Innovation as emergence in healthcare: unpacking change from within

Standing together at the helm - how employees experience employee-driven innovation in primary care

Primary care needs to find strategies to deal with today's societal challenges and continue to deliver efficient and high-quality care. Employee-driven innovation is increasingly gaining ground as an accessible pathway to developing successful and sustainable organisations. This type of innovation is characterised by employees being engaged in the innovation process, based on a bottom-up approach. This qualitative study explores employees' experiences of employee-driven innovation at a primary care centre in Sweden. Data are collected by focus group interviews and analysed by inductive qualitative content analysis. The result is presented with the overarching theme "Standing together at the helm" followed by three categories: "Motivating factors for practising employee-driven innovation", "Challenges in practising employee-driven innovation" and "Benefits of employee-driven innovation", including nine subcategories. The study found that employee-driven innovation fosters organisational innovation, empowers employees, and enhances adaptability at personal and organisational levels. This enables individual and collective learning, and facilitates the shaping, development, and adaptation of working methods to meet internal and external requirements. However, new employees encountered difficulty grasping the concept of employee-driven innovation and recognising its long-term advantages. Additionally, the demanding and task-focused environment within primary care posed challenges in sustaining efforts in innovation work. The employees also experienced a lack of external support to drive and implement some innovative ideas.

We're implementing AI now, so why not ask us what to do? - How AI providers perceive and navigate the spread of diagnostic AI in complex healthcare systems

Despite high expectations of artificial intelligence (AI) in medical diagnostics, predictions of its extensive and rapid adoption have so far not been matched by reality. AI providers seeking to promote and perpetuate the use of this technology are faced with the complex reality of embedding AI-enabled diagnostics across variable implementation contexts. In this study, we draw upon a complexity science approach and qualitative methodology to understand how AI providers perceive and navigate the spread of AI in complex healthcare systems. Using semi-structured, one-to-one interviews, we collected qualitative data from 14 providers of AI-enabled diagnostics. We triangulated the data by complementing the interviews with multiple sources, including a focus group of physicians with experience using these technologies. The notion of embedding allowed us to connect local implementation efforts with systemic diffusion. Our study reveals that AI providers self-organise to increase their adaptability when navigating the variable conditions and unpredictability of complex healthcare contexts. In addition to the tensions perceived by AI providers within the sociocultural, technological, and institutional subsystems of healthcare, we illustrate the practices emerging among them to mitigate these tensions: stealth science, agility, and digital ambidexterity. Our study contributes to the growing body of literature on the spread of AI in healthcare by capturing the view of technology providers and adding a new theoretical perspective through the lens of complexity science.

Modes and models of care delivery in municipal long-term care services: a cross-sectional study from Norway

BACKGROUND

Numerous forces drive the evolution and need for transformation of long-term care services. Decision-makers across the globe are searching for models to redesign long-term care to become more responsive to changing health and care needs. Yet, knowledge of different care models unfolding in the long-term care service landscape is limited. The objective of this article is twofold: 1) to identify and characterise models of care in Norwegian municipal long-term care services based on four different modes of service delivery: Specialised municipal services, Assistive technology, Planning and coordination, and Health Promotion and Activity, and 2) to analyse whether the identified care models vary with regard to municipal characteristics, more specifically 'population size' and 'income'.

METHODS

We adopted a cross-sectional approach and used data from a web-based survey conducted in 2019 to identify and characterize models of care in Norwegian long-term care services, based on four modes of service delivery. The questionnaire was developed through a comprehensive review of national healthcare policy documents and previous research and amended in collaboration with a user panel. A set of questions from the questionnaire were used to create four modes of service delivery. Hierarchical cluster analysis was used to cluster the municipalities based on the mean scores of the modes to identify care models.

RESULTS

In total, 277 municipalities (response rate 66%) completed the survey. The four modes made it possible to identify four care models that differ on the level of Specialised municipal services, Assistive technology, Planning and coordination, and Health Promotion and Activity. Additionally, the models differed regarding municipal population size (p < 0.001) and income (p = 0.006).

CONCLUSIONS

We put forward a theoretical description of the variety of ways long-term care services are provided, offering a way of simplifying complex information which can assist care providers and policymakers in analysing and monitoring their own service provision and making informed decisions. This is important to the development of services for current and future care needs.

Co-design Process of a Digital Return-to-Work Solution for People With Common Mental Disorders: Stakeholder Perception Study

BACKGROUND

Service users and other stakeholders have had few opportunities to influence the design of their mental health and return-to-work services. Likewise, digital solutions often fail to align with stakeholders' needs and preferences, negatively impacting their utility. mWorks is a co-design initiative to create a digital return-to-work solution for persons with common mental disorders that is acceptable and engaging for those receiving and delivering the intervention.

OBJECTIVE

This study aimed to describe stakeholder perceptions and the involvement of a design process during the prototype development of mWorks.

METHODS

A co-design approach was used during the iterative development of mWorks. Overall, 86 stakeholders were recruited using a combination of purposeful and convenience sampling. Five stakeholder groups represented service users with experience of sick leave and common mental disorders (n=25), return-to-work professionals (n=19), employers (n=1), digital design and system developers (n=4), and members of the public (n=37). Multiple data sources were gathered using 7 iterations, from March 2018 to November 2020. The rich material was organized and analyzed using content analysis to generate themes and categories that represented this study's findings.

RESULTS

The themes revealed the importance of mWorks in empowering service users with a personal digital support solution that engages them back in work. The categories highlighted that mWorks needs to be a self-management tool that enables service users to self-manage as a supplement to traditional return-to-work services. It was also important that content features helped to reshape a positive self-narrative, with a focus on service users' strengths and resources to break the downward spiral of ill health during sick leave. Additional crucial features included helping service users mobilize their own strategies to cope with thoughts and feelings and formulate goals and a plan for their work return. Once testing of the alpha and beta prototypes began, user engagement became the main focus for greater usability. It is critical to facilitate the comprehension and purpose of mWorks, offer clear guidance, and enhance motivational and goal-setting strategies.

CONCLUSIONS

Stakeholders' experience-based knowledge asserted that mWorks needs to empower service users by providing them with a personal support tool. To enhance return-to-work prospects, users must be engaged in a meaningful manner while focusing on their strengths and resources.

Perception of Professionals from Different Healthcare Units Regarding the Use of Spray Technology for the Instantaneous Decontamination of Personal Protective Equipment during the Coronavirus Disease Pandemic: A Short Analysis

Within the context of the coronavirus disease (COVID-19) pandemic, different disinfection technologies have been developed to efficiently exercise microbial control, especially to minimize the potential risks that are associated with transmission and infection among healthcare professionals. Thus, the aim of this work was to evaluate the perception of professionals regarding the use of a new technology (chamber) for the instantaneous decontamination of personal protective equipment before the doffing stage. This was a cross-sectional descriptive study where the study data were obtained by using a questionnaire with qualitative questions. In total, 245 professionals participated in the study in three hospitals. Healthcare professionals represented 72.24% (n = 177) of the investigated sample. Approximately 69% of the professionals considered the disinfection chamber as a safe technology, and 75.10% considered it as an important and effective protective barrier for healthcare professionals in view of its application before the doffing process. The results found in this study demonstrate that the use of spray technology in the stage prior to the doffing process is acceptable to professionals, and that it can be an important tool for ensuring the additional protection of the professionals who work directly with patients who are diagnosed with COVID-19.

Doing more with less - How frugal innovations can contribute to improving healthcare systems

The dominance of an innovation discourse laden with cutting edge and expensive technologies, may be preventing us from recognizing alternative and complementary perspectives, which could help cut healthcare costs while improving worldwide access to health services. One such complementary approach is that of frugal innovation. Frugal innovation, as a way to produce efficacious and affordable products using fewer resources to reach the underserved customers, has received increasing attention in the social sciences literature. Although frugal innovation is commonly associated with emerging economies, there is now a rising interest from healthcare providers in developed countries, to find and apply effective, and lower-cost solutions. Nonetheless, knowledge on frugal innovation and its role in healthcare is dispersed across different literatures which hampers researchers and practitioners to access a fuller, and integrated picture of the phenomenon. In this study, by synthesizing extant knowledge, we tackle the fragmentation of the phenomenon. We elucidate on who the actors are, what is being done, how are such innovations being developed, and what the outcomes are, providing a framework that lays out the underlying mechanisms of frugal innovation in healthcare (FIH). The midrange theory that we develop, provides a conceptual framework for researchers to undertake empirical observation and models to guide managerial practices. Furthermore, by providing a more unified perspective of frugal innovation in healthcare, we hope to initiate conversations on the development, adequacy and adoption of these innovations in healthcare services, which could increase affordability and access for the population while maintaining quality.

Using Process Flow Disruption Analysis to Guide Quality Improvement

BACKGROUND

Process flow describes the efficiency and consistency with which a process functions. Disruptions in surgical flow have been shown to be associated with an increase in error. Despite this, little experience exists in using surgical flow analysis to guide quality improvement (QI).

STUDY DESIGN

In a 900-bed teaching hospital with an annual surgical volume of 24,000 cases, a 4-month observational study of process flow was done by experts in complex system evaluation. Identified flow disruptions were used to guide QI. Statistical analysis included descriptive and bivariate techniques.

RESULTS

More than 200 unique process data points were evaluated. There was a high degree of variability in completion of 79 individual intraoperative data elements. Lack of completion of all elements of the time out was associated with number of times the operating room door opened during case (19, 11-27; p = 0.01). Flow disruptions were used to direct surgical QI. One example was a disruption affecting the use of Sugammadex. Resolving this flow disruption resulted in a 59% reduction in the incidence of postoperative respiratory failure (p < 0.01) and a direct and variable cost savings of $447,200 and $313,160, respectively, in the first 12 months.

CONCLUSIONS

The use of process flow analysis to direct surgical quality initiatives is a novel approach that emphasizes system-level strategy. Resolving flow disruptions can lead to effective QI that embraces reliability by focusing attention on common processes rather than adverse events that may be unique and therefore difficult to apply broadly.

Point-of-care dashboards promote coproduction of healthcare services for patients with inflammatory bowel disease

BACKGROUND

Coproduction of healthcare services by patients and professionals is seen as an increasingly important mechanism to support person-centred care delivery. Coproduction invites a deeper understanding of what persons sometimes called 'patients' bring to development of a service. Yet, little is known about tools that may help elicit that information.

OBJECTIVE

Our objective was to explore potential benefits and limitations of an electronic pre-visit survey (PVS) and dashboard by studying uptake and experiences within the inflammatory bowel disease (IBD) community.

METHODS

We conducted a mixed-method evaluation of patients and clinicians using the IBD Qorus PVS and dashboard at 24 programmes participating in the IBD Qorus learning health system. We analysed (i) descriptive statistics and thematic analyses of 537 patient surveys, (ii) semi-structured interviews with seven patients and six care teams and (iii) usage data collected between 25 March 2019 and 26 April 2020.

RESULTS

Nearly two-thirds (64%; n = 38) of clinicians enrolled ≥25 patients into IBD Qorus; 59% (n = 29) of clinicians received ≥25 electronic PVS, with 3834 PVS received during the study period. Post-visit evaluation surveys were completed by patients following 26% (n = 993) of PVS completions. Among patients who reported using the dashboard for 1 or more months (n = 537), two-thirds (65%, n = 344) used the dashboard at a clinic visit and one-third used it outside the clinic (33%, n = 176). Most patients who used the dashboard during a clinic visit said it was helpful in discussions with their clinician (82%), in talking about what matters most (76%) and in making healthcare decisions (71%). Patients using the dashboard during the clinic visit reported higher levels of shared decision-making than those who did not use the dashboard (82% vs. 65%, P < 0.001). This relationship remained significant after controlling for receipt of care at a clinic with the highest levels of patient-reported shared decision-making (odds ratio: 2.1; confidence interval: 1.3-3.3). Patients and clinicians found the greatest value in using the PVS and dashboard to share concerns and symptoms, prepare for a visit and support discussions during the visit. The lack of integration with existing electronic health records (EHRs) limited clinician usage of the PVS and dashboard.

CONCLUSIONS

The PVS and dashboard created a shared language, which supported coproduction and shared decision-making and facilitated a shared understanding of goals, concerns, symptoms and well-being. To support uptake, future systems should reduce implementation burden for healthcare professionals and integrate seamlessly with existing EHR systems and workflows.

Challenges to ensuring valid and useful waiting time monitoring - a qualitative study in Swedish specialist care

BACKGROUND

Access to health care is an essential health policy issue. In several countries, waiting time guarantees mandate set time limits for assessment and treatment. High-quality waiting time data are necessary to evaluate and improve waiting times. This study's aim was to investigate health care providers and administrative management professionals' perceptions of validity and usefulness of waiting time reporting in specialist care.

METHODS

Semi-structured interviews (n = 28) were conducted with administrative management and care professionals (line managers and care providers) in specialized clinics in the Stockholm Region, Sweden. Clinic-specific data from the waiting time registry was used in the care provider interviews to assess face validity. Clinics were purposefully sampled for maximum variation in complexity of care, volume of production, geographical location, private or public ownership, and local waiting times. Thematic analysis was used.

RESULTS

The waiting time registry was perceived to have low validity and usefulness. Perceived validity and usefulness were interconnected, with mechanisms that reinforced the connection. Structural and cognitive barriers to validity included technical and procedural errors, errors caused by role division, misinterpretation of guidelines, diverging interpretations of nonregulated cases and extensive willful manipulation of data.

CONCLUSIONS

We identify four misconceptions underpinning the current waiting time reporting system: passive dissemination of guidelines is sufficient as implemented, cognitive load of care providers to report waiting times is negligible, soft-law regulation and presentation of outcome data is sufficient to drive improvement, and self-reported data linked to incentives poses a low risk of data corruption. To counter low validity and usefulness, we propose the following for policy makers and administrative management when developing and implementing waiting time monitoring: communicate guidelines with instructions for operationalization, address barriers to implementation, ensure quality through monitoring of implementation and adherence to guidelines, develop IT ontology together with professionals, avoid parallel measurement infrastructures, ensure waiting times are presented to suit management needs, provide timely waiting time data, enable the study of single cases, minimize manual data entry, and perform spot-checks or external validity checks. Several of these strategies should be transferable to waiting time monitoring in other contexts.

Organizing work in local service implementation: an ethnographic study of nurses' contributions and competencies in implementing a municipal acute ward

BACKGROUND

The increased prevalence of chronic diseases and an ageing population challenge healthcare delivery, particularly hospital-based care. To address this issue, health policy aims to decentralize healthcare by transferring responsibility and introducing new services in primary healthcare. In-depth knowledge of associated implementation processes is crucial for health care managers, policymakers, and the health care personnel involved. In this article, we apply an ethnographic approach in a study of nurses' contributions to the implementation of a new inpatient service in an outpatient primary care emergency clinic and explore the competencies involved. The approach allowed us to explore the unexpressed yet significant effort, knowledge and competence of nurses that shaped the new service.

METHODS

The study combines observations (250 h) and several in situ interviews with healthcare personnel and individual in-depth interviews with nurses (n = 8) at the emergency clinic. In our analysis, we draw on a sociological perspective on healthcare work and organization that considers nursing a practice within the boundaries of clinical patient work, organizational structures, and managerial and professional requirements.

RESULTS

We describe the following three aspects of nurses' contributions to the implementation of the new service: (1) anticipating worst-case scenarios and taking responsibility for preventing them, (2) contributing coherence in patient care by ensuring that new and established procedures are interconnected, and (3) engaging in "invisible work". The nurses draw on their own experiences from their work as emergency nurses and knowledge of the local and regional contexts. They utilize their knowledge, competence, and organizing skills to influence the implementation process and ensure high-quality healthcare delivery in the extended service.

CONCLUSIONS

Our study illustrates that nurses' contributions are vital to coordinating and adjusting extended services. Organizing work, in addition to clinical work, is a crucial aspect of nursing work. It 'glues' the complex and varied components of the individual patient's services into coherent and holistic care trajectories. It is this organizing competence that nurses utilize when coordinating and adjusting extended services. We believe that nurses' organizing work is generally invaluable in implementing new services, although it has not been well emphasized in practice and research.

Integrating Welfare Technology in Long-term Care Services: Nationwide Cross-sectional Survey Study

BACKGROUND

Welfare technologies are often described as a solution to the increasing pressure on primary health care services. However, despite initiating welfare technology projects in the health care sector and different government incentives, research indicates that it is difficult to integrate welfare technology innovations in a complex and varying setting, such as long-term care.

OBJECTIVE

We aim to describe the types of welfare technology and the extent to which welfare technology is provided in long-term care (ie, nursing homes and home care services); examine whether the extent of welfare technology provision differs on the basis of municipal characteristics (ie, population size, centrality, the proportion of older inhabitants, and income); and identify how local governments (ie, municipalities) describe their efforts toward integrating welfare technologies in long-term care.

METHODS

Quantitative and qualitative data about welfare technology from a larger cross-sectional survey about the provision of long-term care services in Norwegian municipalities were combined with registry data. Representatives of 422 Norwegian municipalities were invited to participate in the survey. Frequencies were used to describe the distribution of the types and extent of welfare technologies, whereas the Fisher exact test and Kruskal-Wallis one-way analysis of variance were used to determine the association between the extent of welfare technology and municipal characteristics. Free-form text data were analyzed using thematic analysis.

RESULTS

A total of 277 municipalities were surveyed. Technology for safety was the most widespread type of welfare technology, whereas technology for social contact was the least prevalent. Two-thirds of the sample (183/277, 66.1%) in nursing home and (197/277, 71.1%) in home care services reported providing one or two different types of welfare technology. There was a statistically significant association between the extent of welfare technology and population size (in both nursing homes and home care services: P=.01), centrality (nursing homes: P=.01; home care services: P<.001), and municipal income (nursing homes: P=.02; home care services: P<.001). The extent of welfare technology was not associated with the proportion of older adults. The municipalities described being in a piloting phase and committing to future investment in welfare technology. Monetary resources were allocated, competency development among staff was initiated, and the municipalities were concerned about establishing collaborations within and between municipalities. Home care services seem to have a more person-centered approach in their efforts toward integrating welfare technologies, whereas nursing homes seem to have a more technology-centered approach.

CONCLUSIONS

Many municipalities provide welfare technologies; however, their extent is limited and varies according to municipal characteristics. Municipal practices still seem dominated by piloting, and welfare technologies are not fully integrated into long-term care services. Innovation with welfare technology appears top-down and is influenced by national policy but also reflects creating a window of opportunity through the organization of municipal efforts toward integrating welfare technology through, for example, collaborations and committing personnel and financial resources.

Models of generalist and specialist care in smaller hospitals in England: a mixed-methods study

Background

The increasing number of older, complex patients who require emergency admission to hospital has prompted calls for better models of medical generalist care, especially for smaller hospitals, whose size constrains resources and staffing.

Objective

To investigate the strengths and weaknesses of the current models of medical generalism used in smaller hospitals from patient, professional and service perspectives.

Methods

The design was a mixed-methods study. Phase 1 was a scoping and mapping exercise to create a typology of models of care, which was then explored further through 11 case studies. Phase 2 created a classification using the Hospital Episode Statistics of acute medical ‘generalist’ and ‘specialist’ work and described differences in workload and explored the links between case mix, typology and length of stay and between case mix and skill mix. Phase 3 analysed the relationships between models of care and patient-level costs. Phase 4 examined the strengths and weaknesses of the models of care through focus groups, a discrete choice experiment and an exploration of the impact of typology on other outcomes.

Results

In total, 50 models of care were explored through 48 interviews. A typology was constructed around generalist versus specialist patterns of consultant working. Twenty-five models were deployed by 48 hospitals, and no more than four hospitals used any one model of care. From the patient perspective, analysis of Hospital Episode Statistics data of 1.9 million care episodes found that the differences in case mix between hospitals were relatively small, with 65–70% of episodes accounted for by 20 case types. The skill mix of hospital staff varied widely; there were no relationships with case mix. Patients exhibited a preference for specialist care in the discrete choice experiment but indicated in focus groups that overall hospital quality was more important. From a service perspective, qualitative work found that models of care were contingent on complex constellations of factors, including staffing, the local hospital environment and policy imperatives. Neither the model of care nor the case mix accounted for variability in the length of stay (no associations were significant at p < 0.05). No significant differences were found in the costs of the models. Professionally, the preferences of doctors for specialist versus generalist work depended on their experiences of providing care and were associated with a healthy organisational culture and a co-operative approach to managing emergency work. Concepts of medical generalism were found to be complex and difficult to define, with theoretical models differing markedly from models in action.

Limitations

Smaller hospitals in multisite trusts were excluded, potentially leading to sample bias. The rapidly changing nature of the models limited the analysis of typology against outcomes.

Conclusions

The case mix of smaller hospitals was dominated by patients with presentations amenable to generalist approaches to care; however, there was no evidence to support any particular pattern of consultant working. Matching hospital staff to better meet local need and the creation of more collaborative working environments appear more likely to improve care in smaller hospitals than changing models.

Future work

The exploration of the relationships between workforce, measures of hospital culture, models of care, costs and outcomes in both smaller and larger hospitals is urgently required to underpin service reforms.

Study registration

This study is registered as Integrated Research Application System project ID 191393.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 4. See the NIHR Journals Library website for further project information.

Digital tools as promoters for person-centered care practices in chronic care? Healthcare professionals' experiences from rheumatology care

Background

Person-centered care (PCC) emphasize the importance of supporting individuals’ involvement in care provided and self-care. PCC has become more important in chronic care as the number of people living with chronic conditions is increasing due to the demographic changes. Digital tools have potential to support interaction between patients and healthcare providers, but empirical examples of how to achieve PCC in chronic care and the role of digital tools in this process is limited. The aim of this study was to investigate strategies to achieve PCC used by the healthcare professionals at an outpatient Rheumatology clinic (RC), the strategies’ relation to digital tools, and the perceived impact of the strategies on healthcare professionals and patients.

Methods

A single case study design was used. The qualitative data consisted of 14 semi-structured interviews and staff meeting minutes, covering the time period 2017–2019. The data were analyzed using conventional content analysis, complemented with document analyses.

Results

Ten strategies on two levels to operationalize PCC, and three categories of perceived impact were identified. On the individual patient level strategies involved several digital tools focusing on flexible access to care, mutual information sharing and the distribution of initiatives, tasks, and responsibilities from provider to patients. On the unit level, strategies concerned involving patient representatives and individual patients in development of digital services and work practices. The roles of both professionals and patients were affected and the importance of behavioral and cultural change became clear.

Conclusions

By providing an empirical example from chronic care the study contributes to the knowledge on strategies for achieving PCC, how digital tools and work practices interact, and how they can affect healthcare staff, patients and the unit. A conclusion is that the use of the digital tools, spanning over different dimensions of engagement, facilitated the healthcare professionals’ interaction with patients and the patients’ involvement in their own care. Digital tools complemented, rather than replaced, care practices.

Model-Informed Precision Dosing: Background, Requirements, Validation, Implementation, and Forward Trajectory of Individualizing Drug Therapy

Model-informed precision dosing (MIPD) has become synonymous with modern approaches for individualizing drug therapy, in which the characteristics of each patient are considered as opposed to applying a one-size-fits-all alternative. This review provides a brief account of the current knowledge, practices, and opinions on MIPD while defining an achievable vision for MIPD in clinical care based on available evidence. We begin with a historical perspective on variability in dose requirements and then discuss technical aspects of MIPD, including the need for clinical decision support tools, practical validation, and implementation of MIPD in health care. We also discuss novel ways to characterize patient variability beyond the common perceptions of genetic control. Finally, we address current debates on MIPD from the perspectives of the new drug development, health economics, and drug regulations.

'Hybrid' top down bottom up health system innovation in rural China: A qualitative analysis

Introduction

China has made considerable progress with health system reforms in recent years. Rural China, however, has lagged behind as the diversity of needs of China’s 3,000 rural counties were not always well addressed by national top-down reforms. China’s Rural Health Reform Project Health XI (HXI) piloted a hybrid process of top down and bottom up implementation of health system reforms which were tailored to rural county level needs and covered a population of more than 21 million. Different studies provide evidence that HXI counties have achieved substantial benefits given the relatively limited investment. The Effectiveness of HXI subsequently raises the question how the hybrid approach may have resulted in effective implementation of interventions. We answer this question to advance understanding of hybrid approaches in general and in the rural Chinese context in particular, where the bottom-up elements might match poorly with the traditional organisational culture and learning style.

Materials & methods

We conducted an in-depth qualitative analysis in three ‘best practice’ counties, performing document-analyses, observations, semi-structured individual and group interviews. In alignment with the research question, this study is of an explorative nature and follows a sequence of deductive and inductive steps

Results

HXI struggled initially as counties had difficulties to take initiative and autonomously select and adapt their own reforms. The initial reforms required multiple improvement iterations before achieving the planned results. The effectiveness of these bottom up reform processes has been aided by tight top down supervision and extensive domestic expert involvement. County level leadership is seen as essential to align the top down and bottom up structures and processes. Where successful, HXI has changed mind-sets and counties developed generic health improvement capabilities.

Conclusion

Tailoring innovations to fit local needs formed a severe challenge for the three ‘best practice’ counties studied. A ‘change of mindset’ to actively take initiative and assume autonomy was needed to advance. Top down supervision and extensive support of experts was required to overcome the barriers. The studied counties finally achieved sustainable improvements and developed double loop learning capabilities beyond HXI objectives. Taken together, the above findings suggest that the continuum of healthcare reform implementation approaches in which hybrid approaches reside—from bottom up to top down—has two dimensions: a content dimension and a procedural dimension. Enabled by top down procedures, counties were able to bottom up tailor the content of best practice innovations to fit local needs.

Formative evaluation of a dashboard to support coproduction of healthcare services in cystic fibrosis

BACKGROUND

Healthcare coproduction engages patients and clinicians to design and execute services, yet little is known about tools that facilitate coproduction. Our objective was to understand uptake, experiences, benefits, and limitations of a dashboard to support patient-clinician partnerships within the cystic fibrosis (CF) community.

METHODS

People living with CF (PwCF) and clinicians co-designed a dashboard that displayed patient-reported and clinical data. Eight CF programmes, including 21 clinicians, and 131 PwCF participated in a pilot study of the dashboard. We conducted descriptive statistics and thematic analyses of surveys (82 PwCF; 21 clinicians); semi-structured interviews (13 PwCF; 8 care teams); and passively-collected usage data.

RESULTS

Two-thirds of the 82 PwCF used the dashboard during a visit, and 59% used it outside a visit. Among 48 PwCF using the dashboard outside the clinic, 92% viewed their health information and 46% documented concerns or requests. Most of the 21 clinicians used the dashboard to support visit planning (76%); fewer used it during a visit (48%). The dashboard supported discussions of what matters most (69% PwCF; 68% clinicians). Several themes emerged: access to patient outcomes data allows users to learn more deeply; participation in pre-visit planning matters; coproduction is made possible by inviting new ways to partner; and lack of integration with existing information technology (IT) systems is limiting.

CONCLUSIONS

A dashboard was feasible to implement and use. Future iterations should provide patients access to their data, be simple to use, and integrate with IT systems in use by clinicians and PwCF.

The stipulation-stimulation spiral: A model of system change

This paper proposes a general model, based on what is known about the nature of (complex) systems, of how systems-in particular, health care systems-respond to attempted change. Inferences are drawn from a critical literature review and reinterpretation of two primary studies. The two fundamental system-change approaches are "stipulation" and "stimulation": stip(ulation) attempts to elicit a specific response from the system; stim(ulation) encourages the system to generate diverse responses. Each has a unique strength: stip's is precision, the ability to directly impact the desired outcome and only that outcome; stim's is resonance, the ability to take advantage of behavior already present within the system. Each approach's inherent strength is its complement's inherent weakness; thus, stip and stim often clash if attempted simultaneously but can reinforce each other if applied in alternation. Opposite patterns (the "stip-stim spiral" vs "stip-stim stalemate") are observed to underpin successful vs failed system change: The crucial difference is whether decision-makers respond to a need for precision/resonance by strengthening the appropriate approach (stipulation/stimulation, respectively), or merely by weakening its complement. With further validation, the model has the potential to yield a more fundamental understanding of why system-change efforts fail and how they can succeed.

A Concept Analysis of Organizational Health and Communication

Concepts of communication and organizational health were analyzed using the parameters set forth by Walker and Avant, including conceptual selection; clarification; synthesis; attribute exploration and identification; and review of corresponding events. Concept synthesis was initiated through exploration of medical and social science journals, and current literature regarding communication and organizational health was scrutinized to aid conceptual clarification. Concept analysis was informed by using the search engines CINAHL, PubMed, and PsycINFO, with inclusion criteria of "hospital," "communication," and "organizational health." Reenvisioning communication through the lens of organizational health will illuminate issues of false centrality, thus leading to improved interdisciplinary communication in hospitals.

Older People Negotiating Independence and Safety in Everyday Life Using Technology: Qualitative Study

Background

Due to demographic changes with an aging population, there is a demand for technology innovations in care services. However, technology innovations have proven difficult to implement in regular use. To understand the complexity of technology innovations in care practices, we need a knowledge base of the complex and diverse experiences of people interacting with established technologies.

Objective

This paper addresses the research gap in relation to understanding the microcontext of co-production of care involving established technologies integrated into care practices. The paper also aims to provide a framework for exploring what really happens when different actors use technology in care practices.

Methods

Participant observations and 22 interviews with actors using social alarms were conducted employing the critical incident technique. A stepwise deductive-inductive analysis was then performed.

Results

The results reveal how co-production of care assumes different meanings according to how actors use the technology. The results also show how technology innovation changes the dynamics between the actors and rearranges care practices. Independent and safe living is co-produced through performing bricolages and optimizing practice. Additionally, this opens up for unexpected results and bricolages as an integrated part of technology innovations.

Conclusions

This study illustrates how care services are always co-produced between the actors involved. By using aspects from science and technology studies, this paper provides a framework for exploring technology in use in care practices. The framework provides tools to unpack and articulate the process of co-producing services.

From pilot project to system solution: innovation, spread and scale for health system leaders

Promoting the scale and spread of effective health innovations requires dedicated action from health system leaders. In order to maximise the effects of leadership strategies to promote the spread and scale of health innovations, conceptual clarity and well-defined strategies are essential. In this commentary, we propose definitions of the concepts of ‘innovation’, ‘spread’ and ‘scale’, and explain how these concepts can be used by health system leaders to generate interest, excitement and commitment for specific innovations from a broad community of stakeholders. We then outline two strategies from the community organising literature that leaders can use to promote spread and scale.

A qualitative study of implementation and adaptations to Progressive Tinnitus Management (PTM) delivery

Background

Tinnitus is a common condition, especially prevalent among military Veterans. Progressive Tinnitus Management (PTM) is an interdisciplinary, structured, stepped-care approach to providing clinical services, including teaching coping skills, to people bothered by tinnitus. PTM has been shown to be effective at reducing functional distress, but implementation of the intervention outside of a research setting has not been studied, even though dissemination is underway within the Veterans Health Administration (VHA) system in the United States. This study was designed to address a gap in knowledge of PTM clinical implementation to date, with a focus on factors facilitating or hindering implementation in VHA audiology and mental health clinic contexts, and whether implementing sites had developed intervention adaptations.

Methods

Qualitative interviews were conducted with 21 audiology and mental health clinicians and service chiefs across a regional service network. Interviews were transcribed and coded using a hybrid inductive-deductive analytic approach guided by existing implementation research frameworks and then iteratively developed for emergent themes.

Results

PTM prioritization was rare overall, with providers across disciplines challenged by lack of capacity for implementation, but with differences by discipline in challenges to prioritization. Where PTM was prioritized and delivered, this was facilitated by perception of unique value, provider’s own experience of tinnitus, observation/experience with PTM delivery, intervention fit with provider’s skills, and an environment with supportive leadership and adaptive reserve. PTM was frequently adapted to local contexts to address delivery challenges and diversify patient options. Adaptations included shifting from group to individual formats, reducing or combining sessions, and employing novel therapeutic approaches.

Conclusions

Existing adaptations highlight the need to better understand mechanisms underlying PTM’s effectiveness, and research on the impact of adaptations on patient outcomes is an important next step. Prioritization of PTM is a key barrier to the scale up and spread of this evidence-based intervention. Developing clinician champions may facilitate dissemination, especially if accompanied by signals of systemic prioritization. Novel approaches exposing clinicians and administrators to PTM may identify and develop clinical champions. Acknowledging the potential for PTM adaptations may make delivery more feasible in the context of existing system constraints and priorities.

Is innovative workforce planning software the solution to NHS staffing and cost crisis? An exploration of the locum industry

BACKGROUND

Workforce planning in the British healthcare system (NHS) is associated with significant costs of agency staff employment. The introduction of a novel software (ABG) as a 'people to people economy' (P2PE) platform for temporary staff recruitment offers a potential solution to this problem. Consequently, the focus of this study was twofold - primarily to explore the locum doctor landscape, and secondarily to evaluate the implementation of P2PE in the healthcare industry.

METHODS

Documentary analysis was conducted alongside thirteen semi structured interviews across five informant groups: two industry experts, two healthcare consultants, an executive director, two speciality managers and six doctors.

RESULTS

We found that locum doctors are indispensable to covering workforce shortages, yet existing planning and recruitment practices were found to be inefficient, inconsistent and lacking transparency. Contrarily, mobile-first solutions such as ABG seem to secure higher convenience, better transparency, cost and time efficiency. We also identified factors facilitating the successful diffusion of ABG; these were in line with classically cited characteristics of innovation such as trialability, observability, and scope for local reinvention. Drawing upon the concept of value-based healthcare coupled with the analysis of our findings led to the development of Information Exchange System (IES) model, a comprehensive framework allowing a thorough comparison of recruitment practices in healthcare.

CONCLUSION

IES was used to evaluate ABG and its diffusion against other recruitment methods and ABG was found to outperform its alternatives, thus suggesting its potential to solve the staffing and cost crisis at the chosen hospital.

How Materiality Enables and Constrains Framing Practices: Affordances of a Rheumatology E-Service

Framing has been presented as a way for micro-level actors to change and diffuse innovations. However, most framing studies have given primacy to language, whereas the role of material artifacts has been largely ignored. The aim of this study is to conceptualize and illustrate how the materiality of technology enables and constrains framing practices. We use empirical data about the development and diffusion of an e-service in the Swedish rheumatology setting from 2000 to 2014. Our results show how three different material features of the technology (data content, user rights, and system integration) initially afforded two different framings of the technology: normalizing and radicalizing framings. The material features, however, lost their ability to afford radicalizing framings over time, along with changes in the collective-action frames governing the field studied.

Nurses and nurse assistants' experiences with using a design thinking approach to innovation in a nursing home

AIM

The aim of this study was to evaluate nurses' and nurse assistants' experiences with a design thinking approach to innovation used in a nursing home in Norway.

BACKGROUND

A design thinking approach to innovation that focuses on users' needs can be employed to address many of the challenges facing health care providers in a field facing a growing ageing population, complex diseases and financial shortfalls.

EVALUATION

This study is based on a thematic analysis of four focus group interviews with nurses and nurse assistants (n = 23).

KEY ISSUES

In the initial phase of developing the new service model, which included defining staff roles and responsibilities, participating nurses and nurse assistants felt engaged and motivated by the designers' inclusive and creative methods. However, during the new model's testing phase, they were critical of management's lack of involvement in the model`s implementation and therefore became less motivated about the project.

CONCLUSION

The findings of the study highlight the importance of the designers cooperating with management and staff for the duration of the innovation process.

IMPLICATIONS FOR NURSING MANAGEMENT

Challenging innovation processes require strong managers who engage with designers, patients, staff and volunteers throughout all phases of an innovation process using a design thinking approach.

Making Electronic Health Records (EHRs) Work: Informal Talk and Workarounds in Healthcare Organizations

A key provision of the American Recovery and Reinvestment Act of 2009 mandated that electronic health records (EHR) be adopted in US healthcare organizations by 2015. The purpose of this study is to examine the communicative processes involved as healthcare workers implement an EHR and make changes, known as workarounds. Guided by theories in social influence, and diffusion of innovations, we conducted a survey of healthcare professionals using an EHR system in an organization. Our structural equation modeling (SEM) and multiple regression results reveal coworker communication, in the form of informal social support and feedback, play an important role in whether people engage in workarounds. Understanding this relationship is important because our study also demonstrates that workarounds predict healthcare employees' overall satisfaction with the EHR system. Specifically, workarounds are associated with higher perceptions of the EHR's relative advantage, higher perceptions of EHR implementation success, and lower levels of resistance to EHR change. This study offers a health communication contribution to the growing research on EHR systems and demonstrates the persuasive effects that coworkers have on new technology use in healthcare organizations.

The performativity of numbers in illness management: The case of Swedish Rheumatology

While there is a proliferation of numerical data in healthcare, little attention has been paid to the role of numbers in constituting the healthcare reality they are intended to depict. This study explores the performativity of numbers in the microlevel management of rheumatoid disease. We draw on a study of patients' and physicians' use of the numbers in the Swedish Rheumatology Quality Registry, conducted between 2009 and 2014. We show how the numbers performed by constructing the disease across time, and by framing action. The numerical performances influenced patients and physicians in different ways, challenging the former to quantify embodied disease and the latter to subsume the disease into one of many possible trajectory standards. Based on our findings, we provide a model of the dynamic performativity of numbers in the on-going management of illness. The model conceptualises how numbers generate new possibilities; by creating tension and alignment they may open up new avenues for communication between patients and physicians.

Persons with rheumatoid arthritis challenge the relevance of the health assessment questionnaire: a qualitative study of patient perception

Background

The Stanford Health Assessment Questionnaire-Disability Index (HAQ) is widely used to measure functional ability in persons with Rheumatoid Arthritis (RA). The instrument was developed with limited involvement from persons with RA, and their perception of the instrument has not been studied in depth. The aim of this study was to explore how persons with RA experience the use of the HAQ in care.

Methods

The study used secondary data analysis. Persons with RA participated in semi-structured interviews in previous research projects. Thirty-nine interviews were included based on data fit, and thematic analysis applied.

Results

The participants questioned the relevance of the HAQ but nevertheless experienced that the instrument had a profound effect on their understanding of health and how care is delivered. The analysis resulted in three themes: Problems with individual items, meaning of the summative score, and effects on care and health perceptions.

Conclusions

To make the HAQ relevant to persons with RA, it needs to be revised or to include an option to select items most meaningful to the respondent. To ensure relevance, the HAQ update should preferably be co-created by researchers, clinicians and persons with RA.

The evolution of weak standards: the case of the Swedish rheumatology quality registry

Research in sociology suggests that the effects of standards are not nearly as straightforward or as homogenising as they first appear. The present study extends these insights by demonstrating how even standards designed simply to collect data can produce extensive and unanticipated effects in medical fields as their uses evolve across actors and contexts. We draw on an embedded case study exploring the multifaceted consequences of the use of a practice-driven voluntary documentation standard: the Swedish rheumatology quality registry from 1995-2014. Data collection included document analysis; 100 interviews with specialists, patients and stakeholders in the field; fieldwork; and observations of physician-patient encounters. Our findings show that the scope and influence of the registry increased over time, and that this standard and its evolution contributed to changes in rheumatologist clinical practice, research practice, and governmental practice. These findings suggest that even initially 'weak', voluntary forms of standardisation can generate far-reaching and unpredictable consequences for the performance and delivery of care as well as for the development of a medical field. Future work about how standards can contribute both to uniformity and diversity is warranted.

Exploring health navigating design: momentary contentment in a cancer context

PURPOSE

The technocratic and medicalized model of healthcare is rarely optimal for patients. By connecting two different studies we explore the possibilities of increasing quality of life in cancer care.

METHODS

The first study captures survival strategies in a historically isolated Arctic village in Norway resulting in Momentary contentment theory, which emerged from analysing four years of participant observation and interview data. The second study conceptualizes everyday life of cancer patients based on in-depth interviews with 19 cancer patients; this was conceptualized as Navigating a new life situation. Both studies used classic grounded theory methodology. The connection between the studies is based on a health design approach.

RESULTS

We found a fit between cancer patients challenging life conditions and harsh everyday life in an Arctic village. Death, treatments and dependence have become natural parts of life where the importance of creating spaces-of-moments and a Sense of Safety is imminent to well-being. While the cancer patients are in a new life situation, the Arctic people show a natural ability to handle uncertainties.

CONCLUSION

By innovation theories connected to design thinking, Momentary contentment theory modified to fit cancer care would eventually be a way to improve cancer patients' quality of life.

Taking mHealth Forward: Examining the Core Characteristics

The emergence of mobile health (mHealth) offers unique and varied opportunities to address some of the most difficult problems of health. Some of the most promising and active efforts of mHealth involve the engagement of mobile phone technology. As this technology has spread and as this technology is still evolving, we begin a conversation about the core characteristics of mHealth relevant to any mobile phone platform. We assert that the relevance of these characteristics to mHealth will endure as the technology advances, so an understanding of these characteristics is essential to the design, implementation, and adoption of mHealth-based solutions. The core characteristics we discuss are (1) the penetration or adoption into populations, (2) the availability and form of apps, (3) the availability and form of wireless broadband access to the Internet, and (4) the tethering of the device to individuals. These collectively act to both enable and constrain the provision of population health in general, as well as personalized and precision individual health in particular.

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.

Policies to foster quality improvement registries: lessons from the Swedish case

BACKGROUND AND OBJECTIVES

Multi-institutional quality improvement registries (QI registries) are a promising approach to quality improvement. They are also used for clinical research, public quality reporting and other valuable purposes. The aim of this study was to identify elements and outcomes of national policies to promote registries in Sweden and to compare them with recent policies in the USA.

METHODS

This case study draws on previous studies of Swedish registries and on interviews, observations and document studies conducted in Sweden and the USA.

RESULTS

In Sweden, registries are fostered by favourable patient data regulation and an indirect control approach combining government funding with soft regulation and professional self-governance. This enables the development of high-quality QI registries which are used for improvements by engaged clinicians, for clinical research and for decision support for practitioners and stakeholders. For example, Riks-HIA/Swedeheart achieved improved outcomes in cardiac intensive care, SCAAR/Swedeheart was used in a unique registry-based randomized trial, and the Swedish Rheumatology Quality Register provides a Web interface for patient encounters and clarifies adverse effects of biologic drugs. Still, the system has persistent limitations, especially the administrative burden on participants. In the USA, Medicare's programme for qualified clinical data registries and other recent changes mirror Swedish policies. Automated data capture is a US advantage, but uncertain funding and complex data regulations stall registry development in the USA.

CONCLUSION

The findings of this study indicate that tailor-made data regulation and a soft regulatory policy approach foster high-quality QI registries with multiple meaningful uses. These findings offer a framework for further cross-country comparative study to evaluate registry policies.

The work of local healthcare innovation: a qualitative study of GP-led integrated diabetes care in primary health care

BACKGROUND

Service delivery innovation is at the heart of efforts to combat the growing burden of chronic disease and escalating healthcare expenditure. Small-scale, locally-led service delivery innovation is a valuable source of learning about the complexities of change and the actions of local change agents. This exploratory qualitative study captures the perspectives of clinicians and managers involved in a general practitioner-led integrated diabetes care innovation.

METHODS

Data on these change agents' perspectives on the local innovation and how it works in the local context were collected through focus groups and semi-structured interviews at two primary health care sites. Transcribed data were analysed thematically. Normalization Process Theory provided a framework to explore perspectives on the individual and collective work involved in putting the innovation into practice in local service delivery contexts.

RESULTS

Twelve primary health care clinicians, hospital-based medical specialists and practice managers participated in the study, which represented the majority involved in the innovation at the two sites. The thematic analysis highlighted three main themes of local innovation work: 1) trusting and embedding new professional relationships; 2) synchronizing services and resources; and 3) reconciling realities of innovation work. As a whole, the findings show that while locally-led service delivery innovation is designed to respond to local problems, convincing others to trust change and managing the boundary tensions is core to local work, particularly when it challenges taken-for-granted practices and relationships. Despite this, the findings also show that local innovators can and do act in both discretionary and creative ways to progress the innovation.

CONCLUSIONS

The use of Normalization Process Theory uncovered some critical professional, organizational and structural factors early in the progression of the innovation. The key to local service delivery innovation lies in building coalitions of trust at the point of service delivery and persuading organizational and institutional mindsets to consider the opportunities of locally-led innovation.

Spreading and sustaining best practices for home care of older adults: a grounded theory study

BACKGROUND

Improving health care quality requires effective and timely spread of innovations that support evidence-based practices. However, there is limited rigorous research on the process of spread, factors influencing spread, and models of spread. It is particularly important to study spread within the home care sector given the aging of the population, expansion of home care services internationally, the high proportion of older adult users of home care services, and the vulnerability of this group who are frail and live with multiple chronic conditions. The purpose of this study was to understand how best practices related to older adults are spread within home care organizations.

METHODS

Four home care organizations in Ontario, Canada that had implemented best practices related to older adults (falls prevention, pain management, management of venous leg ulcers) participated. Using a qualitative grounded theory design, interviews were conducted with frontline providers, managers, and directors at baseline (n = 44) and 1 year later (n = 40). Open, axial, and selective coding and constant comparison analysis were used.

RESULTS

A model of the process of spread of best practices within home care organizations was developed. The phases of spread included (1) committing to change, (2) implementing on a small scale, (3) adapting locally, (4) spreading internally to multiple users and sites, and (5) disseminating externally. Factors that facilitated progression through these phases were (1) leading with passion and commitment, (2) sustaining strategies, and (3) seeing the benefits. Project leads, champions, managers, and steering committees played vital roles in leading the spread process. Strategies such as educating/coaching and evaluating and feedback were key to sustaining the change. Spread occurred within the home care context of high staff and manager turnover and time and resource constraints.

CONCLUSIONS

Spread of best practices is optimized through the application of the phases of spread, allocation of resources to support spread, and implementing strategies for ongoing sustainability that address potential barriers. Further research will help to understand how best practices are spread externally to other organizations.

Frictions as barriers to perioperative alignment: results from a latent class analysis

The quality of the relationship between the sterile processing department (SPD) and the operating room (OR) is an important determinant of OR safety and performance. In this article, the concept of "friction" refers to the SPD behaviors and attributes that can negatively affect OR performance. Panels of SPD professionals initially were asked to identify and operationally define different ways in which behaviors of a hospital's SPD could compromise OR performance. A national convenience sample of OR nurses (N=291) rated 14 frictions in terms of their agreement or disagreement that each had a negative effect on OR performance in their hospital. Overall, more than 50% of the entire sample agreed that 2 frictions, "SPD does not communicate effectively with the OR" (55%) and "SPD inventories are insufficient for surgical volume" (52%), had negative effect on OR performance. However, a latent class analysis revealed 3 distinct classes of nurses who varied with respect to their level of agreement that SPD-OR frictions negatively affected OR performance. The observed heterogeneity in how different groups of nurses viewed different frictions suggests that effective efforts aimed at reducing performance-limiting frictions should be customized so that resources can be used where they are most needed.