det her som et strategisk indsatsområde, og vi også gerne vil lave nogen

strategiske samarbejdspartnere, nej undskyld strategiske samarbejder med både med da vinci eller nej

intuitive mener jeg som har da vinci robotten, og også gerne Medtronic i hvert fald hvor man kan sige, at

den ene har ligesom haft monopol og er i markedet, og den anden vil vi gerne være med til at medvirke til

at udvikle det produkt de har. Og det er jo så der hvor vi kører en process med de to leverandører, meget i

forhold til da vinci er et spørgsmål om at få priserne konkurrencedygtige, det andet er mere et spørgsmål

om at sige kan i finde en niche i det her område altså? Og afhængig af hvordan det går, så skal der nogen

penge til rådighed, og det indgår så i den prioritering vi har i regionen. Og ja, altså der kan ikke sættes tid

på. Det er mere et spørgsmål om hvornår har vi midlerne til rådighed, og hvornår bliver business casen så

god at vi siger nu skal vi slå til på det her.

Interviewer: Ja, så selve beslutningsprocessen kan variere rigti(…)

Informant: Altså der er ikke nogen, altså I princippet kan vi her I efteråret beslutte at vi skal have 2-3

robotter mere, så alle hospitaler får en robot. Men det kan også være der ikke er midler til det, og så får vi

ikke en robot før 2019. Så hele den process kommer simpelthen an på leverandørene, og hvad de kan

tilbyde.

Interviewer: Ja, det jeg godt forstå. Er det vigtigt for jer, eller spiller det en rolle, hvilket firma de her

robotter kommer fra? Altså, vil i tage mere hensyn til et stort og anerkendt brand som Siemens hvis de

kommer med en robot, end lad os sige en ukendt lille virksomhed?

Informant: Ja. Nej. Altså det, det tænker jeg ikke er noget. Altså Medtronic er i forvejen storleverandør til

hospitalerne, og de har ikke en robot på nuværende tidspunkt de kan sælge. Men vi ville være helt trygge

ved firmaet, hvis de kom med en robot og sagde; Nu er vi klar til at sælge, den er CE-mærket og det ene og

det andet. Intuitive har vi jo kendt her nær sagt på godt og ondt igennem mange år. Det er et amerikansk

firma, og de er svære at handle med. Men det har vi fundet ud af gennem tiderne, at sådan er det bare.

Blandt andet fordi, at de jo har haft monopol ikke, så hvis vi har stået med pengene og sagt vi skal have en

robot, eller der har stået en fond og bevilget os pengene, så var vi nødt til at handle med intuitive. Og har

måtte leve med deres amerikanske reglsæt.

Interviewer: Er du bekendt med hvor stort et emne det er, at det kræver oplæring eller træning altså er det

noget man kigger meget på, det her med at læger skal trænes i at bruge den, og hvor meget de skal trænes

og generelt hvor svær den er at bruge og sådan noget her.

Informant: Ja, det mener jeg bestemt vi er meget opmærksomme på. Og de har jo også alle de har

simulatorer, som man kan bruge som træning og så videre ikke også, så vi ved godt at det tager tid altså,

Det er ikke et spørgsmål om at indføre det sådan lige over-night og så operere vi lige en masse med robot.

Altså, det tager tid.

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Interviewer: I region midt, dengang I skulle have den første robot, gjorde i der nogle tanker omkring

hvordan i kunne teste det af i en lille skala først?

Informant: Ja, nej altså, det ved jeg simpelthen ikke, men det håber jeg man har gjort. For det første er det

før min tid, og for det andet så er det jo mange år siden.

Interviewer: Ja.

Informant: Ja, altså, men jeg har da indtryk af, at hvad skal man sige, universitetshospitalet her i Aarhus har

jo haft robot i mange år, og da man så fik det ude i Vest, der er jeg da ret sikker på, altså ude i Herning, der

er jeg sikker på der har været et tæt samarbejde mellem universitetshospitalet og Herning omkring det.

Men altså jeg kan da også sagtens se en situation hvor man undervurdere ressourcerne på afdelingen, for

ligesom at komme i gang. Det kan jeg godt forestille mig. Og det er jo ikke noget som intuitive lige står og

fortæller om højt og larmende, at det her kræver rigtigt rigtigt mange ressourcer. Så jeg tror det er lidt

learning by doing. Og det kan jo godt tage tid jo.

Interviewer: Så har jeg et lidt kompliceret spørgsmål – det er ikke sikkert du ved det, men det kan være du

måske har en idé om det. Er det vigtigt for nogen personer i beslutningsenheden, at det ser godt ud ud ad

til – altså jeg tænker på resultatet af denne her innovation bliver implementeret. Nu tænker jeg på f.eks. at

sygehuset får et godt image overfor bl.a. politikere og patienter. Kan det have noget at sige i forhold til hvor

meget man ønsker en innovation, hvis du forstår?

Informant: Ja, det tror jeg bestemt det kan. Det tror jeg helt bestemt det kan. Hvis man skal sætte det lidt

på spidsen, hvad er formålet så overhoved med at indføre robot kirugi. Og der tror jeg da helt sikkert at ét

er at en af de ting der har drevet det frem er, at det var der nogen der gjorde, og så kunne man ikke stå

tilbage. Altså i en eller anden selvforståelse ud ad til, jamen så kunne man nok ikke forestille sig at

universitetshospitalet i Aarhus ikke har en robot. Fordi, altså, det har man på rigshospitalet og det har man

også i Odense og så videre, så sådan en effekt er der helt klart. Og når det så begynder at blive til, at de

store regionshospitaler de også har en robot, jamen så tror jeg da også altså, så smitter det da på en eller

anden måde. Og som vi også snakkede om med rekruttering og så videre, så bliver det et billede på at det

her er en universitetsafdeling og vi vil internationalt gerne kunne sammenligne os med de bedste og så

videre.

Interviewer: Ja, okay, så har jeg lige nogle sådan lidt små hurtige spørgsmål her til at slutte af på. Jeg

spørger om noget i forhold til innovationer generelt sådan, altså du skal ikke tænke på da vinci robotten

nødvendigvis når du svarer, men bare sådan helt generelt.

Informant: Ja?

Interviewer: Ja, og du skal give en score fra 1 til 10. Det bliver lidt mere tydeligt når jeg lige får stilt det

første spørgsmål, hvad jeg mener. Men altså, i forhold til scoren betyder 1 slet ikke vigtig, 10 er meget

vigtig og 5 er sådan gennemsnitligt vigtigt.

Interviewer: Det første jeg gerne vil vide, er hvor meget, på en skala fra 1 til 10, vil det økonomiske aspekt

betyder for jer når i vurdere en innovation – altså set i en helhed. Etableringsomkostninger, løbende udgif...

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Informant: Ja, okay jeg forstår. Altså det er jo svært lige at give en score på det. Innovationer bliver ikke

vurderet på enkeltstående parametre, men som en helhed.

Interviewer: Ja, men hvis nu du ikke skal tænke for meget over det, men kun vurdere vigtigheden af lige

præcis den ene parametre, hvad vil du så sige.

Informant: Øhm.. Jamen så må det blive 10.

Interviewer: Det her spørgsmål er lidt i relation til noget jeg har spurgt om tidligere. Men hvor vigtig på en

skala fra 1 til 10 er det, at produktet kommer fra et kendt mærke – som f.eks. Siemens?

Informant: Ikke specielt vigtigt. 2.

Interviewer: Godt. Hvor vigtigt er det, at der foreligger stærk evidens der kan bakke producentens udsagn

op?

Informant: Det er ret vigtigt. Det er nogen af de ting som vi bl.a. kigger på her med da vinci robotten, men

ja. Altså jeg får lyst til at sige 10, men her med da vinci robotten f.eks. er der netop ikke meget evidens der

peger i retning af at vi skal anskaffe den, men vi har alligevel gjort det. Fremtiden må jo så sige, om det

fortsætter sådan.

Interviewer: Så det er en 10’er?

Informant: Ej, vi må nok hellere gå med 9,5 – kan man det?

Interviewer: Yes, 9,5 er noteret.

Interviewer: Hvor vigtigt er det så, at innovationen kan levere en bedre sundhedsmæssig ydelse?

Informant: Jamen det er meget vigtigt. Det må blive 10.

Interviewer: Hvor vigtigt er det så, at innovationen er ønsket eller eftertragtet blandt læger og

sygeplejersker?

Informant: Det er også meget vigtigt. Det er jo dem der skal bruge udstyret, og hvis de hverken synes det er

en god opfindelse, eller brugbart i deres daglige virke, jamen så køber vi det ikke. Og det er jo som nævnt

klinikerne der skal ansøge om at få apparatet. Så det må også blive en 10’er.

Interviewer: Hvor vigtigt er det så, at innovationen er ønsket eller eftertragtet blandt patienter og

pårørende?

Informant: Øhm, jamen det er jo også vigtigt. Men det er på en anden måde. Det er klart, vi lytter til hvad

vores patienter fortæller os, men man skal også huske på, at de ikke har faglige kvalifikationer til at vurdere

en ehm, altså forstå mig ret. Der bliver lyttet til forslag, det gør der bestemt, men når vi skal tage en

beslutning tænker vi ikke på hvad patienterne synes eller mener. Men forstå mig ret, patienterne er altid i

fokus. Så det vil jeg vurdere til at være 5.

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Interviewer: Yes. Hvor vigtigt er det så, at en innovation er kompatibel med eksisterende udstyr – jeg

tænker specifikt på, hvor vigtigt det f.eks. er, at der er det samme software eller styresystem, som andre

lignende udstyr i en afdeling. Hvis du forstår?

Informant: Øhh.. Altså hvis det skal bruges sammen med andet udstyr, så er det 10. Vi køber ikke noget,

hvis ikke det fungere.

Interviewer: Yes. Hvor vigtigt er det så, at innovationen er let at forstå, og let at bruge?

Informant: Jeg synes det er nogle svære spørgsmål jeg får. Altså det er klart, at det spiller en rolle, men det

er ikke noget der er altafgørende. Hvis noget udstyr kræver træning, som f.eks. da vinci robotten, så vil vi

lave nogle forskellige beregninger på hvad omkostningerne kommer til at ligge på, for at udstyret netop

bliver let at bruge. Så det skal ses i en større sammenhæng.

Interviewer: Ja, det forstår jeg godt. Så den vil ikke blive vurderet så højt måske?

Informant: Nej, jeg får lyst til at sige 7. For det er ikke helt uden betydning.

Interviewer: Så er der kun 2 spørgsmål tilbage, og de minder lidt om noget vi har været inde på. Først og

fremmest så på en skala fra 1 til 10, hvordan vil du vurdere vigtigheden af at en innovation kan testes i lille

skala før man binder sig til et større køb?

Informant: Det kommer an på om det vil medføre nogle høje løbende udgifter. I så fald kan det være meget

vigtigt, hvis ikke der findes solid evidens på området, for ellers er det en stor usikkerhed. Men også hvis nu

det er noget der skal testes, fordi den er ret dyr i anskaffelse, så kan det være vigtigt. Men altså sådan

ellers, når vi sådan køber ting er det ikke noget vi som sådan tænker over. Vi går ud fra, at læger ansøger

om ting de har brug for, og hvis ikke vi er oppe i de store sedler, så køber vi dem. Så altså sådan generelt vil

jeg nok sige 6.

Interviewer: Yes, og så sidste spørgsmål. Hvor vigtigt er det sådan generelt i beslutningsenheden, at købet

af en innovation kan forbedre hospitalets omdømme? Her tænker jeg bl.a. på hvordan politikere og

patienter f.eks. ser anskaffelsen og sygehuset i sin helhed.

Informant: Ja, som nævnt tidligere er det helt bestemt noget, som nogen mennesker vægter højere end

andre. Personligt er det ikke noget jeg overvejer, når jeg er med til at lave prioritetslister. De ting jeg kigger

mest på er økonomien, det patientmæssige og så den med evidens vil jeg sige.

Interviewer: Okay, jamen så er vi ved vejs ende nu. Det var alle spørgsmål. Tusind tak fordi jeg måtte

forstyrre dig.

Informant: Helt i orden, held og lykke med projektet.

Interviewer: Tak, hej hej.

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Interview 2 – Strategisk Indkøber, Region Hovedstaden

Informant: Hej igen.

Interviewer: Hej XXXX. Passer det dig ok hvis vi tager samtalen nu? Har du tid?

Informant: Ja, det passer helt fint.

Interviewer: Okay, super. Inden vi går i gang vil jeg informere dig om, at interviewet vil blive brugt i

forbindelse med et 10. semesters afsluttende kandidat projekt. Interviewet bliver optaget og

transskriberet, så det kan indgå som en del af rapporten. Du kan få fuld anonymitet hvis du ønsker det, så

dit navn ikke fremgår nogen steder i rapporten, men kun dine udtalelser. Interviewet er frivilligt, og du kan

til enhver tid trække dig eller lade være at svare på spørgsmål.

Informant: Jeg er ikke meget for at mit navn skal stå nogen steder. Skal det stå i rapporten siger du?

Interviewer: Nej, altså dit navn skal ikke stå nogen steder, hvis ikke du vil have det. Men jeg vil gerne bruge

dine udtalelser i rapporten.

Informant: Okay, det er fint nok. Så må jeg lige tænke lidt over hvad jeg siger.

Interviewer: Må jeg nævnte at du fungere som strategisk indkøber i rapporten?

Informant: Ja det er fint nok, jeg gider bare ikke have at mit navn skal stå nogen steder.

Interviewer: Helt i orden. Som jeg snakkede lidt om tidligere, så handler det lidt om da vinci robotten, en

gamma kniv og lidt om de beslutningsprocesser der ligger bag introduktionen af disse innovationer.

*fejl på optagefil*

Informant: Ja, altså arbejdsgruppens område har været, at lave en strategi på området, som vi kan vise til

vores koncerndirektion. Altså, er det en teknologi der skal udbredes, skal det til andre specialer, andre

hospitaler, vi har kun lige pt. I vores region på Herlev og Rigshospitalet. Der har vi tre robotter hvert sted –

skal vi have flere? Og hvis vi skal, hvilke kriterier skal så opfyldes hvis det er.

Interviewer: Ja?

Informant: Ja, så det er en lidt længeresigtet strategi for hvad skal vi egentligt med robotkirugi.

Interviewer: Så du sidder og laver en del af det materiale, som de øverste beslutningstagere bladrer

igennem og træffer beslutninger ud fra, hvis jeg forstår dig ret?

Informant: Ja, ja.

Interviewer: Hvem er det så, som bladrer de ting igennem, som du laver? Altså er det direktionen eller det

overlægerne eller hvor er vi henne?

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Informant: Altså lige præcis i den her robotgruppe der er det et fælles output fra hele gruppen, man

kommer med den her strategi i form af en rapport som vi så aflevere til vores koncendirektion, som der er

den øverste administrative ledelse, og så har den faktisk også været i regionsrådet og blive behandlet. Altså

den politiske ledelse.

Interviewer: Ja, okay. Så der sidder, hvis jeg husker rigtigt, omkring en 41 stykker i regionsrådet og stemmer

om en innovation skal indføres, eller hvad?

Informant: Ehmmm, det kan jeg faktisk ikke lige huske, om det kom til afstemning.

Interviewer: Nå okay, hvad er så formålet med at det skal I regionsrådet? Er det mere for feedbackens

skyld, eller på grund af nogle politiske ting?

Informant: Det altså. Det er forskellige fra sag til sag. Lige præcis i det her tilfælde tror jeg det var, du ved,

man kan godt få en sag lagt frem hvor man beder politikerne om at tage den til efterretning. Så det

egentligt ikke er noget de skal godkende, men bare noget hvor de måske skal komme med noget feedback.

Interviewer:Jaer?

Informant: Men altså i gruppen, hvor vi lavede rapporten, der var der så både læger og alt muligt andet.

Interviewer: Ah okay ja.

Informant: Men generelt når vi beslutter os for at købe ny teknologi eller ej, så er det ikke, altså det er ikke

med mindre det er helt oppe i den høj altså store skala, helt oppe i den store skala så er det ikke noget der

er i regionsrådet. Så er det jo noget som man kan beslutte sig for i vores, vi har et regionalt apparatur

udvalg som jeg også sidder i, som er dem der laver den årlige udmyntning af vores apparatur budget.

Interviewer: Ja, så..

Informant: Så den vej igennem kan man også købe ny teknologi ind.

Interviewer: Ja, det var også sådan jeg havde forestillet mig det.

Interviewer: Vil en beslutningsenhed for gamma knive være nogenlunde tilsvarende en beslutningsenhed

for da vinci robotter? Altså jeg tænker, er det de samme mennesker der går igen?

Informant: Man kan sige, hele stråleterapiområdet har vi gået lidt anderledes til, altså og i øvrigt også for

gamma knife for den sags skyld. Men det som vi gjorde på stråleterapi området er at vi i 2014, der gik vi

igang med at lave en analyse af, altså sådan set en rapport med en 10 årig strategi for hvad vil vi indenfor

stråleterapi i vores region. Ehm. Og den gik så frem til og med 2025. Vi har i vores region, der har vi

stråleterapi på Herlev og Rigshospitalet. Men vi tog så hele øst Danmark med, så vi tog også Sjælland med,

som jo har stråleterapi i Næstved. Og så lavede vi sådan en fremskrivning, og det endte med et kæmpe

stort udbud, som vi kørte af staben sidste år, som også var et af mine projekter. Som endte med at blive

verdens største kontrakt nogensinde indenfor high-end stråleterapi, hvor vi bestilte 17 acceleratorer sidste

år i November.

Interviewer:Ja, det mener jeg faktisk at have læst om – kan det passe det var en pris ala 232 millioner?

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Informant: 323 millioner.

Interviewer: 323 – tallene var da rigtige nok. Jeg mener at have læst om det.

Informant: Ja, det var også kort I medierne. Vi lavede en besparelse på 262.

Informant: Men der købte vi 15 konventionelle linacs og så 2 af de her nye MR linacs.

Interviewer: Ja okay, det er dem med indbygget imaging?

Informant: Ja, ja præcis. Dem som Elekta også laver i deres gamma knife.

Informant: Men der tog vi hele stråleterapi området under ét. Og faktisk på baggrund af den rapport, den

analyse, så sagde jeg til dem - lad os gøre det samme for operations robotter. Selvfølgelig er det ikke det

samme tal, det er ikke helt det samme, men operationsrobotter er også en rigtigt dyr modalitet, eller en

rigtigt dyr kategori for os. De koster vel stortset det samme som en accelerator til stråleterapi, ikke en

gamma knife men en konventionel, og er faktisk endnu dyrere i drift om året end en accelerator. Så derfor

foreslog jeg dem, så lad os gribe operationsrobot-kategorien an på samme måde som med stråleterapien.

Vi laver en fremskrivning af hvor er vi henne klinisk, hvordan udvikler vores patienter sig altså demografisk

udvikling af antal kræft tilfælde og så videre og så videre, og så laver vi en fremskrivning for at se hvad har

vi egentligt brug for af kapacitet. Og det gjorde vi så på stråleterapi der i 2014, og så lavede vi en revision af

den i 16 fordi det var dengang man begyndte at snakke om kræft plan 4, at den skulle udnyttes. Så lavede vi

en revision, og fandt frem til at ud af de 21 lineære acceleratorer vi har til stråleterapi i vores region i dag,

der mente vi i hvert fald man ville have brug for de 17. Så selvom antal kræfttilfælde stiger, selvom der

kommer et proton center i Aarhus, selvom Sjælland skulle finde på at øge deres antal acceleratorer, så

mente vi faktisk at vi kunne gå lidt ned i kapacitet, fordi teknologien er langt mere udviklet, og.. kender du

det der hedder hypofraktionering?

Interviewer: Nej, det kender jeg ikke til.

Informant: HYPO – H, Y, P, O fraktionering.

Interviewer: Ja, nej det er ikke noget jeg kender så meget til.

Informant: Hypofraktionering går ud på istedet for man normalt ville gi’ et eller andet sted mellem 25 og 39

fraktioner i stråleterapi, altså behandlinger, så kan man gå langt længere ned, altså man kan måske gå helt

ned til 5 fraktioner. Så hypofraktionering er at man går fra mange til færre, men at man giver en højere

dosis tilgengæld. Og mere præcist.

Interviewer: Okay ja, så forstår jeg. Det er jo en af fordelene ved en gamma knife?

Informant: Ja, og faktisk så kan man jo stille sig selv det spørgsmål, om teknologien indenfor det

konventionelle linacs uanset om det er elekta eller det er accuray eller det er varian og så sammenligne de

nye MR linacs. Spørgsmålet er, om det i virkeligheden er ved at overhale sådan noget som gamma knife

indenom. Altså med stereotaktiske behandlinger, som er der hvor gamma knife har sin helt store

excellence, spørgsmålet er om man er ved at nå så langt med de konventionelle linacs, at man faktisk gør

den teknologi overflødig. Vi har jo for eksempel besluttet os for ikke at købe nogen gamma knife.

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Interviewer: Okay, simpelthen fordi i vurdere de konventionelle linacs til at være ligeså effektive i forhold til

behandlinger?

Informant: Ja, altså det vi kan se der er på vej er jo, altså vi at vi endte med at købe Varian. Vi indgik en

kontrakt med Varian på 15 konventionelle linacs. Og så har vi de to der producere MR linacs i dag er jo så

Elekta der har Unity produkt og så er der en amerikansk producent der hedder ViewRay som har et produkt

der hedder Meridian. Vi endte med at lave sådan lidt populært sagt et tvangsægteskab. Med lidt frivillig

tvang fik vi Varian og ViewRay til at gå sammen om at kunne byde ind i vores udbud.

Interviewer: Okay, ja.

Informant: Men altså med Varian som hovedleverandør. Så varian med 15 konventionelle linacs og ViewRay

som underleverandør med 2 meridian MR linacs.

Interviewer: Må jeg spørge hvad der lige var udslagsgivende for at netop det blev valget? Altså Varian og

ViewRays produkter.

Informant: Der vandt?

Interviewer: Ja

Informant: Den altafgørende forskel var i virkeligheden at Elekta blev forsinket med CE mærket af Unity’en.

Som de jo stadigvæk ikke har. Så den Unity som OUH har købt. Det kan godt være de kan få den leveret,

men de kan ikke få behandlet patienter på den, fordi den ikke er CE mærket jo.

Interviewer: Okay. Det ly..

Informant: Hvorimod ViewRays produkt både er FDA og CE godkendt.

Interviewer: Okay, så hvis nu Elektas produkt er, eller var CE godkendt, så ville de have været med i

opløbet?

Informant: Jamen de var skam med i opløbet, men de blev valgt fra, fordi de ikke var i stand til at garantere

at de blev CE mærket indenfor den tidsramme hvor vi skulle bruge dem. De var også med i udbuddet og

afgav et tilbud. Og de har hele tiden været med i den dialog vi har haft kørende. Accuray afskrev vi dog ret

hurtigt. Men elekta har jo været med hele vejen. Og jeg tror hvis vi var nået til en evaluering, så ville de så

stærkt på pris, men knap så stærkt på kvalitet. Og det er primært noget at gøre med deres software. Jeg

ved ikke hvor meget du kender til stråleterapi segmentet.

Interviewer: ikke så meget. Jeg kender mere til imaging devices end jeg kender til gamma knifes. Gamma

knifes er jeg først begyndt at arbejde med i forbindelse med det projekt her.

Informant: Ja okay, så hvis du er inde på imaging, så vil det svare til at hvis man skulle sammenligne med

elektas konventionelle linacs så har man software kombinationen. Hvis nu du er indenfor imaging, så kan

det være du vil kigge på at det kan være Siemens f.eks. har en rigtigt spændende MR scanner, men Syngo

via som der er deres software platform, den er håbløst bag ud.

Interviewer: Ja okay.

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Informant: Det er det samme man kunne sige om Elekta. At deres konventionelle linacs, dem som hedder

Versa HD, det er egentligt en udemærket teknologi, men de er håbløst bag ud på software siden. Det der

hedder Monaco og Mosaiq. Som er deres software platform.

Interviewer: Monaco og Mosaiq?

Informant: Ja, Monaco og Mosaiq. Monaco er det der hedder deres OES deres quality information system,

sådan styresystemet kan man sige. Og Mosaiq er deres dosis planlægning system. Der hvor man planlægger

behandling af patienten.

Interviewer: Skal det være kompatibelt med andre dele af hospitalets udstyr? Altså jeg var overbevist om,

at en gamma knife var en separat selvstændig enhed.

Informant: Det gør den også. Det er en ø for sig.

Informant: Jeg tror ikke engang den.. Altså problemet med Elekta er måden de har vokset på. Det er jo i

virkeligheden et gammelt Philips selskab. Altså ham der har grundlagt det, ham professor Leksell, det er jo

derfor det hedder en Leksell Gamma Knife, og det er så hans søn, som jo så i dag er bestyrelsesformand.

Men professor Leksells gamma knife var grundlaget for det, og det er jo så i forhold til de stereotaktisk

behandlinger. Men så ville man gerne over på de konventionelle linacs som resten af markedet, og så

overtog de jo faktisk Philips linacs forretning. Det er derfor de producere Unity’en lige udenfor London. For

det var der Philips oprindelige linac fabrik lige i gamle dage.

Interviewer: Okay.

Informant: Ja, det er en del af historien. Men måden Elekta så er vokset på, er at de på software siden har

købt alle mulige forskellige småting hist og pist. Og det er aldrig lykkedes for dem at få det interegreret. Så

lige pludseligt – altså her indtil for nylig, der har der faktisk været op til 11 software platforme til

stråleterapi hos Elekta. Mens deres konkurrent, altså varian, har to. De har Aria der er deres OES, og

Eclipse der er deres dosis planlægning system. Og det som man indenfor stråleterapi vægter højt , i hvert

fald her i den nordvestlige del af verdenen, hvor vi typisk har meget store afdelinger. F.eks. har i

Skandinavien, Holland og England. Der har vi typisk meget store afdelinger med mange linacs pr. Site. Hvor

imod sådan noget som f.eks. Tyskland, Tyskland er anderledes præget. Hele sundhedsvæsnet er anderledes

præget, og består af flere små klinikker. Og i USA er det endnu værre, altså. En stor klinik i USA har 3-4

linacs, så er man stor.

Interviewer: Ja, altså det er jo det samme i f.eks. Japan, Sydamerikanske lande og så videre. Lande hvor

sundhedssektoren er privatiseret, og baseret på ”reimbursements”.

Informant: Lige præcis. Så det er et helt andet setup. Så det betyder, at når vi som vi har på Herlev 10

maskiner stående. Så har vi ikke lyst til at vi har én Ø der hedder Gamma knife, en anden Ø der hedder

Varian og en tredje Ø der hedder ViewRay. Vi har lyst til at vi har stor fleksibilitet, og vi kan flytte vores

produktion rundt på de forskellige linacs vi nu engang har, og det skal være bundet sammen i ét integreret

software setup. Det er dét vi har brug for.

Interviewer: Kan den del du omtaler med software have en del af skylden for, at elekta har solgt så relativt

få enheder?

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Informant: Altså gamma knifes?

Interviewer: Ja.

Informant: Nej altså, jeg tror for gamma knife vedkommende handler det i høj grad om pris. Det er mit

bedste bud.

Interviewer: Det må også siges at være en udslagsgivende faktor.

Informant: Jae, og så har de ikke formået at, altså de har ikke formået at vise hvad det er for en added

value man får ved at give så mange flere millioner for en gamma knife kontra den nyeste Varian maskine

med det der hedder hyper arch og 6d couch. Det er sådan noget hvor lejdet, altså couchen, også bevæger

sig. Alt er styret af en robotarm, og acceleratoren kører rundt i nogle specielle arch rundt om patienten. Der

er også sådan noget som brainlab. Kender du dem?

Interviewer: Jeg synes jeg har hørt det før, men det siger mig ikke lige noget på stående fod.

Informant: Brainlab er et mega sejt tysk firma nede fra München. Og de har et produkt som hedder exact

track. Og exact track er noget som vi i høj grad også bruger til stereotaksi. Altså lidt populært sagt, hvis jeg

tager den fineste Varian konventionelle linac jeg kan købe – den vi har bestilt 15 af – og kombinere det med

et brainlab exact track system, så kan jeg lave præcis de.. eller det kan mine klinikere – så kan jeg lave

præcis det samme som med gamma knife, men til halv pris.

Interviewer: Det lyder smart.

Informant: Ja, jeg har faktisk et privat innovations projekt kørende med netop brainlab. Hvor vi køber 10 af

deres systemer til Herlev og Rigshospitalet. Så smækker vi det ind i vores nyeste Varian maskiner, og så kan

vi faktisk lave stereotaktisk hjernekirugi på 10 maskiner. Så brainlab, det er i høj grad noget som.. Altså

brainlab kombineret med den høje pris på gamma knife, det er nok i virkeligheden de to afgørende

parametre.

Interviewer: Ja, det lyder i hvert fald spændende.

Interviewer: Jeg har sådan et spørgeskema med 10 hurtige spørgsmål. Er det noget du er frisk på?

Informant: Ja, selvfølgelig. Hvis du har mere om stråleterapi området, eller noget om operations robotter,

så skal du bare sige til, eller du kan sende mig en mail hvis du har brug for nogle svar på yderligere

spørgsmål.

Interviewer: Ja, tusind tak, det sætter jeg stor pris på. Men jeg kan se tiden løber fra mig, og jeg vil rigtigt

gerne lige have svar på de har 10 hurtige spørgsmål, og så tror jeg egentligt at jeg har ganske godt med

materiale.

Informant: Det er helt i orden.

Interviewer: De her spørgsmål vil jeg gerne have at du svarer på sådan relativt hurtigt. Du må ikke sådan

tænke for meget over dem, for jeg ved godt det er meget mere komplekst. Men du skal vurdere det jeg

siger på en skala fra 1 til 10 i forhold til vigtigheden under en beslutning processen. Okay?

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Informant: Øhmm.. Okay

Interviewer: Jeg tror det vil give lidt mere mening når jeg stiller spørgsmålet: Hvor vigtig er økonomien i en

innovation.

Informant: Det må være en 6’er.

Interviewer: Hvor vigtigt er det, at det kommer fra et anerkendt brand?

Informant: 2.

Interviewer: Hvor vigtigt er det, at det er efterspurgt blandt læger og sygeplejersker?

Informant: 9.

Interviewer: Hvor vigtigt er det, at det er efterspurgt blandt patienter og pårørende?

Informant: 7.

Interviewer: Hvor vigtigt er det, at det er klinisk bedre end alternativet?

Informant: Hmm…

Interviewer: Nu ved jeg godt, at man sammenholder det meget med økonomien, QALY og så videre. Men

bare sådan helt lavpraktisk.

Informant: Ja, ja altså.. hmm.. Det er jo super vigtigt, for ellers ville der jo ikke være nogen grund til at gøre

det. Altså så det må være en 9’er.

Interviewer: En 9’er sagde du?

Informant: Jeg skulle lige til at sige 10. For ellers ville der nok ikke være nogen årsag til at gøre det. Altså

implementere den nye innovation istedet for den gamle. Hvis ikke den var bedre.

Interviewer: Ja, okay. Hvor vigtigt er det, at det kan snakke sammen med eksisterende løsninger? Altså

f.eks. IT tænker jeg her.

Informant: Det er en 5’er.

Interviewer: Hvor vigtigt er det, at innovationen er let at bruge og let at forstå. Altså jeg tænker bl.a. på her

at man skal tage højde for, at personale muligvis skal optrænes i at bruge det.

Informant: Ja. Det må være en 7’er.

Interviewer: Hvor vigtigt er det, at man kan teste det af i lille skala?

Informant: Det må være en 8’er.

Interviewer: Hvor vigtigt er det, at nogen ude fra kan se resultatet af den innovation man har

implementeret? Altså f.eks. politikere. Hvor vigtigt er det, at politkere kan se at det her, det er bare godt

det som der sker på det her sygehus.

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Informant: 8’er.

Interviewer: Hvor vigtigt er det, at der er dokumenteret research, der kan bakke eventuelle påstande op,

som producenten har? Altså at der er evidens bag producenten udtalelser?

Informant: Taler vi her helt ny teknologi, eller noget der er klar til at blive markedsført?

Interviewer: Det må være op til hvordan du fortolker spørgsmålet

Informant: Jeg plejer at sige, at det skal være nyt. Og hvis det er nyt, så er det ikke sikkert der er evidens

endnu, men det kan være det er noget vi skal skabe sammen. Jeg vil vove den påstand, at hvis det er noget

du kan hive ned af hylden, så er det jo ikke nyt. Prøv lige at sige spørgsmålet igen.

Interviewer: På en skala fra 1 til 10, hvor vigtigt er det så at de påstande producenten kommer med kan

dokumenteres med evidens? Altså fra forsknings artikler.

Informant: Ja, så vælger jeg at sige 8. Men ud fra den teknologi, som producenten har fundet på, fået

godkendt, og nu skal til at markedsføre.

Interviewer: Er det sjældent, at producenter selv går ud på området og laver forskning, inden de kommer til

jer for at få det solgt?

Informant: Altså, ja det vil jeg sige. Det vil jeg egentligt sige. Altså, nu skal jeg passe på med hvad jeg siger,

for der er stor forskel på tværs af modaliteterne. Men der er nogen af vores, indenfor nogen modaliteter,

der er slet ingen forskning eller evidens overhoved. Og indenfor andre, f.eks. plantater og devices, der er

massere af forskning og evidens indenfor det. Der er stor forskel på hvordan man griber det an. Men hvis

nu vi skal ud og købe det, og der kommer en og siger til mig, jeg vil gerne have at du køber denne her

teknologi, og det ikke er noget jeg selv har været med til at udvikle på, så vil jeg efterspørge evidens og

dokumentation i form af studier.

Interviewer: Ja, jamen super. Jeg synes det var nogle rigtigt gode svar, så jeg er rigtigt glad for, at du gad at

bruge tid på at snakke lidt med mig.

Informant: Jamen velbekom. Jeg synes faktisk det er nogle rigtigt gode spørgsmål du kom med her til sidst.

De minder rigtigt meget om noget jeg selv skrev sidste vinter noget vi kalder ”De 7 bærende principper”.

Og det er 7 princippet der skal kunne tikkes af, for at vi som region siger: Ja, det her private

innovationsprojekt, det er noget vi gerne vil putte penge i. Og mange af de spørgsmål du stillede før, de kan

faktisk kobles direkte på de her 7 bærende projekter. F.eks. med økonomi, klinisk relevans, skalerbarhed og

sådan. Det er lidt sjovt.

Interviewer: Ja. Altså mine spørgsmål har jeg taget på baggrund af teori af en innovationsforsker der

hedder Everett Rogers – eller hed, han er så godt nok død nu. Men han har beskrevet nogle karakteristika

der er vigtige i forhold til udbredelsen og optagelsen af innovationer. Jeg har så kigget lidt på de

karakteristika i forhold til da vinci robotten og gamma kniven, og så har jeg udledt nogle af de her

spørgsmål.

Informant: Hvad siger du han hedder ham?

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Interviewer: Han hedder Everett Rogers.

Informant: Det lyder spændende. Kan jeg ikke få dig til at skrive det til mig på mail?

Interviewer: Jo, helt sikkert. Jeg sender en mail straks.

Informant: Det er godt, tak for det.

Interviewer: Det er mig der takker for din tid, det var både spændende og informativt, så det er jeg rigtigt

glad for.

Informant: Det var godt, jeg er glad for du kunne bruge det. Og held og lykke med projektet, og så kan det

jo være vi mødes lige pludseligt nu du snart skal ud på arbejdsmarkedet.

Interviewer: Ja, det kan snildt ske jeg står en dag og vil sælge dig noget.

Informant: Du skal være velkommen.

Interviewer: Det er jeg glad for, kan du have en fortsat god dag.

Informant: Tak og i lige måde, hej hej.

Interviewer: Hej hej.

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Interview 3 – Birgitte Fjeldgaard, Faglig koordinator & udbudkonsulent, Region Nordjylland

Informant: Det er Birgitte.

Interviewer: Hej Birgitte, det er Claus. Har du tid nu?

Informant: Ja, jo, jeg havde egentligt glemt at du skulle ringe, men det har jeg. Det trak lige lidt ud det jeg

sad til så, men ja. Når man kommer flyvende tilbage så er det ikke altid opdager hvad der lige foregår.

Interviewer: Nej, det kender jeg godt. Men hvis du har tid og lyst, så lad os tage snakken nu?

Informant: Ja, jamen lad os prøve at se, om ikke vi kan få fundet ud af et eller andet fornuftigt.

Interviewer: Ja, som jeg forklarede I mailen, så er det til mit kandidat speciale her på 10. semester. Og

derfor så bliver interviewet optaget, det håber jeg du er okay med, så det kan blive transskriberet og brugt i

min rapport. Du kan naturligvis få fuld anonymitet, så dit navn ikke fremgår nogen steder i rapporten.

Informant: Det er helt fint.

Interviewer: Interviewet er frivilligt, du kan til enhver tid stoppe eller lade være at svare på spørgsmål, og

hvis du fortryder at have givet interviewet kan du kontakte mig på mail eller telefon, og så skal jeg se hvad

jeg kan gøre for at hive det ud af rapporten igen.

Informant: Ja, jamen det er helt i orden.

Interviewer: Interviewet her handler lidt om beslutningsenheder og beslutningsprocesser på sygehusene,

især i forhold til da vinci robotter og gamma knive, som jeg også lige var kort inde på i mailen.

Informant: mmmhh

Interviewer: Først vil jeg spørge lidt ind til da vinci robotten, så vil jeg spørge ind til gamma knifes, og så har

jeg 10 hurtige spørgsmål til sidst.

Interviewer: Først og fremmest vil jeg gerne lige høre, om du ved hvem der sidder i sådan nogle

beslutningsenheder der skal træffe valg vedrørende en da vinci robot?

Informant: Uhm....

Interviewer: Altså, jeg tænker; for at sådan en robot finder vej til et sygehus er der jo nogen der skal

introducere den – nogle sælgere, eller noget. Og så skal nogle læger nok udfylde en ansøgning. Den

ansøgning skal sendes et sted hen, hvor den bliver behandlet. Hvem behandler den?

Informant: Mmh, ja. Altså, først og fremmest vil jeg sige, at det typisk er lægerne selv der opsøger det her.

Altså de holder jo lidt øje med hvad der foregår og sådan, og så tager de måske selv kontakt til de her

firmaere for at få noget mere information og siger kan i ikke lige komme og kan vi ikke lige se hvad det er

for noget. Og så lige høre lidt om det. Og så vil lægerne jo typisk flage det for deres klinik ledelse. At jeg har

set det her nye smarte system, eller hvad det nu kan være, der kan vi faktisk blive bedre til at operere.

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Interviewer: ja, altså. Hvem er det så lægerne skal gå til siger du, for at få det her udstyr?

Informant: Jamen det er typisk klinikledelsen.

Interviewer: Klinikledelsen?

Informant: Ja.

Interviewer: Hvem er klinikledelsen? Altså hvem sidder i sådan en klinikledelse?

Informant: jamen det er nogen der er udpeget. Nu skal jeg lige have mine briller på, for jeg sidder faktisk

lige ved siden af sådan en planche her. Lad mig lige se, hvis nu man er i urologi, de kunne jo godt typisk

have noget med da vinci robotten at gøre, der hedder kliniklederen Anne Dorthe, altså klinikchef. Og så har

hun nogle under sig. Ofte, typisk vil det være en læge, som er klinikchef. Det kan også nogen gange være en

sygeplejerske. Og nogen gange er det en akademiker. Så der er ikke sådan en fast ehm.. Men dengang man

indførte det her klinikchef klinikledelses niveau der var planen egentligt at det sådan skulle være en

lægefaglig chef for det her. Det har så vist sig, at det ikke altid er helt nemt at få, så nogle klinikker har en

klinikchef der er læge. For eksempel i klinikakut der hedder Jens Lauge Johannesen der er læge, og så i en

anden klinik der kan det være det er en økonom eller noget andet.

Interviewer: Ja okay, kan man betragte klinikchefen som den øverste myndighed indenfor at træffe en

beslutn...

Informant: ja, ja det vil man kunne. I forhold til akutspecialet så er Jens Lauge Johannesen den øverste

myndighed. Så har han selvfølgelig over sig hospitalsledelsen, og over dem har vi jo en region.

Interviewer: Så det er regionen der laver nogle rammer for hospitalsledelsen der laver nogle rammer for

klinikledelsen som de skal agere indenfor når de vælger at vurdere hvad der skal købes?

Informant: Ja, lige nøjagtigt. Men lige nøjagtigt når vi snakker udstyr og anskaffelse af medicinsk udstyr i

den kaliber vi er oppe i her pengemæssigt, så skal de faktisk ansøge om det. Så skal klinikakut ansøge til

noget vi kalder vores apparturudvalg. Som hvert år har en bunkepenge, som de siger de ligger på omkring

40-50 millioner stortset hvert år. Hvor alle klinikker sender deres ønsker ind, fra hele regionen altså, og så

sidder der nogen og bedømmer hvor mange kan vi honorere i år. For der er altid for mange.

Interviewer: Ja okay. Det her apparturudvalg, behandler de kun sager for sygehus syd og nord i Aalborg,

eller er det også sygehus vendyssel, frederikshavn og så videre?

Informant: Det er faktisk hele regionen. Det der er, er bare at man faktisk her sidste år delte pengene op i

to puljer. Og sagde, at så og så mange får regionshospital Nordjylland, og så og så mange får Aalborg

Universitetshospital. Altså af de her millioner der nu er bevilget. Og så sidder de jo og bedømmer de har

ansøgninger, hvor der er nogen kloge mennesker som enten ved noget om apparaturet, det kan også være

de ved noget om teknik og noget, og nogen ved noget om økonomi, og faktisk sidder der også typisk en

med fra indkøb i det apparturudvalg, fordi der er noget med udbudsgrænser og hvordan man kan købe

ting.

Interviewer: Så der er folk med forskellige faglige kvaliteter i de her udvalg?

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Informant: Ja. Og det de også er med til at vurdere, det er sådan noget med at gammelt udstyr nogen

gange skal udskiftes, og så har vi ikke råd til at være innovative, det er jo sådan verdenen er skruet sammen

i det offentlige, nogle år har vi, og nogle år har vi ikke, så der er sådan lidt hvad trænger mest.

Interviewer: Ja, okay, så det er også en vurdering af hvordan de får mest for pengene?

Informant: Ja, det er faktisk lidt af et problem nogen steder, at deres udstyr er ved at blive for gammelt

mange steder, fordi der ikke har været så mange penge i sygehusvæsnet i mange år, som der var engang.

Så der sidder sådan nogle forskellige faglige personer og bedømmer de her ansøgninger, og finder ud af,

hvis nu vi tager de her 30 forskellige ansøgninger, så har vi brugt vores penge, og de andre får afslag. Men

de bliver lagt i en pulje, dem som får afslag, og så bliver det tager op i en pulje næste år. Fordi det er jo

sådan, at nogen gange har nogen ønsket noget laboratorieudstyr i 5 år, og så får de det endelige. Men det

er jo en hardcore vurdering simpelthen.

Interviewer: Ja, ved du, eller har du indtryk af hvad de ligger vægt på i sådan nogle vurderinger?

Informant: Jamen det er simpelthen så forskelligt jo. Det kan være alt lige fra et lille lungefunktionsudstyr til

en kæmpe stråleaccelerator, så det er forskellige kriterier der vurderes efter.

Interviewer: Så det er simpelthen en stor mix af det hele?

Informant: Ja, alt mellem himmel og jord.

Interviewer: Kan man sige, at de måske vægter de her indkøbsmuligheder lidt op imod hinanden? For hvis

der er plads til én, er der måske ikke plads til en anden?

Informant: Ja, altså det gør de jo til en hvis grad. De vægter i hvert fald behovet op imod hinanden.

Interviewer: Ja, så et eksempel kan være at de kigger på ansøgningerne og budgettet og siger til sig selv

“Har vi brug for en da vinci eller har vi brug for en ny ultralydsmaskine?”

Informant: Ja, lige nøjagtigt. Hvad er det vigtigste behov at få stillet lige nu. Hvis vi har en stor ventetid på

ultralydsskanninger og 50.000 skanninger i kø, så er det nok dem vi ender med at købe.

Interviewer: Ja

Informant: Hvor imod, hvis det vigtigste behov lige nu er at få en da vinci robot, fordi man har fundet ud af

den skulle være mere skånsom eller hvad det nu kunne være, så vil det jo også tælle som et behov, ik. Og

nogle gange laves der også bevillinger af fonde, hvor man kan søge om de her ting.

Interviewer: Ja, okay. Så vil jeg gå lidt videre til at snakke om gamma knive.

Informant: Ja, okay. Den kender jeg godt nok ikke helt ligeså godt.

Interviewer: Er det sådan set det samme om igen, med en klinikledelse der er ansvarlig for køb af udstyr til

den afdeling, og det går så igennem hospitalsledelsen til region og så videre som med da vinci robotten?

Informant: Ja, det tror jeg det må være, ik. Og altså inden det overhoved kommer til hospitalsledelsen, der

er jeg ret klar over at klinikken allerede har tænkt over om det overhoved er en god ide at søge om det her,

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om man mener der er så meget værdi i det her, i forhold til noget andet. Jeg tror vores klinik efterhånden

er blevet rigtigt god til at se økonomisk på tingene.

Interviewer: Ja, altså er det bare en læge der laver en ansøgning, eller?

Informant: Alle ansøgninger kommer fra klinikledelsen, og altså der kommer behovet fra en læge, som går

til klinikledelsen og siger det her er bare en god idé, prøv lige at se her. Og lægerne er jo typisk ret nørdede

indenfor deres felt, og de har været rundt og se en masse og høre om de her ting inden de går til

klinikledelsen med det, og man taler også med afdelingen om det her – kunne vi have glæde af det her,

hvad kunne det give os, og man taler måske om det i flere måneder nogen gange før man kommer videre

med det.

Interviewer: Ja, så lægerne finder først ud af om det er noget de virkeligt har brug for på afdelingen ved at

snakke med kollegaere, og så går de til klinikledelsen som laver en business case på det, og så ved mindre

anskaffelser kan de give et go eller no-go, og ved større anskaffelser skal den måske lige en tur forbid

hospitalsledelsen og måske enda regionen at vende?

Informant: ja, lige nøjagtigt. Altså mit indtryk er, at de er rimeligt seje til at bedømme det.

Interviewer: Har du en vurdering af, hvem der sidder med mest beslutningskraft i hele den her process? Det

er jo en ret lang og kompliceret process.

Informant: Ja, altså det er jo ledelsen i sidste ende der bestemmer det. Den bliver jo godkendt i sidste ende

den her plan. Hos hospitalsledelsen at det er det her vi gør. Så i sidste ende er det jo dem der bestemmer.

Interviewer: Hvis nu alle i løbet af processen er super glade for et produkt eller en opfindelse, men der er

én som ikke vil have den indført. Hvem er det så der har mandat til at rulle det hele tilbage?

Informant: Jamen det afhænger lidt af størrelsen, og midler der skal bruges. Vi har f.eks. nogle kræftpakker

midler som skal anvendes hvor der er rigtigt mange midler inde over, og der er vi faktisk helt oppe på

regionsråds niveau. Men man med den her appartur plan egentligt får godkendt bevillingens størrelse og

ikke det enkelte køb på regionsrådsniveau. Men der vil man så i hospitalsledelsen skulle godkende at

klinkakut kan få det her og klinikdiagnostik kan få det her, men selvfølgelig fra indstilling fra

apparturudvalget.

Interviewer: Ja, okay. Så indenfor da vinci og gamma knive, så vil det være hospitalsdirektøren, som i sidste

ende kommer med beslutnigen og skal give det sidste go, eller hvad?

Informant: Hospitalsledelsen. Det er nok mest vores lægefaglige direktør.

Interviewer: Ja, okay. Og ved billigere innovationer, som ikke lige er en da vinci eller en gamma kniv, der er

vi måske helt nede hvor en klinikchef på egen hånd vurdere om det skal købes eller ej?

Informant: Ja, afdelingerne har jo også eget budget som de kan købe for, men det er jo altså ikke særligt

store budgetter de har. Men nogle afdelinger kan godt købe ting for 300.000 eller 400.000 eller 500.000

uden egentligt at søge, hvis man i budgettet for afdelingen kan se at vi har faktisk råd til i år at købe en

behandlerstol – nu siger jeg bare et eller andet, jeg ved ikke lige hvad jeg skal finde på. Men det kan de

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sagtens, hvis nu de for eksempel har søgt om den, men ikke fået bevilget den. Så kan de selv bruge penge

på den. Så det kan være sådan noget.

Interviewer: Ja, okay. Så har jeg lige nogle spørgsmål. De har 10 hurtige som jeg snakkede om i starten. Du

må ikke tænke alt for meget over spørgsmålene, for de kan godt virke lidt for simplificerede sådan. Og så

skal du vurdere de udsagn jeg siger på en skala fra 1 til 10 alt efter hvor vigtige de er.

Informant: Ja, okay, vi prøver.

Interviewer: Hvor meget kigger, eller hvor meget vægter det økonomiske aspekt?

Informant: På en skala fra 1 til 10?

Interviewer: Ja, altså her tænker jeg pris, løbende udgif..

Informant: Ja, okay. Jeg tænker 6-7-8 stykker. For Hvis der ingen penge er, så kan man ikke få noget.

Interviewer: Nej, det er klart. Kan vi for lethedens skyld sige 7, er du ok med det?

Informant: Ja, vi siger 7.

Interviewer: Hvor vigtigt er det, at det kommer fra et anerkendt brand?

Informant: Jamen det tror jeg egentligt er rimeligt underordnet. Så det må være 4. Jeg tænker der kan være

noget med, at nogle små firmaer ikke rigtigt har styr på godkendelser og mærkning, men det er også det.

Interviewer: Yes. Hvor vigtigt er det, at der findes forskning der understøtter producentens påstande?

Informant: Det er også ret vigtigt. Der må vi være oppe i en 8-9 stykker.

Interviewer: Hvor vigtigt er det, at produktet kan give beder behandling end et alternative?

Informant: Også ret vigtig. En 8-9 stykker.

Interviewer: Hvor vigtigt er det, at produktet er efterspurgt blandt læger og sygeplejersker?

Informant: Super vigtigt. Der er vi også helt oppe i toppen. 9 vil jeg sige.

Interviewer: Hvor vigtigt er det, at produktet er efterspurgt blandt patienter og pårørende?

Informant: Det tror jeg ikke rigtigt det sådan er. Det har jeg svært ved at svare på. Kan man være neutral?

Interviewer: Altså det må være lige i midten så – en femmer?

Informant: Ja, for jeg tror ikke rigtigt, at de efterspørger det. Ikke den her slags. Det er mere sådan noget

med at de vil have den og den stomipose.

Interviewer: Ja. Men der kan jo godt være nogen patienter, som mener en da vinci er mere sikker end

konventionel laparoscopy.

Informant: Ja, eller at de ikke vil opereres med den, fordi de er bange for den.

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Interviewer: ja, lige nøjagtigt.

Informant: Ja, men vi holder os bare til 5 her så.

Interviewer: Hvor vigtigt er det, at systemerne kan snakke sammen med eksisterende udstyr på sygehuset?

F.eks. IT.

Informant: Det er rigtigt vigtigt. Det er 9.

Interviewer: Hvor vigtigt er det, at innovationen er let at forstå og let at bruge?

Informant: Hmm...

Interviewer: Jeg tænker f.eks. på; hvor meget vægter det at læger eller sygeplejersker skal have træning i at

bruge udstyret?

Informant: Jamen, altså ja og nej. Det må ligge på 6 eller sådan noget. For jeg tænker at det er vigtigt, men

ikke i forhold til hvis det på sigt giver gavn. Altså så er det sådan set ligemeget om det kræver en masse

uddannelse og træning.

Interviewer: Ja, okay, fint. Fint. Hvor vigtigt er det, at man kan teste innovationen af i en lille skala først?

Informant: Det vil for en del, især hvis det skal bruges til klinisk behandling, være meget vigtigt. Nu kommer

jeg lige med et eksempel, jeg ved godt det er lidt hurtigt, men lige for tiden arbejder vi med noget der

hedder intelligent forsendelses kasse ude til vores klinisk biokemisk. Den skal tage rør op af nogen kasser.

Interviewer: En intelligent forsendelses kasse?

Informant: Ja, det lyder helt åndsvagt, det vil sige man kan følge når man henter blodprøverne. Det er

sådan en robotstyring med noget IT i også, ik. Man henter nogle blodprøver ude ved lægerne, og så er der

en sporing på den, og så er der en robot som tager den op og sætter den ned i nogle racks, og tage lågene

af. Det er en ret hård process det her, for der er mange, så deres arbejdsmiljø kan blive forbedret meget af

det her. Men altså hvis nu den robot den ikke lige fungere, så kan man bare gøre det manuelt, det er jo ikke

så stort et problem. Men med for eksempel da vinci robotten, der er det vigtigt at det er testet helt helt af

og det har været prøve i mindre målestok, og en helt masse ting.

Interviewer: Ja, jeg kan heller ikke forestille mig, at man lige køber 10 ind som første ordre. Man prøver nok

lige at se hvordan det går.

Informant: Ja, lige præcis. Så det er sådan lidt et både og svar. I forhold til noget er det vigtigt, og i forhold

til andet er det ikke så vigtigt. Så jeg ved ikke helt hvordan jeg skal ligge det svar.

Interviewer: Så kan vi give den en 5’er, ligesom den med efterspørgsel blandt patienter?

Informant: Ja, lad os gøre det.

Interviewer: I hvor høj grad er det vigtigt, at folk kan se nytten af opfindelsen. Andre end læger og

sygeplejersker. Jeg tænker især politikere og patienter.

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Informant: Det kan godt være rigtigt vigtigt. Især hvis pengene skal bevilges. Der kan den nok godt ligge

oppe omkring 8.

Interviewer: Fint, så er vi faktisk igennem det hele.

Informant: Det var dejligt.

Interviewer: Ja, tusind tak fordi jeg måtte interviewe dig.

Informant: Jeps, jamen så må du videre med dit projekt. God arbejdslyst.

Interviewer: Tak skal du have, hej hej.

Informant: Hej.

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Interview 4 – Indkøber, Region Syddanmark

Interview 4 – Indkøber

Interviewer: Hej, træffer jeg XXXX?

Informant: Nej, det er min chef. Han var ikke i stand til at tage opkaldet, da der kom noget op, så han bedte

mig tage opkaldet når du ringede. Du vil spørge om noget i forbindelse med robotter, ik?

Interviewer: Okay, helt I orden. Jo, jeg har forberedt nogle spørgsmål om Da Vinci robotten og Gamma

kniven. Er det noget du kender noget til?

Informant: Altså, jeg ved lidt om da vinci robotten, men ikke rigtigt noget om gamma kniven.

Interviewer: Okay, vi kan prøve at se. Hvad er dit navn og din jobfunktion?

Informant: Jeg hedder XXXX, og jeg er indkøber.

Interviewer: Okay. Først og fremmest vil jeg gerne lige sige, at det her interview bliver optaget, så det kan

blive transkriberet og brugt I forbindelse med aflevering af mit kandidat speciale. Det håber jeg du er ok

med?

Informant: Ehh.. Det var jeg ikke helt klar over.

Interviewer: Altså, du kan få fuld anonymitet. Dit navn skal ikke fremgå nogen steder, men jeg har bare

brug for den viden du muligvis ligger inde med i forbindelse med mit projekt.

Informant: Okay, fint nok. Jeg er bare ikke helt klar på, at jeg skal udtale mig om alt muligt jeg ikke er helt

sikker på.

Interviewer: nej nej, helt rolig. Jeg har sådan et informeret samtykke, som du skal acceptere. Der står sådan

set det vi lige har snakket om med at interviewet bliver optaget, du kan blive anonym i rapporten hvis du

ønsker det, og så er interviewet frivilligt og du kan til enhver tid trække dig eller lade være med at svare på

spørgsmål du ikke er tryg ved.

Informant: Okay, det er helt i orden. Lad os se.

Interviewer: Yes. Og hvis du har spørgsmål efter interviewet er slut, eller du gerne vil trække dine udtalelser

tilbage, eller andet, så skal du bare kontakte mig. Din chef har både min email og mit telefonnummer, vil du

også have det?

Informant: Nej, det er fint nok.

Interviewer: Helt i orden. Jamen så starter vi. Først vil jeg gerne høre lidt omkring hvem der sidder i en

beslutningsenhed, som kan være med til at implementere sådan en da vinci robot her.

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Informant: Ja, altså. Først skal en læge lave en ansøgning om at få bevilget robotten. Den ansøgning bliver

behandlet i et udvalg bestående af nogle forskellige faggrupper – der er en læge, der er vores chef på

medicoteknik området, der er en økonom og så ved jeg faktisk ikke helt hvem der mere er. Men der sidder

nogle forskellige mennesker og vurdere ansøgningen og behovet, og give så enten godkendelse eller afslag.

Interviewer: Så en læge skal bare lave én ansøgning til et udvalg, og det er så det udvalg som ene og alene

bestemmer om det skal købes eller ej?

Informant: Ja. Altså, det kan godt være det kommer op forbi direktionen også, det er jeg faktisk ikke helt

klar over. Men normalt får vi bare besked fra udvalget omkring hvad der er besluttet at indkøbe, og så

sørger vi for at det bliver købt.

Interviewer: Ja okay, ved du hvem der har mest magt i det udvalg? Er der nogen der bestemmer mere end

andre?

Informant: Nej, det ved jeg faktisk ikke.

Interviewer: Ved du så hvad der kan være afgørende faktorer for, at de lige vælger at købe en da vinci?

Altså hvad lægger de vægt på i det udvalg? Hvad kigger de på?

Informant: Hmm, altså det ved jeg faktisk heller ikke helt, men det er jo meget kompliceret. De kigger i

hvert fald på prisen, for der er jo lagt et budget der skal overholdes, og så kigger de på hvordan det vil

hjælpe at købe den, og så kigger de på alternativer, om der er andre leverandører der kan levere det og

sådan. Altså det er meget kompliceret, og det er ikke fordi jeg sidder og er en del af de her møder.

Interviewer: Nej okay, jeg forstår. Hvad så med gamma kniven, er det det samme udvalg?

Informant: Jeg ved faktisk ikke helt hvilket udvalg der behandler den, men jeg kan forestille mig, at det er

udvalget på afdeling R der har med gamma kniven at gøre, mens da vinci’en hører under afdeling A.

Interviewer: Hvad er afdeling R, og hvad er afdeling A?

Informant: Afdeling R er onkologisk, mens afdeling A er kirugisk.

Interviewer: ja, okay. Nå, men jeg har nogle spørgsmål, som ikke vedrører specifikt da vinci robotten eller

gamma kniven, som jeg gerne vil stille dig. Det handler lidt mere om attituden sådan generelt overfor en

innovation. Er du frisk på det?

Informant: Ja, det kan vi godt prøve.

Interviewer: Finno. Du skal vurdere det jeg siger på en skala fra 1 til 10 alt efter hvor vigtigt eller uvigtigt det

er. 10 er meget vigtigt og 1 er ikke særligt vigtigt.

Informant: Okay.

Interviewer: Hvor vigtig en parameter er økonomien I en opfindelse? Altså det dens pris, løbende udgifter

osv..

Informant: Bummelum bum bum, der må jeg nok sige 9.

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Interviewer: Hvor vigtigt er det, at opfindelsen kommer fra et stort og anerkendt firma? Som f.eks.

Siemens?

Informant: Ikke specielt vigtigt tror jeg. Det er i hvert fald ikke mit indtryk, at det er noget der bliver lagt

vægt på overhoved. Hvis det er et godt produkt, så er det ligemeget om det hedder Siemens eller hvad det

hedder. Så her siger vi 2.

Interviewer: Hvor vigtigt er det, at der findes evidens der understøtter producentens udsagn i forhold til

opfindelsen og dens egenskaber?

Informant: Det er ret vigtigt. Specielt når vi indkøber nye ting, som vi ikke allerede har på sygehuset. Så

forsøger vi altid at finde så god dokumentation som muligt. Og det er både fra forskningsartikler, men også

hvad andre sygehuse har gjort sig af erfaring. Jeg vil sige 9.

Interviewer: Hvor vigtigt er det så, at innovationen yder bedre end alternativet. Altså f.eks. behandler en

patient hurtigere, bedre eller lign.

Informant: Uhm.. 9.

Interviewer: Hvor vigtigt er det, at innovationen er ønsket blandt læger og sygeplejersker?

Informant: 10. Altså, hvis ikke læger og sygeplejerskerne vurderede at der var et behov, og de gerne ville

have den, jamen så vil det aldrig blive købt.

Interviewer: Fint fint. Hvor vigtigt er det så, at den er ønsket blandt patienter?

Informant: Ikke specielt vigtigt. 3.

Interviewer: Hvor vigtigt er det, at innovationen er kompatibelt med eksisterende udstyr på sygehuset?

Informant: Det giver jeeeeeg 6.

Interviewer: Hvor vigtigt er det, at innovationen er let at forstå og let at bruge?

Informant: Altså, det ved jeg ikke helt. Det kommer an på så meget. Hmmm....

Interviewer: Jeg kan prøve at omformulere spørgsmålet: På en skala fra 1 til 10, hvor stor en rolle spiller det

faktum så, at før innovationen kan bruges, skal læger eller sygeplejersker have omfattende træning i at

bruge udstyret, fordi det er et stykke kompliceret udstyr?

Informant: Altså, det spiller en rolle, men det er ikke super vigtigt. Vi har meget forskelligt udstyr rundt

omkring på vores sygehuse, som kræver træning, oplæring og efteruddannelse. Så vi kigger på det, men

min vurdering er at det ikke er super super vigtigt. Det må blive 6.

Interviewer: Hvor vigtigt er det, at innovationen kan testes I lille skala først?

Informant: Der siger vi også 6.

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Interviewer: Hvor vigtigt er det så, at innovationen kan medføre at hospitalet får et bedre omdømme – her

tænker jeg især på at bl.a. politikere og patienter f.eks. kan tænke wauw, det her sygehus er bare med på

moden omkring de nyeste ting, de bedste ting, og det fungere bare på det sygehus her.

Informant: 7.. eller 8. Vi siger 8.

Interviewer: 8?

Informant: Ja, vi går med 8.

Interviewer: Fint, det var faktisk det sidste spørgsmål.

Informant: Det er bare helt i orden. Var der andet?

Interviewer: Nej, det var det hele. Tak for hjælpen.

Informant: Helt i orden, hej hej.

Interviewer: Hej.