Radical change in healthcare organization

Academic medical centres in the Netherlands: muddling through or radical change?

Introduction

Academic medical centres (AMCs) are designed to perform multiple tasks within a single organisation. This institutional complexity gives rise to intricate governance challenges and promotes incrementalism and muddling.

Method

In this study, we hypothesised that radical change could provide a solution to the current incrementalism and we explored the conditions under which such changes could or could not be achieved.

Results

We conducted unstructured interviews with various high-level stakeholders and identified issues that negatively affected the governance of Dutch AMCs, which include: 1) negative undercurrents and unspoken issues due to conflicts of interests, 2) organisational complexity due to relationships with a university and academic medical specialists, 3) lack of sufficient government direction, 4) competition between AMCs due to perverse systemic incentives, 5) different interests, focus, and organisational culture, 6) concentration of care, which does not always lead to enhanced quality and efficiency as the provision of less complex care is of utmost importance for education and research, 7) the infeasibility of public and regional functions of an AMC, 8) the inefficiency of managing three core tasks within the same organisation and, 9) healthcare market regulation.

Discussion

Our hypothesis that radical change offers a solution to the current incrementalism in AMCs could not be adequately explored. Indeed, our exploration of the conditions under which radical change could potentially take place revealed that there are factors currently at play that make a substantive conversation between stakeholders about radical change difficult, if not impossible. The results also show that the government is in a position to take the lead and create conditions that foster mutual trust and common interests among AMCs, as well as between AMCs and other hospitals.

Consumers' and health providers' views and perceptions of partnering to improve health services design, delivery and evaluation: a co-produced qualitative evidence synthesis

BACKGROUND

Partnering with consumers in the planning, delivery and evaluation of health services is an essential component of person-centred care. There are many ways to partner with consumers to improve health services, including formal group partnerships (such as committees, boards or steering groups). However, consumers' and health providers' views and experiences of formal group partnerships remain unclear. In this qualitative evidence synthesis (QES), we focus specifically on formal group partnerships where health providers and consumers share decision-making about planning, delivering and/or evaluating health services. Formal group partnerships were selected because they are widely used throughout the world to improve person-centred care. For the purposes of this QES, the term 'consumer' refers to a person who is a patient, carer or community member who brings their perspective to health service partnerships. 'Health provider' refers to a person with a health policy, management, administrative or clinical role who participates in formal partnerships in an advisory or representative capacity. This QES was co-produced with a Stakeholder Panel of consumers and health providers. The QES was undertaken concurrently with a Cochrane intervention review entitled Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation.

OBJECTIVES

1. To synthesise the views and experiences of consumers and health providers of formal partnership approaches that aimed to improve planning, delivery or evaluation of health services. 2. To identify best practice principles for formal partnership approaches in health services by understanding consumers' and health providers' views and experiences.

SEARCH METHODS

We searched MEDLINE, Embase, PsycINFO and CINAHL for studies published between January 2000 and October 2018. We also searched grey literature sources including websites of relevant research and policy organisations involved in promoting person-centred care.

SELECTION CRITERIA

We included qualitative studies that explored consumers' and health providers' perceptions and experiences of partnering in formal group formats to improve the planning, delivery or evaluation of health services.

DATA COLLECTION AND ANALYSIS

Following completion of abstract and full-text screening, we used purposive sampling to select a sample of eligible studies that covered a range of pre-defined criteria, including rich data, range of countries and country income level, settings, participants, and types of partnership activities. A Framework Synthesis approach was used to synthesise the findings of the sample. We appraised the quality of each study using the CASP (Critical Appraisal Skill Program) tool. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. The Stakeholder Panel was involved in each stage of the review from development of the protocol to development of the best practice principles.

MAIN RESULTS

We found 182 studies that were eligible for inclusion. From this group, we selected 33 studies to include in the final synthesis. These studies came from a wide range of countries including 28 from high-income countries and five from low- or middle-income countries (LMICs). Each of the studies included the experiences and views of consumers and/or health providers of partnering in formal group formats. The results were divided into the following categories. Contextual factors influencing partnerships: government policy, policy implementation processes and funding, as well as the organisational context of the health service, could facilitate or impede partnering (moderate level of confidence). Consumer recruitment: consumer recruitment occurred in different ways and consumers managed the recruitment process in a minority of studies only (high level of confidence). Recruiting a range of consumers who were reflective of the clinic's demographic population was considered desirable, particularly by health providers (high level of confidence). Some health providers perceived that individual consumers' experiences were not generalisable to the broader population whereas consumers perceived it could be problematic to aim to represent a broad range of community views (high level of confidence). Partnership dynamics and processes: positive interpersonal dynamics between health providers and consumers facilitated partnerships (high level of confidence). However, formal meeting formats and lack of clarity about the consumer role could constrain consumers' involvement (high level of confidence). Health providers' professional status, technical knowledge and use of jargon were intimidating for some consumers (high level of confidence) and consumers could feel their experiential knowledge was not valued (moderate level of confidence). Consumers could also become frustrated when health providers dominated the meeting agenda (moderate level of confidence) and when they experienced token involvement, such as a lack of decision-making power (high level of confidence) Perceived impacts on partnership participants: partnering could affect health provider and consumer participants in both positive and negative ways (high level of confidence). Perceived impacts on health service planning, delivery and evaluation: partnering was perceived to improve the person-centredness of health service culture (high level of confidence), improve the built environment of the health service (high level of confidence), improve health service design and delivery e.g. facilitate 'out of hours' services or treatment closer to home (high level of confidence), enhance community ownership of health services, particularly in LMICs (moderate level of confidence), and improve consumer involvement in strategic decision-making, under certain conditions (moderate level of confidence). There was limited evidence suggesting partnering may improve health service evaluation (very low level of confidence). Best practice principles for formal partnering to promote person-centred care were developed from these findings. The principles were developed collaboratively with the Stakeholder Panel and included leadership and health service culture; diversity; equity; mutual respect; shared vision and regular communication; shared agendas and decision-making; influence and sustainability.

AUTHORS' CONCLUSIONS

Successful formal group partnerships with consumers require health providers to continually reflect and address power imbalances that may constrain consumers' participation. Such imbalances may be particularly acute in recruitment procedures, meeting structure and content and decision-making processes. Formal group partnerships were perceived to improve the physical environment of health services, the person-centredness of health service culture and health service design and delivery. Implementing the best practice principles may help to address power imbalances, strengthen formal partnering, improve the experiences of consumers and health providers and positively affect partnership outcomes.

The need for management education of healthcare management employees

Given the wide professional discussion on the dominating professional focus of healthcare managers at the expense of management knowledge, the main goal of this paper is to verify the extent, to which management education of healthcare workers affects the level of their management skills.

METHODOLOGY

The Descriptive statistics methods have been used to answer research questions regarding the differences in the perception of the managerial skills and their disposition importance between managers with a completed management education and without it. Emphasis was placed on people management skills and communication skills. The research sample consisted of 253 healthcare managers.

RESULTS

Managers with a completed specialized management study are characterized by higher values of entrepreneurial competences and communication skills. They also have exceptional skills in the area of initiator of change. Another significant difference is the higher adaptation of roles and low critique of their subordinates. They are oriented at workers and relationships with them.

CONCLUSION

Our results show that management education of healthcare managers significantly contributes to the implementation of newer approaches to people management and the use of the necessary management skills, which are a source of higher efficiency in the context of the present world of work and its challenges.

Hospital reorganization and its effects on physicians' network churn: The role of past ties

Hospital reorganizations are difficult and often fail to produce their intended benefits. Prior research has investigated how and under which contingencies changes in organizational structure affect the modification of clinician behaviors, yet we know little about how organizational redesign interventions affect physicians' collaborative networks. This paper explores how hospital reorganizations affect physicians' network churn. We developed hypotheses on the relationship between structural characteristics of networks before reorganization and the formation of cross-unit network ties after reorganization. We tested our hypotheses on a sample of 175 physicians in a large teaching hospital. The hospital had recently adopted a new organizational model aimed at enhancing a process-based approach to care delivery. Our findings revealed that the physicians' propensity to form cross-unit ties after the change was related to the structure of their collaborative networks before the change. In particular, the formation of cross-unit relations was negatively related to the size of advice networks before the reorganization. Furthermore, we found that the diversity of network ties along with the presence of structural holes in the physicians' networks before the change moderated this relationship. We discussed the theoretical and practical implications of our findings. In particular, our results may inform organizational redesign interventions within hospitals.

Leadership assumptions on implementation of patient involvement methods

Background

From 2014 to 17, a large-scale project, ‘The User-involving Hospital’, was implemented at a Danish university hospital. Research highlights leadership as crucial for the outcome of change processes in general and for implementation processes in particular. According to the theory on organizational learning by Agyris and Schön, successful change requires organizational learning. Argyris and Schön consider that the assumptions of involved participants play an important role in organizational learning and processes. The purpose was to explore leaders’ assumptions concerning implementation of patient involvement methods in a hospital setting.

Methods

Qualitative explorative interview study with the six top leaders in the implementation project. The semi-structured interviews were conducted and analyzed in accordance with Kvale and Brinkmanns’ seven stages of interview research.

Result

The main leadership assumptions on what is needed in the implementation process are in line with the perceived elements in organizational learning according to the theory of Argyris and Schön. Hence, they argued that implementation of patient involvement requires a culture change among health care professionals. Two aspects on how to obtain success in the implementation process were identified based on leadership assumptions: “The health care professionals’ roles in the implementation process” and “The leaders’ own roles in the implementation process”.

Conclusion

The top leaders considered implementation of patient involvement a change process that necessitates a change in culture with health care professionals as crucial actors. Furthermore, the top leaders considered themselves important facilitators of this implementation process.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06497-y.

Reorganizing and integrating public health, health care, social care and wider public services: a theory-based framework for collaborative adaptive health networks to achieve the triple aim

OBJECTIVE

Population health management (PHM) refers to large-scale transformation efforts by collaborative adaptive health networks that reorganize and integrate services across public health, health care, social care and wider public services in order to improve population health and quality of care while at the same time reducing cost growth. However, a theory-based framework that can guide place-based approaches towards a comprehensive understanding of how and why strategies contribute to the development of PHM is lacking, and this review aims to contribute to closing this gap by identifying the key components considered to be key to successful PHM development.

METHODS

We carried out a scoping realist review to identify configurations of strategies (S), their outcomes (O), and the contextual factors (C) and mechanisms (M) that explain how and why these outcomes were achieved. We extracted theories put forward in included studies and that underpinned the formulated strategy-context-mechanism-outcome (SCMO) configurations. Iterative axial coding of the SCMOs and the theories that underpin these configurations revealed PHM themes.

RESULTS

Forty-one studies were included. Eight components were identified: social forces, resources, finance, relations, regulations, market, leadership, and accountability. Each component consists of three or more subcomponents, providing insight into (1) the (sub)component-specific strategies that accelerate PHM development, (2) the necessary contextual factors and mechanisms for these strategies to be successful and (3) the extracted theories that underlie the (sub)component-specific SCMO configurations. These theories originate from a wide variety of scientific disciplines. We bring these (sub)components together into what we call the Collabroative Adaptive Health Network (CAHN) framework.

CONCLUSIONS

This review presents the strategies that are required for the successful development of PHM. Future research should study the applicability of the CAHN framework in practice to refine and enrich identified relationships and identify PHM guiding principles.

Practitioner perspectives on building capacity for evidence-based public health in state health departments in the United States: a qualitative case study

BACKGROUND

Public health agencies are responsible for implementing effective, evidence-based public health programs and policies to reduce the burden of chronic diseases. Evidence-based public health can be facilitated by modifiable administrative evidence-based practices (A-EBPs) (e.g., workforce development, organizational climate), yet little is known about how practitioners view A-EBPs. Thus, the purpose of this qualitative study was to understand state health department practitioners' perceptions about how A-EBPs are implemented and what facilitators and barriers exist to using A-EBPs.

METHODS

Chronic disease prevention and health promotion program staff who were members of the National Association of Chronic Disease Directors were recruited to participate in telephone interviews using a snowball sampling technique. Interviews were transcribed verbatim, and transcripts were analyzed using a common codebook and the a priori method in NVivo.

RESULTS

Twenty seven interviews were conducted with practitioners in four states (5-8 interviews per state). All practitioners felt that their work unit culture is positive and that leadership encouraged and expected staff to use evidence-based processes. Participants discussed the provision of trainings and technical assistance as key to workforce development and how leaders communicate their expectations. Access to evidence, partnerships, and funding restrictions were the most commonly discussed barriers to the use of A-EBPs and EBDM.

CONCLUSIONS

Results of this study highlight practitioners' perspectives on promoting evidence-based public health in their departments. Findings can inform the development and refinement of resources to improve A-EBP use and organizational and leadership capacity of state health departments.

Tracing healthcare organisation integration in the UK using actor-network theory

PURPOSE

The study presents the findings from a study over a four-year period of the emergence of an integrated healthcare organisation in response to policy changes within the United Kingdom (UK). The aim of the research was to understand the process of healthcare organisation integration through the lens of actor-network theory (ANT).

DESIGN/METHODOLOGY/APPROACH

An instrumental case study approach to data collection was selected. Three methods of data collection were used to trace the healthcare organisation integration process: in depth semistructured interviews using a virtual patient journey across services with 36 purposefully selected informants, document analysis and field observations and notes.

FINDINGS

The findings of this study suggest that neither the context nor the actors were the sole determinants of the outcome of the integration. Rather it was the dynamic interplay between the actors, their context, the shared agency and the resources available to them as the change emerged shaped the end result.

RESEARCH IMPLICATIONS

The findings denote that organisations need to attend to frontline workers as key contributors to change and development that is meaningful for service users. Methodologically, combining the ANT and constructive case study to understand the integration process provided us with new perspective to understand the trajectory of change process.

ORIGINALITY/VALUE

This original case study fills a gap in information about the role of healthcare professionals in healthcare policy process and the interactive relationship between all stakeholders of policy process including nonhuman actors.

Persuasive speech in multi-professional change facilitation meetings

Purpose

The purpose of this paper is to describe persuasive speech and discourses in multi-professional organizational change facilitation meetings at a hospital through rhetorical discourse analysis. Previous research has often considered organizational change to be a managerial issue, with other employees given the rather passive role of implementators. This study takes an alternative approach in assuming that organizational change could benefit by involving those who are most familiar with the tasks to be changed.

Design/methodology/approach

The study employed a qualitative, case study approach and focused on the construction of a hospitalist model within multi-professional change facilitation meetings. Eight videos of these multi-professional change facilitation meetings – which occurred between January and September 2017 – were observed and the material was analyzed by rhetorical discourse analysis. An average of 10–20 actors from different professional groups participated in the meetings. The change actors comprised physicians, nursing staff and nursing managers, along with a secretary and hospitalist. The meetings were conducted by a change facilitator.

Findings

The persuasive speech in the analyzed organizational change meetings occurred within five distinct discourses: constructing the change together, positive feedback, strategic change in speech, patient perspective and driving change. The content of these discourses revealed topics that are relevant to persuading members of healthcare organizations to adopt a planned change.

Originality/value

The presented research provides new knowledge about how persuasive speech is used in organizational change and describes the discourses in which persuasive speech is used in a healthcare context.

Priorities and challenges for health leadership and workforce management globally: a rapid review

BACKGROUND

Health systems are complex and continually changing across a variety of contexts and health service levels. The capacities needed by health managers and leaders to respond to current and emerging issues are not yet well understood. Studies to date have been country-specific and have not integrated different international and multi-level insights. This review examines the current and emerging challenges for health leadership and workforce management in diverse contexts and health systems at three structural levels, from the overarching macro (international, national) context to the meso context of organisations through to the micro context of individual healthcare managers.

METHODS

A rapid review of evidence was undertaken using a systematic search of a selected segment of the diverse literature related to health leadership and management. A range of text words, synonyms and subject headings were developed for the major concepts of global health, health service management and health leadership. An explorative review of three electronic databases (MEDLINE®, Pubmed and Scopus) was undertaken to identify the key publication outlets for relevant content between January 2010 to July 2018. A search strategy was then applied to the key journals identified, in addition to hand searching the journals and reference list of relevant papers identified. Inclusion criteria were independently applied to potentially relevant articles by three reviewers. Data were subject to a narrative synthesis to highlight key concepts identified.

RESULTS

Sixty-three articles were included. A set of consistent challenges and emerging trends within healthcare sectors internationally for health leadership and management were represented at the three structural levels. At the macro level these included societal, demographic, historical and cultural factors; at the meso level, human resource management challenges, changing structures and performance measures and intensified management; and at the micro level shifting roles and expectations in the workplace for health care managers.

CONCLUSION

Contemporary challenges and emerging needs of the global health management workforce orient around efficiency-saving, change and human resource management. The role of health managers is evolving and expanding to meet these new priorities. Ensuring contemporary health leaders and managers have the capabilities to respond to the current landscape is critical.

Exploring a transition in Dutch healthcare

PURPOSE

Healthcare systems are facing persistent challenges, such as dealing with an ageing population, related increases in chronic diseases and healthcare costs facilitated by technological progress. The authors argue that the boundaries of optimisation are being reached and a more fundamental change or transition is necessary. The purpose of this paper is to explore the contours of this transition in the Netherlands. The authors do this from the perspective of healthcare organisations that have participated in the "Expedition to Sustainable Healthcare": a learning programme organised by the Dutch Network for Sustainable Healthcare aimed at creating frontrunners in this transition.

DESIGN/METHODOLOGY/APPROACH

The paper combines conceptual with experimental empirical work. The authors use the transition research frameworks to conceptualise persistent problems and transitional dynamics in the healthcare system. In a longitudinal study, the authors analysed how the participating organisations developed after the expedition.

FINDINGS

The process validated the initial understanding of persistent sustainability challenges. An integral approach to sustainable healthcare is translated as a transformation of culture, structures and practices and the development of capacity for crossing borders and domains, inside and outside of the organisation. To facilitate and stimulate such a process the authors found that problem structuring and collective identification of persistent problems and the unsustainability in the healthcare system is a crucial step towards a shared view and discourse that supports change.

ORIGINALITY/VALUE

A transition in the Dutch healthcare system is just starting to emerge and has barely been subject of research. This paper provides an empirical description of a transition management process in this context. The authors hope to lay a foundation for future work that seeks to explore transitions in healthcare in theory and practice.

Inter-occupational cooperation and boundary work in the hospital setting

Purpose The purpose of this paper is to add a little piece to the research on boundary work and inter-occupational cooperation by addressing two questions: how do actors perform boundary work in an inter-occupational cooperation project that seeks to improve the personnel health work in a hospital setting? What impact does the boundary work have on such cooperation in the personnel health project? Design/methodology/approach The study is based on individual, in-depth interviews and participative observations of focus group discussions conducted at a regional municipal organization in Sweden. Respondents are hospital line managers, experts and strategists in the HR departments, and experts from the internal occupational health service. Findings The concepts on boundary work, which include closing/opening boundary strategies, provide the framework for the empirical illustrations. The cooperation runs smoothly in the rehabilitation work because of an agreed upon process in which the professionals' jurisdictions are preserved through closing strategies. Illness prevention and health promotion are not areas of inter-occupational cooperation because the stronger actors use closing strategies. While the weaker actors, who try to cooperate, use opening boundary strategies in these areas, they are excluded or marginalized. Research limitations/implications The empirical investigation concerns one cooperation project and was completed at one data collection point. Originality/value No similar study of boundary work and inter-occupational cooperation in a hospital setting is available despite the frequency of this professional group configuration in practice. A more inclusive concept of professionalism may facilitate the study of boundary work and inter-occupational cooperation among actors with different professional authority.

Innovation Implementation in the Context of Hospital QI: Lessons Learned and Strategies for Success

In 1999, the Institute of Medicine reported that 98,000 people die each year due to medical errors. In the following years, the focus on hospital quality was intensified nationally, with policymakers providing evidence-based practice guidelines for improving health care quality. However, these innovations (evidence-based guidelines) that were being produced at policy levels were not translating to clinical practice at the hospital organizational level easily, and stark variations continued to persist, in the quality of health care. Circa 2009, nearly a decade after the release of the IOM report, the health care organizational literature began referring to this challenge as "innovation implementation failure" in health care organizations (HCOs), ie, failure to implement an evidence-based practice that is new to a HCO. This stream of literature drew upon management research to explain why innovation implementation failure occurs in HCOs and what could be done to prevent it. This paper conducts an integrative review of the literature on "innovation implementation" in hospitals and health systems over the last decade, since the spotlight was cast on "innovation implementation failure" in HCOs. The review reveals that while some studies have retrospectively sought to identify the key drivers of innovation implementation, through surveys and interviews of practitioners (the "what"), other studies have prospectively sought to understand how innovation implementation occurs in hospitals and health systems (the "how"). Both make distinctive contributions to identifying strategies for success in innovation implementation. While retrospective studies have helped identify the key drivers of innovation implementation, prospective studies have shed light on how these drivers could be attained, thereby helping to develop context-sensitive management strategies for success. The literature has called for more prospective research on the implementation and sustainability of health care innovations. This paper summarizes the lessons learned from the literature, discusses the relevance of management research on innovation implementation in HCOs, and identifies future research avenues.

Driving for successful change processes in healthcare by putting staff at the wheel

Purpose

The purpose of this paper is to describe five salient factors that emerge in two successful change processes in healthcare. Organizational changes in healthcare are often characterized by problems and solutions that have been formulated by higher levels of management. This top-down management approach has not been well received by the professional community. As a result, improvement processes are frequently abandoned, resulting in disrupted and dysfunctional organizations. This paper presents two successful change processes where managerial leadership was used to coach the change processes by distributing mandates and resources. After being managerially initiated, both processes were driven by local agency, decisions, planning and engagement.

Design/methodology/approach

The data in the paper derive from two qualitative case studies. Data were collected through in-depth interviews, observations and document studies. The cases are presented as process descriptions covering the different phases of the change processes. The focus in the studies is on the roles and interactions of the actors involved, the type of leadership and the distribution of agency.

Findings

Five factors emerged as paramount to the successful change processes in the two cases: local ownership of problems; a coached process where management initiates the change process and the problem recognition, and then lets the staff define the problems, formulate solutions and drive necessary changes; distributed leadership directed at enabling and supporting the staff’s intentions and long-term self-leadership; mutually formulated norms and values that serve as a unifying force for the staff; and generous time allocation and planning, which allows the process to take time, and creates room for reevaluation. The authors also noted that in both cases, reorganization into multi-professional teams lent stability and endurance to the completed changes.

Originality/value

The research shows how management can initiate and support successful change processes that are staff driven and characterized by local agency, decisions, planning and engagement. Empirical descriptions of successful change processes are rare, which is why the description of such processes in this research increases the value of the paper.

Advancing theory development: exploring the leadership-climate relationship as a mechanism of the implementation of cultural competence

BACKGROUND

Leadership style and specific organizational climates have emerged as critical mechanisms to implement targeted practices in organizations. Drawing from relevant theories, we propose that climate for implementation of cultural competence reflects how transformational leadership may enhance the organizational implementation of culturally responsive practices in health care organizations.

METHODS

Using multilevel data from 427 employees embedded in 112 addiction treatment programs collected in 2013, confirmatory factor analysis showed adequate fit statistics for our measure of climate for implementation of cultural competence (Cronbach's alpha = .88) and three outcomes: knowledge (Cronbach's alpha = .88), services (Cronbach's alpha = .86), and personnel (Cronbach's alpha = .86) practices.

RESULTS

Results from multilevel path analyses indicate a positive relationship between employee perceptions of transformational leadership and climate for implementation of cultural competence (standardized indirect effect = .057, bootstrap p < .001). We also found a positive indirect effect between transformational leadership and each of the culturally competent practices: knowledge (standardized indirect effect = .006, bootstrap p = .004), services (standardized indirect effect = .019, bootstrap p < .001), and personnel (standardized indirect effect = .014, bootstrap p = .005).

CONCLUSIONS

Findings contribute to implementation science. They build on leadership theory and offer evidence of the mediating role of climate in the implementation of cultural competence in addiction health service organizations.

Understanding middle managers' influence in implementing patient safety culture

BACKGROUND

The past fifteen years have been marked by large-scale change efforts undertaken by healthcare organizations to improve patient safety and patient-centered care. Despite substantial investment of effort and resources, many of these large-scale or "radical change" initiatives, like those in other industries, have enjoyed limited success - with practice and behavioural changes neither fully adopted nor ultimately sustained - which has in large part been ascribed to inadequate implementation efforts. Culture change to "patient safety culture" (PSC) is among these radical change initiatives, where results to date have been mixed at best.

DISCUSSION

This paper responds to calls for research that focus on explicating factors that affect efforts to implement radical change in healthcare contexts, and focuses on PSC as the radical change implementation. Specifically, this paper offers a novel conceptual model based on Organizational Learning Theory to explain the ability of middle managers in healthcare organizations to influence patient safety culture change. We propose that middle managers can capitalize on their unique position between upper and lower levels in the organization and engage in 'ambidextrous' learning that is critical to implementing and sustaining radical change. This organizational learning perspective offers an innovative way of framing the mid-level managers' role, through both explorative and exploitative activities, which further considers the necessary organizational context in which they operate.

The Roles of System and Organizational Leadership in System-Wide Evidence-Based Intervention Sustainment: A Mixed-Method Study

If evidence-based interventions (EBIs) are not sustained, investments are wasted and public health impact is limited. Leadership has been suggested as a key determinant of implementation and sustainment; however, little empirical work has examined this factor. This mixed-methods study framed using the Exploration, Preparation, Implementation, Sustainment (EPIS) conceptual framework examines leadership in both the outer service system context and inner organizational context in eleven system-wide implementations of the same EBI across two U.S. states and 87 counties. Quantitative data at the outer context (i.e., system) and inner context (i.e., team) levels demonstrated that leadership predicted future sustainment and differentiated between sites with full, partial, or no sustainment. In the outer context positive sustainment leadership was characterized as establishing a project's mission and vision, early and continued planning for sustainment, realistic project plans, and having alternative strategies for project survival. Inner context frontline transformational leadership predicted sustainment while passive-avoidant leadership predicted non-sustainment. Qualitative results found that sustainment was associated with outer context leadership characterized by engagement in ongoing supportive EBI championing, marketing to stakeholders; persevering in these activities; taking action to institutionalize the EBI with funding, contracting, and system improvement plans; and fostering ongoing collaboration between stakeholders at state and county, and community stakeholder levels. For frontline leadership the most important activities included championing the EBI and providing practical support for service providers. There was both convergence and expansion that identified unique contributions of the quantitative and qualitative methods. Greater attention to leadership in both the outer system and inner organizational contexts is warranted to enhance EBI implementation and sustainment.

Grassroots inter-professional networks: the case of organizing care for older cancer patients

Purpose

The purpose of this paper of inter-professional networks is to analyze the evolution of relationships between professional groups enacting new forms of collaboration to address clinical imperatives.

Design/methodology/approach

This paper uses a case study based on semi-structured interviews with physicians and nurses, document analysis and informal discussions.

Findings

This study documents how two inter-professional networks were developed through professional agency. The findings show that the means by which networks are developed influence the form of collaboration therein. One of the networks developed from day-to-day, immediately relevant, exchange, for patient care. The other one developed from more formal and infrequent research and training exchanges that were seen as less decisive in facilitating patient care. The latter resulted in a loosely knit network based on a small number of ad hoc referrals while the other resulted in a tightly knit network based on frequent referrals and advice seeking.

Practical implications

Developing inter-professional networks likely require a sustained phase of interpersonal contacts characterized by persuasion, knowledge sharing, skill demonstration and trust building from less powerful professional groups to obtain buy-in from more powerful professional groups. The nature of the collaboration in any resulting network depends largely on the nature of these initial contacts.

Originality/value

The literature on inter-professional healthcare networks focusses on mandated networks such as NHS managed care networks. There is a lack of research on inter-professional networks that emerged from the bottom up at the initiative of healthcare professionals in response to clinical imperatives. This study looks at some forms of collaboration that these “grass-root” initiatives engender and how they are consolidated.

The importance of role sending in the sensemaking of change agent roles

Purpose

– The purpose of this paper is to investigate what happens when a lack of role-sending results in ambiguous change agent roles during a large scale organisational reconfiguration. The authors consider the role of sensemaking in resolving role ambiguity of middle manager change agents and the consequences of this for organisational restructuring.

Design/methodology/approach

– Data were collected from a case study analysis of significant organisational reconfiguration across a local National Health Service Trust in the UK. Data consists of 82 interviews, complemented by analysis of over 100 documents and field notes from 51 hours of observations collected over five phases covering a three year period before, during and after the reconfiguration. An inductive qualitative analysis revealed the sensemaking processes by which ambiguity in role definition was resolved.

Findings

– The data explains how change agents collectively make sense of a role in their own way, drawing on their own experiences and views as well as cues from other organisational members. The authors also identified the organisational outcomes which resulted from this freedom in sensemaking. This study demonstrates that by leaving too much flexibility in the definition of the role, agents developed their own sensemaking which was subsequently very difficult to manipulate.

Practical implications

– In creating new roles, management first needs to have a realistic vision of the task and roles that their agents will perform, and second, to communicate these expectations to both those responsible for recruiting these roles and to the agents themselves.

Originality/value

– Much of the focus in sensemaking research has been on the importance of change agents’ sensemaking of the change but there has been little focus on how change agents sensemake their own role in the change.

Reforming primary healthcare: from public policy to organizational change

Purpose

– Governments everywhere are implementing reform to improve primary care. However, the existence of a high degree of professional autonomy makes large-scale change difficult to achieve. The purpose of this paper is to elucidate the change dynamics and the involvement of professionals in a primary healthcare reform initiative carried out in the Canadian province of Quebec.

Design/methodology/approach

– An empirical approach was used to investigate change processes from the inception of a public policy to the execution of changes in professional practices. The data were analysed from a multi-level, combined contextualist-processual perspective. Results are based on a longitudinal multiple-case study of five family medicine groups, which was informed by over 100 interviews, questionnaires, and documentary analysis.

Findings

– The results illustrate the multiple processes observed with the introduction of planned large-scale change in primary care services. The analysis of change content revealed that similar post-change states concealed variations between groups in the scale of their respective changes. The analysis also demonstrated more precisely how change evolved through the introduction of “intermediate change” and how cycles of prescribed and emergent mechanisms distinctively drove change process and change content, from the emergence of the public policy to the change in primary care service delivery.

Research limitations/implications

– This research was conducted among a limited number of early policy adopters. However, given the international interest in turning to the medical profession to improve primary care, the results offer avenues for both policy development and implementation.

Practical implications

– The findings offer practical insights for those studying and managing large-scale transformations. They provide a better understanding of how deliberate reforms coexist with professional autonomy through an intertwining of change content and processes.

Originality/value

– This research is one of few studies to examine a primary care reform from emergence to implementation using a longitudinal multi-level design.

Aligning leadership across systems and organizations to develop a strategic climate for evidence-based practice implementation

There has been a growing impetus to bridge the gap between basic science discovery, development of evidence-based practices (EBPs), and the availability and delivery of EBPs in order to improve the public health impact of such practices. To capitalize on factors that support implementation and sustainment of EBPs, it is important to consider that health care is delivered within the outer context of public health systems and the inner context of health care organizations and work groups. Leaders play a key role in determining the nature of system and organizational contexts. This article addresses the role of leadership and actions that leaders can take at and across levels in developing a strategic climate for EBP implementation within the outer (i.e., system) and inner (i.e., organization, work group) contexts of health care. Within the framework of Edgar Schein's "climate embedding mechanisms," we describe strategies that leaders at the system, organization, and work group levels can consider and apply to develop strategic climates that support the implementation and sustainment of EBP in health care and allied health care settings.