From boundaries to boundary work: middle managers creating inter-organizational change

Observing, spanning and shifting boundaries: working with data in non-clinical practice

Purpose

Effective use of data across public health organisations (PHOs) is essential for the provision of health services. While health technology and data use in clinical practice have been investigated, interactions with data in non-clinical practice have been largely neglected. The purpose of this paper is to consider what constitutes data, and how people in non-clinical roles in a PHO interact with data in their practice.

Design/methodology/approach

This mixed methods study involved a qualitative exploration of how employees of a large PHO interact with data in their non-clinical work roles. A quantitative survey was administered to complement insights gained through qualitative investigation.

Findings

Organisational boundaries emerged as a defining issue in interactions with data. The results explain how data work happens through observing, spanning and shifting of boundaries. The paper identifies five key issues that shape data work in relation to boundaries. Boundary objects and processes are considered, as well as the roles of boundary spanners and shifters.

Research limitations/implications

The study was conducted in a large Australian PHO, which is not completely representative of the unique contexts of similar organisations. The study has implications for research in information and organisational studies, opening fields of inquiry for further investigation.

Practical implications

Effective systems-wide data use can improve health service efficiencies and outcomes. There are also implications for the provision of services by other health and public sectors.

Originality/value

The study contributes to closing a significant research gap in understanding interactions with data in the workplace, particularly in non-clinical roles in health. Research analysis connects concepts of knowledge boundaries, boundary spanning and boundary objects with insights into information behaviours in the health workplace. Boundary processes emerge as an important concept to understand interactions with data. The result is a novel typology of interactions with data in relation to organisational boundaries.

Understanding implementation science from the standpoint of health organisation and management: an interdisciplinary exploration of selected theories, models and frameworks

Purpose

As a discipline, health organisation and management is focused on health-specific, collective behaviours and activities, whose empirical and theoretical scholarship remains under-utilised in the field of implementation science. This under-engagement between fields potentially constrains the understanding of mechanisms influencing the implementation of evidence-based innovations in health care. The aim of this viewpoint article is to examine how a selection of theories, models and frameworks (theoretical approaches) have been applied to better understand phenomena at the micro, meso and macro systems levels for the implementation of health care innovations. The purpose of which is to illustrate the potential applicability and complementarity of embedding health organisation and management scholarship within the study of implementation science.

Design/methodology/approach

The authors begin by introducing the two fields, before exploring how exemplary theories, models and frameworks have been applied to study the implementation of innovations in the health organisation and management literature. In this viewpoint article, the authors briefly reviewed a targeted collection of articles published in the Journal of Health Organization and Management (as a proxy for the broader literature) and identified the theories, models and frameworks they applied in implementation studies. The authors then present a more detailed exploration of three interdisciplinary theories and how they were applied across three different levels of health systems: normalization process theory (NPT) at the micro individual and interpersonal level; institutional logics at the meso organisational level; and complexity theory at the macro policy level. These examples are used to illustrate practical considerations when implementing change in health care organisations that can and have been used across various levels of the health system beyond these presented examples.

Findings

Within the Journal of Health Organization and Management, the authors identified 31 implementation articles, utilising 34 theories, models or frameworks published in the last five years. As an example of how theories, models and frameworks can be applied at the micro individual and interpersonal levels, behavioural theories originating from psychology and sociology (e.g. NPT) were used to guide the selection of appropriate implementation strategies or explain implementation outcomes based on identified barriers and enablers to implementing innovations of interest. Projects aiming to implement change at the meso organisational level can learn from the application of theories such as institutional logics, which help elucidate how relationships at the macro and micro-level have a powerful influence on successful or unsuccessful organisational action. At the macro policy level, complexity theory represented a promising direction for implementation science by considering health care organisations as complex adaptive systems.

Originality/value

This paper illustrates the utility of a range of theories, models and frameworks for implementation science, from a health organisation and management standpoint. The authors’ viewpoint article suggests that increased crossovers could contribute to strengthening both disciplines and our understanding of how to support the implementation of evidence-based innovations in health care.

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.

Together stronger: boundary work within an Australian systems-based prevention initiative

Complexity and systems science are increasingly used to devise interventions to address health and social problems. Boundaries are important in systems thinking, as they bring attention to the power dynamics that guide decision-making around the framing of a situation, and how it is subsequently tackled. Using complexity theory as an analytical frame, this qualitative exploratory study examined boundary interactions between local government and community health organizations during the operationalization of a systems-based initiative to prevent obesity and chronic diseases (Healthy Together Communities-HTCs) in Victoria, Australia. Across two HTC sites, data was generated through semi-structured interviews with 20 key informants, in mid-2015. Template analysis based on properties of complex systems was applied to the data. The dynamics of boundary work are explored using three case illustrations: alignment, boundary spanning and boundary permeability. Alignment was both a process and an outcome of boundary work, and occurred at strategic, operational and individual levels. Boundary spanning was an important mechanism to develop a unified collaborative approach, and ensure that mainstream initiatives reached disadvantaged groups. Finally, some boundaries exhibited different levels of permeability for local government and community health organizations. This influenced how each organization could contribute to HTC interventions in unique, yet complementary ways. The study of boundary work offers potential for understanding the mechanisms that contribute to the nonlinear behaviour of complex systems. The complementarity of partnering organizations, and boundary dynamics should be considered when designing and operationalizing multilevel, complex systems-informed prevention initiatives.

Collaborative governance as a policy strategy in healthcare

Purpose

The purpose of this paper is to examine the enactment of collaborative governance as a policy strategy in healthcare – in particular its effects in coordinating multiple collaborative initiatives dedicated to improve the performance of health organizations. It studies overarching governance mechanisms that serve as platforms at a meta-level between policy and frontline practice.

Design/methodology/approach

Four collaborative governance arrangements dedicated to improve health outcomes in the Netherlands are analyzed in a comparative case-study design, based on extensive document analysis (n=121) and interviews (n=56) with key stakeholders in the field, including the Dutch Ministry of Health, health organizations and other actors.

Findings

The studied policy-based governance mechanisms for the coordination of multiple micro-level collaborative initiatives function partly as platforms in bringing actors and resources together successfully. They do so, by fostering evolvability (the capacity to generate diversity in emergent ways) in relation to goal-setting and intermediation between actors. Yet, they marginalize open access to participants through high selectivity and deliberate exclusion strategies for certain actors, contrary to a platform logic of action.

Research limitations/implications

While the collaborative governance literature focuses on these dimensions as independent elements, findings reveal both trade-offs and interdependencies between studied dimensions of coordination associated with platforms, that need to be negotiated and managed.

Practical implications

Selectivity and exclusion in collaborative arrangements may negatively affect relational bonds and ties between actors, which challenges the application of collaborative governance as a policy strategy in pursuit of health objectives.

Originality/value

Responding to recent calls in the literature, this study applies ideas from public administration to the field of health organization and management to avert failures in the translation of policy ambitions into health practice.

Designing and pilot testing of a leadership intervention to improve quality and safety in nursing homes and home care (the SAFE-LEAD intervention)

OBJECTIVE

To describe the design of a leadership intervention for nursing home and home care, including a leadership guide for managers to use in their quality and safety improvement work. The paper reports results from the pilot test of the intervention and describes the final intervention programme.

DESIGN

Qualitative design, using the participation of stakeholders.

METHODS

The leadership guide and intervention were designed in collaboration with researchers, coresearchers and managers in nursing homes and home care organisations, through workshops and focus group interviews. The pilot test consisted of three workshops with managers working on the leadership guide, facilitated and observed by researchers, and evaluated by means of observation and focus group interviews with the participants. The analysis combined the integration of data from interviews and observations with directed content analysis.

SETTING

Norwegian nursing homes and home care services.

PARTICIPANTS

Managers at different levels in three nursing homes and two home care services, coresearchers, and patient and next-of-kin representatives.

RESULTS

The managers and coresearchers suggested some revisions to the leadership guide, such as making it shorter, and tailoring the terminology to their setting. Based on their suggestions, we modified the intervention and developed learning resources, such as videos demonstrating the practical use of the guide. Evaluation of the pilot test study showed that all managers supported the use of the guide. They adapted the guide to their organisational needs, but found it difficult to involve patients in the intervention.

CONCLUSIONS

A participatory approach with stakeholders is useful in designing a leadership intervention to improve quality and safety in nursing homes and home care, although patient participation in its implementation remains difficult. The participatory approach made it easier for managers to adapt the intervention to their context and to everyday quality and safety work practice.

What are the perceived added values and barriers of regulating long-term care in the home environment using a care network perspective: a qualitative study

BACKGROUND

Changes in Dutch policy towards long-term care led to the Dutch Health and Youth Care Inspectorate testing a regulatory framework focusing on care networks around older adults living independently. This regulatory activity involved all care providers and the older adults themselves.

METHODS

Semi-structured interviews with the older adults, and focus groups with care providers and inspectors were used to assess the perceived added value of, and barriers to the framework.

RESULTS

The positive elements of this framework were the involvement of the older adults in the regulatory activity, the focus of the framework on care networks and the open character of the conversations with the inspectors. However, applying the framework requires a substantial investment of time. Care providers often did not perceive themselves as being part of a care network around one person and they expressed concerns about financial and privacy issues when thinking in terms of care networks.

CONCLUSIONS

The experiences of the client were seen as important in regulating long-term care. Regulating care networks as a whole puts cooperation between care providers involved around one person on the agenda. However, barriers for this form of regulation were also perceived and, therefore, careful consideration when and how to regulate care networks is recommended.

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.

Improving quality and safety in nursing homes and home care: the study protocol of a mixed-methods research design to implement a leadership intervention

INTRODUCTION

Nursing homes and home care face challenges across different countries as people are living longer, often with chronic conditions. There is a lack of knowledge regarding implementation and impact of quality and safety interventions as most research evidence so far is generated in hospitals. Additionally, there is a lack of effective leadership tools for quality and safety improvement work in this context.

METHODS AND ANALYSIS

The aim of the 'Improving Quality and Safety in Primary Care-Implementing a Leadership Intervention in Nursing Homes and Homecare' (SAFE-LEAD) study is to develop and evaluate a research-based leadership guide for managers to increase quality and safety competence. The project applies a mixed-methods design and explores the implications of the leadership guide on managers' and staffs' knowledge, attitudes and practices. Four nursing homes and four home care services from different Norwegian municipalities will participate in the intervention. Surveys, process evaluation (interviews, observations) and document analyses will be conducted to evaluate the implementation and impact of the leadership intervention. A comparative study of Norway and the Netherlands will establish knowledge of the context dependency of the intervention.

ETHICS AND DISSEMINATION

The study is approved by the Norwegian Centre for Research Data (2017/52324 and 54855). The results will be disseminated through scientific articles, two PhD dissertations, an anthology, presentations at national and international conferences, and in social media, newsletters and in the press. The results will generate knowledge to inform leadership practices in nursing homes and home care. Moreover, the study will build new theory on leadership interventions and the role of contextual factors in nursing homes and home care.

How to improve healthcare? Identify, nurture and embed individuals and teams with "deep smarts"

Purpose Unlocking and transferring skills and capabilities in individuals to the teams they work within, and across, is the key to positive organisational development and improved patient care. Using the "deep smarts" model, the purpose of this paper is to examine these issues. Design/methodology/approach The "deep smarts" model is described, reviewed and proposed as a way of transferring knowledge and capabilities within healthcare organisations. Findings Effective healthcare delivery is achieved through, and continues to require, integrative care involving numerous, dispersed service providers. In the space of overlapping organisational boundaries, there is a need for "deep smarts" people who act as "boundary spanners". These are critical integrative, networking roles employing clinical, organisational and people skills across multiple settings. Research limitations/implications Studies evaluating the barriers and enablers to the application of the deep smarts model and 13 knowledge development strategies proposed are required. Such future research will empirically and contemporary ground our understanding of organisational development in modern complex healthcare settings. Practical implications An organisation with "deep smarts" people - in managerial, auxiliary and clinical positions - has a greater capacity for integration and achieving improved patient-centred care. Originality/value In total, 13 developmental strategies, to transfer individual capabilities into organisational capability, are proposed. These strategies are applicable to different contexts and challenges faced by individuals and teams in complex healthcare organisations.