Innovation inside the box : how contextual constraints can contribute to improvement in health care

Sammanfattning: Background Health care is becoming increasingly complex because of the major advances achieved in clinical and biomedical knowledge in the last 50 years. Many more important advances are on the horizon that will create opportunities to improve outcomes for patients. However, this promising scientific development is accompanied by the ever-escalating cost of care. This challenge represents a fundamental paradox as health care organizations struggle with how to achieve the “Triple Aim” of better care experience for patients, improved population health, and, at the same time, reductions in per capita health care cost. While downsizing is a common strategy used in health care to reduce costs, this strategy may have negative effects on the quality of care. Thus, innovation and significant organizational changes are needed at all levels. Although Quality Improvement (QI) is one of the predominant approaches to making changes in health care, its application and effectiveness are increasingly questioned and discussed. The Triple Aim framework embodies the challenge of innovating under financial constraints, which has been studied in the business sector. However, constraint driven innovation is not well understood in health care. Aim The aim of this thesis is to explore how the (paradoxical) juxtaposition of constraints (such as pairing downsizing with increased quality in patient outcomes and experience) can be used as a driver for innovation in health care design and delivery. The case studied is a Danish OB/GYN department faced with external requirements to reduce costs. The department was required to reduce the number of beds by 36%, the number of nursing staff by 20%, and its budget by 10% while still maintaining a high quality of care and patient satisfaction. More explicitly, this thesis explores change management in pursuit of the Triple Aim from the individual perspective (Study I) and at the organizational level (Study III), validates the Danish version of the Organizational Readiness for Implementing Change scale (ORIC) (Study II), and attempts to explain how the managers addressed external demands without compromising patient outcomes and experiences (Study IV). Methods The overall research design was an organizational case study that draws upon multiple data sources and utilizes various data collection and analytical methods. Study I is an interview study of staff’s and managers’ understandings and the underlying mental models related to the Triple Aim. Study II is a validation study that tests the validity and reliability of the Danish version of the ORIC scale. Study III assesses the organizational readiness for implementing large-scale change in pursuit of the Triple Aim and determines associated factors. Both studies use data from a web-based questionnaire. Study IV is an explanatory case study with a longitudinal design. Multiple qualitative data (i.e. interviews, observations, and documents) were analyzed using a complexity-based leadership framework that combined the Cynefin framework and Adaptive Leadership. Findings Study I show that staff and managers identified with the Triple Aim consistent with the divisions that exist between professions and managers. Mental models of change and economics in health care were elicited, and a complex interplay among these mental models was explored. Staff perceived the Triple Aim as a dilemma between quality or economics and a threat to patient care, whereas managers saw a paradox that could inspire them to make improvement efforts. Study II, which establishes the reliability and validity of the Danish version of the ORIC scale can be used to measure organizational readiness for implementing change in a Danish health care context. Study III reveals a high degree of agreement with the commitment statements but low agreement with the efficacy statements. Managerial status and temporary employment were significant predictors of high efficacy scores. Study IV shows that managers in pursuit of the Triple Aim reframed the efficiency requirement as an opportunity to improve patient care. They chose a “professional path” and systematically analyzed every clinical pathway. They developed appropriate responses for simple, complicated, and complex situations. The locus of responsibility for improvement was shared with, or placed on, staff for the majority of the innovations that were implemented. By analyzing the clinical pathways and developing improvement suggestions, patterns of complex organizational challenges emerged. Appropriate responses that addressed these previously unknown situations also emerged. Conclusions The juxtaposition of paradoxical constraints, as framed by the Triple Aim of health care, may be used to drive innovation and improvement in health care. In the face of efficiency requirements, the case studied in this thesis demonstrates that simple, complicated, and complex challenges can be identified, and appropriate responses can be developed. When downsizing requirements are accepted and reframed as stretch goals that resonate with the dominant mental models of change and economics in health care, innovation can occur at the department level. By integrating insights from complexity, this thesis demonstrates how QI efforts can be used to support innovation that achieves the Triple Aim. Managers need to deal with the high levels of uncertainty, including staff’s worries and concerns, associated with large-scale and complex changes. Thus, managers may benefit from reframing societal discourse and efficiency demands as stretch goals that resonate with the staff´s professional ethos.