Implementing managerial innovations in primary care: can we rank change drivers in complex adaptive organizations?

Healthcare leaders' experiences of implementing artificial intelligence for medical history-taking and triage in Swedish primary care: an interview study

BACKGROUND

Artificial intelligence (AI) holds significant promise for enhancing the efficiency and safety of medical history-taking and triage within primary care. However, there remains a dearth of knowledge concerning the practical implementation of AI systems for these purposes, particularly in the context of healthcare leadership. This study explores the experiences of healthcare leaders regarding the barriers to implementing an AI application for automating medical history-taking and triage in Swedish primary care, as well as the actions they took to overcome these barriers. Furthermore, the study seeks to provide insights that can inform the development of AI implementation strategies for healthcare.

METHODS

We adopted an inductive qualitative approach, conducting semi-structured interviews with 13 healthcare leaders representing seven primary care units across three regions in Sweden. The collected data were subsequently analysed utilizing thematic analysis. Our study adhered to the Consolidated Criteria for Reporting Qualitative Research to ensure transparent and comprehensive reporting.

RESULTS

The study identified implementation barriers encountered by healthcare leaders across three domains: (1) healthcare professionals, (2) organization, and (3) technology. The first domain involved professional scepticism and resistance, the second involved adapting traditional units for digital care, and the third inadequacies in AI application functionality and system integration. To navigate around these barriers, the leaders took steps to (1) address inexperience and fear and reduce professional scepticism, (2) align implementation with digital maturity and guide patients towards digital care, and (3) refine and improve the AI application and adapt to the current state of AI application development.

CONCLUSION

The study provides valuable empirical insights into the implementation of AI for automating medical history-taking and triage in primary care as experienced by healthcare leaders. It identifies the barriers to this implementation and how healthcare leaders aligned their actions to overcome them. While progress was evident in overcoming professional-related and organizational-related barriers, unresolved technical complexities highlight the importance of AI implementation strategies that consider how leaders handle AI implementation in situ based on practical wisdom and tacit understanding. This underscores the necessity of a holistic approach for the successful implementation of AI in healthcare.

Exploring settings as social complex adaptive systems in setting-based health research: a scoping review

Since launching health health-promoting settings approach to health by WHO, valuable progress has happened in implementing its holistic concepts in settings such as cities, schools, workplaces, hospitals and healthcare services. However, significant knowledge-intention-success gaps still exist in creating sustainable health-promoting changes in settings. The complexity of the task of bridging this gap has contributed to the call for a complexity-informed paradigm shift to health as well as settings, followed by increasing consultation of relevant complexity theories, frameworks and tools in health research. This paper provides a critical scoping review of the application of complex adaptive system (CAS) theory in settings-based health promotion research. We included 14 papers, mostly qualitative studies, reporting on planning or implementation of change initiatives, less on its evaluation. CAS theory application was often incomplete thereby reducing the potential benefit of using this lens to understand change management. We suggest some recommendations how to comprehensively apply the CAS theory in setting-based health research and to report on all CAS characteristics to enhance the understanding of settings as adaptive health-promoting settings.

The Perioperative Steering Committee as an Accountable Infrastructure to Enable and Sustain Change

Leaders in perioperative and interventional procedure areas need to be able to initiate and sustain change to improve operational processes in their departments or service lines. Although available literature discusses change in health care organizations, there is a lack of published articles on the implementation and sustainment of change. This article provides a review of supporting literature on change management and an infrastructure model that we have successfully implemented to sustain change. An organizational case study focused on creating sustained improvements for first procedure on-time starts and turnover times details the process of creating the accountability system for actualizing the performance targets in a perioperative environment. The case study examines the existing process and initial challenges with creating sustainable and quantifiable outcomes, describes the process of implementing the infrastructure discussed in the article, and evaluates the results. Perioperative leaders can use the information to improve processes in their work environments.

A focused ethnography in the context of a European cancer research hospital accreditation program

Background

A quality accreditation program (AP) is designed to guarantee predefined quality standards of healthcare organizations. Evidence of the impact of quality standards remains scarce and somewhat challenging to document. This study aimed to investigate the accreditation of a cancer research hospital (Italy), promoted by the Organization of European Cancer Institutes (OECI), by focusing on the individual, group, and organizational experiences resulting from the OECI AP.

Methods

A focused ethnography study was carried out to analyze the relevance of participation in the accreditation process. Twenty-nine key informants were involved in four focus group meetings, and twelve semistructured interviews were conducted with professionals and managers. Inductive qualitative content analysis was applied to examine all transcripts.

Results

Four main categories emerged: a) OECI AP as an opportunity to foster diversity within professional roles; b) OECI AP as a possibility for change; c) perceived barriers; and d) OECI AP-solicited expectations.

Conclusions

The accreditation process is an opportunity for improving the quality and variety of care services for cancer patients through promoting an interdisciplinary approach to care provision. Perceiving accreditation as an opportunity is a prerequisite for overcoming the barriers that professionals involved in the process may report. Critical to a positive change is sharing the values and the framework, which are at the basis of accreditation programs. Improving the information-sharing process among managers and professionals may limit the risk of unmet expectations and prevent demotivation by future accreditation programs. Finally, we found that positive changes are more likely to happen when an accreditation process is considered an activity whose results depend on managers’ and professionals’ joint work.

Leading Innovative Practice: Leadership Attributes in LEAP Practices

Policy Points An onslaught of policies from the federal government, states, the insurance industry, and professional organizations continually requires primary care practices to make substantial changes; however, ineffective leadership at the practice level can impede the dissemination and scale-up of these policies. The inability of primary care practice leadership to respond to ongoing policy demands has resulted in moral distress and clinician burnout. Investments are needed to develop interventions and educational opportunities that target a broad array of leadership attributes.

CONTEXT

Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes.

METHODS

A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices.

FINDINGS

We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others.

CONCLUSIONS

Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.

'Doing more with less': a qualitative investigation of perceptions of South African health service managers on implementation of health innovations

Building resilience in health systems is an imperative for low- and middle- income countries. Health service managers' ability to implement health innovations may be a key aspect of resilience in primary healthcare facilities, promoting adaptability and functionality. This study investigated health service managers' perceptions and experiences of adopting health innovations. We aimed to identify perceptions of constraints to adoption and emergent behaviours in response to these constraints. A convenience sample of 34 facility, clinical service and sub-district level managers was invited to participate. Six did not respond and were not contactable. In-depth individual interviews in a private space at participants' place of work were conducted with 28 participants. Interviews were audio recorded and transcribed verbatim. NVivo 11 was used to store data and facilitate framework analysis. Study participants described constraints to innovation adoption including: staff lack of understanding of potential benefits; staff personalities, attitudes and behaviours which lead to resistance to change; high workload related to resource constraints and frequent policy changes inducing resistance to change; and suboptimal communication through health system structures. Managers reported employing various strategies to mitigate these constraints. These comprised (1) technical skills including participatory management skills, communication skills, community engagement skills and programme monitoring and evaluation skills, and (2) non-technical skills including role modelling positive attitudes, understanding staff personalities, influencing perceptions of innovations, influencing organizational climate and building trusting relationships. Managers have a vital role in the embedding of service innovations into routine practice. We present a framework of technical and non-technical skills that managers need to facilitate the adoption of health innovations. Future efforts to build managers' capacity to implement health innovations should target these competencies.

Innovative Implementation Studies Conducted in US Safety Net Health Care Settings: A Systematic Review

Little is known about dissemination and implementation in safety net settings. The authors conducted a literature review of innovation/implementation studies in US safety net health care settings between 2008 and 2017. Each article was coded for (1) intervention characteristics, (2) implementation stage, (3) internal versus external ownership, and (4) prespecified implementation outcomes (eg, acceptability and fidelity). Twenty studies were identified; the majority were implemented within community clinics or integrated safety net systems (15 articles), most involved care process improvements (13 articles), and most were internally developed (13 articles). The internally developed innovations reported fewer barriers to acceptability among staff/providers, higher leadership involvement and organizational alignment, greater amounts of customization to the local setting, and better sustainment. Future work should harness the high levels of alignment and acceptability in implementation research within safety net settings, with an eye toward maintaining fidelity to facilitate dissemination across sites.

General practitioners: Between integration and co-location. The case of primary care centers in Tuscany, Italy

Healthcare systems have followed several strategies aimed at integrating primary care services and professionals. Medical homes in the USA and Canada, and primary care centres across Europe have collocated general practitioners and other health and social professionals in the same building in order to boost coordination among services and the continuity of care for patients. However, in the literature, the impact of co-location on primary care has led to controversial results. This article analyses the possible benefits of the co-location of services in primary care focusing on the Italian model of primary care centres (Case della Salute) in terms of general practitioners’ perception. We used the results of a web survey of general practitioners in Tuscany to compare the experiences and satisfaction of those general practitioners involved and not involved in a primary care centre, performed a MONAVA and ANOVA analysis. Our case study highlights the positive impact of co-location on the integration of professionals, especially with nurses and social workers, and on organizational integration, in terms of frequency of meeting to discuss about quality of care. Conversely, no significant differences were found in terms of either clinical or system integration. Furthermore, the collaboration with specialists is still weak. Considering the general practitioners’ perspective in terms of experience and satisfaction towards primary care, co-location strategies is a necessary step in order to facilitate the collaboration among professionals and to prevent unintended consequences in terms of an even possible isolation of primary care as an involuntary ‘disintegration of the integration’.

Scoping review of complexity theory in health services research

Background

There are calls for better application of theory in health services research. Research exploring knowledge translation and interprofessional collaboration are two examples, and in both areas, complexity theory has been identified as potentially useful. However, how best to conceptualize and operationalize complexity theory in health services research is uncertain. The purpose of this scoping review was to explore how complexity theory has been incorporated in health services research focused on allied health, medicine, and nursing in order to offer guidance for future application. Given the extensiveness of how complexity theory could be conceptualized and ultimately operationalized within health services research, a scoping review of complexity theory in health services research is warranted.

Methods

A scoping review of published research in English was conducted using CINAHL, EMBASE, Medline, Cochrane, and Web of Science databases. We searched terms synonymous with complexity theory.

Results

We included 44 studies in this review: 27 were qualitative, 14 were quantitative, and 3 were mixed methods. Case study was the most common method. Long-term care was the most studied setting. The majority of research was exploratory and focused on relationships between health care workers. Authors most commonly used complexity theory as a conceptual framework for their study. Authors described complexity theory in their research in a variety of ways. The most common attributes of complexity theory used in health services research included relationships, self-organization, and diversity. A common theme across descriptions of complexity theory is that authors incorporate aspects of the theory related to how diverse relationships and communication between individuals in a system can influence change.

Conclusion

Complexity theory is incorporated in many ways across a variety of research designs to explore a multitude of phenomena.. Although complexity theory shows promise in health services research, particularly related to relationships and interactions, conceptual confusion and inconsistent application hinders the operationalization of this potentially important perspective. Generalizability from studies that incorporate complexity theory is, therefore, difficult. Heterogeneous conceptualization and operationalization of complexity theory in health services research suggests there is no universally agreed upon approach of how to use this theory in health services research. Future research should include clear definitions and descriptions of complexity and how it was used in studies. Clear reporting will aid in determining how best to use complexity theory in health services research.

Advancing the application of systems thinking in health: South African examples of a leadership of sensemaking for primary health care

BACKGROUND

New forms of leadership are required to bring about the fundamental health system changes demanded by primary health care (PHC). Using theory about complex adaptive systems and policy implementation, this paper considers how actors' sensemaking and the exercise of discretionary power currently combine to challenge PHC re-orientation in the South African health system; and provides examples of leadership practices that promote sensemaking and power use in support of PHC.

METHODS

The paper draws on observational, interview, and reflective data collected as part of the District Innovation and Action Learning for Health Systems Development (DIALHS) project being implemented in Cape Town, South Africa. Undertaken collaboratively between health managers and researchers, the project is implemented through cycles of action-learning, including systematic reflection and synthesis. It includes a particular focus on how local health managers can better support front line facility managers in strengthening PHC.

RESULTS

The results illuminate how the collective understandings of staff working at the primary level - of their working environment and changes within it - act as a barrier to centrally-led initiatives to strengthen PHC. Staff often fail to take ownership of such initiatives and experience them as disempowering. Local area managers, located between the centre and the service frontline, have a vital role to play in providing a leadership of sensemaking to mediate these challenges. Founded on personal values, such leadership entails, for example, efforts to nurture PHC-aligned values and mind-sets among staff; build relationships and support the development of shared meanings about change; instil a culture of collective inquiry and mutual accountability; and role-model management practices, including using language to signal meaning.

CONCLUSIONS

PHC will only become a lived reality within the South African health system when frontline staff are able to make sense of policy intentions and incorporate them into their everyday routines and practices. This requires a leadership of sensemaking that enables front line staff to exercise their collective discretionary power in strengthening PHC. We hope this theoretically-framed analysis of one set of experiences stimulates wider thinking about the leadership needed to sustain primary health care in other settings.

The growth and composition of primary and community-based care services. Metrics and evidence from the Italian National Health Service

Background

Over the past few decades, in OECD countries there has been a general growing trend in the prevalence of out-of-hospital healthcare services, but there is a general lack of data on the use of these services.

Methods

We defined a list of 303 indicators related to primary and community healthcare services in collaboration with 13 Italian Local Health Authorities (LHAs). Then, for each LHA, we collected and analyzed these indicators for two different years (2003 and 2007).

Results

Out-of-hospital care absorbs 56% of all costs in our sample of LHAs. Expenditure on outpatients’ visits to specialists and on diagnostic examinations accounts for 13% of the costs, while spending on primary care (including prevention and public health) accounts for 9%, and for intermediate structures (including those related to rehabilitation, elderly people, disabled people, and mental health) the figure is 11%. Different Italian LHAs have made different strategic choices with respect to primary and community-based care (PCC).

Conclusions

Two distinct strategic orientations in the adoption of PCC services by LHAs has emerged from our study. The first has been an investment mainly in ambulatory and home-based primary care services in order to increase the number of low-complexity settings. A second strategy has prioritized the allocation of resources to intermediate inpatient structures for specific types of patients, namely elderly and disabled people, post-acute patients in need of rehabilitation and long-term care, and patients in hospices.

Change agency in a primary health care context: the case of distributed leadership

BACKGROUND

Integration of services across disciplines and organizations has been pursued increasingly in the primary care sector. Successful integration requires adept leadership of change. There have been questions about the extent to which studies on change agency that focus on a stand-alone leader are applicable in the complex setting of health care. It has been suggested that a model of collective leadership is more appropriate to this setting.

PURPOSE

The objective is to understand the dynamics of collective or distributed leadership by attending to change agency roles in a context involving collaboration across health organizations. The study examines how change agency roles develop, evolve, interact, and complement each other. It also examines the bases of the change agents' ability to exercise influence.

METHODOLOGY

A qualitative, longitudinal case study allowed us to map the evolution of a successful model of leadership. We tracked changes and agents' roles by engaging in extensive observations and conducting 74 interviews over a period of 4 years.

FINDINGS

The findings point to the importance of the distributed change leadership model in contexts where legitimacy, authority, resources, and ability to influence complex change are dispersed across loci. Distributed leadership has both planned and emergent components, and its success in bringing about change is associated with the social capital prevalent in the site.

PRACTICE IMPLICATIONS

Change leaders need to build a winning coalition of agents with complementary skills and resources that support the change. Successful change leadership involves investing time in finding common ground across stakeholders and in building credibility and trust. Having an agent whose main responsibility is to manage the change process is likely to bring more success than asking busy health care practitioners to take on this charge because in the latter case, there is likelihood of dilution of change focus and momentum.

Understanding pathways for scaling up health services through the lens of complex adaptive systems

Despite increased prominence and funding of global health initiatives, efforts to scale up health services in developing countries are falling short of the expectations of the Millennium Development Goals. Arguing that the dominant assumptions for scaling up are inadequate, we propose that interpreting change in health systems through the lens of complex adaptive systems (CAS) provides better models of pathways for scaling up. Based on an understanding of CAS behaviours, we describe how phenomena such as path dependence, feedback loops, scale-free networks, emergent behaviour and phase transitions can uncover relevant lessons for the design and implementation of health policy and programmes in the context of scaling up health services. The implications include paying more attention to local context, incentives and institutions, as well as anticipating certain types of unintended consequences that can undermine scaling up efforts, and developing and implementing programmes that engage key actors through transparent use of data for ongoing problem-solving and adaptation. We propose that future efforts to scale up should adapt and apply the models and methodologies which have been used in other fields that study CAS, yet are underused in public health. This can help policy makers, planners, implementers and researchers to explore different and innovative approaches for reaching populations in need with effective, equitable and efficient health services. The old assumptions have led to disappointed expectations about how to scale up health services, and offer little insight on how to scale up effective interventions in the future. The alternative perspectives offered by CAS may better reflect the complex and changing nature of health systems, and create new opportunities for understanding and scaling up health services.

Towards sustainable traumatic brain injury care systems: healthcare leadership imperatives in Canada

Traumatic brain injuries pose strategic population health challenges in the face of burgeoning clinical demands that continue to tax capital, financial, and social resource capacities. The sustainability of traumatic brain injury care systems depends on paradigmatic shifts in healthcare leadership thinking. In quest for high-performance care and sustained quality of life for traumatic brain injury patients, this article presents a unique paradigm of seven care performance layers and seven health leadership imperatives that together form the paradigm for the systemic sustainability of TBI care systems of the future.

Quality assurance of endoscopy units

This chapter reflects on how England has led the world in service development and quality assurance of endoscopy. It draws out themes of leadership, strategic vision and organisational culture. It emphasises the pivotal importance of focussing service improvement on enhancing the quality of a patient's experience of endoscopy. It describes the processes used here for quality assurance of endoscopy units and how these have dovetailed with other strands of work in transforming the English endoscopy service. The chapter presents discussion of the responses to accreditation processes and how the design of the JAG Accreditation process maximises its effectiveness.

What motivates professionals to engage in the accreditation of healthcare organizations?

OBJECTIVE

Motivated staff are needed to improve quality and safety in healthcare organizations. Stimulating and engaging staff to participate in accreditation processes is a considerable challenge. The purpose of this study was to explore the experiences of health executives, managers and frontline clinicians who participated in organizational accreditation processes: what motivated them to engage, and what benefits accrued?

DESIGN/PARTICIPANTS

The setting was a large public teaching hospital undergoing a planned review of its accreditation status. A research protocol was employed to conduct semi-structured interviews with a purposive sample of 30 staff with varied organizational roles, from different professions, to discuss their involvement in accreditation. Thematic analysis of the data was undertaken.

RESULTS

The analysis identified three categories, each with sub-themes: accreditation response (reactions to accreditation and the value of surveys); survey issues (participation in the survey, learning through interactions and constraints) and documentation issues (self-assessment report, survey report and recommendations). Participants' occupational role focuses their attention to prioritize aspects of the accreditation process. Their motivations to participate and the benefits that accrue to them can be positively self-reinforcing. Participants have a desire to engage collaboratively with colleagues to learn and validate their efforts to improve.

CONCLUSION

Participation in the accreditation process promoted a quality and safety culture that crossed organizational boundaries. The insights into worker motivation can be applied to engage staff to promote learning, overcome organizational boundaries and improve services. The findings can be applied to enhance involvement with accreditation and, more broadly, to other quality and safety activities.

Network organizations of general practitioners: antecedents of formation and consequences of participation

Background

Network forms of organization are increasingly popular in primary care. At the end of the 1990s General Practitioners (GPs) in Italy were given the opportunity to adopt network forms of organization with the aim of improving the quality of their services. However factors affecting GPs' choices to join a network and the consequences of network membership have not been evaluated.

Methods

Administrative data of a Local Health Authority in Central Italy were analyzed using statistical methods at individual and dyadic levels of analysis.

Results

Homophily factors seem to influence a GP's choice of network. The consequences of network membership on GP performances seem very limited.

Conclusions

When considering to foster the diffusion of network organizational forms in health care creating a network structure, like that of Italian GPs, is not sufficient. Other features of the implementation phase, work organization and human resource management should also be considered.

Is the PRISMA-France glass half-full or half-empty? The emergence and management of polarized views regarding an integrative change process

AIM

The PRISMA-France pilot project is aimed at implementing an innovative case management type integration model in the 20th district of Paris. This paper apprehends the emergence of two polarized views regarding the progression of the model's spread in order to analyze the change management enacted during the process and its effects.

METHOD

A qualitative analysis was conducted based on an institutional change model.

RESULTS

Our results suggest that, according to one view, the path followed to reach the study's current level of progress was efficient and necessary to lay the foundation of a new health and social services system while according to the other, change management shortcomings were responsible for the lack of progress.

DISCUSSION

While neither of these two views appears entirely justified, analyzing the factors underlying their differences pinpoints some of the challenges involved in managing the spread of an integrated service delivery network. Meticulous preparation for the change management role and communication of the time and effort required for a wholesale institutional change process may be significant factors for a successful integrative endeavor.

Social network analysis in primary care: the impact of interactions on prescribing behaviour

OBJECTIVES

In many healthcare systems of affluent countries, general practitioners (GPs) are encouraged to work in collaborative arrangements to increase patients' accessibility and the quality of care. There are two lines of thought regarding the ways in which belonging to a network can affect GP behaviour: (1) the social capital framework posits that, through relationships, individuals acquire resources, such as information, that allow them to perform better; and (2) the social influence framework sees relationships as avenues through which individual actors influence other individuals and through which behavioural norms are developed and enforced. The objective of this study is to provide an evaluation of the effects of GP network organisation on their prescribing behaviour.

METHODS

We used administrative data from a Local Health Authority (LHA) in Italy concerning GPs organisation and prescriptions.

RESULTS

We found that GPs working in a collaborative arrangement have a similar prescribing behaviour while we did not find a significant relationship between the centrality of a GP and her capability to meet LHA's targets.

CONCLUSIONS

Our data support the conclusion that, in the case of GP collaboration initiatives, the social influence mechanism is more relevant than the social capital mechanism.

Factors influencing physician use of clinical electronic information technologies after adoption by their medical group practices

BACKGROUND

A major factor limiting efficiency and quality gains from clinical information technologies is the lack of full use by the clinicians.

PURPOSE

To identify the practice and physician characteristics that influence the use of e-scripts after adoption.

METHODS

Data were obtained from 27 primary care medical group practices that had e-script technology for 2 years. Physician and practice characteristics were obtained from the clinics, and the proportion of each physician's prescriptions sent electronically was calculated from the prescription records. Practice culture data were obtained from a survey of the physicians in each practice. Data were analyzed using hierarchal regression.

FINDINGS

Practice-level variables explain most of the variance in the use of e-scripts by physicians, although there are significant differences in use among specialties as well. General internists have slightly lower use rates and pediatricians have the highest rates. Larger practices and multispecialty practices have higher use rates, and five practice culture dimensions influence these rates; two have a negative influence and three (organizational trust, adaptive, and a business orientation) have a positive influence.

PRACTICE IMPLICATIONS

While previous studies have identified physician characteristics and product deficiencies as factors limiting the use of electronic information technologies in medical practices, our data indicate that the influence of these factors may be highly dependent on the culture of the practice. Consequently, practice administrators can improve physician acceptance and use of these technologies by making sure that there is a culture/technology fit before deciding on a product.