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Table 2 Contextual conditions, policy-level knowledge integration activities, and frontline knowledge brokering experiences

From: Creating conditions for effective knowledge brokering: a qualitative case study

 

Timeline

PHASE 1 (pre-2008)

Drivers of change, the beginning of an innovation discourse, and an unprepared local context

PHASE 2 (2008 – 2011)

Early implementation, a partial shift in policy approach, & the problem of legitimacy

PHASE 3 (2012 – 2015)

Adolescent implementation & the problem of coordination

PHASE 4 (2016 – 2018)

Maturing implementation & emergent collaboration

DISTAL CONTEXT

Contextual conditions

• Burgeoning interest in QI methods for healthcare, globally; growing interest in organization theory. Business process re-engineering at Royal Leicester Infirmary gains renown.

• Rising influence, domestically, of organization theorists & international boundary organizations specializing in improvement (e.g. Institute for Healthcare Improvement).

• Domestically, public hospitals in deep financial trouble; rising urgency to curb expenditure & improve value.

• Federal domestic performance targets established to improve patient flow through EDs & surgery; Australian hospitals experiment with Lean.

• Influence of organization theorists on healthcare performance improvement organizations grows.

• High Performance Work Systems & Lean-inspired healthcare interventions flourish, internationally.

• Domestic interest in improving value & efficiency heightens.

• Domestic Lean networks and Lean boundary organizations capture policy interest.

• Growing local discontent with poor research impact fuels domestic interest in research translation & knowledge integration. A knowledge translation & integration movement emerges.

• Healthcare is fastest growing area of domestic government expenditure; hospital expenditure is greatest within healthcare funding envelope.

• Government concern with waste peaks.

• Seed funding provided to establish domestic research translation centres and accelerate knowledge translation, particularly in hospitals.

• Research translation centres facilitate greater collaboration between universities & health, but integration with government health departments and policy-makers is poor.

• Maturing conversations about knowledge translation, mobilisation, brokering, and integration.

• Importance of research translation and knowledge integration gains recognition at Federal policy level.

• Additional research translation centres established.

• Push for greater transparency of hospital performance across a range of measures; push for innovation, rather than greater capital investment, to solve hospital capacity issues.

 

Policy-level ‘knowledge integration’ activities & events

• Perceived need for hospitals to acquire improvement capabilities.

• Perceived need for hospitals to address lack of critical thinking skills in frontline staff, and lack of mechanisms for staff to challenge taken-for-granted, non-value-adding processes.

• Perceived need for greater efficiency and waste reduction, although no “burning platform” (ES P1) to reduce waste.

• Distant rather than local searches for new knowledge carried out. Ideas parachuted in.

• Early efforts to build basic process mapping, process redesign, and project management skills, facilitated by the funding of multiple, small improvement projects (“products”, not an holistic approach, PM P9).

• Top-down approach to improving hospital performance through target setting and performance monitoring (the use of a “stick”, PM P9).

• Policy intervention commences (2008).

• Policy strategy is to differentiate the intervention from already well-embedded, potentially synergistic programs and methodologies (e.g. quality improvement).

• Rationale for intervention betrays a strong interest in improving efficiency.

• Lack of enthusiasm amongst hospitals leads policy-makers to dangle funds untethered to outcomes, to encourage engagement.

• Substantial involvement of Lean-inclined industry & consultants in shaping & governing of the intervention.

• Improvement leader roles funded & embedded in hospitals; training in Lean techniques commences; performance improvement work carried out via multiple projects within participating hospitals.

• Industry internships, site visits & mentoring for improvement leaders commence.

• Improvement leader network established.

• Extensive suites of Lean-inspired tools developed & shared across improvement advisor network.

• Improvement capability framework for hospitals developed.

• “My original and to this day strong recommendation, which wasn't taken up, is that the quality managers and the people working in quality in the hospitals should have been the targeted personnel for this [process improvement] training and this capability uplift. Because, to my way of thinking, it's the same family of theories.” (Policy-maker, Participant 43).

• Policy intervention evaluated (2012). Discrete project successes identified, but clinician engagement, organizational capability, fragmented knowledge integration & poor diffusion of ideas identified as issues.

• Government restructure brings policy intervention together with clinical networks & leadership development activities.

• Organizational improvement capability tool rolled out. Focus on organizational capability intensifies: “It’s complex work, it’s not simple, because we’re trying to change the way organizations run, not just attack [performance] targets.” (Policy-maker, Participant 2).

•“We saw ourselves as facilitating and coordinating and supporting the hospitals to build their capability to improve.” (Policy-maker, Participant 9).

• Training programs in process improvement for clinicians continue.

• Review of public hospital capacity conducted (2015). Improvement capability (rather than capital investment) identified as key to sustainability of hospitals.

• Improvement Advisor roles continue, but concerns emerge regarding impact and value of these roles.

• Improvement clearinghouse is established.

• Further policy restructure takes place in light of recent reviews. Policy functions of improvement, safety & hospital capacity brought together, as policy integration and synergies are sought.

• Intervention survives, with new emphasis placed on:

 • Clarification of roles and expectations of Improvement Advisor positions.

 • Appointment of specialized “industry coaches” (specialists in process improvement) to work alongside Improvement Advisors, but with new conversations about knowledge brokering issues.

 • Engagement with Improvement Advisors to develop individual capability-building framework that extends beyond building technical knowledge and mastery of technical tools.

 • Engagement with Improvement Advisors to re-develop organizational improvement capability framework for hospitals, so that improvement knowledge can be better exploited.

 • Facilitation of peer-to-peer mentoring amongst improvement advisors through strengths-appreciation process that teams up experienced & inexperienced Improvement Advisors.

 • Establishment of an Improvement Advisor community of practice, resulting in open sharing, including of failure: “Initially, you could see people walked in, they stayed in their groups …. You know, we had to work really hard to facilitate it and it tended to be quite didactic. Now, it is completely different … And although we may have shifted some individuals, there are still some challenges for some health services … because actually, in sharing, you're sharing your failures as well as your success, otherwise it's not sharing. And a number of health services had real problems with that concept of sharing failure.” (Policy maker, Participant 34).

 • Cross-hospital knowledge-sharing via centrally-coordinated, cross-hospital networking & system-wide showcase events.

 • Use of social media to communicate & enhance profile & discoverability of local improvement learning.

 • New emphasis placed on looking locally for improvement inspiration and mobilizing local know-how.

PROXIMAL / LOCAL CONTEXT

Frontline knowledge brokering experiences

• Hospitals exposed to basic project management skills and rudimentary process improvement tools.

• Concept of knowledge brokering and knowledge integration unestablished within jurisdiction.

• No sense of urgency for reform amongst frontline staff, leading to desultory process improvement attempts targeting only “low hanging fruit” (Executive Sponsor, Participant 1).

• Basic skills required to prepare workforce for required improvement: “The main goal [from my perspective] was to increase capability and capacity to be able to respond to problems that [front line staff] identified. But the challenge was you didn’t have a workforce that even asked questions and solved problems.” (Executive Sponsor, Participant 1).

• Project approach becomes wearing on frontline staff, with Improvement Advisors bearing the brunt: “Death by a thousand projects” seems to be a familiar refrain among Improvement Advisors. (Field note).

• Improvement Advisor network established, and successful in terms of circulating knowledge throughout this network. At the same time, collaboration between health services is seen as unusual: “That network means that there’s a culture in [improvement] of sharing. That’s unusual [here] in health – it’s crazy, but it’s unusual.” (Executive Sponsor, Participant 14).

• “I think broadly from [policy-makers, the ICPH in its early days] was [about] seeing health organizations tooling up.” (Improvement Advisor, Participant 7).

• “My experience of watching [hospitals] go Lean is that after a point in time your staff do a backflip and start to resent it: ‘Here come the Lean people’”. (Improvement Advisor, Participant 4).

• The Department should actually be building their policy knowledge based on the [local] issues that appear in health systems. And they don’t necessarily to the extent they could. It’s a power shift. So, do with, not to. So that’s the shift that I would see should be made.” (Improvement Advisor, Participant 13).

• “I think [the IA network has] run its race in [terms of] being a supportive group, for a group who are thinking about, ‘Maybe I’ll do this [improvement] thing’”. (Improvement Advisor, Participant 7).

• Improvement Advisors report difficulties in engaging clinicians in process improvement and encountering receptiveness issues.

• Competitive nature of system openly acknowledged by Improvement Advisors, Executive Sponsors, and policy-makers.

• “By the time we got to the third [collaboration event] it opened right up because people started talking about their problems. We started to realize that actually, the issue you've got here at [this health service] is the same issue as [over there]. And [that other health service] has just recently solved that same issue as well, and we start to see this more collegiate kind of thing happen. For the most part, I think they've got these relationships now where everyone will pick up the phone and talk to each other.” (Improvement Advisor, Participant 48).

• Improvement Advisors begin to express mixed opinions about the competitive nature of the system, and can instead point to examples of collaboration that extend beyond the Improvement Advisor cohort.