Table 4.

Illustrative quotes of first order concepts

First order concept	Respondent	Date	Illustrative quote
Care intensity Packages	Business manager	21–01-2015	We need to deal with incidents in our client registration system that lists the Care Intensity Packages of all our clients. And that drives a whole array of bureaucratic plans, lists and systems
	Teamleader Care	21–01-2015	If I have higher CIPs, I need more specialized staff. That is difficult to manage. Currently, I have this Excel sheet in which I try to keep up; how many hours do I have according to CIPs and how many do I have available from my current staff
Normative Housing Component	Member Supervisory board	30–09-2014	We will get more entrepreneurial because the NHC is no longer related to our housing costs, but rather to the number of clients we care for. That could also mean we profit from keeping our old real estate longer
	Controller	15–04-2016	Currently, we can use the NHC to compensate for our deficits in care. Over time, however, we have to reorganize, because NHC is barely enough to cover our new real estate
Normative Inventory component	Business manager	17–06-2014	We will bear all risks related to our inventory, as the NIC consists of norm amounts that need to cover inventory. Whether they do remains to be seen
	Director	30–09-2015	Over time, we will fall through the floor of our ratios. I can accept this for a limited time, but obviously, we cannot sustain shortages in funding for our inventory for a very long time
Distribution between different CIPs	Director	21–01-2015	We could reason really business-like: "how much does each CIP return" and then manage our operations accordingly. From a purely economic standpoint, I'd rather have no low CIP's
	Project support staff member	14–10-2015	The transition from low CIPs to higher CIPs has dislodged many things that we were working on. For example, this has great consequences for type of housing we can have and the types of staff we can employ
Rate per CIP	Project support staff member	01–07-2014	We are starting to calculate towards matching CIP's with our costs. Our business case is now based on matching our formation with the CIP's. Rates may change, and then we see that we need to act accordingly
	Member Supervisory board	07–09-2015	The rates have remained stable over recent years. But the government wants people to run their own households for longer. Yet, simultaneously, the rates for home care, meant for lower CIPs are dropping. So what are we to do?
Room occupancy rate	Controller 2 / Interim manager	14–12-2016	I was very surprised that in the first MT-setting where I was present, and which I could chair, that occupancy rates didn't come up: that we did not talk about how that relates to employment. The first determines our revenues, and the second determines our costs for 70%
	Teamleader Care	21–01-2015	Once a year, I learn how many hours my people have available to care for people. Sometimes, when a client leaves or dies, we get someone new in exactly the same CIP, so I am fine then. But when we get 5 new people in a higher CIP, that has major consequences for my care hours. So, occupancy is not just related to how many rooms are filled, but also to the kinds of CIP they are filled with
Budget overruns for intramural care	Teamleader Day care	21–01-2015	We can see this in creative activities. For people who reside in their private homes, there is a relatively large budget for creative activities and supervision thereof. The argument is of course that if you live at home, you need to take part in a lot of activities, so you don't get so expensive at later stages, so to say. But when your health deteriorates, and you end up in a home like ours, there is no real interest for policymakers to fund creative activities, except perhaps quality of life arguments, but those are not in the immediate interest of policy makers. So, you see that the system has led to a situation where the budgets for intra-mural activity supervision have been reduced a lot. I hope that we will remain somewhere in the CIP's, but it is tight
	Business manager	17–06-2014	We are now in the midst of the transition from intramural to extramural care. And this is immediately turned into to a cost-cutting exercise, because the municipalities that need to do this are getting less money as well
Staff shortages	Teamleader Care	17–06-2014	We are going to deliver a different kind of care, more specialized and focused on people with more severe afflictions. We need staff with a different profile for that. Currently, we may have too many people who are either educated in a wrong field or not educated enough. But we do not have enough people with the proper profile, and they are much harder to find
	Director	21–01-2015	It is a challenge, especially when someone is ill or on holiday. We need to replace them or ask other staff to work more
Vulnerable business management due to small labor contracts	Teamleader Care	21–01-2015	We have many very small contracts, some even 5 h per week. […] That has an impact on efficiency and quality. So where possible, we try to combine these, but that is not always possible, so it takes a lot of management
	Controller 2 / Interim manager	14–12-2016	Imagine, someone resigns, and I have to find an administrator for twelve hours. I will not find a capable person, who is willing to work for twelve hours. So that this too vulnerable, too risky and qualitatively, it is too unstable
Budget overruns for extramural care	Member Supervisory board	30–09-2014	We will be getting rates for home care that are severely loss-giving. We could say "these are our future clients" and justify these losses, but we cannot do this for ever
	Project support staff member	11–11-2014	We will experience declining rates and we need to counter the resulting budget overruns. We now have the basic rule that especially in the lower function categories, we will not extend labor contracts beyond two times, so as to avoid appointing people on permanent contracts
Bureaucratic auction system	Member Supervisory board	01–06-2015	In these auctions, all parties can tender bids at certain prices. But the consequence has been that we got really large organizations. For example, one municipality is now dealing with a large organization from another part of the country, which is very cheap because they do it very differently to us. They schedule people through computer scheduling software and they are much cheaper. They do not have a large office; they just have employees located throughout the country. And so, they can accept much lower rates
	Business manager	21–01-2015	The auction system really auctions clients
Erosion of rates	Controller	15–04-2016	People are getting older. And that population need more and more specialized and dedicated care. But, in contrast, there is a squeeze on our rates. So, you have to provide more care, but every time for a little bit less money. And that cannot continue, because our wages continue to rise
	Business manager	21–01-2015	For home care, in 2014, we received €23,97 for an hour of work. This year, the rate will be €22,11 and the expectation is that we will provide discounts on those rates as well
Leave rooms empty	Project support staff member	14–10-2015	With regards to overproduction, we need better methods and systems to predict what is coming, to get at least some insight in some of its predictable causes. Based on those types of figures, we can then decide to keep rooms empty. We have always said that we have a social remit, and we don't want to deny anyone appropriate care. So, we entered a new phase
	Director	03–03-2014	We calculated that we would have overproduction of about €200.000,-, last year. Fortunately, we were able to get additional funding for additional services rendered, but that is not going to happen again. So, we need to manage much stricter on occupancy of rooms, and, if needed, keep them empty
Abandon home care business	Business manager	21–01-2015	Home care is a difficult story. If we were to lose 30 intramural clients, we would need at least 60 home care clients to recoup some of the lost revenues. The rates are just that bad, because that market is highly competitive
	Member Supervisory board	01–06-2015	Home care is currently loss-giving. We should get rid of it, and we are thinking about it. Thus far, our thinking was that these losses may be justified, because they lead to new business later. If you are a client of our home care, and it is time to orient yourself towards more specialized intramural care, it is more likely that you think of us first. But this reasoning only goes so far as home care may become untenable, real quick, financially speaking
Close on-site kitchen	Controller	15–04-2016	The kitchen and its staff obviously are not part of "hands at the bed" workforce. So if you have to cover € 100.000,- for your kitchen, you just have to eliminate it. You need to organize differently, because it allows us to retrieve this money quite quickly, without affecting direct care. We now get ready-to-eat meals that we heat and serve
	Director	30–09-2015	There is a full-blown reorganization, as we need to save about €450.000,-. It is going to hurt. Overhead, such as cleaning, reception, but especially the kitchen are going to suffer, because we try to keep principal care going for as long as possible
Create joint "business bureau" with two neighboring institutions	Controller 2 / Interim manager	14–12-2016	A business bureau makes a lot of sense: you are much less vulnerable, and I can get a much better sense if I deploy people in the best ways, related to their skills, salary, education and abilities. It is good to have this bureau, because up to now, there was too much discussion, too many policy changes, too many things going on. Now business management is isolated from all that
	Controller	12–02-2016	All those solo-functions… We are working hard to combine them and to have more people capable of doing them, just to reduce our exposure to risks. If we see that this works well, after a few months, we can start to integrate more
Seek cooperation with banks and building societies	Project support staff member	21–01-2015	We have hired a consultant who connects us to parties in the market. We have made a business case for the new real estate that we want to erect, and they will see which banks or other parties are interested and which rates they are looking for to fund our plans. […] These things are important, because the government is also withdrawing from housing, so we need parties with competencies in this area as well
	Member Supervisory board	30–09-2014	We need banks, but they are not eager to finance care institutions. That is a problem, but in the past, we could go to the municipality to get guarantees that would bring banks on board. Unfortunately, we do not get these anymore. The system seems to suffer from a loss in solidarity
Become "center of expertise" for severe cases of dementia	Director	30–09-2015	We want to be a regional center of expertise for Alzheimer's disease. That is our growth model. It does mean that we need to employ the right type of psychologist, behavioral experts, specialized nurses or care specialists who can work with this specific type of problem
	Member Supervisory board	01–06-2015	[CareX] knows a lot about dementias, because we already have many clients with Alzheimer's at different stages. We already have several "living rooms", so it is just a matter of adding a few more
Experiment with small-scale "living rooms"	Teamleader Care	21–01-2015	We just created new living rooms, with the most recent one for clients in CIP 4. I am really enthusiastic. With proper guidance and supervision, these are people who can still manage parts of a household, and that is what we do in these living rooms. There is a small team of supervisors and when they cannot manage, the care team helps out. In these rooms, people eat together, they drink coffee together. There is simply more attention for them. I have seen people really rebound and become more active and engaged
	Director	30–09-2015	Eight clients share a living room, and financially, that is more than sustainable, because we get to retain some return on capital. It just makes sense. We already knew that people came to us for our care, sometimes from afar. And then, real estate does not matter as much: people like living together in a good, cozy living space. People find that here and just really good care