The next phase of healthcare improvement: what can we learn from social movements?

Improving access to general practice for and with people with severe and multiple disadvantage: a qualitative study

BACKGROUND

People with severe and multiple disadvantage (SMD) who experience combinations of homelessness, substance misuse, violence, abuse, and poor mental health have high health needs and poor access to primary care.

AIM

To improve access to general practice for people with SMD by facilitating collaborative service improvement meetings between healthcare staff, people with lived experience of SMD, and those who support them; participants were then interviewed about this work.

DESIGN AND SETTING

The Bridging Gaps group is a collaboration between healthcare staff, researchers, women with lived experience of SMD, and a charity that supports them in a UK city. A project was co-produced by the Bridging Gaps group to improve access to general practice for people with SMD, which was further developed with three inner-city general practices.

METHOD

Nine service improvement meetings were facilitated at three general practices, and six of these were formally observed. Nine practice staff and four women with lived experience of SMD were interviewed. Three women with lived experience of SMD and one staff member who supports them participated in a focus group. Data were analysed inductively and deductively using thematic analysis.

RESULTS

By providing time and funding opportunities to motivated general practice staff and involving participants with lived experience of SMD, service changes were made in an effort to improve access for people with SMD. These included prioritising patients on an inclusion patient list with more flexible access, providing continuity for patients via a care coordinator and micro-team of clinicians, and developing an information-sharing document. The process and outcomes improved connections within and between general practices, support organisations, and people with SMD.

CONCLUSION

The co-designed strategies described in this study could be adapted locally and evaluated in other areas. Investing in this focused way of working may improve accessibility to health care, health equity, and staff wellbeing.

Exploring social movement concepts and actions in a knowledge uptake and sustainability context: A concept analysis

Objectives

To share a concept analysis of social movement aimed at advancing its application to evidence uptake and sustainability in health-care.

Methods

We applied Walker and Avant method to clarify the concept of social movement in the context of knowledge uptake and sustainability. Peer-reviewed and grey literature databases were systematically searched for relevant reports that described how social movement action led to evidence-based practice changes in health and community settings. Titles, abstracts and full texts were reviewed independently and in duplicate, resulting in 38 included articles.

Results

Social movement action for knowledge uptake and sustainability can be defined as individuals, groups, or organizations that, as voluntary and intrinsically motivated change agents, mobilize around a common cause to improve outcomes through knowledge uptake and sustainability. The 10 defining attributes, three antecedents and three consequences that we identified are dynamic and interrelated, often mutually reinforcing each other to fortify various aspects of the social movement. Examples of defining attributes include an urgent need for action, collective action and collective identity. The concept analysis resulted in the development of the Social Movement Action Framework.

Conclusions

Social movement action can provide a lens through which we view implementation science. Collective action and collective identity – concepts less frequently canvassed in implementation science literature – can lend insight into grassroots approaches to uptake and sustainability. Findings can also inform providers and change leaders on the practicalities of harnessing social movement action for real-world change initiatives. By mobilizing individuals, groups, or organizations through social movement approaches, they can engage as powered change agents and teams that impact the individual, organizational and health systems levels to facilitate knowledge uptake and sustainability.

Unleading during a pandemic: Scrutinising leadership and its impact in a state of exception

Characterising COVID-19 pandemic as a ‘state of exception’, we might expect great hero models of leadership to come to the fore. Instead, drawing on a thematic analysis of 246 news articles, this paper illustrates something different: communities, companies, individuals picked-up the leadership mantle but were reluctant to frame their practices under a leadership rhetoric. The paper explores spontaneous initiatives and leaderly actions that were made visible during the pandemic and proposes practice-based implications for redrawing leadership conceptualisations. These practices, coined as unleading, are characterised under four dimensions: unconditionality and social intention; purposeful action in the absence of an achievement motivation; sensing and attending to local conditions; and confident connecting and collaborating. The analysis and discussion of the four dimensions affirm that while leading and unleading are always present when organising, they are more or less visible and practiced depending on organisational, social and individual circumstances. The paper concludes by surfacing questions and reflections for the future of unleading and implications for leadership theorising and practice.

Black nurses in action: A social movement to end racism and discrimination

We bear witness to a sweeping social movement for change-fostered and driven by a powerful group of Black nurses and nursing students determined to call out and dismantle anti-Black racism and discrimination within the profession of nursing. The Black Nurses Task Force, launched by the Registered Nurses' Association of Ontario (RNAO) in July 2020, is building momentum for long-standing change in the profession by critically examining the racist and discriminatory history of nursing, listening to and learning from the lived experiences of the Black nursing community, and shaping concrete, actionable steps to confront anti-Black racism and discrimination in academic settings, workplaces, and nursing organizations. The Black Nurses Task Force and the RNAO are standing up and speaking out in acknowledgment of the magnitude of anti-Black racism and discrimination that exist in our profession, health system, justice system, and economic system. This social movement is demonstrating, in actions, how individuals and a collective act as change agents to drive meaningful and widespread change for our present and future Black nurses. We also acknowledge the Black nurses who have gone before us.

Digital health for quality healthcare: A systematic mapping of review studies

Objective

To systematically catalogue review studies on digital health to establish extent of evidence on quality healthcare and illuminate gaps for new understanding, perspectives and insights for evidence-informed policies and practices.

Methods

We systematically searched PubMed database using sensitive search strings. Two reviewers independently conducted two-phase selection via title and abstract, followed by full-text appraisal. Consensuses were derived for any discrepancies. A standardized data extraction tool was used for reliable data mining.

Results

A total of 54 reviews from year 2014 to 2021 were included with notable increase in trend of publications. Systematic reviews constituted the majority (61.1%, (37.0% with meta-analyses)) followed by scoping reviews (38.9%). Domains of quality being reviewed include effectiveness (75.9%), accessibility (33.3%), patient safety (31.5%), efficiency (25.9%), patient-centred care (20.4%) and equity (16.7%). Mobile apps and computer-based were the commonest (79.6%) modalities. Strategies for effective intervention via digital health included engineering improved health behaviour (50.0%), better clinical assessment (35.1%), treatment compliance (33.3%) and enhanced coordination of care (24.1%). Psychiatry was the discipline with the most topics being reviewed for digital health (20.3%).

Conclusion

Digital health reviews reported findings that were skewed towards improving the effectiveness of intervention via mHealth applications, and predominantly related to mental health and behavioural therapies. There were considerable gaps on review of evidence on digital health for cost efficiency, equitable healthcare and patient-centred care. Future empirical and review studies may investigate the association between fields of practice and tendency to adopt and research the use of digital health to improve care.

Implementing cancer patient pathways in Scandinavia how structuring might affect the acceptance of a politically imposed reform

Through political decisions all three Scandinavian countries implemented national reforms in cancer care introducing cancer patient pathways. Though resistance from the professional community is common to top-down initiatives, we recognized positive receptions of this reform in all three countries and professionals immediately contributed in implementing the core measures. The implementation of a similar reform in three countries with a similar health care system created a unique opportunity to look for shared characteristics. Combining analytical framework of institutional theory and research on policy implementation, we identified common patterns of structuring of the initial implementation: The hierarchical processes were combined with supplementary structures located both within and outside the formal management hierarchy. Some had a permanent character while others were more project-like or even resembled social movements. These hybrid structures made it possible for actors from high up in the hierarchy to communicate directly to actors at the operational hospital level. Across the cases, we also identified structural components acting together with the traditional command-control; negotiation, consensus and counseling. However, variations in the presence of these did not seem to have significant impact on processes causing decisions and acceptance. These variations may, however, influence the long-term practice and outcome of cancer-care pathway-reform. Knowledge from our study should be considered when orchestrating future health care reforms and especially top-down politically initiated reforms.

Transformando la enfermería a través el conocimiento: pasado, presente y futuro del programa de guías de buenas prácticas de Registered Nurses’ Association of Ontario

Introducción. El programa de guías de buenas prácticas de Registered Nurses’ Association of Ontario (RNAO) es integral, pues incluye el desarrollo de las guías, el apoyo activo para la implementación, y un sistema internacional de datos para la evaluación de resultados. Objetivo. Reflexionar sobre el proceso de transformación de la enfermería a través del conocimiento, teniendo en cuenta el pasado, presente y futuro del programa de guías de buenas prácticas de RNAO. Síntesis. Inicialmente se presentan los antecedentes que permiten el desarrollo del programa de las guías, la difusión, implantación y sostenibilidad de las guías de buenas prácticas. La expansión del programa se da a tres niveles: 1) ampliación hacia arriba, o mediante la ampliación de la cobertura; 2) ampliación hacia afuera, o mediante la adaptación de políticas, leyes y directrices; 3) ampliación hacia adentro, o mediante el cambio de normas y cultura. En relación con la difusión del programa de guías de buenas prácticas a gran escala se logran identificar factores de éxito tales como: localización, integralidad, solidez, resultados comprobados, accesibilidad, vanguardia e identidad colectiva. Conclusiones: El programa hace posible que las instituciones y los sistemas sanitarios se centren en la atención al paciente y en la excelencia clínica, usando la investigación más reciente para servir de base para la práctica y optimizar los resultados. El programa de guías ha ayudado a impulsar las prioridades gubernamentales, así como los resultados de pacientes, profesionales, instituciones y sistemas sanitarios.

Improving patient safety in two French hospitals: why teamwork training is not enough

PURPOSE

The persistent challenges that healthcare organizations face as they strive to keep patients safe attests to a need for continued attention. To contribute to better understanding the issues currently defying patient safety initiatives, this paper reports on a study examining the aftermath of implementing a national team training program in two hospital units in France.

DESIGN/METHODOLOGY/APPROACH

Data were drawn from a longitudinal qualitative study analyzing the implementation of a French patient safety program aimed at improving teamwork in hospitals. Data collection took place over a four-year period (2015-2019) in two urban hospitals in France and included multiple interviews with 31 participants and 150 h of observations.

FINDINGS

Despite explicit efforts to improve inter-professional teamwork, three main obstacles interfered with healthcare professionals' attempts at safeguarding patients: perspectival variations in what constituted "patient safety", a paradoxical injunction to do more with less and conflicting organizational priorities.

ORIGINALITY/VALUE

This paper exposes patient safety as misleadingly consensual and identifies a lack of alignment between stakeholders in the complex system that is a hospital. This ultimately interferes with patient safety objectives and highlights that even well-equipped, frontline actors cannot achieve long-term results without more systemic organizational changes.

Social movements thinking for managing change in large-scale systems

Purpose

This study explores the efficacy of social movements thinking for mobilizing resources toward sustainable change in large-scale systems such as health and social services.

Design/methodology/approach

The study proceeds from a critical realist perspective employing a qualitative multi-case study approach. Drawing on the tenets of grounded theory (i.e. constant comparative analysis and theoretical sampling), data from semi-structured interviews and field notes were analyzed to facilitate theoretical integration and elaboration.

Findings

One case study explores the emergence of social movements thinking in mobilizing a community to engage in sustainable system change. Data analysis revealed a three-stage conceptual framework whereby building momentum for change requires a fundamental shift in culture through openness and engagement to challenge the status quo by acknowledging not only the apparent problems to be addressed but also the residual apathy and cynicism holding the system captive to entrenched ideas and behaviors. By challenging the status quo, energy shifts and momentum builds as the community discovers shared values and goals. Achieving a culture shift of this magnitude requires leadership that is embedded within the community, with a personal commitment to that community and with the deep listening skills necessary to understand and engage the community and the wider system in moving forward into change. This emergent conceptual framework is then used to compare and discuss more intentional applications of social movements thinking for mobilizing resources for large-scale system change.

Originality/value

This study offers a three-stage conceptual framework for mobilizing community/system resources toward sustainable large-scale system change. The comparative application of this framework to more intentional applications of social movements thinking to planned change initiatives offers insights and lessons to be learned when large-scale systems attempt to apply such principles in redesigning health and social service systems.

Bibliometric Review of the Knowledge Base on Healthcare Management for Sustainability, 1994–2018

In response to the United Nations’ (UN) Sustainable Development Goals (SDGs), health care organizations throughout the world have adopted management initiatives designed to increase their sustainability. This review of research used bibliometric methods to analyze a dataset comprised of 477 documents extracted from the Scopus database. The review sought to document research on sustainable healthcare management (SHM) that has accumulated over the past 25 years. Results indicated that the intellectual structure of this body of knowledge is comprised of three schools of thought: (1) sustainable change in health care services, (2) innovations in managing health care operations, and (3) prioritizing and allocating resources for sustainability. The review also highlighted the recent topical focus of research in this literature. Key topics were linked to organization and management of health care services, quality of patient care, and sustainability of health care delivery.

Driving sustainable change in antimicrobial prescribing practice: how can social and behavioural sciences help?

Addressing the growing threat of antimicrobial resistance is, in part, reliant on the complex challenge of changing human behaviour-in terms of reducing inappropriate antibiotic use and preventing infection. Whilst there is no 'one size fits all' recommended behavioural solution for improving antimicrobial stewardship, the behavioural and social sciences offer a range of theories, frameworks, methods and evidence-based principles that can help inform the design of behaviour change interventions that are context-specific and thus more likely to be effective. However, the state-of-the-art in antimicrobial stewardship research and practice suggests that behavioural and social influences are often not given due consideration in the design and evaluation of interventions to improve antimicrobial prescribing. In this paper, we discuss four potential areas where the behavioural and social sciences can help drive more effective and sustained behaviour change in antimicrobial stewardship: (i) defining the problem in behavioural terms and understanding current behaviour in context; (ii) adopting a theory-driven, systematic approach to intervention design; (iii) investigating implementation and sustainability of interventions in practice; and (iv) maximizing learning through evidence synthesis and detailed intervention reporting.

Improving the waiting times within a hospice breathlessness service

Background

Breathlessness, a common symptom in advanced disease, is a distressing, complex symptom that can profoundly affect the quality of one’s life. Evidence suggests that specialist palliative care breathlessness intervention services can improve physical well-being, personal coping strategies and quality of life. In the UK, the use of quality improvement methods is well documented in the National Health Service. However, within the independent hospice sector there is a lack of published evidence of using such methods to improve service provision.

Aim

The aim of this project was to reduce the waiting time from referral to service commencement for a hospice breathlessness service by 40%—from a median of 19.5 to 11.5 working days.

Methods

Using a quality planning and systems thinking approach staff identified barriers and blockages in the current system and undertook plan-do-study-act cycles to test change ideas. The ideas tested included offering home visits to patients on long-term oxygen, using weekly team ‘huddles’, streamlining the internal referral process and reallocating staff resources.

Results

Using quality improvement methods enabled staff to proactively engage in positive changes to improve the service provided to people living with chronic breathlessness. Offering alternatives to morning appointments; using staff time more efficiently and introducing accurate data collection enabled staff to monitor waiting times in real time. The reduction achieved in the median waiting time from referral to service commencement exceeded the project aim.

Conclusions

This project demonstrates that quality improvement methodologies can be successfully used in a hospice setting to improve waiting times and meet the specific needs of people receiving specialist palliative care.

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.

Implementation of Crew Resource Management: A Qualitative Study in 3 Intensive Care Units

Objectives

Classroom-based crew resource management (CRM) training has been increasingly applied in health care to improve safe patient care. Crew resource management aims to increase participants' understanding of how certain threats can develop as well as provides tools and skills to respond to such threats. Existing literature shows promising but inconclusive results that might be explained by the quality of the implementation. The present research systematically describes the implementation from the perspective of 3 trained intensive care units (ICUs).

Methods

The design of the study was built around 3 stages of implementation: (1) the preparation, (2) the actions after the CRM training, and (3) the plans for the future. To assess all stages in 3 Dutch ICUs, 12 semistructured interviews with implementation leaders were conducted, the End-of-Course Critique questionnaire was administered, and objective measurements consisting of the number and types of plans of action were reported.

Results

The results categorize initiatives that all 3 ICUs successfully launched, including the development of checklists, each using a different implementation strategy. All ICUs have taken several steps to sustain their approach for the foreseeable future. Three similarities between the units were seen at the start of the implementation: (1) acknowledgment of a performance gap in communication, (2) structural time allocated for CRM, and (3) a clear vision on how to implement CRM.

Conclusions

This study shows that CRM requires preparation and implementation, both of which require time and dedication. It is promising to note that all 3 ICUs have developed multiple quality improvement initiatives and aim to continue doing so.

A 'movement for improvement'? A qualitative study of the adoption of social movement strategies in the implementation of a quality improvement campaign

Given the difficulties of implementing 'top-down' quality improvements, health service leaders have turned to methods that empower clinicians to co-produce 'bottom-up' improvements. This has involved the adoption of strategies and activities associated with social movements, with clinicians encouraged to participate in collective action towards the shared goal of improvement. This paper examines the adoption of social movement methods by hospital managers as a strategy for implementing a quality improvement 'campaign'. Our case study suggests that, despite the claim of empowering clinicians to develop 'bottom-up' improvements, the use of social movement methods can be more narrowly concerned with engaging clinicians in pre-determined programmes of 'top-down' change. It finds a prominent role for 'hybrid' clinical leaders and other staff representatives in the mobilisation of the campaign, especially for enrolling clinicians in change activities. The work of these 'hybrids' suggests some degree of creative mediation between clinical and managerial interests, but more often alignment with the aspirations of management. The study raises questions about the translation of social movement's theories as a strategy for managing change and re-inventing professionalism.

Healthcare Quality Improvement and 'work engagement'; concluding results from a national, longitudinal, cross-sectional study of the 'Productive Ward-Releasing Time to Care' Programme

Background

Concerns about patient safety and reducing harm have led to a particular focus on initiatives that improve healthcare quality. However Quality Improvement (QI) initiatives have in the past typically faltered because they fail to fully engage healthcare professionals, resulting in apathy and resistance amongst this group of key stakeholders. Productive Ward: Releasing Time to Care (PW) is a ward-based QI programme created to help ward-based teams redesign and streamline the way that they work; leaving more time to care for patients. PW is designed to engage and empower ward-based teams to improve the safety, quality and delivery of care.

Methods

The main objective of this study was to explore whether PW sustains the ‘engagement’ of ward-based teams by examining the longitudinal effect that the national QI programme had on the ‘work-engagement’ of ward-based teams in Ireland. Utilising the Utrecht Work Engagement Scale questionnaire (UWES-17), we surveyed nine PW (intervention) sites from typical acute Medical/Surgical, Rehabilitation and Elderly services (representing the entire cohort of a national phase of PW implementation in Ireland) and a cohort of matched control sites. The numbers surveyed from the PW group at T1 (up to 3 months after commencing the programme) totalled 253 ward-team members and 249 from the control group. At T2 (12 months later), the survey was repeated with 233 ward-team members from the PW sites and 236 from the control group.

Results

Overall findings demonstrated that those involved in the QI initiative had higher ‘engagement’ scores at T1 and T2 in comparison to the control group. Total ‘engagement’ score (TES), and its 3 dimensions, were all significantly higher in the PW group at T1, but only the Vigour dimension remained significantly higher at T2 (p = 0.006).

Conclusion

Our results lend some support to the assertions of the PW initiative itself and suggest that when compared to a control group, ward-based teams involved in the QI programme are more likely to be ‘engaged’ by it and its associated improvement activities and that this is maintained over time. However, only the Vigour dimension of ‘engagement’ remained significantly higher in the PW over time.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2446-2) contains supplementary material, which is available to authorized users.

Equipping future doctors: incorporating management and leadership into medical curriculums in the United Kingdom

Throughout their careers, doctors are likely to come across complex management and leadership scenarios that many would not have had prior training in. Expectations of doctors are rising and it is becoming increasingly necessary to be able to astutely handle a variety of situations. Medical curricula must reflect this change and adapt to include the teaching of key management and leadership skills. Despite budgeting pressures, the National Health Service continues to spend vast sums of money on external management consultants. The 2013 Francis Report stressed the need for better management skills and leadership, especially in doctors who were identified as the spearheads of change. This view is backed up by senior professionals who stress that by incorporating it into undergraduate curricula, doctors will be equipped with the skills to flourish in the future. The challenges of doing so must be highlighted, since the teaching of managerial and leadership concepts must effectively combine theoretical approaches with practical applications. Empowering students of today will enable them as tomorrow's doctors to tackle the challenges of modern medicine.

Productive Ward: Releasing Time to Care, or capacity for compassion: results from a longitudinal study of the quality improvement initiative

Recent concerns about the poor quality of healthcare and diminishing compassion within patient care have prompted many healthcare organisations to adopt ‘compassion’ and ‘care’ into their value and mission statements. Productive Ward: Releasing Time to Care (PW) is a quality improvement (QI) programme designed to meet the value and mission intentions around quality and compassion. The purpose of this study is to measure the impact that PW has on direct patient care (DPC) times and the capacity of ward-based teams to provide compassionate care. This study used an exploratory longitudinal, cohort design (with an experimental test outcome, using a matched control group) to examine DPC times and ‘engagement’ (the antithesis of ‘burnout’ and ‘compassion fatigue’) amongst ward-based teams involved the PW QI initiative in Ireland. Ward-based teams involved in PW reported higher baseline levels of ‘engagement’ (vigour, absorption and dedication) compared to a control group which remained unchanged after a 12-month period. DPC times improved in just over half the study sites, but no significant changes were observed. No statistically significant relationships between ‘engagement’ and DPC were established. This study demonstrates that PW does not necessarily ‘release time to care’ in every instance and that many factors influence this. Compared to a control group it does, however, show encouraging signs that it may engage ward-based teams, thus creating some of the conditions and capacity in which compassion and quality can flourish.

The Strange Career of an Idea and its Resurrection

Partly a memoir, this article traces the history of an article (Zald & Berger, 1978) the author published in the American Journal of Sociology on social movements in organizations. The article originated in events observed while a graduate student in 1957-1958. It showed the value of a political sociology approach to organizational conflict and analyzed coup d’etat, bureaucratic insurgencies, and mass insurrections in organizations. Although published in a leading journal, the article had little impact in the years immediately following its publication. Recently, working with Calvin Morrill and Hayagreeva Rao, the author revisited the topic. Moreover, there has been an upsurge of interest from other scholars, leading to conferences and publications. Recent work includes proactive, applied work attempting to use social movement approaches to promote organizational change. This article examines how the author’s work in this area intersected with his career and attempts to explain why there was so little interest originally but much more interest recently.

Using a Design Approach to Assist Large-Scale Organizational Change

A team of practitioners, university researchers, and health care policy makers has been working to develop and apply “design sciences” thinking within the challenging context of a national system aiming to bring about a “revolution in health care.” As members of that team, the authors share that thinking and early findings with those interested in the concept, theory, and practice of design as an approach to large-scale organizational change. The article builds on what to date has been a somewhat abstract debate around the design sciences, its aim being to forge stronger links between the concept and the practice of design. Using empirical data from the English National Health Service as a case study, the article seeks to demonstrate how design sciences may first, expand our thinking around organizational theory and practice and second, offer organization development some new methods, approaches, and processes around the “doing” of large-scale change.

Generalist palliative care in hospital - Cultural and organisational interactions. Results of a mixed-methods study

BACKGROUND

It can be challenging to provide generalist palliative care in hospitals, owing to difficulties in integrating disease-oriented treatment with palliative care and the influences of cultural and organisational conditions. However, knowledge on the interactions that occur is sparse.

AIM

To investigate the interactions between organisation and culture as conditions for integrated palliative care in hospital and, if possible, to suggest workable solutions for the provision of generalist palliative care.

DESIGN

A convergent parallel mixed-methods design was chosen using two independent studies: a quantitative study, in which three independent datasets were triangulated to study the organisation and evaluation of generalist palliative care, and a qualitative, ethnographic study exploring the culture of generalist palliative nursing care in medical departments.

SETTING/PARTICIPANTS

A Danish regional hospital with 29 department managements and one hospital management.

RESULTS

Two overall themes emerged: (1) 'generalist palliative care as a priority at the hospital', suggesting contrasting issues regarding prioritisation of palliative care at different organisational levels, and (2) 'knowledge and use of generalist palliative care clinical guideline', suggesting that the guideline had not reached all levels of the organisation.

CONCLUSION

Contrasting issues in the hospital's provision of generalist palliative care at different organisational levels seem to hamper the interactions between organisation and culture - interactions that appear to be necessary for the provision of integrated palliative care in the hospital. The implementation of palliative care is also hindered by the main focus being on disease-oriented treatment, which is reflected at all the organisational levels.

A framework for scaling up health interventions: lessons from large-scale improvement initiatives in Africa

Background

Scaling up complex health interventions to large populations is not a straightforward task. Without intentional, guided efforts to scale up, it can take many years for a new evidence-based intervention to be broadly implemented. For the past decade, researchers and implementers have developed models of scale-up that move beyond earlier paradigms that assumed ideas and practices would successfully spread through a combination of publication, policy, training, and example.

Drawing from the previously reported frameworks for scaling up health interventions and our experience in the USA and abroad, we describe a framework for taking health interventions to full scale, and we use two large-scale improvement initiatives in Africa to illustrate the framework in action. We first identified other scale-up approaches for comparison and analysis of common constructs by searching for systematic reviews of scale-up in health care, reviewing those bibliographies, speaking with experts, and reviewing common research databases (PubMed, Google Scholar) for papers in English from peer-reviewed and “gray” sources that discussed models, frameworks, or theories for scale-up from 2000 to 2014. We then analyzed the results of this external review in the context of the models and frameworks developed over the past 20 years by Associates in Process Improvement (API) and the Institute for Healthcare improvement (IHI). Finally, we reflected on two national-scale improvement initiatives that IHI had undertaken in Ghana and South Africa that were testing grounds for early iterations of the framework presented in this paper.

Results

The framework describes three core components: a sequence of activities that are required to get a program of work to full scale, the mechanisms that are required to facilitate the adoption of interventions, and the underlying factors and support systems required for successful scale-up. The four steps in the sequence include (1) Set-up, which prepares the ground for introduction and testing of the intervention that will be taken to full scale; (2) Develop the Scalable Unit, which is an early testing phase; (3) Test of Scale-up, which then tests the intervention in a variety of settings that are likely to represent different contexts that will be encountered at full scale; and (4) Go to Full Scale, which unfolds rapidly to enable a larger number of sites or divisions to adopt and/or replicate the intervention.

Conclusions

Our framework echoes, amplifies, and systematizes the three dominant themes that occur to varying extents in a number of existing scale-up frameworks. We call out the crucial importance of defining a scalable unit of organization. If a scalable unit can be defined, and successful results achieved by implementing an intervention in this unit without major addition of resources, it is more likely that the intervention can be fully and rapidly scaled. When tying this framework to quality improvement (QI) methods, we describe a range of methodological options that can be applied to each of the four steps in the framework’s sequence.

Prospects and problems of transferring quality-improvement methods from health care to social services: two case studies

INTRODUCTION

This study examines the use of quality-improvement (QI) methods in social services. Particularly the key aspects-generalizable knowledge, interprofessional teamwork, and measurements-are studied in projects from the QI program Forum for Values in Sweden.

METHODS

This is a mixed-method case study. Two projects using standard QI methods and tools as used in health care were chosen as critical cases to highlight some problems and prospects with the use of QI in social services. The cases were analyzed through documented results and qualitative interviews with participants one year after the QI projects ended.

RESULTS

The social service QI projects led to measurable improvements when they used standard methods and tools for QI in health care. One year after the projects, the improvements were either not continuously measured or not reported in any infrastructure for measurements. The study reveals that social services differ from health care regarding the availability and use of evidence, the role of professional expertise, and infrastructure for measurements.

CONCLUSIONS

We argue that QI methods as used in health care are applicable in social services and can lead to measurable improvements. The study gives valuable insights for QI, not only in social services but also in health care, on how to assess and sustain improvements when infrastructures for measurements are lacking. In addition, when one forms QI teams, the focus should be on functions instead of professions, and QI methods can be used to support implementation of evidence-based practice.

Rethinking capacity building for knowledge mobilisation: developing multilevel capabilities in healthcare organisations

Background

Knowledge mobilisation in healthcare organisations is often carried out through relatively short-term projects dependent on limited funding, which raises concerns about the long-term sustainability of implementation and improvement. It is becoming increasingly recognised that the translation of research evidence into practice has to be supported by developing the internal capacity of healthcare organisations to engage with and apply research. This process can be supported by external knowledge mobilisation initiatives represented, for instance, by professional associations, collaborative research partnerships and implementation networks. This conceptual paper uses empirical and theoretical literature on organisational learning and dynamic capabilities to enhance our understanding of intentional capacity building for knowledge mobilisation in healthcare organisations.

Discussion

The discussion is structured around the following three themes: (1) defining and classifying capacity building for knowledge mobilisation; (2) mechanisms of capability development in organisational context; and (3) individual, group and organisational levels of capability development. Capacity building is presented as a practice-based process of developing multiple skills, or capabilities, belonging to different knowledge domains and levels of complexity. It requires an integration of acquisitive learning, through which healthcare organisations acquire knowledge and skills from knowledge mobilisation experts, and experience-based learning, through which healthcare organisations adapt, absorb and modify their knowledge and capabilities through repeated practice. Although the starting point for capability development may be individual-, team- or organisation-centred, facilitation of the transitions between individual, group and organisational levels of learning within healthcare organisations will be needed.

Summary

Any initiative designed to build capacity for knowledge mobilisation should consider the subsequent trajectory of newly developed knowledge and skills within the recipient healthcare organisations. The analysis leads to four principles underpinning a practice-based approach to developing multilevel knowledge mobilisation capabilities: (1) moving from ‘building’ capacity from scratch towards ‘developing’ capacity of healthcare organisations; (2) moving from passive involvement in formal education and training towards active, continuous participation in knowledge mobilisation practices; (3) moving from lower-order, project-specific capabilities towards higher-order, generic capabilities allowing healthcare organisations to adapt to change, absorb new knowledge and innovate; and (4) moving from single-level to multilevel capability development involving transitions between individual, group and organisational learning.

The transition of a large-scale quality improvement initiative: a bibliometric analysis of the Productive Ward: Releasing Time to Care programme

AIMS AND OBJECTIVES

To examine the literature related to a large-scale quality improvement initiative, the 'Productive Ward: Releasing Time to Care', providing a bibliometric profile that tracks the level of interest and scale of roll-out and adoption, discussing the implications for sustainability.

BACKGROUND

Productive Ward: Releasing Time to Care (aka Productive Ward) is probably one of the most ambitious quality improvement efforts engaged by the UK-NHS. Politically and financially supported, its main driver was the NHS Institute for Innovation and Improvement. The NHS institute closed in early 2013 leaving a void of resources, knowledge and expertise. UK roll-out of the initiative is well established and has arguably peaked. International interest in the initiative however continues to develop.

METHODS

A comprehensive literature review was undertaken to identify the literature related to the Productive Ward and its implementation (January 2006-June 2013). A bibliometric analysis examined/reviewed the trends and identified/measured interest, spread and uptake.

RESULTS

Overall distribution patterns identify a declining trend of interest, with reduced numbers of grey literature and evaluation publications. However, detailed examination of the data shows no reduction in peer-reviewed outputs. There is some evidence that international uptake of the initiative continues to generate publications and create interest.

CONCLUSIONS

Sustaining this initiative in the UK will require re-energising, a new focus and financing. The transition period created by the closure of its creator may well contribute to further reduced levels of interest and publication outputs in the UK. However, international implementation, evaluation and associated publications could serve to attract professional/academic interest in this well-established, positively reported, quality improvement initiative.

RELEVANCE TO CLINICAL PRACTICE

This paper provides nurses and ward teams involved in quality improvement programmes with a detailed, current-state, examination and analysis of the Productive Ward literature, highlighting the bibliometric patterns of this large-scale, international, quality improvement programme. It serves to disseminate updated publication information to those in clinical practice who are involved in Productive Ward or a similar quality improvement initiative.

Improving quality and safety of care using "technovigilance": an ethnographic case study of secondary use of data from an electronic prescribing and decision support system

CONTEXT

"Meaningful use" of electronic health records to improve quality of care has remained understudied. We evaluated an approach to improving patients' safety and quality of care involving the secondary use of data from a hospital electronic prescribing and decision support system (ePDSS).

METHODS

We conducted a case study of a large English acute care hospital with a well-established ePDSS. Our study was based on ethnographic observations of clinical settings (162 hours) and meetings (28 hours), informal conversations with clinical staff, semistructured interviews with ten senior executives, and the collection of relevant documents. Our data analysis was based on the constant comparative method.

FINDINGS

This hospital's approach to quality and safety could be characterized as "technovigilance." It involved treating the ePDSS as a warehouse of data on clinical activity and performance. The hospital converted the secondary data into intelligence about the performance of individuals, teams, and clinical services and used this as the basis of action for improvement. Through a combination of rapid audit, feedback to clinical teams, detailed and critical review of apparent omissions in executive-led meetings, a focus on personal professional responsibility for patients' safety and quality care, and the correction of organizational or systems defects, technovigilance was-based on the hospital's own evidence-highly effective in improving specific indicators. Measures such as the rate of omitted doses of medication showed marked improvement. As do most interventions, however, technovigilance also had unintended consequences. These included the risk of focusing attention on aspects of patient safety made visible by the system at the expense of other, less measurable but nonetheless important, concerns.

CONCLUSIONS

The secondary use of electronic data can be effective for improving specific indicators of care if accompanied by a range of interventions to ensure proper interpretation and appropriate action. But care is needed to avoid unintended consequences.

Anti-leaders(hip) in Social Movement Organizations: The case of autonomous grassroots groups

Through the Arab Spring and the Occupy movement, the idea of horizontal, leaderless organization has come to the attention of the mass media. In this article we explore radical, participative-democratic alternatives to leadership through an empirical study of four Social Movement Organizations (SMOs). Whilst there has been some writing on leadership within SMOs, it has mirrored the ‘mainstream’ assumption that leadership is the product of individual leaders possessing certain traits, styles and/or behaviours. In contrast, critical leadership studies (CLS) recognize that leadership is a relational, socially constructed phenomenon rather than the result of a stable set of leadership attributes that inhere in ‘the leaders’. We utilize this framing to analyse how leadership is understood and performed in anarchist SMOs by examining how actors manage meaning and define reality without compromising the ideological commitments of their organizations. Furthermore, we also pay attention to the organizational practices and processes developed to: (a) prohibit individuals from permanently assuming a leadership role; (b) distribute leadership skills and roles; and (c) encourage other actors to participate and take-up these roles in the future. We conclude by suggesting that just because an organization is leaderless, it does not necessarily mean that it is also leadershipless.

Collective learning, change and improvement in health care: trialling a facilitated learning initiative with general practice teams

RATIONALE, AIMS AND OBJECTIVES

Many patients, families, health care professionals and politicians desire for quality improvement within the UK National Health Service. One way to achieve this change is for health care teams to work and learn together more effectively. This research aimed to design and trial a facilitated learning programme with the aim of supporting general practice teams in fostering the characteristics of learning organizations.

METHODS

This is an action research study. Qualitative data were captured during and after the trial from 40 participants in two multi-professional general practice teams within different Scottish health boards. Data were gathered using observations, semi-structured interviews and written learning notes.

RESULTS

Taking part in the LPP was a positive experience of learning together as a practice and enhanced communication within the team was a particular outcome. External facilitation helped provide focus and reduce inter-professional barriers. Teams found working in small, mixed role discussion groups particularly valuable in understanding each others' perspectives. The active learning style of the LPP could be daunting at times but teams valued the chance to identify their own quality improvement goals. Teams introduced a number of changes to improve the quality of care within their practice as a result of their participation.

CONCLUSION

This trial of the learning practice programme shows that, with facilitation and the appropriate input of resources, general practice teams can successfully apply learning organization principles to produce quality improvement outcomes. The study also demonstrates the value of action research in researching iterative change over time.

BC Patient Safety & Quality Council: using network and social movement theory to improve healthcare

The BC Patient Safety & Quality Council has a mandate to bring health system stakeholders together in a collaborative partnership to improve quality of care. Our experience has demonstrated the value of networks to provide a forum for individuals to "think like a system," considering the perspectives of others in addressing system issues. This transition from silo-based thinking is important as we move to improve the quality of care at the pace that is required.

Large-scale improvement initiatives in healthcare: a scan of the literature

CONTEXT

The goal of this article is to provide a succinct scan of the literature as it relates to the current thinking and practice in large-scale improvement initiatives in healthcare.

METHOD

We employed a scan of the literature using a modified Delphi technique. A standard review form was used. The scan was limited to large-scale spread efforts in hospitals and healthcare systems. Each of the main factors that emerged during the scan was linked to secondary factors and organized using a driver diagram.

FINDINGS

Four primary drivers (factors) emerged during our scan that inform large-scale change initiatives in healthcare: Planning and Infrastructure; Individual, Group, Organizational, and System Factors; The Process of Change; and Performance Measures and Evaluation.

CONCLUSION

Our scan identified a tremendous amount of work being done around the world to improve healthcare. In general, our findings suggest these initiatives tend to be fragmented from an implementation standpoint. We identified primary and secondary drivers (factors) that can be used by those responsible for implementing large-scale improvement initiatives both at a strategy level and in their daily work. These drivers could serve as a "checklist" of ideas to consider in different testing and implementation situations.

Moving from research to large-scale change in child health care

There is a large and persistent failure to achieve widespread dissemination of evidence-based practices in child health care. Too often studies demonstrating evidence for effective child health care practices are not brought to scale and across different settings and populations. This failure is not due to a lack of knowledge, but rather a failure to bring to bear proven methods in dissemination, diffusion, and implementation (DD&I) science that target the translation of evidence-based medicine to everyday practice. DD&I science offers a framework and a set of tools to identify innovations that are likely to be implemented, and provides methods to better understand the capabilities and preferences of individuals and organizations and the social networks within these organizations that help facilitate widespread adoption. Successful DD&I is dependent on making the intervention context sensitive without losing fidelity to the core components of the intervention. The achievement of these goals calls for new research methods such as pragmatic research trials that combine hypothesis testing with quality improvement, participatory research that engages the target community at the beginning of research design, and other quasi-experimental designs. With the advent of health care reform, it will be extremely important to ensure that the ensuing large demonstration projects that are designed to increase integrated care and better control costs can be rapidly brought to scale across different practices settings, and health plans and will be able to achieve effectiveness in diverse populations.

Explaining Michigan: developing an ex post theory of a quality improvement program

CONTEXT

Understanding how and why programs work-not simply whether they work-is crucial. Good theory is indispensable to advancing the science of improvement. We argue for the usefulness of ex post theorization of programs.

METHODS

We propose an approach, located within the broad family of theory-oriented methods, for developing ex post theories of interventional programs. We use this approach to develop an ex post theory of the Michigan Intensive Care Unit (ICU) project, which attracted international attention by successfully reducing rates of central venous catheter bloodstream infections (CVC-BSIs). The procedure used to develop the ex post theory was (1) identify program leaders' initial theory of change and learning from running the program; (2) enhance this with new information in the form of theoretical contributions from social scientists; (3) synthesize prior and new information to produce an updated theory.

FINDINGS

The Michigan project achieved its effects by (1) generating isomorphic pressures for ICUs to join the program and conform to its requirements; (2) creating a densely networked community with strong horizontal links that exerted normative pressures on members; (3) reframing CVC-BSIs as a social problem and addressing it through a professional movement combining "grassroots" features with a vertically integrating program structure; (4) using several interventions that functioned in different ways to shape a culture of commitment to doing better in practice; (5) harnessing data on infection rates as a disciplinary force; and (6) using "hard edges."

CONCLUSIONS

Updating program theory in the light of experience from program implementation is essential to improving programs' generalizability and transferability, although it is not a substitute for concurrent evaluative fieldwork. Future iterations of programs based on the Michigan project, and improvement science more generally, may benefit from the updated theory present here.

Problems and promises of innovation: why healthcare needs to rethink its love/hate relationship with the new

Innovation is often regarded as uniformly positive. This paper shows that the role of innovation in quality improvement is more complicated. The authors identify three known paradoxes of innovation in healthcare. First, some innovations diffuse rapidly, yet are of unproven value or limited value, or pose risks, while other innovations that could potentially deliver benefits to patients remain slow to achieve uptake. Second, participatory, cooperative approaches may be the best way of achieving sustainable, positive innovation, yet relying solely on such approaches may disrupt positive innovation. Third, improvement clearly depends upon change, but change always generates new challenges. Quality improvement systems may struggle to keep up with the pace of innovation, yet evaluation of innovation is often too narrowly focused for the system-wide effects of new practices or technologies to be understood. A new recognition of the problems of innovation is proposed and it is argued that new approaches to addressing them are needed.

Beyond evidence: the micropolitics of improvement

This paper aims to draw attention to the social and micropolitical dimensions of attempting to implement improvements within healthcare organisations. It is argued that quality improvement initiatives, like other forms of organisational innovation, will fail unless they are conceived and implemented in such a way as to take into account the pattern of interests, values and power relationships that surround them. Drawing on examples, it is suggested that innovators can intervene more successfully if they understand how the benefits and costs of interventions are likely to be distributed among stakeholders within their setting, how different but equally legitimate value sets may structure peoples' understanding of them and how the nature of the interventions themselves (and, in particular, the shape of their hard core and soft periphery) might provide scope for redesigning or adapting interventions in ways that are likely to make them both more effective and politically feasible.

Integrating Evidence-Based Design and Experience-Based Approaches in Healthcare Service Design

Objective:

To investigate the connections between, and respective contributions of, evidence-based and experience-based methods in the redesign of healthcare services.

Background:

Evidence-based medicine (EBM) preceded (and inspired) the development of evidence-based design (EBD) for healthcare facilities. A key feature of debate around EBM has been the question of interpretation of the guidance by experienced clinicians, to achieve maximum efficacy for individual patients. This interpretation and translation of guidelines—avoiding a formulaic approach, allowing for divergent cultural and geographical exigencies, creating innovative, context-specific solutions—is the subject of this discussion, which examines the potential for integration of evidence-based and experience-based approaches in the development of creative solutions to healthcare services in England. This paper examines Practice-Based Commissioning (PBC) in England, which devolves responsibility for commissioning new services for patients to frontline clinicians, relying on their understanding of patient needs at the local level.

Methods:

An 18-month project, funded by the Health and Care Infrastructure Research and Innovation Centre (HaCIRIC), examined PBC frameworks in England, investigating the impact of different models of governance on the development of service redesign proposals to answer the following questions: How do clinicians interpret the multiplicity of guidance from government agencies and translate this into knowledge that can be effectively used to redesign patient care pathways aligned with local healthcare priorities? How can understanding patient and staff “experiences” and key “touch points” of interaction with local healthcare services be used to provide a creative, customized solution to the design of healthcare services in a local, community-based framework?

Can high-impact nursing actions result in enhanced patient care?

Professor Alan Glasper outlines the Government’s vision for an NHS ‘liberated from bureaucracy’, where nurses will be expected to drive quality improvements at grass-roots level

Postoperative handover: problems, pitfalls, and prevention of error

OBJECTIVE

To identify the information transfer and communication problems in postoperative handover and to develop and validate a novel protocol for standardizing this communication.

BACKGROUND

Effective clinical handover ensures continuity of patient care. Patient handovers within surgical units are largely informal. A thorough understanding of the problem is vital to develop standardized protocols.

METHODS

A qualitative semistructured interview study was conducted with 18 healthcare professionals to uncover the problems with postoperative handover and to identify solutions, including components of a postoperative handover protocol. Interviews were recorded, transcribed verbatim, and submitted to emergent theme analysis. Multiple blind coders were used to ensure triangulation and reliability of the coding process. A Delphi method was used to elicit consensus from a group of 50 surgical professionals so as to validate the handover protocol.

RESULTS

Many of the information transfer and communication failures at the postoperative phase are deemed to be due to an incomplete handover. All the interviewed healthcare professionals agreed that postoperative handover should be structured in the form of a standardized protocol so as to prevent omissions of any critical information. Based on this, 28 items were submitted to the Delphi process. Of these, 21 items had a mean importance score greater than 4.0 and were included in the final postoperative handover proforma under the following headings: patient-specific information, surgical information, and anesthetic information.

CONCLUSION

The present study identified that the postoperative handover is informal, unstructured and inconsistent with often incomplete information transfer. Based on end-user input, a handover protocol was successfully developed and validated. Use of this may facilitate standardization of this critical activity and thereby improve the quality of patient care.

The value analysis team: a shared mental model

Value analysis teams, which standardize procurement and use of products across hospitals and health systems, have experienced great success in saving money for health care organizations. One example is the work of the Medical/Surgical Value Analysis Team at a larger New York metropolitan multihospital system, which has saved the system $1.2 million. This article examines what managers need to consider before forming such teams and how to guide the work. It will also look at the qualities and qualifications of the people who must be involved to make the process effective.

Interventions in organizational and community context: a framework for building evidence on dissemination and implementation in health services research

The effective dissemination and implementation of evidence-based health interventions within community settings is an important cornerstone to expanding the availability of quality health and mental health services. Yet it has proven a challenging task for both research and community stakeholders. This paper presents the current framework developed by the UCLA/RAND NIMH Center to address this research-to-practice gap by: (1) providing a theoretically-grounded understanding of the multi-layered nature of community and healthcare contexts and the mechanisms by which new practices and programs diffuse within these settings; (2) distinguishing among key components of the diffusion process-including contextual factors, adoption, implementation, and sustainment of interventions-showing how evaluation of each is necessary to explain the course of dissemination and outcomes for individual and organizational stakeholders; (3) facilitating the identification of new strategies for adapting, disseminating, and implementing relatively complex, evidence-based healthcare and improvement interventions, particularly using a community-based, participatory approach; and (4) enhancing the ability to meaningfully generalize findings across varied interventions and settings to build an evidence base on successful dissemination and implementation strategies.

Experience-based design: from redesigning the system around the patient to co-designing services with the patient

Involving patients in service improvement and listening and responding to what they say has played a key part in the redesign of healthcare processes over the past five years and more. Patients and users have attended stakeholder events, participated in discovery interviews, completed surveys, mapped healthcare processes and even designed new hospitals with healthcare staff. However, to date efforts have not necessarily focused on the patient's experience, beyond asking what was good and what was not. Questions were not asked to find out details of what the experience was or should be like ("experience" being different from "attitudes") and the information then systematically used to co-design services with patients. Knowledge of the experience, held only by the patient, is unique and precious. In this paper, attention is drawn to the burgeoning discipline of the design sciences and experience-based design, in which the traditional view of the user as a passive recipient of a product or service has begun to give way to the new view of users as integral to the improvement and innovation process.