Table 1.

Identified context-mechanism relations that were mentioned by respondents as having impacted the introduction of the PAVIAS program in Rotterdam, the Netherlands.

THEME	CONTEXT FACTOR AND DESCRIPTION		MECHANISM(S) DESCRIPTION (MECHANISM #)
Goals & motivation	C1	Across stakeholders, the main goals and origin of motivations for initiating the program were generally overlapping.	Feelings of frustration with the current situation (M1), feeling a shared sense of urgency for change (M2), the potential benefit (i.e., better value for patients or more knowledge on VBP) worth the time and effort (M3)
	C2	Although respondents generally had similar overarching goals, they had substantially different views on how to achieve and operationalize these shared goals.	Perceived tension between short and long-term goals (M4), demotivating conflicts of interest that undermine a shared rationale (M5)
	C3	Some respondents expressed uncertainty about whether the introduction of the program would substantially improve value in the short run due to limited patient volumes and time required to make significant changes to healthcare delivery.	Perceived tension between short and long-term goals (M4), scepticism about meaningful change in a reasonable time (M6)
	C4	Lacking evidence on positive effects of VBP and limited experience with integrated payment hardly affected their motivations to contribute to the program.	Feelings of frustration with the current situation (M1), feeling a shared sense of urgency for change (M2)
	C5	Motivational leadership of individuals from different organizations was identified as a major contributing factor. Such leadership entailed setting deadlines, showing clear dedication to meet these deadlines, and persuasion of other people.	feeling of having a shared commitment to make the program work (M7)
Trust, relations & support	C6	The existence of good historic working relations and pre-existing trust among stakeholders with a good reputation was a crucial contributor to the introduction of the program.	Feeling comfortable in making investments (M8), having a feeling of ‘being in it together’ (M9)
	C7	Strong organizational support was an often-mentioned facilitator, although some respondents representing the hospital added that more pro-active support could have prevented delay.	Feeling comfortable in making investments (M8), Having limited fear of (severe) repercussions during trial and error (M10).
	C8	All respondents mentioned some degree of conflicting interests between and within organizations.	scepticism about each other’s motives (M11), perceived suboptimal inter- and intra-organizational relationships (M12)
	C9	There appeared to be a lack of a shared responsibility for (the costs of) all care in the bundle. Some stakeholders only considered responsibility for care delivered by their own organizations, whereas others (n = 3) stressed the importance of joint responsibility for all care in the bundle, including care provided by other organizations.	high perceived importance attached to autonomy (M13), perceived loss of control over responsibilities (M14), professional obstination (M15)
Design of VBP contract	C10	The introduction of the program was experienced to be complex. in dealing with this complexity, the decision to make an outline agreement (instead of attempting to reach consensus on a detailed and complex contract that accounts for all possible contingencies) was beneficial.	Perceived complexity and experienced control over the program (M16)
	C11	The choice for a multi-year contract with no accountability for financial losses in the first year was identified as a contributing factor.	Reduced reluctance and uncomfortable feelings of being exposed to too much risk from the outset (M17)
	C12	Although the reluctance to take on financial risk was generally low (in part because stroke-related revenue was relatively small for most stakeholders), respondents did mention that the degree of financial risk under the program varied heavily among stakeholders.	The potential benefit (i.e., better value for patients or more knowledge on VBP) (not) worth the time and effort (M3), Loss or gain of interest in the program (M18).
Regulatory compatibility	C13	The compatibility of the BP contract with the existing FFS reimbursement rules and billing system facilitated the introduction of the program	Limit the perceived complexity and enhance experienced control over the program (M16)
	C14	Existing privacy and anti-trust legislation was a barrier, especially with respect to data exchange among competing organizations. This barrier was partly overcome by involving a trusted third party (TTP) for data definition, accumulation, and comparison	Perceived complexity and enhance experienced control over the program (M16), reduced experienced possibilities for care coordination among stakeholders (M19), scepticism about the possibilities for improving care (M20)
Resource management	C15	The degree to which resources were made available and the level of leadership was generally proportional to the size of the respective stakeholder organizations	feelings of fairness (M21), perceived equality in workload (M22)
	C16	A lack of continuity in personnel and project groups was a barrier leading to delays (e.g., people in key positions leaving to other employers, insufficient feedback among different project subgroups, premature disbandment of these groups without follow-up)	Perceived support and cooperation (M23), feelings of demotivation (M24)
	C17	Insufficient human and financial resources frustrating effective program management was identified as a barrier	High perceived workload (M25), feelings of stress (M26), and feelings of dissatisfaction (M27)
Data management & monitoring	C18	The involvement of a trusted third party (TTP) for data management was mentioned as an important contributing factor for making shared data definitions, financial metrics, accumulation of data, and providing insights into achieved outcomes and costs	Perceived complexity and experienced control over the program (M16), confidence and trust in the validity of data (M28)