Dawn of a new era

A stakeholder-innovation programme implemented at Novo Nordisk, a pharmaceutical company, aimed to link customers to other external stakeholders and employees to enable better diabetes care. Søren Skovlund explains how the programme has led the organisation to form new partnerships and mindsets, and how it is helping to sustain competitive advantage worldwide.

The political, social and economic environment of the pharmaceutical industry is constantly changing, forcing it to prepare for a future that will embrace a more holistic vision of healthcare. A future outlook developed by Novo Nordisk, a pharmaceutical company specialising in diabetes care, for the year 2020 and beyond showed that knowledge management and networking will be the prime drivers of successful businesses in the future. For healthcare companies to thrive in this challenging environment, they need to go beyond typical customer-oriented solutions by reaching out to a diverse group of stakeholders, to capitalise on combined knowledge, insight and skills.

Building relationships with key stakeholders in global, international and local communities is at the core of our business approach. We call it the ‘triple bottom line’, which reflects an integrated understanding of how the social, environmental and economic bottom lines are inter-related. Business performance that aims to be socially responsible, environmentally sound and economically viable serves two purposes: it generates long-term profitability and earns our societal licence to operate.

Novo Nordisk engages with stakeholders to reconcile dilemmas and to find common ground to develop more sustainable solutions. Innovation is enhanced through the cross-fertilisation of knowledge and experience. Novo Nordisk has always done business this way and it has become part of the company culture. Employees pride themselves on being there for their customers and strive to better understand their needs.

The diabetes attitudes wishes and needs (Dawn) programme, [1] which builds upon a global survey of the psychological aspects of diabetes and involved thousands of people from 13 countries, is a classic example of stakeholder innovation. Tapping into this global knowledge base allowed Novo Nordisk and its stakeholders to develop a new approach to diabetes care that looked more closely at the person behind the disease. The knowledge from Dawn has become an integral part of the Novo Nordisk national diabetes programme (NDP), a collaborative approach to improving international diabetes care. The NDP facilitates the development of effective national diabetes programmes through sharing best practices among more than 40 countries.

For people with chronic diseases such as diabetes, there is increasing evidence that prevention and a care model based on the psychological – as well as the physical aspects – of a disease can have a dramatic impact on the quality and outcome of care. Despite the availability of effective diabetes therapies, more than half of those with diabetes do not achieve full health and quality of life.

A main reason for this is inadequate care, leading to poor self-care, lack of empowerment and lack of acceptance of required therapies. Ultimately, this can lead to severe long-term complications. While healthcare systems are increasingly focusing their efforts on reducing the socio-economic burden of disease, as well as the healthcare costs, through reorganisation of the care process and structure, the product-focused pharmaceutical industry is falling behind.

“The only thing that makes a company unique is knowledge – others can replicate your products, replicate your services, can reverse engineer your strategies, but they cannot replicate your knowledge and how you use it to create a collaborative advantage,” says Debra Amidon, CEO of Entovation. If the pharmaceutical industry can rise to the challenge and make itself part of a larger solution, its potential involvement in addressing the burden of disease on a national and global scale can increase dramatically, and those who move from product differentiation to know-how and knowledge-innovation management will be those best prepared for the future.

Establishing the knowledge advantage

In 2001, Novo Nordisk identified an urgent need to engage stakeholders around the world in a discussion about how diabetes care could be improved so more people with diabetes would achieve adequate control of their condition.

Health statistics showed that people with diabetes were suffering unnecessarily from severe complications due to inadequate blood-sugar control. The clinical and quality-of-life benefits of the latest therapeutic regimens for diabetes were not realised for the majority of people with diabetes due to unknown or poorly defined barriers to effective support for self-management.

In order to set a global movement in motion to identify these non-medical barriers to better diabetes care and treatment outcomes, Novo Nordisk initiated the Dawn study in 2001. This was the largest diabetes study of its kind ever conducted. The study took place in Sweden, Denmark, Norway, Germany, Netherlands, France, Spain, the UK, US, Japan, India and Poland, and involved more than 5,400 people with diabetes and more than 3,800 healthcare professionals, including specialist physicians, general practitioners, nurse specialists and general nurses. It was carried out in collaboration with the International Diabetes Federation and an international expert advisory board, both of which are integral parts of today’s ongoing Dawn programme, which aims to translate the findings into practical initiatives worldwide.

The objective of the study was to explore the attitudes, wishes and needs of both people with diabetes and diabetes healthcare professionals in order to identify critical gaps in healthcare and generate new hypotheses. In addition, it was hoped that the results of the study would identify areas in diabetes care where it would be most cost effective for Novo Nordisk to engage in partnership with relevant stakeholders, such as NGOs, governments, healthcare professionals and leading scientists.

The Dawn study questionnaire was created following focus groups with people with diabetes and healthcare professionals in eight countries. It assessed views of different types of healthcare professionals and people with diabetes on various topics and contrasted the responses. The questionnaire gave rise to an array of insights into opportunities for innovation by bringing stakeholders together.

The new knowledge-value proposition

The results of the Dawn study were embraced by leading representatives of organisations such as International Diabetes Federation, World Health Organisation, professional associations, healthcare ministries, key opinion leaders, healthcare professionals, those with diabetes, politicians and media around the world. The main conclusion drawn from the study findings was that to improve health outcomes in diabetes, the total healthcare system must focus more on the psychological issues attached to living with the condition: in other words, to focus on the person behind the disease.

The Dawn study quantitatively showed for the first time how people with diabetes across continents suffer from different types of emotional distress and poor psychological wellbeing. Poor self-management due to psychological and social factors was confirmed as a major contributing factor to impaired diabetes health outcomes.

Healthcare professionals acknowledge a lack of resources to identify and care for the many psychosocial problems and it was revealed that team-based, patient-centred communication was globally inadequate. Healthcare professionals were not aware of certain psychosocial barriers that many people with diabetes experience and which could often prevent them from accepting much needed therapy. For instance, many physicians were not aware that most people with type-two diabetes would blame themselves for failing to self-manage if they were asked to start using insulin.

The study also indicated actions that might be taken to minimise this problem, as many healthcare professionals reported using threats about insulin therapy to motivate their patients to follow oral or lifestyle therapy. The Dawn study offered an urgently needed platform for dialogue across all diabetes stakeholder groups, as well as concrete guidance on how the processes of diabetes care might be optimised to improve care in industrialised, as well as less developed, societies.

As much as the Dawn study identified missed opportunities for better health and healthcare, the study gave rise to new optimism and strategies. These included ventures such as national train-the-trainer programmes for primary-care physicians on the psychological aspect of care and quality-of-life questionnaires for people with diabetes, which several countries now incorporate into routine health evaluations. The common aim of such initiatives is to improve quality of life of people with diabetes and reduce the socio-economic burden of the condition by enabling people to utilise the currently available therapeutic regimens more effectively.

This new knowledge-value proposition – linking the economic, social and technological elements – emerged from the Dawn study and was translated into a culture and stakeholder approach to business through knowledge innovation.

Knowledge innovation

Within Novo Nordisk, the key findings of the Dawn study were circulated to increase customer understanding and orientation, and to spark innovation that would allow the company to contribute even more to defeating diabetes.

To secure a deep understanding of the Dawn findings, a target of 60 per cent of all employees in relevant areas were required to discuss the study with a person or people with diabetes in the first year. Workshops took place that involved 30 employees at a time and a group of people with diabetes. These were conducted across the organisation and resulted in valuable feedback and the initiation of new activities.

Externally, the Dawn results were shared with leading diabetes experts, clinicians, diabetes sufferers, the media, industry, NGOs and decision makers worldwide. A broad and open multi-stakeholder process of interpreting the findings involved many individuals and organisations, and led to the second International Dawn Summit of Novo Nordisk in 2003, which was organised in collaboration with the International Diabetes Federation.

Summit participants – representing 31 different countries and including members of government, the World Health Organisation, the International Diabetes Federation and many other key players in diabetes – issued an international call to action for better diabetes care. This was subsequently published in non-specialist, clinical and scientific magazines, as well as the International Diabetes Federation publications, reaching a total of over 140 countries and several million people.

The critical areas for concern and action identified by the Dawn study were examined through the web of stakeholders engaged in the process. As illustrated in the diagram, knowledge comes from all nodes on the stakeholder innovation network. Novo Nordisk can now be viewed – with its extended knowledge base – as a zone for innovation where, according to Amidon, knowledge can move from the point of origin to the point of need and opportunity.[2] In this case, the central focus is on people with the disease.

Today, the Dawn programme provides an international framework for concerted advocacy, guidelines, practical tools and best practices to facilitate the translation of Dawn learnings into practice. The Dawn programme is influencing healthcare systems, both through policy and practices that are locally driven.

Over the past two years, the Dawn programme has successfully increased awareness about the importance of psycho-social issues in diabetes care and contributed to the initiation of wide-reaching national and regional educational activities; the implementation of psychosocial support tools; the facilitation of new dialogue between key stakeholders in diabetes; and the revision of treatment guidelines in a number of countries.

The Dawn study has laid the foundations for collaborative relationships among diverse groups of society, enhancing not only the value of the knowledge, but also the future for patient-centred care.

Driving knowledge innovation

Taking the Dawn programme to the next level meant effectively converting intangible knowledge assets into concrete value propositions. Setting aside a traditional approach in favour of a new stakeholder approach offers a number of business benefits. These include:

Increased customer loyalty;
The creation of new knowledge assets;
Improved use of effective therapies;
More appropriate use of modern delivery systems to address psycho-social barriers;
A heightened focus on the need for more convenient care regimens to improve quality of life.

The main goal was to promote a shift in internal mindsets that encouraged interaction between different units and functions within the organisation. Insights from Dawn were applied, for example, in strategies for development of innovative insulin-delivery systems and to help clinical investigators communicate more effectively with participants in clinical trials with regards to psychosocial barriers to therapy.

Tapping the knowledge base of Dawn through stakeholder innovation delivered many impressive results, including:

An exclusive dialogue tool with key opinion leaders, governments, healthcare professionals and people with diabetes about new perspectives on how to improve diabetes care;
A deep understanding of the real needs of both healthcare professionals and people with diabetes, and the inter-relations, as a basis for shaping an evidence-based customer-focused research and service organisation;
A unique understanding of the motivational processes of empowerment of an individual applied to the interaction between healthcare professionals and people with diabetes and customers;
Opportunities to develop innovative products and services that enhance the value of combined products to end-users.

The practical implementation of the programme relied on local and regional know-how, networks and resources within Novo Nordisk. Affiliates were given responsibility for translating Dawn into action, together with key stakeholders and opinion leaders. Best practices were shared through the intranet and international meetings, promoting local ownership of the values and ideas of the Dawn programme in the company.

What we have learnt

The national use of Dawn was made possible because of guidance from an international key-opinion-leader advisory board and what arose from major meetings with attendants from more than 30 counties. These elements helped build loyalty and deepen relationships with the influential diabetes stakeholders in each country and thereby promote sustainable partnerships.

The Dawn programme has taught us the importance of prioritising KM so that we can continuously drive stakeholder innovation. While local ownership and effective distribution of the core concept is key, centralised conceptualisation and co-ordination is likely to be pivotal in order to achieve tangible company benefits.

The knowledge-innovation process clearly had to be presented as a facilitative dialogue aimed at enabling local pioneers, both inside and outside the company, to excel in their own country. This was necessary to initiate an accumulative process of distributed knowledge generation.

We believe that the psycho-social topic of the Dawn study had a beneficial impact on the thinking of many stakeholders, as it is a universally relevant topic and encompasses underlying motivational process that link to the deeper motivations of employees and stakeholders to do well. The adoption of these concepts requires the local endorsement of their relevance to ensure cost-effective use of budget resources.

What we can do differently

Conducting a global survey may be manageable, but creating a sustainable innovation process that changes the attitudes and behaviours of an entire organisation is a daunting task that requires a strong culture, constant efforts and a multi-tier strategy. The process is long term and requires constant expansion of our interaction with key organisations and people in diabetes to keep our approach fresh and relevant, while at the same time showcasing local success stories that demonstrate the practical implementation of Dawn.

The dynamic knowledge-innovation process may conflict with streamlined product-focused business processes. Crucial to success is the timely development of adequate IT and HR programmes to properly implement formal aspects of the intended change for external stakeholders, as well as cross-organisational functioning. Without appropriate, tailored, interactive IT systems to support the process upfront, it may be difficult to reach distant parts of the organisation.

The challenge remains to create sufficient momentum to implement concrete incentive and evaluation systems for employees that are aligned with the proposed change in behaviour and attitude towards a more collaborative, solution-focused approach. These are the new intangible performance criteria based upon intellectual capital and sustainability indicators.

Many opportunities can be missed if the essential internal and external knowledge-innovation processes are counteracted by remuneration systems that focus on short-term goals and individual achievements. However, this is a long-term process. We have also learnt that establishing clear ownership of knowledge innovation by those who are expected to exploit that knowledge is a key motivational aspect.

Where to go from here?

Using the lessons learnt through the Dawn programme, all stakeholders in today’s healthcare industry should engage in new forms of interactive sharing of knowledge and the creation of solutions in partnership. In this way they can promote a sustainable approach to improved care for chronic diseases and effectively utilise corporate social responsibility as a catalyst for change.

It is only through the constant creation of well structured and carefully managed knowledge programmes, and the development of new partnerships, that innovation in public health-promotion activities can flourish and the burden of disease can effectively be reduced.

References
1. www.dawnstudy.com
2. www.inthekzone.com

Søren Skovlund is senior adviser, corporate stakeholder relations at Novo Nordisk. He can be contacted at sesk@novonordisk.com