Program. |
Organizational Behaviour in Health Care (OBHC)
Conference. May 13 - 16, 2018 | Montreal, QC |
Program. |
Organizational Behaviour in Health Care (OBHC)
Conference. May 13 - 16, 2018 | Montreal, QC |
In and out of the mainstream: Coordinating inclusivity across organizational boundaries and borders Anna Horton & Tom Shakespeare |
Reducing social health inequalities: A balancing act between cross-sectorial coordination and influencing individual health behavior Gro Kvåle, Charlotte Kiland & Dag Olaf Torjesen |
Negotiating professional and organizational boundaries of emergency care in the Netherlands Peter Nugus, Anne Schoenmakers, Maryse Fröling, Odaily Augustuszoon & Cordula Wagner |
Historically, as in high-income countries, the response to the disability problem in Southern Africa has most often been segregated homes, schools and workplaces. The disabled people’s organization sector, whilst undoubtedly more progressive, is also somewhat separate from mainstream organizations, which arguably may reemphasize difference and ghettoize disabled people all over again. This presentation seeks to explore the coordination of success and support of disabled people in and out of mainstream organizations in Southern Africa. We explore opportunities and limitations of inclusivity through interviews with successful disabled people from Uganda, Kenya and Zambia, who have spent their education and careers in and out of the mainstream. Our findings highlight boundaries and borders created in the facilitation of principles of inclusion for disabled people. Emphasizing the multiplicity of experiences seen in our respondents, our analysis offers insights into how inclusion for disabled people in Southern Africa might be better coordinated across different sectors and organizations. |
Increased social inequality in health is a global challenge. The aim of this paper is to understand how the Norwegian government is tackling social inequalities in health. Applying a collectivist and an individualist approach, we study how ideas about public health are presented and articulated in the national policy. The collectivist perspective considers public health a common good that requires structural and collective solutions. On the other hand, the individualist perspective on public health policy, emphasize individual health choices and health related behavior change. These approaches are applied to describe and discuss empirical findings obtained from content analysis of documents on national public health strategies. The analysis shows a cyclic pattern of priorities alternating between a collectivist and an individualist approach to public health challenges between 2003 and 2017. The paper concludes that the current public health policy is blurred with a complex mix of ideas and measures that need to be balanced in order to achieve goals and to reduce social inequalities in health. |
The emergency Department (ED) represents a sharp case of the challenge of integrated care – optimizing resources, and maximizing specialization among those in different roles, and in different departments, organizations and settings. Emergency medicine (EM) has expanded its scope of practice enormously in the past 50 years, often to compensate for shortcomings in primary case systems. Much of the literature on integrated care has focused on interactional negotiation of jurisdictional boundaries – mainly centred on occupations – on the one hand, and policy-level efforts to enhance care integration, on the other. The aim of this paper is to understand the way an entire disciplinary (sub-occupational) body is positioned, and seeks to influence its jurisdictional boundaries. The case setting for this ethnographic study is the Netherlands, which is unique in having a strong primary care system, but which features a relatively weak status of professionalization of EM. The study was conducted in two large, metropolitan EDs, and in which EM doctors and nurses, and doctors from in-patient specialties were shadowed and interviewed. The findings point to an implied dichotomy between minimalist and maximalist interpretations of EM, the former largely held by emergency nurses and in-patient doctors, and the latter largely held by emergency physicians. Against challenges of legitimacy and organizational power, manifested in financial, spatial and technological incentives in favour of departments and services outside of the ED, EM physicians promote organizational complexity, and coordinative functions in servicing outpatients efficiently, as the foundation of a hoped-for future increase in their professional and organizational status. Grounded in micro-level data, the study is a contribution to meso-level theorizing about the manifestations, context and prospects of negotiating occupational and disciplinary jurisdictions in health care. |
Major system transformation and the public voice: Conflict, challenge or complicity? Graham Martin, Pam Carter & Mike Dent |
Organizational change capability: The role of HR support and the value of an OD orientation Aoife McDermott, Louise Fitzgerald, Tom Powell, Aled Jones & Daniel Kelly |
Health System Transformation in the UK: Implementing the New Care Models in the NHS Gregory Maniatopoulos, David J Hunter, Jonathan Erskine & Bob Hudson |
Calls for major reconfigurations of healthcare systems, to create more joined-up, cross-sectoral, cost-effective care, have been accompanied by recommendations that wideranging stakeholders, including patients and the public, be involved in such processes. But public involvement is fraught with challenges, and little research to date has focused on involvement in such initiatives. This paper examines the design and function of public involvement in major reconfiguration of the English National Health Service. We collected qualitative data including interviews, observation and documents in two English healthcare ‘transformation’ programmes, including public and professional participants. Data were analysed using parallel deductive and inductive approaches. Public involvement in the programmes was extensive, and involved time and effort from both professionals and public participants. All groups acknowledge the importance of public involvement and appeared to engage in the process sincerely, but the programmes’ terms of reference, and the individuals involved as public participants, were constrained by policy pressures and programme objectives. The process highlighted the importance of boundaries between often-homogenised publics: the degree to which participants descriptively or substantively represented wider groups was limited; participants sought to ‘speak for’ the wider public but their own views on what was ‘acceptable’ and likely to influence the process led them to restrict what they put forward, avoiding more contentious or challenging contributions, and providing an input that was sympathetic to the cost-saving ambitious of ‘transformation’. In all, public involvement in these case studies was seen as important and functional, and could not be characterised as tokenistic. Yet it fell short of normative ideals, and could inadvertently reduce, rather than enlarge, public influence on system-reconfiguration decisions. |
In healthcare, organizational change capability is pivotal, but neglected (Fitzgerald, 2017). Given recognition that current systems of health care delivery in developed nations are unsustainable without major reforms (OECD, 2016) organizational change capability is only likely to enhance and endure in importance. Here we consider HR support for organizational change capacity in a UK policy context emphasizing ‘integrated working’ across previously separate health and social care services. Similar trends are evident internationally, and are leading to an increased emphasis on enhanced cross-organisational working – and in some cases mergers over time. Cross organisational working is characterised by ambiguity and complexity, increased by fragmented relationships, and different pay, terms and conditions (Boaden et al., 2008). Thus, HR has a role in developing organizational change capacity that responds to national, as well as organisational, pressures for change in health care. We add to the limited body of empirical knowledge regarding the influence of HR roles on change (c.f. Brown et al. 2017), with a particular focus on the role of the HR function on the development of hitherto neglected organizational change capabilities (Fitzgerald, 2017). Specifically, we respond to calls to empirically assess ‘the desirable form, function and benefit of HR’s support’ (Fitzgerald & McDermott, 2017, 194) for organizational change capability. In so doing, we note the potential value of an OD orientation in enabling HR to contribute to change. |
Following publication of the United Kingdom National Health Service (NHS) Five Year Forward View in 2014, a Vanguard programme was introduced by NHS England charged with the task of designing and delivering a range of new care models (NCMs) aimed at tackling deep-seated problems of a type facing all health systems to a greater or lesser degree. They include: managing rising demand on accident and emergency services, keeping people out of hospital, effecting rapid discharge for those no longer in need of acute care, integrating health and social care, reducing silo working, and giving higher priority to prevention. The principal objective at the heart of the transformation agenda is achieving the Triple Aim: improving the patient experience of care; improving the health of populations; reducing the cost of health care. This paper explores the organisational and policy factors shaping the implementation of five Vanguard pilot sites for the NCM programme in the North East region of England. The NCMs embodied by these Vanguards span urgent and emergency, acute hospital, primary, community and social care services. We aim to identify key aspects that can be shared across all five Vanguards in the region and draw out any lessons learned from the implementation in order to inform future transformational change underway in the NHS. |
Road to nowhere? A critical consideration of the use of the metaphor ‘care pathway’ in health service organisation and delivery Katherine Checkland, Jon Hammond, Pauline Allen, Anna Coleman, Lynsey Warwick-Giles, Alex Hall, Nick Mays & Matt Sutton |
Care trajectory management: A conceptual framework for the institutionalisation of emergent organisation in health and social care Davina Allen |
Increasing the internal and external coordination of a health organization through users’ participation in the implementation of care pathways: Multiple issues of adaptation and coherence Lara Maillet, Georges-Charles Thiebaut, Marie-France Duranceau, Luiza-Maria Manceau, Mylaine Breton & JeanSébastien Marchand |
Care pathways are ubiquitous in healthcare across the world. Introduced as a tool to standardise and control care processes across organisational and professional boundaries, they have become institutionalised within health systems, spawning dedicated journals and professional bodies devoted to their promulgation. However, ‘care pathway’ is a metaphor, and Schon (1993) highlights the fact that metaphors are generative. They do not just describe the world, but they also determine what is seen and what is unseen, what is attended to and what is ignored, and what solutions seem possible. In this paper we explore the use of the care pathways metaphor in health care commissioning (planning & purchasing). Using data from a study of a recent significant reorganisation of the NHS in England, we show that the pathways metaphor was ubiquitous, used repeatedly by interviewees to explain and describe their work. However, we also found that its use is not necessarily straightforward. Conceptualising the task of health care planning as ‘designing a pathway’ may actually make the task more difficult, suggesting a limited range of approaches and solutions. We offer an alternative metaphor: the care map. We discuss how care design might be altered by the use of this different metaphor, and explore what it might offer for patients and care providers seeking to integrate services, whilst paying attention to its generative potential. We argue not for a barren language devoid of metaphors, but for their more conscious use, with active consideration of the effect that particular metaphors might have on the tasks being undertaken. |
This paper argues for the institutionalisation of emergent forms of organisation in health and social care and offers a conceptual framework for this purpose. Drawing on ethnographic research on the organising work of nurses and Translational Mobilisation Theory, this paper extends two classic Straussian concepts – illness trajectory and articulation work – to conceptualise emergent organisation as Care Trajectory Management. While ubiquitous in healthcare systems, emergent forms of organisation lack legitimacy and are not well served by dominant neoliberal management discourses. |
The implementation of care pathways in a Quebecois healthcare organization, aiming to better respond to the needs of users and to increase their participation at all levels of government, will form the basis of our presentation on the issues relating to adaptation and coherence, both internal and external to the organization. Based on the Complex Adaptive Systems (CAS) approach and multi-level governance, we have developed an analytical framework allowing us to highlight the sense-making processes that lead to the adaptation of governance in order to facilitate user participation. This process has three main dimensions that are interdependent: (1) values, (2) identity and (3) cognitive and organizational schemas. A better understanding of this process would make it possible to identify the tools that can guarantee this cultural, organizational and clinical change. Our paper has three objectives: (1) to describe the structure and process of implementing care pathway including the involvement of users; (2) to define the elements of the conceptual framework to account for the characteristics of complex systems, and (3) to outline the research proposals for putting these schemata into practice, in order to support adaptation and change in the organization and its governance. In order to explain the proposed conceptual framework, we put forward and discuss three research proposals. |
Hierarchies of space and the boundaries to care in the Intensive Care Unit Élise Paradis, Warren Liew & Myles Leslie |
An ethnographic study exploring top team use of work and social space to enact strategic activities at a university teaching hospital in the English NHS Sarah Woolley, Graeme Currie & Charlotte Croft |
Know your place: A comparative case study of how place, people and effort shape innovation and coordination of healthcare delivery Rosemary Hollick, Alison Black, David Reid & Lorna McKee |
Much scholarship on healthcare delivery and healthcare practice has noted interprofessional hierarchies, and the noxious boundaries they create among clinicians. Yet this scholarship has rarely placed an emphasis on the role that bodies in space challenge and reproduce these boundaries, despite the fact that healthcare delivery cannot happen when either clinicians or physicians are fictitiously dis-embodied. In this chapter, we draw on an ethnographic study of teamwork in four Intensive Care Units (ICUs) to explore the fruitfulness of applying Henri Lefebvre’s (1991 [1974]) theoretical framework on space to an analysis of clinicians’ and patients’ negotiations of space. Lefebvre’s framework draws attention to the political role of bodies in the production of conceived, lived, and perceived spaces; to the power and hierarchies that are manifested by the interactions of bodies in space. Our narrative analysis of three ethnographic vignettes—which we call “The Fight,” “The Carnival,” and “The Plan”—explores how nurses’, physicians’ and patients’ spatial practices manifest and contest power relationships among them in the ICU. Our vignettes closely document the movement and actions of bodies in space, and thus reflect their importance in boundary processes. We argue that paying particular attention to healthcare actors’ embodied spatial practices can illuminate the complexities of healthcare delivery, making conformity and resistance to interprofessional and care hierarchies visible, but also raising important questions about gender and race. As we demonstrate, the social orderings of bodies in space creates profound boundaries to care, creating frictions and alienations. Using theory makes these orderings visible, and constitutes a first step in redressing them. |
We studied how top managers in a pluralist, public sector healthcare setting used work and social spaces as resources to support strategic change in response to the external environment. Our initial findings, from a year long ethnographic study, using a strategy as practice theoretical frame, have uncovered three different organizational space constellations, associated with different patterns of change: organizationally networked space; externally oriented, (top down) partially networked space; internally oriented, (bottom up) partially networked space. Our findings indicate that the top management team experienced significant challenge in organizing and configuring their strategic space. Only one of these constellations, the organizationally networked space, was associated with an accelerated organization-wide strategic response. Here, the top management team invested extensive resource to create a stabilised network of interconnected work spaces, across their internal and external environments. This space was associated with highly focused material structuring of the space and the social interactions that took place within it. Contrastingly, the two other partially networked spaces did not lead to the same pattern of accelerated change. These meeting spaces were not fully aligned across the executive team’s internal and external environments and were less focussed in terms of the material structuring of the spaces and the social interactions that took place within them. Firstly, we contribute by showing that organizational work spaces are important resources that top managers use to organise their strategic responses and accomplish coupling of their external and internal environments to support concerted strategic activities, in pluralist contexts (Denis et al., 2001; Denis et al, 2007; Jarzabkowski and Fenton, 2006). Our second contribution is to respond to calls for further research considering the material aspects of strategic practices (Vaara and Whittington, 2012). We illuminate the interplay of material resources and social interactions during strategic episodes, as they enfold over time, across an organization, and how the top management team can configure these resources to accomplish their strategic roles. |
In an increasingly complex healthcare system, successful service delivery involves coordination of care across a number of boundaries; physical, policy, organisational and professionals. Yet there is little empirical research examining the dynamic interaction between human action (people), organisations and the wider system context (place) to practically support frontline efforts to improve care. This paper aimed to address this gap, based on six comparative case studies of parallel ‘real time’ and retrospective longitudinal analysis of the introduction of mobile bone density scanning services across diverse organisational and country contexts in the National Health Service (NHS) in Scotland and England. An action research approach informed the work of implementation in real time cases and the Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework (Greenhalgh et al. 2017) was used as a sensitising tool. Findings surfaced the role of ‘place’, people and effort at key stages in shaping the outcome of services ironically designed to eliminate the ‘problem’ of place. In particular, it revealed the importance and multifaceted nature of rurality: as a key driver for initial service development, counteracting negative aspects of the competitive healthcare policy context in England and in shaping the value assigned to the service by service adopters. The ‘right’ or ‘wrong’ kind of rurality was an important determinant of success. The ‘contextual adroitness’ of service champions was key in the early stages of service development to harness opportunities in the wider context. It also revealed important insights into the work of implementation; the importance of continued effort to maintain momentum as well as the role of ‘soft intelligence’ and practical wisdom to navigate around awkward people and places. The study revealed rich learning opportunities and insights into factors influencing effective coordination of care across boundaries and borders which may be practically applied in other healthcare settings. |
Quality improvement interventions and the transformation of organizational practices: What role for theory? Olivier Saulpic, Emilie Berard, Jean-Louis Denis & Philippe Zarlowski |
Developing pragmatic boundary capabilities: A micro level exploratory study of boundary work for quality improvement Catherine French, Laura Lennox & Julie Reed |
What shapes the organisational response to a board-level quality improvement intervention in public sector hospitals? Lorelei Jones, Linds Pomeroy, Glenn Robert, Susan Burnett, Janet Anderson, Estela Capelas Barbosa, Stephen Morris & Naomi Fulop |
Quality improvement (QI) interventions are a specific case of a broader contemporary trend in organizations, which sees the adoption and implementation of managerial tools and techniques as a way to overcome obstacles to practice improvement and change. However, QI interventions remain challenging in the healthcare field. Despite their broad diffusion and the wealth of research on their implementation effects and processes, it remains unclear how and why QI interventions work in practice. Several ideas have been put forward to overcome this problem, including calls for more theory or theorization. This paper aims to contribute to answering these calls. It draws on a recent literature review which describes four research approaches for studying QI interventions: process- and practice-based studies, implementation science studies, descriptive and normative work, and socio-cultural perspectives. The analysis of these approaches shows that the effects of QI interventions involve multiple and reciproqual causal relationships between a large set of constructs that cast doubt on the project of building a theory that would provide an encompassing explanatory model of QI and would be coherent with the implementation science project. Moreover, theory in the other approaches aims to explain organizational change or how change inflences actor representations rather than outcomes. We thus suggest that another conception of theory is needed to help managers and practioners reach predefined outcomes when implementing QI interventions. Based on an analysis of the four approaches and the literature on the theorization of management instruments, we propose a new way to envision theory that takes into account insights from the different approaches, as well as addresses the difficulty of defining an integrative theoretical framework. We call it the action theory of the QI. It is a situated theorization of change constructed and appropriated by local actors based on the research results that are part of the change process. |
Top down packages of managerial ‘quality improvement’ (QI) approaches such as Lean can be ineffective in supporting healthcare professionals to improve care for patients in complex, multi-disciplinary environments. Improving care requires micro level work across knowledge boundaries between different professions and these micro level processes remain under theorised. This qualitative exploratory study contributes to addressing this gap by using Carlile’s (2004) knowledge boundary framework of three progressively complex forms of boundary (syntactic, semantic and pragmatic) to analyse how bottom up, facilitated quality improvement approaches using boundary objects, knowledge brokers and interactions can transform knowledge from different domains and support improved practice. Using 2 QI tools (the Action Effect Method and Long Term Success Tool) as tracer cases, our empirical study draws on 17 quality improvement initiatives in Northwest London, UK. Data collected through semi structured interviews (38), non-participant observations (90 hours) and documents (270) were analysed deductively (using a boundary framing) and inductively to explore boundary interactions at the micro level. Our findings suggest that when the process for object co-creation is supported by knowledge brokers through boundary interactions pragmatic boundary work is more likely to occur. Similar to top down approaches, clinicians do not accept QI tools uncritically: rather those tools that are likely to enact pragmatic work are adapted by professionals to local contexts and preferences in line with professional knowledge jurisdictions. We contribute to the knowledge boundaries literature by providing an empirical case of pragmatic boundary work in healthcare through a bottom up approach and develop our understanding of the socio-cultural context of quality improvement by applying a knowledge boundary framework to under theorised micro level processes. When QI methods are not imposed but allowed to be adapted to local clinician demands they may be more effective. |
This paper reports findings from a qualitative study that formed part of an evaluation of an organisational development intervention (iQUASER) intended to help hospital boards develop and implement an organisation-wide quality improvement strategy. We found that the organisational response to the intervention, and the subsequent effects, were contingent on the availability of ‘slack’, and on ‘organisational readiness’. In two cases the organisation did not benefit from the intervention because the board was not fully functioning. In one of these cases a high degree of turnover in board membership led to what we have called the ‘nominal board’. In the other, the board was, in practice, a performance of decisions that had already been made by the smaller executive team; we refer to this as the ‘staged board’. We discuss the implications of our findings for interventions aimed at developing the capability of hospital boards to improve the quality of patient care. |
Intentional Partnering: A grounded theory study on developing effective partnerships among nurse and physician managers as they co-lead in an evolving healthcare system Christina Clausen, Melanie Lavoie-Tremblay, Margaret Purden & Lise Lamothe |
Beyond hybridity in clinical leadership: A case study of medical curriculum change Simon Moralee & Simon Bailey |
Background: A number of healthcare systems in Canada and abroad are instituting co-leadership models to redistribute responsibility in management decision making. Nurses and physicians are uniquely positioned to share the executive roles of co-leadership. However, little known about how this management dyad operates in the healthcare setting. Context: A nurse-physician management structure (Partnered Management Model) was adopted by senior leaders throughout an urban Canadian university affiliated teaching hospital in 2008 where nurse and physician managers in each division or program were expected to formally “partner” with each other to address clinical management issues. Design: A constructivist grounded theory (GT) approach was used to investigate the process of how nurse and physician managers work together in formalized dyads as GT provides a systematic approach to generating theory that illuminates human behavior as a social process among participants in their interactional context. Methods: Data collection occurred from September 2013 - August 2014. Data included participant observation (N=142 hours) and intensive interviews (N=36) with nurse-physician manager dyads (12 nurses, 9 physicians) collected in a surgical department. Theoretical sampling was used to elaborate on properties of emerging concepts and categories. Results/Findings: A substantive theory on ‘intentional partnering’ was generated. Nurses’ and physicians’ professional agendas, which included their interests and purposes for working with each other served as the starting point of ‘intentional partnering’. The theory explains how nurse and physician managers align their professional agendas through the processes of ‘accepting mutual necessity’, ‘daring to risk (together)’ and ‘constructing a shared responsibility’. Being credible, earning trust and safeguarding respect were fundamental to communicating effectively. Conclusion: ‘Intentional partnering’ elucidates the relational components of working together and the strategizing that occurs as each partner deliberates on what he or she is willing to accept, risk and put into place to reap the benefits of collaborating. |
Although hybridity has a rich conceptual and empirical history in the study of public organisation and management, some dissatisfaction with the concept has emerged in more recent work due to the changing conditions being described in relation to continuing and deepening discourses of new/post new public management and corresponding shifts in professional and managerial work, identities, and ethos. Where a central tenet of the concept of hybridity is an epistemic tension between competing world views, vis-à-vis ‘the manager’ and ‘the professional’ the question is increasingly posed as to whether such tensions are not experienced at the individual level in such a conflicted manner. Put another way, this might suggest that professionals have been successfully enrolled in managerial discourses and practices. This paper examines these questions in light of longitudinal qualitative data generated with participants in a national medical leadership project. By situating the programme and the experiences of participants within a historical account of the changing character of the medical profession in the UK since around the 1970s, we show the intermediary work undertaken by agents in making sense of, internalising and resolving the conflicts experienced in relation to their hybridity. In discussion we consider the conceptual implications of this situation, which counters conventional understandings of professional power and jurisdiction. We conclude by considering the conceptual and practical ramifications of being ‘beyond’ hybridity, and what this might mean for our understanding of resistance and enrolment in professional organisations. |
Public hospital reforms in China: Towards a model of New Public Management? Ian Kirkpatrick |
Reforming health care from within: The rise of the entrepreneurial NHS? Mark Exworthy, Simon Bailey, Damian Hodgson, Paula Hyde, John Hassard & Mike Bresnan |
Collaborative governance platforms in health: an analysis of four empirical cases from the Netherlands Andrea Frankowski |
Despite impressive growth, the Chinese healthcare system is reaching a crisis point, characterised by poor access, variable quality and an increasingly overworked and demoralised workforce. To address these concerns, the government has initiated a series of ambitious reforms of the funding, management and governance of public hospitals. In this paper, our aim is to describe the origins of these reforms and raise questions about how far they imply convergence towards a global model of new public management (NPM). Drawing on a systematic review of published research, we note how plans to ‘modernise’ hospital management in China have much in common with healthcare reforms in other developed countries. However, we also note how the Chinese experience represents a distinctive pathway. With regard to goals and rationale, although there is a continued interest in increasing the role of the private sector, the thrust of current reforms is to reverse previous tendencies of marketization in order to strengthen the public orientation of public hospitals. Second, a key question in the Chinese case is how far the current rhetoric of empowering management and the separation of ‘political’ from ‘managerial’ domains will be realised in practice, given the command and control approach to decision making and the hegemony of the party over government officials. |
A decade of austerity in the UK has had increasingly severe impacts upon the organisation and delivery of health services. An important, but hitherto neglected, aspect has been the response of organisations and their staff. In the face of such austerity, one strategy which many organisations have adopted has been greater entrepreneurialism and commercialism. This has been aided by legislative opportunities enabled by the 2012 Health and Social Care Act (HSCA), allowing NHS Trusts to earn up to 49% of their revenue from non-NHS sources. To date, 9.2% of the income from all NHS trust comes from non-NHS sources (Exworthy and Lafond, 2017). In this paper, we examine the impact of commercialisation upon staff in one organisation. We frame this study in terms of shifting boundaries and meanings regarding public services and commercialisation. Using analysis of 28 in-depth interviews over two periods, we assess their views on the NHS financial crisis, illustrating the shifting boundaries between commercial and non-commercial activities, the associated challenges to identity and the ethical dilemmas this presents. We draw conclusions about the extent and impact of public service entrepreneurialism and its ramifications for the delivery of health services in the future. |
Collaborative governance is seen as a relatively new governance concept, distinct from both traditional – hierarchical, procedural and bureaucratic – and market oriented – performance based and managerial - forms of governance. It departs from a model of equal relationships between involved actors, including government, and it emphasizes collaboration between partners. Collaborative governance has been gaining momentum in the health sector where it is introduced as a promising solution to conflicts arising from misalignments between both hierarchical and managerial types of governance and medical practice. Recently, public administration scholars have recognized collaborative governance platforms as important drivers for collaborative governance. Instead of single case collaborative efforts, platforms allow for an understanding of collaborative governance as an overarching governance principle of many different multi-actor initiatives. This study analyses four health cases in the Netherlands in which collaborative governance platforms play a major role. In all cases, the Dutch Ministry of Health engaged in a multitude of direct partnerships with health organizations and additionally with other health actors (such as authorities, agencies, medical associations and other representative organizations, sectoral and support organizations and knowledge institutes). By focusing on prominent logics of platforms directed at two key elements, namely goal setting (open-end goals, shared processes and evolvability) and actors (intermediation and openness to actors), and by means of a document analysis (N = 121) and interviews with relevant stakeholders (N = 56), this study examines which (new) roles for health actors emerge from applying a collaborative governance platform approach in health. |
Coordinating care across boundaries in mental health facilities: A qualitative approach to understanding perceptions of fit at work Jessica Herkes, Kate Churruca, Louise A. Ellis & Jeffrey Braithwaite |
Let’s have a meeting: How hospitals use scheduled meetings to support cross-boundary collaboration Thim Praetorius, Peter Hasle & Anders Paarup Nielsen |
Wait, the baby could die! Integrating expertise differences in a hospital merger Karla Sayegh & Samer Faraj |
In the midst of the burgeoning interest in organisational and workplace culture within healthcare, there is growing recognition of the importance of an individual feeling they fit in at work. This paper focuses on the individuals’ perception of fit in 31 primary mental health facilities across six Australian states. It examines perceptions of fitting in, in the context of geographical (state), psychological (self-other) and organisational (person-environment) boundaries of one national organisation. To explore how individuals perceived this sense of their own fit within the workplace and organisation, a hybrid thematic analysis was conducted on information from two qualitative sources: extended response survey questionnaire items (n=156) and follow-up interviews (n=9). Three themes were derived from the thematic analysis. The first was based on the individual adapting to his or her workplace to achieve compatibility. The second highlighted a different mindset in which some participants were adamant they should be their authentic selves in the work environment. The third explored needs-supplies fit, and the ways the environment could support the individual to increase fit. Ultimately, the data suggested themes regarding the boundary between the self and the environment, and between different workplaces. The results propose that, contrary to previous studies, boundaries between the person and their environment are permeable rather than rigid. There is a need to recognise that both individuals and environments are not static in their characteristics, but rather have the propensity for flexibility and adaptation. |
This paper studies how and why hospitals use scheduled meetings in practice. The many negative views on meetings expressed by health care professionals coupled with the fact that hospitals use them extensively make meetings an interesting research phenomenon. By focusing on the how and why of meetings, we add to previous research studying when meetings are used (e.g., task and input uncertainty). In particular, we focus on meetings’ role for achieving collaboration across occupational and departmental boundaries and for developing the collaboration skills component of organizational social capital: factors attributed to patient safety and quality. We carried out a qualitative multiple-case study of five departments in four Danish hospitals and identified two general meeting types: Operational, daily meetings such as huddles and work shift meetings; and Quality, improvement meetings such as Kaizen. Because meetings create space and time for dialogue they are key means for managers and staff to manage interdependencies and collaborate efficiently about solving tasks. The meetings are typically short, focused and led by a chair, and for meetings to be valuable, meetings should make sense and help those involved to solve concrete care tasks. Meetings are often inter-disciplinary, thereby having the potential to develop relations, common goals and trust (organizational social capital components) across occupational and departmental boundaries. For hospital managers, our findings are important because they can use meetings to respond to the pressing need for more and better intra-organizational health care collaboration. Using meetings sensibly also allows hospitals to benefit from the positive outcomes of collaboration and social capital (e.g., knowledge sharing, performance and employee wellbeing). |
When human lives are at stake, implicated experts must perform their work reliably and consistently. In extreme contexts where the work is unpredictable, complex and time-sensitive, and errors can be fatal; performance differences in work practice are deeply consequential and must be resolved. This 24-month longitudinal field study examines how two groups of medical experts in a single occupation integrated differing performances of care work on a single type of ill baby following the largest hospital merger in recent Canadian history. Our findings highlight the salient role of occupational newcomers in mobilizing the structural tools of the occupation (i.e. protocols as rules) as resources to spread accountability across various roles, thereby provoking a resolution of differences among seasoned experts. Our contribution revisits the one-sided view of expertise-based socialization that renders novices as green blank slates in need of legitimation from more central experts. We extend this view by showing how newcomers can play an active part in re-socializing seasoned hands while themselves becoming socialized. We found this reciprocal socializing process to be a critical mechanism by which expert practice performances were integrated following a radical change in extreme organizing. The deployment of formal occupational tools and rules by novices to activate a crucial integrating condition, accountability, also illustrates the interplay between formal mechanisms and informal approaches in the coordination of expertise. Our study also highlights the importance of examining integration processes in a situated, longitudinal manner in order to understand the dynamics of how expertise-based organizations respond to radical, discontinuous changes such as a mergers or organizational restructurings. Thus, we provide a processual understanding of how expert work practices are integrated within a single high-reliability occupation. |
Crystallizing management: The institutionalization of kaizen in Ethiopia’s sugar factory campuses Gordon Shen, Peter Martelli & Fekadu Deresse |
Losing the battle and winning the war? How change leader receptivity and responsiveness to resistance affect change targets’ engagement Kelly Thomson & Maitreya Coffey |
The public’s trust and information brokers in health care, public health and research Jodyn Platt, Minakshi Raj & Sharon Kardia |
This is a qualitative study of two-fold diffusion of kaizen: From Japan to Ethiopia and from the manufacturing to the health care facilities in the Ethiopian sugar industry. We address two research questions. First, how do managers and frontline workers interpret and implement a novel, foreign management modality? Second, is the adoption of a new management model problematic in an emerging economy, or one that is transitioning from being centrally planned to being market-based? We reviewed archival documents, engaged in non-participant observation, and conducted 35 semi-structured interviews. We organized the data using NVivo and analyzed them using abductive reasoning. In so doing, we found that high goal specificity is a requisite for a management innovation to be disseminated within the Ethiopian Sugar Corporation. We also found evidence that the institutionalization of a management innovation entails adequate staffing and a constant rotation of the personnel belonging to different levels of the sugar factory, akin to the turning of a Rubik’s Cube. Finally, an external agent, like the Ethiopian Kaizen Institute, can mediate managers and frontline workers’ involvement in the institutionalization of a management innovation. This external agent can also broker knowledge across organizations, sectors, and countries. Our findings fill a niche in the intersection of cross-cultural management and world polity theories. |
Ford et al (2008) argued that organizational scholars have approached studies of organizational change from a ‘managerialist’ perspective, presuming that change leaders’ prescriptions are correct and resistance to change is a barrier to be overcome. They suggest that resistance may instead be construed as constructive “feedback” to change leaders, helping them to improve the change programme to better achieve overall objectives. We outline how perceptions of change leader receptivity and responsiveness to “resistance” can affect change targets’ views and continued engagement with the change programme as well as their willingness to acknowledge practices that diverge from the programme. This study documents the efforts of a team of change leaders who developed a program to improve handoff practice with a view to achieving reductions in medical errors. Drawing on focus groups and interviews with almost 100 of the participants drawn from 8 hospitals across North America, we illustrate that while the pattern of adoption across sites was remarkably similar, residents’ perceptions of the implementation process, the valence of their overall views of the programme as and their willingness to disclose patterns of adherence/divergence from the programme varied quite dramatically across sites. |
The nation is investing in technologies such as electronic health records (EHRs) in order to collect, store, and transfer information across boundaries of healthcare, public health, and research. Health information brokers such as healthcare providers, public health departments, and university researchers function as “access points” to manage relationships between the public and the health system. The relationship between the public and health information brokers is influenced by trust; and this relationship may predict the trust that the public has in the health system as a whole, which has implications for public trust in the system under circumstances of health information data sharing in the future. In this study, we aimed to examine characteristics of trustors (i.e., the public) that predict trust in health information brokers; and further, to identify the factors that influence trust in brokers that also predict system trust. We developed a survey that was administered to respondents in 2014 using GfK’s nationally representative sample, with a final sample of 1,011 participants and conducted Ordinary Least Squares (OLS) regression for data analyses. Results suggest that healthcare providers are the most trusted information brokers of those examined. Beliefs about medical deceptive behavior were negatively associated with trust in each of the information brokers examined; however, psychosocial factors were significantly associated with trust in brokers suggesting that individual attitudes and beliefs are influential on trust in brokers. Positive views of information sharing and the expectation of benefits of information sharing for health outcomes and healthcare quality are associated with system trust. As such, our study suggests that demonstrating the benefits and value of information sharing could be beneficial for building public trust in the health system; however, trust in brokers of information are variable across the public; that is, knowledge, attitudes, and beliefs influence the level of trust different individuals have in various health information brokers—suggesting that the need for a personalized approach to building trust. |
Killing time: Professionals, patients and long-term care Ruth McDonald & Marianna Fotaki |
Dynamic risk in mental health services Agnieszka Latuszynska, Eivor Oborn & Patricia Reay |
Framing Contests and Legitimacy: Compromises and Settlements in an Integrated mental health service Tom Forbes & Robin Fincham |
A key assumption in the organisations literature is that time pressures have negative impacts on individuals and groups and that having more time available for tasks will produce positive benefits. This paper challenges this supposition using a study of mentally disordered offenders and the professionals who care for them. Based on our data, we find that the absence of time pressures leads to surprising consequences, in light of existing literature, creating problems for staff and patients. To make sense of this empirical puzzle, we develop theory around the emotional processes and temporal orientations of individuals that allow them to cope in the absence of time constraints. We investigate our research questions using a case study from the field of forensic psychiatry in England. This concerns patients who are treated in enclosed facilities where government policy ostensibly aimed at curing and returning them to the community is at odds with the reality that many will remain hospitalised for most of their lives. Doctors and patients interact with each other over many years and the pace of life is more relaxed than that characterising most healthcare settings. Drawing on 70 interviews, focus groups and site visits, we ask how people cope in the absence of time pressures. This might seem to be a strange question and we might think that organisations characterised by such a state of affairs are so untypical or deviant that any learning from them has limited applicability. We suggest that this is not the case and we draw on psychodynamic literatures to explain the reasons for this state of affairs. |
In this paper, we contribute and elaborate on a dynamic approach to risk as encountered by an acute crisis team in Mental Health Services. Dynamic risk is characterised by several key attributes that differentiates it from the static risk traditionally analysed in literature. Dynamic risk is multifaceted and the spectrum of case specific risks is large and cannot be measured in advance. It is emergent in the sense that relevant information about its intensity and type arises gradually and is indicated through multiplicity of risk markers that may or may not be accurately observable. Consequently, the recognition of dynamic risk requires continual reassessment as it unfolds over time. Dynamic risk also evolves on both short and long timescales simultaneously. Its short time scale relates to outbursts of high risk that have an episodic nature and is characterised by unpredictable changes. The long term risk trajectory may achieve stability given appropriate stabilisation stimuli and protective layers have been put in place. We present how different professionals in Mental Health Services conceptualise the dynamic risk they deal with, how they focus on its different aspects, discover it through continual reassessment and collaborate in their tailored actions to manage risk as a team. |
The integration of health and social care services have been a consistent problem in the UK and internationally for many years. Health services (provided by the UK NHS) and social care services (provided by UK Local Authorities or Councils) have been delivered by separate agencies working independently and are funded in different ways adding to problems with integration. There has been significant duplication and resource inefficiencies in the absence of a whole-systems approach to care. Following repeated attempts to encourage integration, this key area of public policy remains problematic. Using a series of semi-structured interviews, we provide an examination of an integrated mental health service brought together by the implementation of Scottish Government policy. We use framing and frame analysis to identify NHS and managerial group responses to the new service and how framing contests between these groups were used to legitimate specific action and reaction to integration. We found that each group had a particular view of each other and of integration shaped by group collective action frames which dictated responses to integration. These responses sought to either maintain existing institutional arrangements in mental health (NHS groups) or to change to a new way of working (management group). While positions were entrenched, frames moved to be more accepting of integration due to the benefits brought by changes to working practices. This process highlights the importance of collective action frames in setting legitimation agendas with the framing processes of actors adapting to new circumstances allowing compromise and settlement in the new service arrangements. |
The Role of objects in sustaining and disrupting professional jurisdictions in health care Bjørn Erik Mørk, Davide Nicolini & Jasmina Masovic |
A pebble in still water: How implementing 3D printing reconfigures boundary relations in a UK hospital Stavros Polykarpou, Michael Barrett & Samer Faraj |
Implementing best practice: The challenge of reworking boundaries in order to scale innovation Graeme Currie, Eivor Oborn, Gareth Owen, Karl Prince & Giovanni Radaelli |
In this paper we explore the neglected role of objects in jurisdictional struggles in healthcare. We build on the results of a longitudinal study of Transcatheter Aortic Valve Implantation (TAVI), a ground breaking medical procedure in the field of cardiology. Contrary to the traditional view which gives prominence to social, symbolic and discursive elements, we show that technologies, spaces and technologies play a central role in the negotiation of occupational and professional jurisdictions. We argue in particular that objects, artefacts and their configurations constitute both the trigger of jurisdictional tensions and conflict, the arena where these conflicts are played out and the outcome of past struggles. Objects, artefacts and their configurations can therefore both maintain and disrupt occupational and professional boundaries. We conclude by suggesting that careful attention needs to be paid to materiality when analyzing the dynamic between occupations and professions in Healthcare. |
This paper examines how occupations mobilize and protect their jurisdictional boundaries when a new technology creates upheaval in the context of healthcare.We report on a two-year, longitudinal qualitative study of how medical 3D printing – an emerging technology that transforms digital models into physical objects – was implemented in a UK hospital. We adopt a practice lens for examining boundary work practices as enacted by different occupational groups, viewing boundaries as relational, dynamic,and in a state of becoming. We extend theory on how occupations enact boundary work practices when a new technology is implemented in an organization and focus on how jurisdictional boundaries are challenged over time; how new competences are developed, new roles established, status challenged or reinforced and with what occupational consequences for the groups involved. Our findings highlight the ongoing jurisdictional contestations between four groups, and the consequentiality of their boundary work practices for their task boundaries and status. Additionally, the findings support calls for a sociomaterial perspective on work and organizing, presenting an opportunity for unpacking how the materiality of artifacts and spaces is constitutive of the way occupations mobilize,maintain and expand their jurisdictional boundaries. |
Our study considers the global challenge of scaling up healthcare innovation, which requires knowledge to cross professional and organisational boundaries. Our study builds on recent research that examines benefits of “hybrid” knowledge mobilisation approaches within healthcare. Two broad solutions are presented in the knowledge mobilisation literature. One solution is the ‘blurring’ of professional and organisational boundaries through, for example, development of communities of practice that engage a wide range of clinical practitioners to mobilise knowledge. Another solution is the ‘bridging’ of professional and organisational boundaries to mobilise knowledge through, for example, knowledge brokering by a clinical champion, or via a more sociomaterial means, such as a training programme or protocol. To consider the effect of blurring and bridging strategies upon scaling up, we draw upon geography literature about ‘scalecraft’ to take account of boundaries to be crossed from which different types of scaling are derived -- scale framing, scale jumping, scale bending, Empirically, we identify variations in the type of scale up apparent across three comparative cases of triage: medically unexplained symptoms, pregnant women presenting at hospital, older patients with a trauma and orthopaedic condition. We consider attempts to scale up evidence-based interventions within and beyond the hospital within which the intervention originated. Our study highlights both blurring and bridging professional and organisational boundaries are evident, but the balance between the two relates to type of scaling. Thus, we develop a contingency model of knowledge mobilisation (bridging or blurring) related to type of scaling (scale jumping, scale bending, scale framing). Following which, we outline implications for policymakers and healthcare organisations keen to scale up innovation across healthcare systems. |
Strengthening a Climate of Safety following a Never Event John Richmond |
How does context explain variations in the implementation of patient safety programmes? Simon Cooper & Martin Kitchener (presented by Martin Kitchener) |
Organisational communication as trespass: A patient safety perspective Deborah Debono, Joanne Travaglia & Hamish Robertson |
This in-depth qualitative case study follows one interdisciplinary surgical team's journey through a Never Event which strengthened their team's climate, becoming safer, and encouraged speaking-up among professionals in lower hierarchical positions. This study looks at evidence for enhanced use of voice by professionals in response to the occurrence of a never event. Multiple factors are involved in strengthening a climate of safety, including a collectively vigilant mindset, and invigorating a sentiment of care among professionals. While many professionals are affectively impacted, labeled as `second victims' of medical error, some thrive following these traumatic events, performing above previous performance levels, contributing to a safer climate. These factors are explored in detail, and recommendations presented so that other healthcare teams can learn from this experience, to strengthen their climate, and prevent further Never Events. |
We explored the impact of the context for implementing patient safety programmes by considering the interplay between key groups of actors (policy designers, hospital executives and clinicians). Drawing on a standard model from social science, our analysis concentrated on three levels of context: (i) the macro level, of the political economy, (ii) the meso level, of the hospital, and (iii) the micro level, of individual activity in relation to the implementation of patient safety programmes. By focusing on these layers of context we had a basis for analysing the implementation of patient safety, identifying variations to the delivery of programme interventions. Our decision to concentrate on three layers of context also enabled us to identify differences to implementation relating to the broad systems of commonly-held beliefs and values (logics). These logics shaped interests and behaviours during the introduction of the Welsh patient safety programme. In addition to the persistent influence of the two traditional and competing logics within healthcare: (i) the bureaucratic command and control logic, of hospital executives, emphasising standardisation, and (ii) the professional logic of clinicians, emphasising autonomy and discretion, we also identified the emergence of (iii) an improvement, logic that was mobilized by programme designers to combine elements of the traditional bureaucratic and professional logics. We add to the few research studies recognising that the implementation of patient safety can occur in different ways, within different contexts. We also offer a nuanced examination of the context for implementing patient safety at the macro, meso, and micro stages. |
Significant, sustained improvement in patient safety has proved to be a difficult goal to achieve. Attempts to address the problem have largely focused on technical solutions to what are conceptualised as clinical, cultural or systems issues. While communication is at the core of many remediation strategies, the focus has remained largely on communication between professionals or professionals and patients, and on the creation of centralised guidelines as communicative mechanisms for the transmission of approved practice. As a result of the limited impact of current attempts at improvement and the consistent findings of patient safety inquiries internationally, new ways of conceptualising and exploring the internal organisational relations and actions which are meant to constitute safe actions, need to be developed. Utilising theory from geography and sociology, we draw analogies between ‘objective’ space and ‘subjective’ place in order to propose and reconceptualise trespass and transgression, traditionally positioned as infringements, as acts of resistance: mechanisms for intrusion which intentionally or unintentionally disrupt the territorial claims of professions and organisations. Drawing on the literature, our research, and professional experience we discuss two forms of trespass: that of the largely invisible and understudied ancillary staff into the world of clinicians; and the use of workarounds by clinicians themselves. In both cases, the transgression is intended to increase rather than decrease patient safety, and could, upon further examination prove to do so. Trespasses and transgressions in this light offer the opportunity to make visible people, relationships and actions which have previously remained hidden in our understanding of, and therefore proposed solutions to, patient safety |
Too many hands on the wheel? The impact of leadership churn on quality of care in public hospitals Sandra Leggat & Cathy Balding |
Tempered tenacity: The leadership required to work across boundaries Liz Wiggins & Janet Smallwood |
Exploring the contribution of middle managers to strategic processes in healthcare organizations: A scoping review Jennifer Gutberg, Whitney Berta, Tyrone Perreira & G. Ross Bake |
Purpose. The purpose of this study was to explore the relationship between frequent turnover (churn) of the chief executive officer (CEO), quality manager and members of the governing board with the quality systems and quality improvement outcomes in eight Australian hospitals. Method. A mixed method three year longitudinal study was conducted using validated quality system scales, quality indicators and focus groups involving over 800 board members, managers and clinical staff. Findings. There were high levels of both governance and management churn during the three year study. Churn among CEOs and quality managers was negatively associated with compliance in aspects of the quality system used to plan, monitor and improve quality of care. Qualitatively, staff identified lack of quality improvement vision in the hospitals and changing priorities with high levels of churn, which they described as confusing and de-motivating. There was no relationship with quality processes or indicators detected for churn among governing board members. Practical implications. Governing boards must recognize the risks associated with management change and minimize these risks with quality governance processes that assure the focus of management on strategic, long term quality improvement. Value. While management turnover and lack of consistent leadership has been blamed for quality problems, this is the first study that uses longitudinal empirical data to explain some of the ways in which these changes are associated with the effectiveness of organisational quality systems and clinical quality results. |
The healthcare landscape is a veritable patchwork, with multiple boundaries that define and divide ways of working and local cultures between and within organizations, between professions and between layers in the hierarchy. Policy shifts signal the imperative to move from fortresses to more collaborative way of working (Ham et al., 2015) but with little specification of the leadership required from either a theoretical or practical perspective. Action Research, undertaken with 25 senior health leaders across the NHS, in all four countries of the UK, seeks to address this gap by exploring the leadership required to work well across boundaries and borders. The findings suggest an interlinked and nested set of benefits arise from adopting an approach to understanding organizations and leadership informed by complexity thinking (Stacey, 2015). Such an approach frees leaders of the felt need to be in control and, rather than reifying borders, allows them to see them as mutable, permeable and socially constructed. Change is viewed as happening one conversation at a time (Shaw, 2002) with a focus on making small but often significant moves that build relationship and trust. A further theme emerging from the research is the need for leaders to be thoughtful, choosing with care when and how to challenge the power relations embedded in the status quo, to make ‘in the moment’ judgements about walking the line versus toeing the line and to do so persistently, often over considerable time. This combination of complexity informed thinking, relationship building through small gestures persistently, with the intent of working well across perceived boundaries, we call tempered tenacity. |
Rationale: Leadership is one of the most impactful and frequently cited factors associated with organizational change. Theories of implementation and change management support the importance of leadership at all levels facilitating change, and recently, the importance of leadership at the level of middle management (MM) in strategic change initiatives has been highlighted. This paper aims to better understand current evidence regarding MM’s contribution to strategic processes, particularly in the healthcare context. Objectives and Research Question: This paper will present a scoping review which aims to map out and synthesize the extant literature on the subject, and is guided by the following research question: What is the contribution of middle managers to the strategic processes of healthcare organizations? Methods: Comprehensive literature searches were conducted four databases, and grey literature was searched as well as reference lists. 1,993 total abstracts were scanned and 80 were included in the full-text search. Results: 61 articles were included in the scoping review. Qualitative thematic analysis of the articles led to the development of three overarching themes related to the role of MM in strategic processes. These themes are articulated as three key questions: 1) What are the activities that MM engage in throughout the strategic process?; 2) What are MM’s needed skills and capabilities to influence strategic processes in healthcare organizations?; 3) What are the contextual barriers and facilitators related to MM and strategy? Conclusion: This review provides an important synthesis of the existing literature on middle managers and their current – and potential – contributions to the strategic management processes of healthcare organizations. The results demonstrate that MM do appear to be in a position to meaningfully influence the strategic process, from planning through implementation and sustainment. However, MM require the necessary conditions in order to meaningfully contribute in this way, instead of shifting to the other extreme and becoming barriers to the strategic process. Senior leadership should actively involve MM as early in the planning process as is feasible. |
Are public sector managers a ‘ bureaucratic burden’? The case of english public hospitals Gianluca Veronesi, Ian Kirkpatrick & Ali Atlanlar |
Coordinating the oversight of care across public governors and executive boards: A deliberative analysis of hospital governance in England Ross Millar, Tim Freeman, Russell Mannion & Huw Davies |
Governmentality as a relevant idea for the study of healthcare networks: A scoping review Jean-Sébastien Marchand, Dominique Tremblay & Jean-Louis Denis |
Although managers are, globally, a central part of the new public management reform agenda, in recent years policy makers, the media and the general public have raised concerns about their effectiveness and contribution. In some countries, notably the UK and the US, this debate has been heavily influenced by public choice theory (PCT), which depicts ‘bureaucrats’ as rent seeking, self-serving individuals. In this study, focusing on the case of acute care hospital trusts in the English National Health Service, we formally test whether public sector managers represent a ‘bureaucratic burden’. Using a longitudinal database spanning six years (2007-2012) and employing multivariate regression analysis, the findings reveal that, contrary to PCT assumptions, managers do not engage, in the main, in rent seeking behaviour and, crucially, appear to have a positive impact on organisational performance. Specifically, we find that a higher manager-to-staff ratio is positively associated to better patient experience and lower infection rates (while not negatively affecting financial efficiency). The effect on all three outcome measures is positively confirmed and accentuated when managers have higher salaries and greater employment stability. Implications for theory, policy and practice are discussed. |
Public and user involvement in healthcare services planning and management decisions remains a contested field. Debates range over the intrinsic value of such involvement and the extent to which potential benefits are realised in specific instances. We draw on recent developments in deliberative theory to make an empirical contribution, exploring the interface between experts and local stakeholders within NHS Foundation Trust (FT) Hospitals in England. These organisations have complex internal governance arrangements, intended to provide space for the articulation of co-operative and mutual traditions of ownership and accountability for staff, patients and members of the wider local public. While recent studies of NHS FT Hospital governance have explored the role and experience of FT Governors and examined FT hospital Boards to understand how executives exercise oversight, there is currently no detailed investigation of interactions between Governors and members of hospital Boards in England. Using a case study design of four hospital trusts (n=4) we draw on observational and interview data to directly address this gap in the literature and explore the local instantiation of these complex internal governance arrangements as ‘deliberative systems’. By tracing interactions between the actors involved and exploring their understandings of events, we explore the extent to which the promise of ‘meta-regulation’ was realised at each site, examining how public Governors become informed about governance issues; how they engage with the executive Board; and the extent to which deliberations create a space for shared understandings of hospital governance. We maintain that this approach has an essential role to play in developing our understanding of how deliberative systems function, the nature of their interconnections, how they are experienced, and how they might be improved. |
The notion of “governmentality” has been increasingly employed in the study of healthcare systems and especially healthcare networks. In this article we present a state of the science on the use of governmentality in the study of healthcare networks, aiming to clarify how the notion has been used in existing literature and propose avenues for future research. A scoping review is undertaken to explore studies applying governmentality to healthcare networks. The review covers 17 databases over a 42-year period between 1975 and 2017. We identify 1673 records, of which 98 are fully assessed and 38 meet inclusion criteria. Our review shows three usages of “governmentality” in the domain of healthcare networks: as an epistemology, as a framework, an as a specific form of governance. For each record, we detail the object of study, the network analysed, the country of origin, method and data sources, and the definition of governmentality. The review contributes to clarifying the usage, definitions, and concepts of governmentality in existing literature on healthcare networks. We propose that the idea of governmentality warrants great attention in future research, while cautioning that more careful definition of terms and concepts is needed to improve the coherence of this body of work. We conclude on knowledge gaps and promising avenues for future research. |
Trial and error, together: Divergent thinking and collective Learning in the implementation of Integrated Care Networks Jenna Evans, Agnes Grudniewicz & Peter Tsasis |
The role of teams’ social capital on employees’ knowledge sharing: A cross-level investigation in healthcare operations Giovanni Radaelli, Emanuele Lettieri, Matteo Mura & Nicola Spiller |
Enacting care in healthcare teams: Developing knowledge and expertise from lived experience Eivor Oborn, Michael Barret, Steven Gillard & Sarah Gibson |
Integrated care networks that link disparate professionals and organizations are increasingly common in healthcare as a means to deliver integrated care to patients. Recent literature argues that successful implementation of integrated care networks demands a socio-cognitive perspective in which stakeholder mentalframes and thought processes are prioritized, investigated, and compared. Theaims of this paper are to identify where mindsets diverge among clinical andmanagerial stakeholders involved in the implementation of integrated carenetworks known as “Health Links” (HLs) in Ontario, Canada, and to describe strategiesto support stakeholders’ capacity to collectively learn and develop more convergent views. Two theories were used to guide the study, practice-based learning theory and shared mental model theory. A secondary analysis was conducted of semi-structured interview data with 55 healthcare professionalsand managers involved in the implementation of HL networks. Overall,participants conceptualized the implementation of HLs as a learning process,involving trial and error and gradual adaptation. Using the IntegrationMindsets Framework, we identified examples of divergences in stakeholders’conceptualization of the HL design and approach (“strategy mental model”) and theirperceptions of each other and how they work together (“relationship mental model”). We also identified four strategies that facilitate learning andpossibly mental model convergence. The results of the study can be used to facilitatemulti-stakeholder dialogue towards collective learning and coordinated actionfor integrated care delivery. |
Knowledge sharing is crucial for production and delivery systems, especially when they cannot be standardized. Past research acknowledges that individuals with more personal connections with external actors have more interest and opportunities to share their operational knowledge. Our study extends this evidence investigating how team-mediated connections influence employees’ knowledge sharing behaviors. Operations management is showing increased interest in cross-fertilizing its discipline with psychological and organizational theories to study complex operational dynamics. The study contributes to this effort by showing how team properties influence employees’ perceptions of the benefits, opportunities and pressures associated with operations-relevant behaviors. Hospice and Palliative Care Organizations (H&PCOs) are exemplary for our study. We collected a sample of 226 employees embedded in 39 teams in four H&PCOs. We evaluated the model through multilevel structural equation modelling. Employees embedded in teams with greater social capital share knowledge more often. Different dimensions of team social capital elicited distinct responses: structural social capital increases employees’ exposure to others’ view, and thus their perception of social pressures and opportunities; relational social capital increases employees’ affective bonding, and thus their awareness of social responsibilities; cognitive social capital increases employees’ attitude toward knowledge sharing. Our study remarks that employees embedded in teams that are richer with social connections with the ‘outside world’ are more likely to perform behaviors that are socially and operationally relevant for the organization. Possible approaches to increase team social capital are suggested in the manuscript. |
Our research contributes an understanding of how different forms of knowledge and expertise are important in caring for people with mental health problems. We build on the theoretical developments regarding the multiple ontologies of knowing about illness, and how one can know illness as an object or a subject. We examine how knowledge of mental health problems, learned by being subject to illness rather than through objective study, is enacted in healthcare teams. Our case study examines how Peer Support Workers, individuals who have lived experience of mental health problems, contribute knowledge and expertise to patient care by working within multidisciplinary healthcare teams. We find the knowledge and expertise in practices of caring for patients with mental health problems do not draw on a singular reality of mental illness, but rather multiple ontologies of knowing about mental and physical health. Our paper contributes new insight into subjective knowing and expertise as important elements of tacit knowledge. We suggest that subjective knowledge is temporally embedded into lived experiences, in contrast to objective decontextualized ways of knowing. Further, our findings suggest that subjective knowledge supports care practices around managing risk, social coping, and the reshaping of relationships. |
A dynamic capabilities view of improvement capability Joy Furnival, Ruth Boaden & Kieran Walshe |
Accomplishing reform and systems improvement in international context: Learning about change within and across the borders of 60 countries Jeffrey Braithwaite, Kristiana Ludlow, Wendy James, Jessica Herkes, Louise A. Ellis, Kate Churruca & Elise McPherson |
A qualitative exploration of sustainability processes for improvement: The role of structured sustainability tools Laura Lennox, Catherine French & Julie Reed |
Organisations increasingly operate in rapidly changing environments and present wide variation in performance. It can be argued that this variation is influenced by the capability of an organisation to improve: its improvement capability. However, there is conceptual heterogeneity within the literature, and there is insufficient theoretical research on capability-led improvement interventions. This paper sets out the current diverse body of research on improvement capability and develops a theoretically informed framework. The conceptualisation of improvement capability is reviewed before critiquing three capability-led theoretical perspectives. One, the dynamic capabilities view, takes a process view of performance and focuses on how organisational routines bundle and interact. Dynamic capabilities are configured from three constituent microfoundations: sensing, seizing and reconfiguring, which can be unpacked into individual factors requiring orchestration. This is used to explore how improvement capability can be understood, contributing to the literature by identifying and inductively categorising eight dimensions of improvement capability into these microfoundations. This illustrates that the three microfoundations that make up a dynamic capability are present in the identified improvement capability dimensions. This paper conceptualises improvement capability as a dynamic capability, comprising organisational routines that are bundled together in a unique way to adapt and react to organisational circumstances. This theoretically based framework provides a richer explanation of how improvement capability can be configured within an organisation. Breaking improvement capability into its component parts helps explain why some organisations are less successful in improvement than others. Microfoundation orchestration is required to ensure that focus on one microfoundation is not at the expense of another. This perspective can support managers to identify improvement capability dimensions in need of attention. Further research is now required to understand how the improvement capability dimensions are orchestrated, inter-relate, and aggregate at a micro-level. Empirical research is particularly required from non-market situations, such as healthcare. |
Much work about health reform and systems improvement in healthcare looks at shortcomings and problems that every system faces. Few comparative international studies of health systems include a sufficiently wide selection of low-, middle- and high-income countries in their analysis. We address these issues by examining recent work which involved the reform and improvement efforts of 60 countries, focused on them each providing a case study of success. We use this extensive source material, a compendium of these success stories in a book to be published in 2018, and derive, through a grounded analysis of them, nine themes which have widespread application beyond the boundaries of any one health system: Improving policy, coverage and governance, Enhancing the quality of care, Keeping patients safe, Regulating standards and accreditation, Organizing care at the macro-level, Organizing care at the meso- and micro-level, Developing workforces and resources, Harnessing technology and IT, and Making collaboratives and partnerships work. These universal themes provide a model of what constitutes success across this wide sample of health systems, offering a store of knowledge about the way successful reforms and improvement initiatives can be articulated and used as a source of learning about change across the borders of health systems. Whether low-, middle- or high-income countries, researchers, policymakers, managers and other stakeholders have a lot to learn from each other, across their bounded interests, about how to improve healthcare and health systems. This work acts as a counterbalance to the usual way of assessing reform and systems improvement, which is to critique progress, or study only one or a handful of countries. It is a more balanced approach to consider where achievements are being made across healthcare, and what we can do to replicate and spread successful exemplars internationally. |
Introduction: Many promising improvement initiatives fail to sustain and do not produce long term benefits. This has resulted in a growing interest in understanding how sustainability of initiatives can be influenced. To aid the analysis of sustainability in practice, various tools have been developed. There is little evidence on if or how these tools influence initiative processes or outcomes. This paper aims to investigate the processes by which improvement teams influence sustainability in improvement initiatives using The Long Term Success Tool (LTST). Methods: A longitudinal mixed methods study was conducted from January 2015 to July 2017. Data was collected from 3 Quality Improvement programmes in the United Kingdom. The LTST was used across programmes at varying intervals during initiatives. Observation (37 hours) was conducted at meetings and workshops where the tool was used and where results were discussed. Semi-structured interviews (34) were conducted to gain in-depth understanding of perceptions of the tool as well as sustainability processes and actions. Results: Data was collected from 56 improvement teams across the 3 programmes. Our findings indicate the LTST supported 3 high-level processes: collaboration, decision making and action planning. These processes were underpinned by 8 mechanisms: identifying and engaging stakeholders, gathering team perspectives, giving people the space to express opinions, raising awareness, identifying risks and needs, providing direction or focus, suggesting actions, and taking action. The use of the LTST throughout initiatives aided teams to enhance knowledge of sustainability risks within ongoing initiatives, highlighted diverse perspectives within teams and directed attention to areas for improvement. Discussion: Prospective sustainability planning can allow people within initiatives to maintain focus and mitigate risks to enhance chances of achieving long term success. This study indicates the LTST provides a potentially useful approach to assessing teams’ perceptions of sustainability to prompt planning and actions to increase chances of success. |
Coordinating compassionate care across nursing teams: The implementation journey of a planned intervention Jacky Bridges, Carl May, Peter Griffiths, Alison Fuller, Jane Frankland, Wendy Wigley, Lisa Gould, Hannah Barker & Paula Libberton |
How nurses practice informal inter- organizational coordination Anne Doessing |
From the classroom into the fire: Learning the reality of nursing through rotation programmes for newly qualified nurse Rowan Myron, Healther Loveday & Claire Anderson |
Background. Despite concerns about the degree of compassion in contemporary health care, there is a dearth of evidence for health service managers about how to promote and coordinate compassionate health care. This paper reports on the implementation journey of a compassionate care intervention targeted at hospital ward nursing teams, and draws out the implications for intervention design. Objectives. To identify and explain the extent to which CLECC was implemented into existing work practices by nursing staff, to inform conclusions about how such interventions can be optimised to support compassionate care in acute settings. Methods. Process evaluation guided by normalisation process theory. Data gathered included staff interviews (n=47), observations (n=7 over 26 hours), and ward manager questionnaires on staffing (n=4). Results. Frontline staff were keen to participate in CLECC, were able to implement many of the planned activities and valued the benefits to their wellbeing and to patient care. Nonetheless, factors outside of the direct influence of the ward teams mediated the impact and sustainability of the intervention. These factors included an organizational culture focused on tasks and targets that constrained opportunities for staff mutual support and learning. Conclusions. Complex and coordinated health care work such as relational care depends not just on individual caregiver agency but also on whether or not this work is adequately supported by resources, norms and relationships located in the wider system. High cognitive participation in compassionate nursing care interventions such as CLECC by senior nurse managers and other wider system restructuring are likely to result in improved impact and sustainability. |
With the coordination of healthcare services becoming increasingly complex, the challenges of fragmentation cannot be solved by administrative restructuring alone. Attention must also be given to the coordination practices of professional groups, and, in this respect, the nursing profession is a particularly interesting case often referred to as ‘organizational glue’. Based on a qualitative case study involving Danish nurses in hospital, municipality and general practice, this paper will address the way nurses practice informal inter-organizational coordination in complex pathways. The paper advances our understanding of operative coordination among the large group of nurses who practice coordination as an integrated part of their everyday work, and the findings contribute to the inter-organizational literature by describing supplementary inter-organizational coordination practices in healthcare and by identifying four specific types of informal inter-organizational coordination practices. Overall, the nurses’ engagement in informal inter-organizational coordination was triggered by random encounters with fragmentation, a strong professional engagement in making things work in the interest of the patient, and a constant striving to be on top of things. Informal inter-organizational coordination is broken down into supplementary and by-passing practices, and four specific by-passing practices are identified: pro-forma coding, the divergent administration of materials, contact without patient consent and esoteric coordination. Telephone calls were the preferred type of supplementary inter-organizational coordination, and this informal practice is linked with seven different coordination purposes; appropriate behaviour, transfer confirmation, handling mistakes, unravelling the pathway, mediation, instant peer-guidance and gathering missing information. Finally, informal inter-organizational coordination is considered in terms of ‘rule bending’ within complex systems. |
The nature of nurse education has changed considerably since the inception of nursing as a profession in the mid-nineteenth century. The challenge for modern student nurses is bridging the conceptual gap between formal (classroom) learning and practical (on the ward) competence. The nature of post-registration transition into nursing practice is challenging for many nurses. The Capital Nurse Foundation Programme (CNFP) provides support for newly qualified nurses who begin their practice with National Health Service (NHS) Trusts within the UK capital. Crossing this boundary from academia to practice can be daunting for new nurses. This programme uses rotation to provide supported educational experiences for new nurses crossing this boundary aiming to support retention and prevent high turnover. This paper is a qualitative evaluation of newly qualified nurses and programme managers experiences of the Capital Nurse Programme across 9 different London Healthcare Trusts. The findings revealed five primary themes including Recruitment and Retention; Programme Support; Challenges; Rotation and new experiences; and Career development. Overall newly qualified nurses found the programme a positive experience. The support of the rotation programme to cross the boundary from ‘new’ nurse to working nurse was appreciated. There was a strong sense that the programme increased, and in some cases accelerated the acquisition of skills, providing a varied and worthwhile experience. In conclusion, the support of new nurses in crossing this pedagogical to practical boundary was valuable and initial data indicates the programme is succeeding in developing nurses within the UK capital system. |
The means not the end: Stakeholder views of toolkits developed from healthcare research Charlotte Sharp, Ruth Boaden, Will Dixon & Caroline Sanders |
Electronic information sharing to improve post-acute care transitions Dori Cross, Jane Banaszak-Holl, Julia Adler-Milstein & Jeffrey McCullough |
The development of ‘products’ such as toolkits from healthcare research is on the rise (Davis et al 2017), in response to a recognised need to close the gap between healthcare research and practice (Cooksey 2006), and to achieve research ‘impact’ (Higher Education Funding Council for England 2014). Our study investigates the development of toolkits to offer new insights on the meaning and practice of knowledge mobilisation in applied health research. We propose that toolkits may be viewed as boundary objects (Star and Griesemer 1989) between communities of healthcare research and service delivery, and apply this theoretical lens to an analysis of stakeholder perspectives on toolkits from healthcare research. We identify that toolkits and other products from healthcare research have the potential to fulfil a number of different roles including: designated boundary objects and boundary objects-in-use (Levina and Vaast 2005); negative boundary objects (Oswick and Robertson 2009); and symbolic boundary objects (Swan et al. 2007). The findings identify three main boundaries between: healthcare researchers and practice; research funders and researchers; and researchers and research participants. We use these findings and our analysis to illuminate limitations in the development of toolkits, and suggest how their use in practice might be maximised. |
U.S. Healthcare organizations are actively working to improve coordination of care between hospital and post-acute settings such as skilled nursing facilities (SNFs). One key strategy is to strengthen information continuity through improved information sharing processes. Electronic information sharing (EIS) has demonstrated benefits in other contexts, but has not yet been explored for transitions to post-acute care. We first use a difference-in-differences analysis to analyze whether the selective implementation of an EIS system between one large academic hospital and three partnering SNFs resulted in an improvement in patient outcomes, relative to outcomes for patients discharged to SNFs without electronic information access. Specifically, we use 30-day patient rehospitalization as a transition-sensitive measure of care quality. We then use a novel longitudinal dataset generated by these three SNFs’ audited use of the EIS system to explore variation in whenand how SNF providers access outside sources of patient health information, and relationships between this variation and demonstrated improvement to patient outcomes. We find no overall net effect on patient rehospitalizations over time due to the implementation of an EIS system connecting SNFs to the discharging hospital. However, we detect significant variation in system use within the electronically enabled SNF facilities. On average, EIS was only utilized for 46% of patients for whom it was available. Only one of the three facilities consistently used the system in the critical transition window immediately following patient transition from hospital to SNF; for this facility, we observe a significant reduction in likelihood of patient rehospitalization as the volume of information retrieved during this window increases. Organizations must find ways to increase the value of these systems through better design and integration of use with existing workflows if we are to fully realize the value of investment in IT infrastructure that connects hospitals and post-acute care providers. |
Walking the tightrope: How quality rebels ‘do’ quality of care in healthcare organizations Iris Wallenburg, Anne Marie Weggelaar & Roland Bal |
How occupational community shapes the quality of care coordination Nikolaus Krachler |
Teamwork and well-being of staff members and their impact on patient satisfaction and treatment success in medical rehabilitation Mirjam Körner, Sonja Becker, Samuel Tomzcek |
This paper addresses the contemporary policy urge to strengthening ‘compassionate care’ and ‘positive deviance’ as a response to the perverse effects that have emerged from a system-based approach to performance management. We claim that the call for deviant care actually reinforces the dominant managerial approach of capturing and ‘rolling out’ best practices, and leaves unnoticed the care practices of practitioners that (sometimes) consciously deviate from established rules and measurement systems to crafting their own practices of good care. Drawing on an ethnographic study on ‘quality rebels’ in the Netherlands, we explore these alternative practices of good care and how they are accounted for. To that end, we selected three clinical groups in hospitals with a high reputation on quality of care and scrutinized their daily practices of care provision and accounting. Quality rebels, we show, are those that dare to ‘color outside the lines’ and give shape to clinical practices through crafting deviant clinical microsystems. We use the notion of Crossing Boundaries to (1) point out how rebels seek to ‘do’ quality by obeying, using and ignoring existing organisation’s quality systems as a way of moving in and out of the organisational system; and (2) to show how rebels sometimes cross organisational boundaries to collaborate with external stakeholders, and at other times work closely together with actors within their organization to achieving their goals. Rebels, we show, walk the tightrope in order to remain trusted and safeguard their good reputation within the organization. Based on our analysis we develop an emerging approach of ‘doing good care’, yet we also highlight the importance of the development of systems for generative accountability to govern emergent quality practices. |
Policymakers in advanced economies have pursued the aim of increasing the coordination of care among different occupational groups. While there is evidence that this can increase health outcomes, the conditions under which the implementation of care coordination policies is successful remains unclear, especially in terms of the conditions related to workforce dynamics. Through a matched case comparison of two outpatient-based clinics with care coordination programs, I highlight the importance of conditions that support the development of an occupational community of care coordinators. To explain why one clinic boasts more intensive and more frequent care coordination than the other clinic despite being part of the same health system, I demonstrate how occupationally-based management as well as the relevant work experience in one agency increased the quality of care coordination while in the other, cost-driven management and a lack of relevant work experience led to worse care coordination. My contribution is not only to highlight the importance of occupational dynamics for successful care coordination but also to explain the conditions that support the development of the emerging occupation of care coordinators. |
Existing studies on patient satisfaction in medical rehabilitation largely consider the influencing factors from health care professionals (HCPs), patients, and the rehabilitation center separately. On the basis of the model of organizational behavior, the three levels (organization, team (HCPs), and individual (patients) were linked to test for effects and interactions on patient satisfaction and treatment success. For this purpose, a written survey was conducted to collect data from the patients (N=464) and staff members (N=251) of eight centers in southern Germany. With multi-level models with mixed effects, the influence of teamwork and staff well-being on satisfaction and treatment success from the patient perspective was examined; patient age and educational level were included as control variables. Patient satisfaction was found to be linked positively with patient age and negatively with HCP exhaustion. No significant predictors of treatment success could be identified. Only minor differences between centers were found in terms of these relationships. The lack of significance of teamwork does not correspond to theoretical expectations. The high standard errors in the estimate at least suggest a large variance in the estimate. One of the main reasons for the non-significant estimate is the difficulty in data aggregation. Further limitations of the study include the relatively small sample size for multi-level analysis as well as potential selection effects (low return rates – particularly for HCPs). Teamwork at the center can be assessed differently for each treatment, and there may be overall differences in assessments by staff members. Nevertheless, the study suggests that reducing HCP exhaustion, for instance by improving working conditions, can positively influence patient satisfaction and treatment quality. |
Enacting HRM beyond the line manager in professional organisations: The role and status of quality managers in HR interventions Giovanni Radaelli & Graeme Currie |
Redefining professional autonomy in health care organizations Domenico Salvatore, Giovanni Fattore & Dino Numerato |
The impact of non-monetary recognition sources on nurses’ turnover intentions: The mediating role of stress Steven Kilroy, Janine Bosak, Denis Chênevert & Patrick C. Flood |
Our study focuses upon implementation of multidisciplinary team working across twelve Italian hospitals, to examine the enactment of HRM by a tripartite configuration of actors -- hybrid line managers, high status occupational professionals (doctors), lower status organisational professionals (quality managers). When doctors are receptive towards implementation of multidisciplinary team working, then quality managers intervene to support development of multidisciplinary team working. Following which, the focus of quality managers’ HRM efforts lie either in the administrative domain, where they enact low-level work to support powerful professionals that wish to implement multidisciplinary team working, or quality managers intervene more strategically. To intervene more strategically, quality managers need to work with hybrid line managers and act through organisational infrastructure for education and service delivery that align with professional practice. Whether quality managers intervene administratively or strategically, this has implications for their status with others. |
Professional autonomy is one of the core concepts in health care management. Despite -or perhaps because- its tradition and centrality, professional autonomy is an ill-defined construct and the lack of a clear definition slows down the progress of research on this specific field and broadly on health care management. In this working paper, I briefly review the theoretical contributions from the many different disciplines that I find useful in clarifying the construct of professional autonomy from the perspective of health care organizations and management. I use this review to present the definition of professional autonomy as a multi-level, multi-dimensional, and relational construct. It is the relational nature of autonomy which makes autonomy a multi-level and multi-dimensional construct. In the last section I conclude by discussing the contributions of this paper and directions for future research. |
There is a growing shortage of nurses internationally which represents a worldwide crisis for health care organisations. Therefore, understanding the factors which cause them to consider leaving their jobs as well as identifying the factors that reduce this propensity to leave remains an important topic for researchers and practitioners alike. The present study investigates (a) the impact of non-monetary recognition from both the organisation and line managers on turnover intentions and (b) the mediating role of stress in these relationships. Adopting a contingency perspective, the study further proposed and investigated the interactive effects of both recognition sources to identify whether dependencies among them exist. Using Structural Equation Modeling (SEM), we tested the proposed hypotheses on a random sample of nurses (N=1,135) working in hospitals in Ireland. The results revealed that employees ‘perceptions of non-monetary recognition from both the organisation and line managers is related to lower levels of perceived stress, which in turn is related to lower turnover intentions. Stress partially mediated the relationship between line manager recognition and turnover intentions while stress fully mediated the relationship between organisation recognition and turnover intentions. In addition, line manager recognition moderated the relationship between organisation recognition and stress so that when line manager recognition was low, the negative relationship between organisation recognition and stress was attenuated. We discuss the implications of these findings for research and practice. |
Hospital Participation in Medicare Shared Savings ACOs is Not Associated with Improved Readmission Rates, Regardless of the Quality of Hospital Care Transitions Sunny Lin, Julia Adler-Milstein, John Hollingsworth & Andrew Ryan |
Repositioning the boundaries between public and private healthcare providers in the English NHS Rod Sheaff, Mark Exworthy, Alex Gibson, Pauline Allen, Jonathan Clarke, Sheena Asthana & Russell Mannion |
Understanding how values of US community foundations guide their programmatic funding choices: A discrete choice experiment Jane Banaszak-Holl, Michael Rozier, Kara Kiessling & Simone Singh |
In the United States, healthcare delivery is often fragmented as care for a single patient is typically delivered by multiple providers and organizations. Efforts to improve inter-organizational care coordination include Medicare’s Accountable Care Organization (ACO). ACOs unite multiple healthcare organizations into a single “virtual” entity responsible for the care of a designated patient population. Each year, ACOs are eligible to receive financial bonuses if they meet benchmarks for healthcare spending and quality, which include readmission rates and measures of care coordination. Policymakers hope ACOs will encourage providers to improve inter-organizational care coordination, leading to lower cost growth and improved patient outcomes. One strategy to improve care coordination is to improve the quality of hospital care transitions. We tested whether hospitals that participated in ACOs improved care transitions and whether this resulted in decreased readmissions. To do this, we linked four years of data (2013-2016) on hospital participation in ACOs with annual publicly reported data on care transitions and hospital-wide risk adjusted 30-day readmission rates for 3,022 US hospitals. We then estimated a linear regression model with hospital and year fixed-effects and time-varying controls to test whether hospitals that participate in ACOs and improve the quality of care transitions improve readmission rates. We found that ACO participation does not improve readmission rates, even when coupled with higher quality care transitions. ACO participation without changes in care transition quality was associated with a non-significant 0.212 percentage point change in readmission rates (p=0.69). For all hospitals (ACO participating and non-participating), every point increase in the care transition measure was associated with a non-significant -0.004 percentage point change in readmission rates (p=0.39). For ACO participating hospitals, every point increase in the care transition measure was associated with an additional non-significant -0.006 percentage point change in readmission rates (p=0.56), for a total effect of -0.010 percentage point change in readmission rates per point in crease in care transition quality (p=0.31). Our findings suggest that ACOs may need to look to other care coordination strategies to improve hospital readmission rates. |
Background and Objectives: Neoliberal ‘reform’ has in many countries shifted services across the boundary between the public and private sector. This policy re-opens the question of what structural and managerial differences, if any, differences of ownership make to healthcare providers. This paper examines the relationships between ownership, organisational structure and managerial regime within an elaboration of Donabedian’s reasoning about organisational structures. Using new data from England it considers:
Findings: The relationships between ownership (one one hand) and organisation structures and managerial regimes (on the other), these relationships differed at different organisational levels. Top-level governancestructures diverged by organisational ownership and objectives among the case-study organisations. All the case-study organisations irrespective of ownership had hierarchical, bureaucratic structures and managerial regimes for coordinating everyday service production, but to differing extents. In doctor-owned organisations the doctors’,but not other occupations’,work was controlled and coordinated in a more-or-less democratic,self-governing ways. Conclusion: Ownership does make important differences to healthcare providers’ top-level governance structures and accountabilities; and to work coordination activity, but with different patterns at different organisational levels. |
For community-based nonprofits and health service organizations providing population health services, foundations play an active role in developing programming and in proactively organizing community partners to create new, complimentary and/or joint health programs. This paper examines the values that decision-makers in U.S. health and wellness foundations prioritize in community grant giving and evaluates whether the values held by foundation decision-makers are similar to those among their partners, who may include health systems, public health departments and community nonprofits. This study uses a Discrete Choice Experiment (DCE), presenting foundation respondents with choices between programmatic options defined by carefully identified attributes. Across different attributes of programmatic activity, the strongest value choices of foundation decision-makers appear to be for coalitions of community partners, growing or existing evidence for programmatic effectiveness, and for programs that focus on social determinants and do less to address advocacy; decision-makers were more ambivalent when it came to choosing the population served and in the expected time to impact for community programs. These results indicate that foundation decision- makers understand their role of coordinating across community organizations and that is reflected in their emphasis on collaboration in programmatic choices. |
Hybrid professionals in healthcare: How managerial training can promote their boundary-spanning role Giogio Giacomelli, Francesca Ferrè, Manuela Furlan & Sabina Nuti |
Strategies of the underdog: How lower status hybrid managers influence strategy for an organization wide service improvement effect Nicola Burgess & Graeme Currie |
Leading through boundaries: Medical managers performing boundary work Mathilde Berghout, Lieke Oldenhof, Isabelle Fabbricotti & Carina Hilders |
Hybrid professionals have a two-fold - professional and managerial - role: this hybridization requires professionals with managerial responsibilities to integrate both clinical and managerial knowledge, in order to lead teams of highly skilled professionals in their clinical work and achieve collective actions for improved organizational performance. Hybrid professionals should then ease interactions across organizational and professional boundaries. Investing on managerial training programs aims to support this goal by empowering professionals with managerial skills and competencies. Does this pay back? Assessing the impact of such training programs is still a limited practice. This contribution explores how managerial training programs in healthcare can lead to the active engagement of hybrid professionals through the activation of a managerial curriculum. Specifically, the mediational effects of performance information awareness and its use are explored. Survey data from more than 3,000 heads of department of 69 public health authorities from five regional healthcare systems in Italy are considered. Relationships between participation in managerial training programs, management practices (i.e., awareness and use of performance information) and the level of clinicians’ engagement and interaction with the top management are studied using a three-path mediation analysis with structural equation modelling. Performance information awareness and the use of information mediate, both independently and sequentially, the relationship between participation in management training and the involvement in decision-making. The results show how managerial training is a socialization where to build boundary-spanning capacity. |
Extant literature suggests the efficacy of hybrid managers in negotiating between professional and managerial worlds varies in relation to an individual’s knowledge of context, and their power and status. Such contingencies belie universal claims about hybrid managers as strategic actors and signals a need for a practice-based analysis of what different levels of hybrid managers actually do. Notwithstanding the hierarchical challenge faced by lower status hybrid managers, our study considers how they can influence strategy for an organization wide service improvement effect. Situated within a healthcare context, our empirical analysis reveals insights about the mechanisms employed by lower-status hybrids to influence practice across professions in line with policy aspirations for clinical governance. We highlight the important role of the lower-status hybrid manager in driving strategy through a series of deliberate actions inside and outside of the organization to manoeuvre, manipulate, and mediate managerial control for an organization wide service improvement effect. |
Boundaries are often viewed as barriers in service integration and the provision of multi-disciplinary, effective and cost-efficient care. However, we argue that boundaries are not merely obstacles that must be ‘bridged’; rather we show how they can function as junctures that could possibly lead to service integration and enhanced patient care. We shadowed six hospital-based medical managers, that are physicians who function as department head in addition to their daily clinical work, to study boundary work in-depth. Although medical managers are often assumed as ideal ‘boundary spanners’ because of their spatial conceptualization in-between management and medicine, studies that show how medical manager conduct boundary work and to what effect remain lacking. By zooming in on one specific case in the department of psychiatry, our study demonstrates how a medical manager performs boundary work by using boundary language, objects and spaces. We show the dynamic and temporal nature of boundaries and the micro-practices that are involved in drawing and blurring boundaries to establish multi-disciplinary collaboration. We illustrate how the medical manager of psychiatry is aligning among differences by acknowledging differences between disciplines and emphasizing the advantages for patient care of bringing these differences together. Although these results show the functionality and malleability of boundaries, our study also takes into account the highly institutionalized context in which medical managers operate. This shows that in a field like medicine, boundary work is sometimes ‘easy’ to achieve, but more often extremely difficult. While we thus acknowledge that boundaries are not merely static nor ‘roadblocks’ for change, we also note that the degree to which boundaries are ‘flexible’ and ‘negotiable’ highly depends on the context wherein boundary work practices are embedded. We therefore advise future research on boundary work to take into account macro –and institutional elements. |
From research evidence to ‘evidence by proxy’? Organisational enactment of evidence-based healthcare in four high-income countries Roman Kislov, Greta Cummings, Anna Ehrenberg, Wendy Gifford, Gill Harvey, Janet Kelly, Alison Kitson, Lena Pettersson, Lars Wallin & Paul Wilson |
Reconsidering the role of evidence in diffusion of innovations: A qualitative study of decision-making on innovation in the UK National Health Service Simon Turner, Danielle D’Lima, Jessica Sheringham, Nick Swart, Emma Hudson, Stephen Morris & Naomi Fulop |
What forms of codified knowledge, i.e. knowledge that is formal, systematic and expressible in language or numbers, are seen as credible evidence? What is their impact on evidence-based practice? By addressing these questions, we move away from the previously examined dichotomy of tacit versus codified knowledge, focusing instead on the composition of the latter and the relationships between its components. Drawing on multiple qualitative case studies of evidence-based nursing conducted in Sweden, Canada, Australia and the UK, we challenge the assumption that research evidence and its direct derivatives, such as clinical guidelines, are the dominant forms of codified knowledge deployed in the organisational enactment of evidence-based healthcare. We describe the chain of codified knowledge which reflects the institutionalisation of evidence-based practice as organisational ‘business as usual’. This chain is dominated by performance standards, policies and procedures, and locally collected (improvement and audit) data, i.e. various forms of ‘evidence by proxy’ which are, at best, informed by research only partly or indirectly but are nevertheless perceived as credible evidence. Our analysis reveals dual effects of this codification dynamic on evidence-based practice. On the one hand, the legitimisation and mobilisation of contextual and local knowledge counterbalance ‘dogmatic authoritarianism’ apparent in the more restrictive interpretations of ‘evidence’ and potentially enable bottom-up knowledge flows. On the other hand, this is achieved through a significant dilution of the initial paradigm, excessive formalisation, and detachment of frontline staff from the fundamental competencies and knowledge base of evidence-based decision-making, whereby direct use of research evidence and clinical guidelines is becoming a prerogative of experts, represented by professional elites and designated facilitators. Comparing and contrasting our findings across four high-income countries, we also highlight the influence of macro-level ideological, historical and technological factors on the composition and circulation of codified knowledge in the organisational enactment of evidence-based healthcare. |
A policy aspiration is that evidence should inform and expedite decision-making on introducing health service innovations. The relationship between evidence and innovation adoption is not straightforward. A range of contextual processes – including professional group, organisational and local system processes – influence the use of evidence in adoption decisions. This paper examines the role of both evidence and contextual processes, and potential interplay between the two, in shaping adoption decisions. The paper distinguishes between rationalist concepts of evidence (i.e. that innovations have fixed characteristics that can be revealed through evaluation) found in evidence-based medicine and diffusion of innovations theory, and the idea from science and technology studies (STS) that evidence has ‘agency’ too: STS suggests that evidence can influence the social and organisational context of decision-making, and are influenced by it. Three case studies of decision-making on innovation from the UK National Health Service (NHS) are described: the reconfiguration of acute stroke services in different metropolitan areas; the diffusion of ‘virtual’ clinics for glaucoma outpatients across an organisational network; and responses to new guidance on referral for suspected cancer in primary care. Qualitative data were collected using interviews, observations, and documentary analysis (November 2016-August 2017). In stroke, restructuring and resource pressures at the local system level inhibited change, although evidence was used creatively to seize opportunities for innovation. In glaucoma, senior doctors were key stakeholders in diffusing innovation across clinics using research evidence as common currency. In cancer, the importance of local system actors in shaping responses to the guidance was highlighted. The paper argues that evidence influences the context of decision-making in multiple ways (its perceived strength, unfolding nature, and use by stakeholders to steer decision-making). The paper concludes that dynamic models of innovation diffusion are needed where both the agency of evidence and contextual processes play significant roles in decision-making. |
Emerging approaches, processes and practices on physician engagement: A rapid review Graham Shaw, Asif Khowaja, Neale Smith, Craig Mitton, Jean-Louis Denis & Chris Lovato |
The ‘Nurse-Doctor’: Nurse Practitioners, Disruption and Identity Threat Karen McNeil, Brendan Boyle, Tony Smith, Nola Ries & Rebecca Mitchell |
Team-based improvement work, physician engagement and the development of transformative capacities in healthcare organizations Susan Usher & Alexander Sasha Dubrovsky |
While the literature on physician engagement shows that facilities with higher levels of engagement have better patient outcomes, there is limited agreement about how best to increase physician engagement through deliberate intervention. This paper reports on the findings of a rapid review that gathers information about approaches or strategies to increase physician engagement. Our search included peer-reviewed and grey literature, in English-languagepublications published between 2012-2017.Of the 36 articles retained in the final review, 15 were from the grey literature; and 21 were peer-reviewed. The articles revealed physician engagement approaches which we categorized into five prescriptive themes: 1) Assess the problem and identify and acknowledge barriers to physician engagement; 2) Collaboratively develop and pursue meaningful targets for healthcare quality and outcomes; 3) Strengthen physician leadership and expand physicians’ roles to include realization of organizational goals; 4) Use appropriate rewards and incentives; and 5) Align values and strengthen culture, community and communication across the organization. The review also includes information about models that combine discrete strategies to achieve synergistic effects and suggests that intervention activities may simultaneously incorporate several of the approaches described. We recommend a rigorous assessment of the problem of disengagement in its specific context as the starting point for deciding what is most important and as a prerequisite to considering the optimum sequence of intervention approaches. This area is still developing an evidence base about what works in what context. System change interventions that carefully monitor and report their effects on physician engagement are needed. |
Although new, extended scope of practice health roles have been promoted as a lower-cost, disruptive innovation capable of addressing health service gaps, particularly in rural and remote areas, their implementation has been met with resistance and conflict in a number of countries. Drawing on the sociology of the professions literature and social and relational identity theory, as well as empirical evidence from our study of the nurse practitioner (NP) role in rural and remote Australia, our analysis highlights how social and relational considerations are pivotal in the construction of new professional identities, while threats to existing professional identities are likely central to the opposition that NPs often encounter in the implementation of their roles. We conducted semi-structured interviews with fifteen NPs and their nursing and physician colleagues with questions guided by the extant literature, relating to the NP scope of practice, patients’ and professional colleagues’ responses to the role, and perceived barriers to and enablers of practice. Data analysis focussed on the themes of professional identity construction and on the reported interactions that NPs had with other health professions and managers. We found that NPs constructed a hybrid professional identity, sitting on the boundary of the medical and nursing profession, largely influenced through their interactions with their patients. In occupying this professional space, NPs threatened the distinctiveness of the medical profession and the value and values of the nursing profession, potentially engendering hostility and conflict. However, the NPs were able to mitigate these threats through adopting strategies that responded to these different triggers of inter- and intraprofessional identity conflict. In sum, we provide a more nuanced account of how innovative, boundary-spanning health roles lead to the construction of new professional identities, and potentially provoke identity threat within the healthcare context. |
Healthcare organizations increasingly rely on team-based projects to produce improvements in quality and performance. However little is known about the lasting impact of these efforts on an organization’s capacity for change beyond the particular project mandate. Engaging physicians in this work is challenging due to professional autonomy and the highly institutionalized nature of medicine that can impede collaboration; it is also essential in order to produce meaningful change. This case study focuses on a cross-functional team, including physicians, engaged in a project to improve communication around safety concerns in an academic health centre. Interviews conducted after the team’s first year, and two years following project completion, enabled us to explore mechanisms involved in the lasting impact of teamwork. Realist analysis based on theories of organizational learning, team effectiveness and professional hybridity identified characteristics of team formation and functioning that contributed to capacities for ongoing change within the organization. These include interest-based and voluntary team formation, autonomy in setting objectives, unobtrusive supervision, and a focus on learning together and finding out what others know. Three streams of learning emerge in this context: how to work as a team, what others do in the organization, and how to bring about change in the organization. This learning serves as an intermediate outcome between teamwork and the development of transformative capacities. Practices and processes learned through teamwork are spread through existing and newly created structures within the organization. Professional identities are redefined through recognition of interdependencies that drives further collaborative improvement efforts. These findings can guide organizational policies to support teamwork as a significant learning forum in which to develop lasting capacities for change and improvement. |
Where theorists and empiricists fear to tread: Comparing and contrasting the interplays between complexity science and organisational cultural accounts of health care organisation Jeffrey Braithwaite, Jessica Herkes, Kate Churruca, Chiara Pomare, Louise A Ellis, Janet Long, Kristiana Ludlow, Luke Testa & Gina Lamprell |
Explaining change through generative mechanisms: The promise of critical realism for policy analysis Antoine Malone |
In organisational behaviour studies in health care settings, there has been much research and theory addressing organisational and workplace cultures. More recently, work has been conducted to understand the features of health care as a complex adaptive system. As burgeoning areas of health services research, health care as complex adaptive systems, and organisational and workplace cultural studies, have followed parallel paths. They have been investigated in isolation, and there is little understanding of the interplay, if any, between them. It is time for these paths to intercept, and for us to see whether, and if so the extent to which, the boundaries between these different paradigms are solid or permeable. In this study, we first provide an overview of complexity science and organisational cultural conceptualisations of organisation. Then, we examine a group of 62 studies identified as measuring the association between culture and patient outcomes, drawn from a recent systematic review. The articles are re-analysed to identify the features of complex adaptive systems that the study settings presented, with a view to traverse the boundaries between the two domains. We found considerable overlap between these constructs, and present the results of this re-analysis. We argue that there is a generalisable point to be made: theorists and empiricists in the organisational behaviour field might beneficially navigate across the boundaries in the field, as we attempt to do here, rather than perpetuate the divides that have been created through academic specialisation and sub-specialisation. This can be fruitful. |
Health sector reform should lend itself idealy to a plural mode of policy design. Advanced Health systems are the playing field for a number of powerful actors ; Ministers and Government agencies, health professionals including doctors, interest groups and electedofficials, scholars, etc. However, at least in the case of France, Genieys and Hassenteufelhave shown that Welfare Elite’s dominant rôle explains the direction that the French Healthcare system has followed for the last thirty years. We believe that Critical-Realism(CR) is well suited to solve this apparent paradox. By focusing on the search for generativemechanisms, CR offers a novel and powerful way to look for causality in complex social phenomena. In doing so, it recognizes that both agents and structures posses causal powers, that are activated through these mechanims. We begin by outlining the main features of a Critical Realist approach. We then show how Genieys and Hasssenteufel’s work can gain additionnal explanatory power through a CR approach. Finaly, we propose a Boundary Control mechanism which we believe can account for both the Elite’s successes and shortcomings. |
Risk work or resilience work? A situated interview study with community health workers negotiating the tensions between biomedical and community-based forms of health promotion Nicola Gale & Manbinder Sidhu (presented by Manbinder Sidhu) |
A contingency model to answer the mismatch between what PPI policy makers want and what they get Yaru Chen, Graeme Currie, Sophie Staniszewska & Magdelena Skrybant |
Building resilient and healthy cities: Complements to a scoping review Marie-Christine Therrien & Iseut Beauregard-Guérin |
Emplaced health promotion interventions, delivered by community health workers (CHWs) are increasingly being used internationally. However, the application of epidemiological risk knowledge to individuals within such communities is not straightforward and creates tensions for community health workers who are ‘part of’ the communities that they are serving. Qualitative data were co-constructed with community health workers employed in a superdiverse, deprived, post-industrial region of the UK, using photo-voice methods, to develop an account of how they made sense of the challenges of their work. The analysis draws on and develops theories of risk work and resilience work, which draw on practice theory. The key findings were that, first, being a critical insider enabled CHWs to make sense of the diverse constraints on health and lifestyles within their community. Second, they understood their own public health role as limited by operating within this context, so they articulated their occupational identity as focused on supporting clients to make small but sustainable changes to their own and their families’ lifestyles. Third, the uncertainties of translating population based risk information to individual clients were (at least partially) resolved at an embodied level, with the CHWs identifying as accessible and trusted role models for the value of changed lifestyles. The article is important for policy and practice as it provides a critique of a rapidly evolving new mode of delivery of public health services, and insights on the development of this new public health workforce. |
This paper examines Patient and Public Involvement (PPI) in research, which has been prevalent in the healthcare sector. Despite the popularity of PPI, effective evaluation of PPI activities has been a problem for both policy makers and practitioners. In order to tackle this problem, we employs personal identity theory and looks at how the identity and aspirations of PPI members affect how they are involved and types of involvement they engage in. We draw from a qualitative case study encompassing 45 semi-structured interviews with PPI members involved in research. We develop a typology of PPI members and explains why and how they are involved in a certain way. |
There is great interest around the concept of creating “healthy cities” with municipal governments investing in projects aimed at rendering the city and neighbourhood environments more conducive to the work, play, and living aspirations of citizens. Public health officers are also partnering with municipalities to contribute to improving population health. In parallel however, cities face substantial shocks as a result of extreme weather phenomena and stresses such as aging populations, changing demographics, food insecurity, social inequalities, and air pollution. Solutions and ideas towards creating healthy cities and the capacity to face shocks and stresses emerge from concerted actions among actors. Yet, little is known about the processes leading to effective, concerted action and governance in building and maintaining healthy and resilient cities. Increasing urban resilience has been identified as a useful approach to bolstering healthy cities. Despite adherence to the concept of resilience, actors in the field are uncertain regarding how to operationalize resilience in an impactful manner. Moving from ideas to action raises a number of implementation challenges that call for a transdisciplinary approach to intervention development and implementation involving network governance, citizen participation, stakeholder management, and mobilization of social capital. Yet, there is a dearth of scientific evidence on these urban practices. In this paper, we present an extract from a scoping review which we conducted which represents the knowledge acquired to date from empirical study of attempts to implement urban resilience (Therrien et al. 2017 working paper). The extract is based on the issues which concern health and resilience. Within this scoping review, the literature on health and well-being has received little attention. We therefore decided to go back into the literature more focused on health specifically, to complete the scoping review. |
Application of psychological theories to organizational behavior: The case of tailoring interventions to promote health care professionals’ adherence to hand hygiene guidelines Thomas von Lengerke, Bettina Schock, Christian Krauth, Karin Lange, Jona T. Stahmeyer & Iris F. Chaberny |
Implementation of genomics into clinical practice: A service level view Stephanie Best, Janet Long, Natalie Taylor & Jeffrey Braithwaite |
An empirical comparison of theory versus reality in health care coordination Rebecca Wells, Mónica Sianez, Loida Tamayo, Ellen Breckenridge & Cara Pennel |
In health care, guidelines are important instruments to ensure quality. However, such quality can only be achieved if guidelines are implemented. Professional guideline adherence in health care may be conceptualized as organizational behavior (OB), with psychological theories of behavior change being increasingly applied to implementation. Implications of these theories for interventions to promote adherence include tailoring based on empirical assessment of determinants and causal processes. As an example, results of the cluster-randomized controlled PSYGIENE-trial on hand hygiene compliance at Hannover Medical School (MHH), a tertiary care university hospital in Northern Germany, are summarized. In the pre-trial period, i.e. after the German “Clean Care is Safer Care”-campaign (Aktion Saubere Hände [ASH]) had been incepted (2008), hand hygiene had re-emerged an “old innovation” in that World Health Organization’s (WHO) “Five moments for hand hygiene”-concept reframed the task of hand disinfection in daily routine. Eventually, differences in adoption occurred, and compliance rates in MHH’s 10 intensive care units (ICUs) and two hematopoietic stem cell transplantation units had dropped to baseline levels in 2012. The question arose whether interventions psychologically tailored using the Health Action Process Approach (HAPA) as the campaign’s compliance model would lead to more sustained compliance increases in this relapse situation, and whether wards with high vs. low pretrial compliance (earlier vs. later adopter-wards) would differ in their response. On the 12 units mentioned above, compliance determinants as defined in the HAPA were assessed among employees via questionnaire (response: physicians: 71%; nurses: 63%), and among stakeholders via interviews (100%). The intervention arm (6 wards) used 29 behavior change techniques (BCTs) in educational training sessions and feedback discussions in 2013, while in the control arm, educational campaign sessions with 15 BCTs were conducted. Outcomes were hand hygiene compliance rates in 2014-15 (assessed by non-participating direct observation following WHO’s gold-standard). Earlier- vs. later adopter wards were defined by median split at 63% in terms of mean compliance 2008-12. Tailored interventions led to more sustainable increases in compliance after two years than the ASH-campaign (16% from 54% in 2013 to 70% in 2015), while in the ASH-arm, the increase was smaller (+9% [2013: 55%, 2015: 64%]).. At the same time, the highest increase (+15% from 2013-15) was found among earlier adopter-wards who had received the tailored interventions. Also, these interventions were superior to the ASH-interventions (+6%) among the earlier adopter-wards only. Thus, while overall the interventions tailored psychologically based on the HAPA resulted in more sustainable increases in hand hygiene compliance, the difference between earlier- and later adopter wards raises issues of “Money makes money”-effects in nosocomial infection prevention. The question is how to reach later adopter-wards more successfully by meeting their specific demands. Despite its limitations, the PSYGIENE trial (by following the call to integrate behavioral approaches and incorporate readiness to change- and innovativeness-perspectives) adds evidence on guideline adherence as OB. If interventions empirically assess behavioral determinants of innovations, psychologically tailor interventions to different groups, and use appropriate BCTs, the task of improving OB in health care will face new, especially transdisciplinary opportunities. |
The potential health benefits of genomic medicine have been promised for many years but have been slow to be realised in patient care. Translating evidence based findings across the boundaries of the research setting into clinical practice is challenging. In this regard genomic medicine is no different to other clinical fields. For many clinical arenas, however, genomics has the potential to be a disruptive evidence based health care practice and as such will need support from the service level personnel to, for example, change policies and reallocate funding. If the potential benefits of genomic medicine are to be realised, changes in clinician practice need to be supported by the organisation. The focus of implementation research in this area has largely centred on clinical practice, yet this disregards the essential role the organisation and service level personnel play in the manifestation of new frontline clinical services. This paper has two aims: one, to review the literature to identify what organisational barriers are known to hinder implementation of genomics; and two, to set out a theory informed research plan to explore organisational factors that influence the uptake of clinical genomics. The review discovered a paucity of studies in this area, supporting the need for further research. Themes from the papers indicate the importance of the operational infrastructure, the need for multilevel involvement, and the challenge of the rapidly evolving genomic evidence base. The research plan builds on these findings and, using the Translation Science to Population Impact (TSci Impact) framework, outlines a research protocol to investigate perceptions of service level personnel in the early phases of implementation of clinical genomics. Initial findings will be available early 2018. |
Objective: Care coordination is an increasingly popular strategy for meeting patients’ individual needs through health education and facilitating access to needed services. By supporting disease self-management and service use, coordination is intended to increase patients’ use of preventive care and thus improve health outcomes. The purpose of the current study was to measure alignment between coordination programs funded through a Medicaid waiver incentive payment program in Texas and two of the most prominent related disease management models: the Chronic Care Model, which focuses on system resources, and the Care Transitions Program, which focuses on individual patient experiences. Study Design: The study was designed as a comparative case study of care coordination programs throughout Texas. Although the nature of these programs varied, all sought to reduce emergency department use among patients with a history or risk of high utilization. Methods: During December 2015–May 2016, the study team visited sites and interviewed program leaders and front-line staff at nine sites. One site that was inoperational was excluded. In January–March 2016, patients were surveyed by phone about experiences with care coordination. The study team used data from staff interviews and patient surveys to assess alignment between programs and Chronic Care Model and Care Transitions Program attributes. Results: Most sites had system resources stipulated in the Chronic Care Model, but patient-reported interaction with care coordinators generally fell below levels recommended by the Care Transitions model. Conclusion: Community settings generally have system capacity for providing care coordination to patients with complex needs, but patients’ experience of coordination was typically limited. These services may not be sufficient as currently provided to improve health behaviors and service use among patients with complex health conditions. |
Buddies, mergers, and regimes: Reassessing inter-organisational partnerships in the English National Health Service Ross Millar & Robin Miller |
Expanding the academic mission across boundaries in healthcare: A realistic evaluation of institutional work dynamics Élizabeth Côté-Boileau, Marie-Andrée Paquette & Jean-Louis Denis |
Modernising chronic care: Algorithms as a megaphone for patient voice Anna Essen, Eivor Oborn & Michael Barrett (Presented by Eivor Oborn) |
Partnership working is synonymous with endeavours to improve healthcare systems, processes, and practices. It is central to current policy agendas in the English National Health Service (NHS) as the most effective means to improve population health and the quality of care. Current developments in the NHS can be situated in a policy tradition of promoting partnerships, networks, and collaboration. However, despite receiving much coverage, the study of these connections and ways of working remains significantly underdeveloped. This working paper examines a range of partnering arrangements between health care providers in contemporary NHS settings. It presents the qualitative experiences of five case studies reflecting a continuum of partnering – mandated, voluntary, individual and structural. In doing so, the findings provide a range of insights into the dynamics and practices of forming and norming different partnerships. The paper raises a number of implications about current and future partnering arrangements as well as a range of theoretical and practical insights for future research in this area. In doing so, it looks to build on perspectives that draw attention to the limits partnership working orthodoxy as ‘means/ends’ relationships, recasting them as situated practices and dynamics shaped by social efficacy and regulatory regimes. |
Purpose: The purpose of this paper is to understand how, in the context of the latest healthcare reform in Quebec (2015), organizational actors mobilize transformative capacities through the process of integrating the academic mission across the care continuum. Methodoloy/approach/design: Realistic evaluation was used to explore forms of institutional work that manifest in the enactment of policy reform and their contribution to the development of transformative capacities among organizational actors (Cloutier, Denis, Langley et al., 2015; Denis, 2015). A qualitative embedded single-case study was conducted in the Eastern Townships (Estrie in French, used hereafter) Integrated Academic Health and Social Services Centre in Quebec. Data were collected through document review and semi-structured interviews with key informants. Empirical data were first categorized as either context, intervention, mechanism or outcome, then sub-categorized as either structural, conceptual, operational or relational work (Cloutier et al., 2015). Findings: Main results show that in a context of centrally managed reorganization, integration and differentiation mechanisms evolve in tension to generate structural capacities. The alignment of conceptual capacities across boundaries develops from frequent and inclusive local interaction among various actors. In a context of high performance pressure, a lack of perceived value and feasible guidelines jeopardize operational capacities and increase tensions between senior and local leadership. The mobilization of relational capacities is central to supporting structural, conceptual and operational work. Relational work transcends context, mechanism and outcome, and accelerates the potential for expanding the academic mission across boundaries. Conclusion: The development of transformative capacities through the integration of the academic mission across boundaries in a healthcare reform is a heterogeneous, non-linear and social process. Further research could explore the particular role of relational capacities, developed through experimentation, in fostering better alignment between actors across hierarchical boundaries during large-scale health system transformation. |
As a response to growing demands and costs for chronic care, healthcare providers are extending their use of digital technologies to measure and track interventions and patients. This data feeds into algorithms, which are becoming increasingly central in processes of patient care. In this paper we consider how algorithms are emerging from and reorganising patient care practice. We zoom in empirically on rheumatology, tracing the practice/research-driven development of an algorithm that provides an “overall” “summative” score of an RA patient’s disease activity (the Disease Activity Score based on 28 joint counts, DAS28) from the 1990s and onwards, based on archival material. We also conceptualize the implications of this algorithm in the Swedish rheumatology setting based on interviews and observations performed in 2010-2015. Our case suggests that the development of the DAS28 algorithm implied a formalization of clinical judgment. As the algorithm was diffused and normalized across practices, it also allowed more attention to be given to patients’ subjective experiences whilst masking the visibility of the patient’s involvement in their care process. Algorithms-in-practice (the Disease Activity Score based on 28 joint counts, DAS28 (DAS)) achieved this by developing in tandem with professional criteria and categories, by objectifying/quantifying patient’s experiences, and by hiding the fact that the patients experience was part of the algorithm rules. These results challenge the view that the hidden nature of algorithms makes humans into victims of their algorithmic logic, suggesting instead that algorithms can augment subjective experiences. This mechanism could inform the development and implementation of algorithms in patient care, in particular efforts aiming for increased patient participation. |
Driving change across boundaries: Eliminating crusted scabies in Northern Territory, Australia Helen Dickinson, Karen Gardner, Michelle Dowden, Naomi van der Linden, Hanna Woerle, Meg Scolyer & Irene O’Meara |
Opportunities and challenges in the collaboration and organization of acute care: Can emergency physicians and general practitioners bridge the gap between primary and secondary care? Anne Schoenmakers |
Understanding how professional cultures impact implementation for a pediatric oncology genomic test: The use of ethnographic participant observation in deliberative stakeholder consultations Justin Gagnon, Vasiliki Rahimzadeh, Cristina Longo, Peter Nugus & Gillian Bartlett |
Aboriginal communities in the Northern Territory (NT) of Australia have some of the highest reported rates of scabies in the world. Skin and secondary infections associated with scabies threaten the health and well-being of individuals and are a major cost burden for communities already struggling to deal with a significant burden of ill health. People with compromised immunity are particularly susceptible to crusted scabies, a chronic form of the condition that also perpetuates transmission of simple scabies. This paper reports on a new approach to controlling crusted scabies that is being implemented by a not-for-profit organisation, One Disease, into primary health care organisations in the NT with the aim of eliminating this disease in this state by 2019 and from Australia by 2022. The elimination of this disease will require significant collaborative work across a range of different types of boundaries if it is to be successful. Yet it is well established in the literature that cross-boundary work can be a challenging activity in the face of a wicked problem such as this public health challenge poses. The provision of philanthropic funding and/or specialist equipment, professionals and other resources can be a helpful way to focus attention on a particular issue. However, there are questions about the degree to which organisations external to the health system can work to influence this, and the sustainability of any change. In this paper we report on research that examines the One Disease approach to eliminating crusted scabies in the Australian Northern Territory and the degree to which it has succeeded in effectively coordinating across boundaries. |
Objectives In the Netherlands, the strong primary care system possibly influences the professionalization status of Emergency Medicine (EM), a relatively new Dutch hospital specialty. Currently, patient numbers and health care costs in acute care are rising. The Dutch government therefore fosters a transmural approach, resulting in an increase in co-located Emergency Departments (EDs) and acute primary care centers (‘general practitioner cooperative’. This article addresses the perspective of General Practitioners (GPs) on collaboration with EM physicians in acute care. Methods An qualitative online survey was conducted including 155 GPs. Qualitative analysis followed via thematically hand-by-hand categorizing of the data. Results Despite the rising GPC workload, most GPs support the amalgamation process because of logistic reasons, patient safety and additional collegial interaction. Overall, contact with EM physicians is positively valued. GPs estimate to refer 11,47 percent (range 0-100, SD18.03) of their acute patients directly to emergency physicians. Only 7 percent includes emergency physicians in their top three of hospital specialists when referring acute cases. GPs favor emergency physicians when a rapid holistic approach is needed to insure patient safety. They refer to EM physicians in case of unclear diagnosis, when simple procedures or tests are needed and when in-hospital specialists are unavailable. Yet, challenges are seen in the lack of 24 hour EM physician coverage and existing authority issues of EM. Due to varying local policies and an information deficit, GPs often feel unsurewhen to bypass a traditional in-hospital specialist and directly refer a patient to an EM physician. Discussion Mutual trust and understanding between primary and secondary care is vital within acute care collaboration. A greater insight on the role of professional status and associated day-to-day responsibilities is needed. The further establishment of EM can be achieved by strengthening regulation and improving - in-hospital and primary care - training programs. |
Increased healthcare innovation, exemplified by genomic medicine, requires increasingly sophisticated understanding of the interdisciplinary-organizational context in which new innovations are implemented. Deliberative stakeholder consultations are public engagement tools that are gaining increasing traction in health care, as a means of maximizing the diversity of roles and interests vested in a particular policy or practice issue. They engage participants from different knowledge systems (which can be called “cultures”) in mutually respectful debate to enable group consensus on implementation strategies. Current deliberation analytic methods tend to overlook the cultural contexts of the deliberative process[PN1] . This conceptual paper proposes adding ethnographic participant observation to provide a more comprehensive account of the process that gives rise to deliberative outputs, to enable us to better assess the quality of engagement across professional cultures in implementation studies. To underpin this conceptual paper, we draw on our experience engaging healthcare professionals for implementation of genomics in the care for pediatric oncology patients with treatment-resistant glioblastoma at two tertiary care hospitals. Ethnography allowed us to nuance deliberative outcomes by combining rhetorical and non-rhetorical analysis to identify the implementation and coordination of care barriers across professional cultures. |
Understanding the boundaries of urgent and emergency healthcare: Findings from citizen panels with diverse publics and healthcare providers in England Joanne Turnbull, Gemma Mckenna, Jane Prichard, Anne Rogers & Catherine Pope |
Creating patient and public involvement strategies: Enabling participatory working or reinforcing organisational boundaries? Meerat Kaur, Rachel Matthews & Catherine French |
Urgent healthcare services are often positioned in an ill-defined space somewhere between general or family practice and emergency hospital care. They often overlap with, emergency care departments ambulance services, and other care provision such that the borders between services are unclear. Increasingly urgent care services are being enrolled to divert people away from overburdened emergency healthcare services. For patients attempting to navigate the boundaries between services the landscape seems confusing and complex. Often at the point when they are sick or injured they have to make sense of healthcare needs and a variety of possible services, to which access may vary. This paper examines how publics (including patients and service providers) define and conceptualise the boundaries of urgent and emergency healthcare using a novel technique - citizens panels. We conducted four panels with a total of 41 participants - two designated as ‘general public’, one comprising healthcare professionals, and one made up of members of service commissioners. Each panel took place over a single day and three panels included between 10-15 participants, and the commissioner panel comprised three participants. The panel discussions explored the boundaries between urgent and emergency care and the tensions created by these. The paper discusses four emerging themes that address the broader themes of the conference, these are: confusing boundaries of care, contingent boundaries of need, borderlines and moral positioning, and re-imagined borders. Together these themes help explain why sense making and help seeking in the current UK urgent and emergency healthcare landscape is so problematic. |
Introduction. Legal and political drivers have aimed to embed Patient and Public Involvement shape healthcare systems. Yet there is a gap between what these aim to achieve and how this happens in practice. We explored how organisations’ PPI strategy documents could facilitate or hinder patients/public being involved. Methods. 15 patient and public involvement strategies from healthcare planning, delivery and research organisations across North West London (UK) were assessed. 4Pi: National Involvement Standards was used to form the framework, with Gibson et al’s theoretical framework providing additional insight. Results. The strategies varied in how clearly they articulated their PPI plans against 4Pi. Purpose was likely to be the component most strategies fully articulated. Principles, followed closely by Impact, were the components least likely to be articulate by the strategies. Those strategies which involved patients/public in the process of creating the strategies tended to better articulate PPI plans and vision. Searching for the strategies was time-consuming. 4Pi: National Involvement Standards and Gibson et al’s theoretical framework were useful in helping assess the content of the strategies, but could not assess PPI practice within the organisation. Discussion. PPI plans were better articulated when patients/public had a strong voice in the process of creating or influencing the strategy, yet this involvement was rare. PPI strategy documents had to meet competing agendas, and without structured frameworks some struggled to model participatory ways of working. Instead they reinforced organisational boundaries. The use of existing frameworks highlights models that could facilitate the creation and articulate PPI strategy documents. Many of the documents fell short of having the clear purpose or rationale needed to achieve meaningful, actionable and embedded PPI. This clearer articulation could help those participating share knowledge of what can work and how. Implications. This paper presents frameworks that can help create and articulate their plans and visions for PPI. |
Violence against child protection workers: A study of workers’ experiences, attributions, and coping strategies Josianne Lamothe, Amélie Couvrette, Gabrielle Lebrun, Gabrielle Soulière-Yale, Camille Roy & Steve Geoffrion |
Unmasking or reproducing abuse? Elaborating truth-telling processes through ‘dark-side’ field research Diane Burns |
Emotional labour in the ED: Feeling rules, gender stereotypes and emotional stoicism Kate Kirk, Laurie Cohen, Stephen Timmons & Alison Edgley |
Child protection workers (CPWs) are frequently exposed to client violence, both psychological and physical, in their line of work whether they operate in the community or in residential settings. Despite this known vulnerability, research on the subject has lagged. The current study sought to analyze CPWs’ experiences with client violence, their interpretation of it, its perceived consequences and their coping strategies. Specifically, 30 CPWs working both in the community and in residential settings, took part in an in-depth, semi-structured interview. A thematic analysis revealed that CPWs view client violence as a recurring and pervasive problem in their line of work. Residential workers described a greater frequency of violence, especially physical violence. CPWs however perceived violence differently, with some viewing this problem as ‘part-of-the-job’ while others described client violence as a ‘call-for-help’ on behalf of clients. Perceived consequences varied in severity and breath. CPWs reported consequences at the psychological (e.g. fear, hypervilence, sadness, nightmares), organizational (e.g. loss of motivation, turnover intention, sick leaves) and clinical levels (e.g. emotional detachment from clients, avoiding clients). CPWs also described numerous coping strategies, some effective while others appeared short-sighted. This study concludes with recommendations with regards to client violence in child protection work. |
The purpose of this paper is to consider the ethical challenges of undertaking field research into ‘dark side’ issues in healthcare – in this case, research examining why elder abuse in nursing homes occur. With recourse to the Foucauldian concept of parrhesia (truth-telling) as a mode of discourse, this paper examines the processes involved for speaking out about abuse in a nursing home. Namely, drawing on first-hand experiences of field research, extracts from interviews and field notes, the parrhesical opportunities taken by a resident to speak out about abuse are illuminated. This assessment shows why opportunities to ‘speak out’ about abuse can be a) fleeting and b) predominantly ineffectual. It is argued that parrhesic speech aimed at challenging poor care standards in the nursing home, are swiftly tapered when management respond with counter claims. The paper concludes by elaborating the potential for ‘dark side’ field research to surface how truth-telling in institutional care settings is both supported and suppressed. Simultaneously, caution is recommended, as unmasking ‘dark side’ concerns during field research brings a risk of reproducing abuse if the ‘truth-teller’s’ exposure to harm intensifies as a result. |
The National Health Service in England is under significant pressure. Emergency Departments (ED’s) in particular, are struggling to meet patient demand, with an upward trajectory of patient attendance since the 1970’s (Jones 2008). Furthermore, governmental pressures such as the ‘4-hour wait’ increase the challenges for those working within ED’s (Mortimore and Cooper 2007). It is perhaps undeniable that the challenges facing the NHS have implications for staff tasked with delivering care. The Boorman Report on the Health and Well-being of NHS Staff (2009) found high rates of poor well-being, which had a direct impact on the quality of care that patients received. English nurses specifically, also fare poorly when compared on an international perspective (Aiken et al 2012). The rates of stress, burnout, and the intention to leave are amongst the highest against other European countries, and America (Aiken et al 2012). Despite the strong evidence showing the importance of positive nurse well-being, the emotional component of the nurse’s role, a great influencer in well-being (Warren 2016; Johnson and Spector 2007), is overlooked (Smith 2012). Emphasis is given to physical tasks, with little value allocated to those which are less visible, and as such, less quantifiable (Bone 2002). As a consequence, a significant component of the role is left depreciated (Sawbridge and Hewison 2011), described as the emotional labour of nursing. This paper therefore, aims to theoretically and empirically explore the concept of emotional labour through the case study setting of the ED. It will focus specifically on the ‘feeling rules’ of the ED, and the likely diverse factors which instrument the frequency, ease and intensity of the emotional labour undertaken by ED nurses. It will unpack how the environmental and institutional factors, organisational dynamics, gender customs, patient population and their expectations, influence the emotional labour undertaken by staff. |
Bridging the safety net: A case study of how the MAP clinics use collaboration as a catalyst to meet the needs of vulnerable Patients Deborah Goldberg & Akhilesh Mohan |
Coordination in cancer care: Case studies in patient handovers Paul Gemmel, Bert Meijboom, Bo Edvardsson, Jeroen Akkermans & Titia Debergh |
Work organization in breast cancer centers: Do hospital structures account for differences? Lena Ansmann, Christoph Kowalski & Holger Pfaff |
The goal of this research is to illustrate a care model that uses collaboration and partnership as a critical means to address the health and social needs of vulnerable populations. The case study provides detailed information on the Mason and Partners (MAP) clinics, its collaboration partners, and the support provided by partners that contributes to the success and sustainability of this clinic model. The detailed case study description is intended to help other educational institutions, existing clinics, or other types of organizations who intend to establish a similar model. This qualitative case study research used semi-structured key informant interviews with local collaboration leaders and in-depth document review of the literature, collaboration charters, and project reports. Individuals interviewed are leaders and community representatives from local healthcare delivery systems, health insurance companies, non-profit health foundations, healthcare providers, government health departments and universities. Resource dependency theory, organizational culture, and theories on leadership were used to understand influences on the MAP clinic. The case study focuses on providing detailed information on the role of collaboration in the MAP clinics that serve low income, uninsured patients in the Northern Virginia area. The foundation of the MAP Clinics is the Bridge Care model, which is designed to provide short-term care and help patients enter a more permanent medical environment. The first role of collaboration is through interdisciplinary teaching, an approach known as Guided Interprofessional Focused Teaching (GIFT) Model that depends on collaboration with other university departments and external institutions to provide care. A second role of collaboration is the relationships between the MAP Clinics and referral organizations to link patients to needed health and social services. The third role of collaboration is the partnerships between the MAP clinics and organizations that provide support such as public health departments, school systems, local health systems, and funding sources. |
Cancer is a complex disease. It usually requires the input of multiple disciplines to meet a patient’s cancer-related needs. As a result, a better coordination is required We address the research question if and how coordination mechanisms such as clinical pathways (CP) and case management (CM) ensure safe and reliable handovers in complex cancer care processes. In two consecutive cases in two different hospitals (A and B), case managers, physicians, nurses and patients were interviewed. The empirical findings learn that CP and CM contribute to patient handovers in terms of information transfer, shared understanding and teamwork. Furthermore, clinical pathways and case management are clearly complementary coordination mechanisms. Moreover, analysing the handovers in terms of organizational routines is an adequate theoretical perspective to understand why CP and CM contribute to the quality and efficiency of handovers in a complementary way. |
Background: We investigate whether the work organization in hospitals contributes to explain the found variation in quality of care by structural characteristics of hospitals. The aim of this work is to study possible associations between hospital structures and the work organization from the employees’ perspective. Methods: A key information survey and an employee survey conducted in breast cancer centers in the state of North Rhine-Westphalia (NRW), Germany, build the basis of our analysis. The data was completed with obligatory hospital quality reports. Data from all sources (139 leadership positions, 1000 employees, 46 quality reports from 46 hospitals) were combined in order to calculate multilevel models, in which associations between hospital structures and individual employee perceptions of the work organization were analyzed. Results: In the multilevel analysis, the employees’ ratings of the work organization substantially varied by hospital. Compared to nurses, the physicians and other occupational groups were significantly less likely to report problems with process organization. Other occupational groups were less likely to report problems with internal interfaces compared to nurses, whereas nurses and physicians do not significantly differ in this regard. Regarding hospital structures the strongest relationships were found for teaching status. Employees in teaching hospitals and especially in university hospitals were significantly more likely to report problems with process organization. Besides, employees in university hospitals were significantly more likely to also report problems with internal interfaces. Discussion: The finding that employees in teaching hospitals report significantly more problems within the hospital’s work organization may explain why prior studies find a lower patient satisfaction in teaching hospitals. More research is needed to further explain those mechanisms. Moreover, the problems in work organization for teaching hospitals may have consequences in terms of the employees’ motivation and performance, which should be highly relevant topics for hospital management. |
Centre Mont Royal 2200 Rue Mansfield Montréal, QC H3A 3R8 |