Four System Enablers of Large-System Transformation in Health Care: A Mixed Methods Realist Evaluation

Outpatient Virtual Care Among People Living With and Beyond Cancer From Culturally and Linguistically Diverse Backgrounds in Australia: A Protocol for a Realist Evaluation

BACKGROUND

Virtual care is increasingly being used to deliver outpatient cancer services, yet people from culturally and linguistically diverse (CALD) backgrounds can experience inequities in accessing these services. A range of complex and context-specific factors impact the effectiveness of virtual care and equity in its use and outcomes. This study draws on the methodological principles of realist evaluation to provide contextual understanding and account of how, why and in what circumstances outpatient virtual care services work (or not) for people from CALD backgrounds accessing cancer services in Australia.

DESIGN

Realist evaluation, a theory-driven approach, allows researchers to provide a nuanced understanding of how, for whom and why different interventions work (or not) under different circumstances. We propose an iterative and stakeholder-driven four-phase study design that is exploratory and sequential, following the Realist and Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES II) quality standards for realist studies. Phase 1 will generate the initial program theory from a realist synthesis of theories for how virtual care interventions are implemented into routine care and semi-structured interviews with key stakeholders, including CALD service providers, service leaders and people with cancer and/or their carers who are from CALD backgrounds. Phase 2 will use semi-structured realist interviews and focus group discussions with stakeholders and retroductive, theory-driven realist analysis to test and refine the initial program theory. Phase 3 will validate the program theory with a small purposive participant sample outside those who participated in phases 1 and 2. The final phase will coproduce theory-informed actionable recommendations and guidelines for effective virtual models of care implementation through interactive workshops with consumers, managers, service leaders and providers.

DISCUSSION

Knowledge of the contexts and mechanisms that produce optimal outcomes from virtual care is essential to guide the design, adjustment and implementation of virtual care models that provide equitable care outcomes for all patients. Outputs from this realist evaluation, including the program theory and actionable recommendations and guidelines, will inform policy and practice about implementing or adjusting virtual care models and policies or procedures in Australian healthcare to make them more accessible and equitable.

PATIENT OR PUBLIC CONTRIBUTION

The conceptualisation and design of this study were developed with healthcare consumers from diverse cultural and linguistic backgrounds, healthcare providers and academics as part of a national project in Australia. Multicultural consumers who have lived experience of accessing cancer services contributed to the project's design as investigators and are coauthors of this protocol paper. Patients and the public are also represented as Project Steering Group members who will inform the data collection processes, development, and refinement of our program theory.

Organizational Factors Driving the Realization of Digital Health Transformation Benefits from Health Service Managers: A Qualitative Study

Introduction

Healthcare is experiencing a global period of profound transformation, and digital health shows the promise of dispensing innovative and contemporary service models. However, changes are required to improve the capabilities of health managers in driving successful digital transformation.

Objective

This paper aims to explore the organizational barriers that health service managers have encountered when realizing the benefits of a digitally transforming environment. This is part of a larger research study exploring digital competencies for health service managers, with the findings from focus group discussions providing a baseline from which to address the organizational improvements and changes in system capabilities required to assist in realizing the benefits of digital health transformation.

Methods

The study is qualitative in nature. It employs focus group discussions to gain an in-depth understanding of the experiences and views of health service managers and identify the benefits and barriers that managers have experienced in introducing digital health in their workplace.

Results

Barriers encountered in realizing digital health benefits in the workplace were evidenced across five major themes: (1) change resistance and usage, (2) trust and uniformity, (3) resourcing and procurement, (4) digital literacy, and (5) siloed systems.

Discussion

Findings from this study demonstrate that in driving the realization of digital health transformation benefits, health service managers need organizational and system-wide efforts to support managing in the digital health context. The key identified barriers experienced by health service managers include facing human and technical challenges with system adoption and the governance of data-driven decision-making in the digital context.

Conclusion

The importance of digital transformation in healthcare is evident and will increasingly become a necessity for organizational survival and success. This study adds important insights into the organizational barriers that health service managers have encountered when realizing the benefits resulting from digital transformation. Addressing these barriers requires macro-, meso- and micro-level system investments. These benefits are enhanced by enabling factors critical for digital health adoption that have been described in key categories involving health system related: (1) policy and system, (2) organizational structure and processes, and human resource management, and (3) people factors. The importance of ensuring the organizational factors driving the realization of benefits in a digitally transforming environment is also addressed and capitalized upon for health service managers.

Activating Mechanisms Through Employee-Driven Innovation Comment on "Employee-Driven Innovation in Health Organizations: Insights From a Scoping Review"

Caddedu and colleagues' paper "Employee-Driven Innovation in Health Organizations: Insights From a Scoping Review," presents findings regarding the state of the literature around employee-driven innovation (EDI). In uncovering the who, what, and how of EDI in healthcare organizations the authors suggest that embracing EDI at an organizational level may be a key to supporting larger system transformation efforts. This commentary builds on this contention suggesting that to help realize that broader vision, attention should be paid to the overlapping implementation mechanisms around empowerment, adaptability, learning, and meaning and value that drive both processes. Finally, it is suggested that what may be most powerful about EDI is its ability to bring joy and vitality back to a healthcare workforce that is currently in crisis.

Implementation of large, multi-site hospital interventions: a realist evaluation of strategies for developing capability

BACKGROUND

This study presents guidelines for implementation distilled from the findings of a realist evaluation. The setting was local health districts in New South Wales, Australia that implemented three clinical improvement initiatives as part of a state-wide program. We focussed on implementation strategies designed to develop health professionals' capability to deliver value-based care initiatives for multisite programs. Capability, which increases implementers' ability to cope with unexpected scenarios is key to managing change.

METHODS

We used a mixed methods realist evaluation which tested and refined program theories elucidating the complex dynamic between context (C), mechanism (M) and outcome (O) to determine what works, for whom, under what circumstances. Data was drawn from program documents, a realist synthesis, informal discussions with implementation designers, and interviews with 10 key informants (out of 37 identified) from seven sites. Data analysis employed a retroductive approach to interrogate the causal factors identified as contributors to outcomes.

RESULTS

CMO statements were refined for four initial program theories: Making it Relevant- where participation in activities was increased when targeted to the needs of the staff; Investment in Quality Improvement- where engagement in capability development was enhanced when it was valued by all levels of the organisation; Turnover and Capability Loss- where the effects of staff turnover were mitigated; and Community-Wide Priority- where there was a strategy of spanning sites. From these data five guiding principles for implementers were distilled: (1) Involve all levels of the health system to effectively implement large-scale capability development, (2) Design capability development activities in a way that supports a learning culture, (3) Plan capability development activities with staff turnover in mind, (4) Increased capability should be distributed across teams to avoid bottlenecks in workflows and the risk of losing key staff, (5) Foster cross-site collaboration to focus effort, reduce variation in practice and promote greater cohesion in patient care.

CONCLUSIONS

A key implementation strategy for interventions to standardise high quality practice is development of clinical capability. We illustrate how leadership support, attention to staff turnover patterns, and making activities relevant to current issues, can lead to an emergent learning culture.