Managing management innovations: Contextual complexity and the pursuit of improvements in healthcare

Sammanfattning: In a context characterised by complexity and conflicting demands, healthcare managers at a meso-level struggle to pursue improvements in the quality and efficiency of care operations. An influential approach on how to pursue improvements is quality management (QM). QM adopts the view that systems are centred around a common aim and should be appreciated and managed to reduce undesired variation and improve performance incrementally. Nuancing this view, complexity science propels the idea of healthcare as a complex adaptive system (CAS), which refutes prediction and managerial control of development. As one component of the CAS of healthcare, various management innovations (MIs) provide suggestions on how to achieve improvements. However, achieving any improvement is not often as simple as portrayed and MIs can rarely be fully and exclusively applied in practice. Starting from the practical issue of how to achieve improvements in healthcare, this thesis seeks to explore how healthcare managers at a meso-level can understand and use MIs to handle complexity and achieve improvements. A qualitative and action research-inspired approach is adopted to investigate this issue, concentrating on the context of psychiatric care at the Sahlgrenska University Hospital in Gothenburg, Sweden. Four studies, resulting in five appended papers, are presented. By investigating contemporary MIs, the studies contribute to an improved understanding of how MIs can be used, and complexity handled, in the pursuit of improvements. Study 1 starts by exploring the concept of value at a time when lean was succeeded by value-based healthcare (VBHC) as the MI in fashion in the context and the study follows the implementation of VBHC in an action research-inspired approach. Study 2 tests the utility of the value configurations framework to handle conflicting logics and pursue improvements in psychosis care. In study 3, literature on network configurations in different healthcare contexts is reviewed. Lastly, study 4 is an action research study focusing on contextualisation of learning health systems (LHS) as yet an example of an MI in healthcare. Based on the findings of five appended papers and earlier literature from the fields of QM, complexity science, and MIs, a model is developed that points to the centrality and utility of logics to connect MIs and other system components to improve the understanding of both MIs and CASs. By investigating the logics underlying different MIs, actors in the healthcare system (e.g., politicians, physicians, and managers), and technical features of care (e.g., their predictability and inclination to standardised treatments), a relative appreciation of a CAS can be pursued, which can guide managers in how to use MIs and attract change that can lead to improvements. Furthermore, the thesis supports the view that MIs are often ambiguous concepts that can be translated and adapted to fit a local context in a process of contextualisation. For scholars, the thesis also contributes by integrating the perspectives of QM and complexity science, and of QM and MIs in general, as two parallel approaches to pursue improvements in healthcare.