A Gateway Framework to Guide Major Health System Changes Comment on "'Attending to History' in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration".

Recent events - on both a global scale and within individual countries - including the lockdowns associated with COVID-19 pandemic, inflation concerns, and political tensions, have increased pressure to reconfigure social services for ongoing sustainability. Healthcare services across the world are undergoing major system change (MSC). Given the complexity and different contextual drivers across healthcare systems, there is a need to use a variety of perspectives to improve our understanding of the processes for MSC. To expand the knowledge base and develop strategies for MSC requires analysing change projects from different perspectives to distil the elements that drove the success. We offer the Gateway Framework as a collaborative transformational system tool to assess and reorganise operations, services, and systems of healthcare organisations. This framework and guiding questions, accounts for past events whilst being proactive, future orientated, and derived from externally defined and a standardised requirements to promote safe, high-quality care.

Looking Back, Looking Forward: A Study Protocol for a Mixed-Methods Multiple-Case Study to Examine Improvement Sustainability of Large-Scale Initiatives in Tertiary Hospitals.

Background Hospitals invest extensive resources in large-scale initiatives to improve patient safety and quality at an organizational level. However, initial success, if any, does not guarantee longer-term improvement. Empirical and theoretical knowledge that informs hospitals on how to attain sustained improvement from large-scale change is lacking. Aim The proposed study aims to examine improvement sustainability of two large-scale initiatives in an Australian tertiary hospital and translate the lessons into strategies for achieving sustained improvement from large-scale change in hospital settings. Design and Methods The study employs a single-site, multiple-case study design to evaluate the initiatives separately and comparatively using mixed methods. Semi-structured staff interviews will be conducted in stratified cohorts across the organizational hierarchy to capture different perspectives from various staff roles involved in the initiatives. The output and impact of the initiatives will be examined through organizational documents and relevant routinely collected organizational indicators. The obtained data will be analyzed thematically and statistically before being integrated for a synergic interpretation. Implications Capturing a comprehensive organizational view of large-scale change, the findings will have the potential to guide the practice and contribute to the theoretical understandings for achieving meaningful and longer-term organizational improvement in patient safety and quality.

Implementing health system improvement: resources and strategies for interprofessional teams.

Health system improvement (HSI) is focused on systematic changes to organisational processes and practices to improve the efficient delivery of safe care and quality outcomes. Guidelines that specify how interprofessional teams conduct HSI and knowledge translation are needed. We address this urgent requirement providing health professional teams with resources and strategies to investigate, analyse and implement system-level improvements. HSI encompasses similar, yet different, inter-related activities across a continuum. The continuum spans three categories of activities, such as quality improvement, health management research and translational health management research. A HSI decision making guide and checklist, comprising six-steps, is presented that can be used to select and plan projects. This resource comprises six interconnected steps including, defining the activity, project outcome, aim, use of evidence, appropriate methodology and implementation plan. Each step has been developed focusing on an objective, actions and resources. HSI activities provide a foundation for interprofessional collaboration, allowing multiple professions to create, share and disseminate knowledge for improved healthcare. When planned and executed well, HSI projects assist clinical and corporate staff to make evidence-informed decisions and directions for the benefit of the service, organisation and sector.

Sustaining improvement of hospital-wide initiative for patient safety and quality: a systematic scoping review.

BACKGROUND: Long-term sustained improvement following implementation of hospital-wide quality and safety initiatives is not easily achieved. Comprehensive theoretical and practical understanding of how gained improvements can be sustained to benefit safe and high-quality care is needed. This review aimed to identify enabling and hindering factors and their contributions to improvement sustainability from hospital-wide change to enhance patient safety and quality. METHODS: A systematic scoping review method was used. Searched were peer-reviewed published records on PubMed, Scopus, World of Science, CINAHL, Health Business Elite, Health Policy Reference Centre and Cochrane Library and grey literature. Review inclusion criteria included contemporary (2010 and onwards), empirical factors to improvement sustainability evaluated after the active implementation, hospital(s) based in the western Organisation for Economic Co-operation and Development countries. Numerical and thematic analyses were undertaken. RESULTS: 17 peer-reviewed papers were reviewed. Improvement and implementation approaches were predominantly adopted to guide change. Less than 6 in 10 (53%) of reviewed papers included a guiding framework/model, none with a demonstrated focus on improvement sustainability. With an evaluation time point of 4.3 years on average, 62 factors to improvement sustainability were identified and emerged into three overarching themes: People, Process and Organisational Environment. These entailed, as subthemes, actors and their roles; planning, execution and maintenance of change; and internal contexts that enabled sustainability. Well-coordinated change delivery, customised local integration and continued change effort were three most critical elements. Mechanisms between identified factors emerged in the forms of Influence and Action towards sustained improvement. CONCLUSIONS: The findings map contemporary empirical factors and their mechanisms towards change sustainability from a hospital-wide initiative to improve patient safety and quality. The identified factors and mechanisms extend current theoretical and empirical knowledgebases of sustaining improvement particularly with those beyond the active implementation. The provided conceptual framework offers an empirically evidenced and actionable guide to assist sustainable organisational change in hospital settings.

Optimising outcomes for complex trauma survivors: assessing the motivators, barriers and enablers for implementing trauma informed practice within a multidisciplinary health setting.

BACKGROUND: Complex trauma is a significant public health issue with detrimental health, interpersonal and psychological impacts, which can impede client recovery and result in multiple representations. 'Trauma Informed Practice' (TIP) is an evidence-based model which ensures safe and effective services for clients and staff. This study examines health professional's use of TIP, and the motivators, enablers and barriers to implementation in a multidisciplinary setting. METHODS: A mixed methods study with 24 front-line clinicians and managers within a community health setting in Australia. A purpose designed, expert validated TIP checklist was completed, followed by semi-structured focus groups. Survey data was reported using descriptive statistics. Focus group data was digitally recorded, transcribed and thematically analysed. RESULTS: Ten key factors were identified motivating, restricting or enabling TIP implementation. Seven were organisational factors including supportive and informed management, flexibility of service models, levels of service demands, resource availability, education opportunities, good client outcomes, and reporting requirements. Philosophical approach, team orientation, and vicarious trauma/stress management were three individual professional factors. Critically, alignment in two ways was necessary for successful implementation, that is: in knowledge and understanding across organisational role levels - clinician, manager and executive; and, in professional philosophy and team orientation of individual clinicians. CONCLUSION: Providing TIP is essential for ensuring optimum client outcomes for trauma survivors and for maintaining workforce wellbeing. Although the increasing uptake to TIP is evident within the health setting, further attention is required to address the tension between service models focused on efficiently servicing whole populations and those attuned to effectively meeting the needs of high risk groups. A complex strategy to unite therapeutic and managerial goals is necessary if client, professional and organisational needs are to be effectively met.

Large scale healthcare facility redevelopment: A scoping review.

Internationally, organisations are undertaking large scale facility redevelopment as a strategy for the transformation of care systems. Redeveloping facilities provides a once in a generation opportunity to transform health service delivery, typically, however, system level changes are poorly understood. To address this gap, our aim was to investigate the empirical knowledge base regarding large scale redevelopment of healthcare facilities. A scoping review was undertaken, guided by the redeveloped health service management (HSM) scoping review framework (HSM-SRF). Across 17 articles, five key concepts were identified, and they form the principles for successful redevelopment. First, establish a strong governance framework integrating diverse expertise and evidence base. Second, engage with internal and external stakeholders to build effectual relationships. Third, consult with end users, including clinicians and patients, to encourage the acceptance of the redevelopment and actively manage stakeholder dynamics, including politics and power undercurrents. Fourth, commit appropriate resources, including time, workforce, technology and finance to ensure redevelopment success. Finally, reimagine workflows through consultation with end users, including staff and consumers, allowing them to conceptualise how the space will be utilised. This scoping review is the first to synthesise the empirical knowledge base of the redevelopment of healthcare facilities.

Improving knowledge translation for increased engagement and impact in healthcare.

Ineffective knowledge dissemination contributes to clinical practice and service improvements not being realised. Meaningful knowledge translation can occur through the understanding and matching of appropriate communication mediums that are relevant for different stakeholders or audiences. To this end, we present a dissemination instrument, the 'REAch and Diffusion of health iMprovement Evidence' (README) checklist, for the communication of research findings, integrating both traditional and newer communication mediums. Additionally, we propose a 'Strategic Translation and Engagement Planning' (STEP) tool, for use when deciding which mediums to select. The STEP tool challenges the need for communicating complex and simple information against the desire for passive or active stakeholder interaction. Used collaboratively by academics and health professionals, README and STEP can promote co-production of research, subsequent diffusion of knowledge, and develop the capacity and skills of all stakeholders.

The Embedded Health Management Academic: A Boundary Spanning Role for Enabling Knowledge Translation Comment on "CIHR Health System Impact Fellows: Reflections on 'Driving Change' Within the Health System".

Healthcare organisations are looking at strategies and activities to improve patient outcomes, beyond clinical interventions. Increasingly, health organisations are investing significant resources in leadership, management and team work training to optimise professional collaboration, shared decision-making and, by extension, high quality services. Embedded clinical academics are a norm in, and considered a strength of, healthcare organisations and universities. Their role contributes, formally and informally, to clinical teaching, knowledge sharing and research. An equivalent, but significantly less common role, addressing the management of healthcare organisations, is the embedded health management academic (EHMA). A stimulus encouraging this intertwined embedded academic role, in both clinical and managerial fields, is the demand for the translation of knowledge between academic and industry contexts. In this essay, we describe the EHMA role, its value, impact and potential for enabling healthcare organisation improvement. Focusing on the business of healthcare, the EHMA is a conduit between sectors, stakeholders and activities, enabling different organisations and experts to co-create, share and embed knowledge. The value and impact achieved is significant and ongoing, through the nurturing of an evidence-based management culture that promotes ongoing continuous improvement and research activities.

Health system redesign: Changing thoughts, values, and behaviours for the co-production of a safety culture.

PURPOSE: Simultaneous incremental and revolutionary systems change is a norm for many health care organisations. Organisational redesign, incorporating physical redevelopments and technological innovations, drives revolutionary transformations. Redesigning health facilities provides opportunities for improving and sustaining safe, high-quality patient care. There is a need for the creation of knowledge, based on empirical research, to inform how to effectively plan, implement, and evaluate health organisational redesign, underpinned by co-production principles. FINDINGS: Using an Australian case study, we identify and discuss the opportunities and challenges, aligned with safety and quality requirements, to undertake redesign projects. Through an analysis of redesign and governance accountabilities, we identify five key foci for health leaders, and their communities, to plan, implement and evaluate organisational redesign. CONCLUSION: By rebuilding and engaging with patients and consumers to organise, manage and deliver care, the redesign process allows us to change thoughts, values, and behaviours to achieve better patient outcomes.

How to improve healthcare? Identify, nurture and embed individuals and teams with "deep smarts".

Purpose Unlocking and transferring skills and capabilities in individuals to the teams they work within, and across, is the key to positive organisational development and improved patient care. Using the "deep smarts" model, the purpose of this paper is to examine these issues. Design/methodology/approach The "deep smarts" model is described, reviewed and proposed as a way of transferring knowledge and capabilities within healthcare organisations. Findings Effective healthcare delivery is achieved through, and continues to require, integrative care involving numerous, dispersed service providers. In the space of overlapping organisational boundaries, there is a need for "deep smarts" people who act as "boundary spanners". These are critical integrative, networking roles employing clinical, organisational and people skills across multiple settings. Research limitations/implications Studies evaluating the barriers and enablers to the application of the deep smarts model and 13 knowledge development strategies proposed are required. Such future research will empirically and contemporary ground our understanding of organisational development in modern complex healthcare settings. Practical implications An organisation with "deep smarts" people - in managerial, auxiliary and clinical positions - has a greater capacity for integration and achieving improved patient-centred care. Originality/value In total, 13 developmental strategies, to transfer individual capabilities into organisational capability, are proposed. These strategies are applicable to different contexts and challenges faced by individuals and teams in complex healthcare organisations.

It Takes Two to Tango: Customization and Standardization as Colluding Logics in Healthcare Comment on "(Re) Making the Procrustean Bed Standardization and Customization as Competing Logics in Healthcare".

The healthcare context is characterized with new developments, technologies, ideas and expectations that are continually reshaping the frontline of care delivery. Mannion and Exworthy identify two key factors driving this complexity, 'standardization' and 'customization,' and their apparent resulting paradox to be negotiated by healthcare professionals, managers and policy makers. However, while they present a compelling argument an alternative viewpoint exists. An analysis is presented that shows instead of being 'competing' logics in healthcare, standardization and customization are long standing 'colluding' logics. Mannion and Exworthy's call for further sustained work to understand this complex, contested space is endorsed, noting that it is critical to inform future debates and service decisions.

Empirical exploration of brilliance in health care: perceptions of health professionals.

Objective The aim of the present study was to develop a positive organisational scholarship in health care approach to health management, informed by health managers and health professionals' experiences of brilliance in health care delivery. Methods A sample of postgraduate students with professional and/or management experience within a health service was invited to share their experiences of brilliant health services via online discussions and a survey running on the SurveyMonkey platform. A lexical analysis of student contributions was conducted using the individual as the unit of analysis. Results Using lexical analysis, the examination of themes in the concept map, the relationships between themes and the relationships between concepts identified 'care' as the most important concept in recognising brilliance in health care, followed by the concepts of 'staff' and 'patient'. Conclusions The research presents empirical material to support the emergence of an evidence-based health professional perspective of brilliance in health management. The findings support other studies that have drawn on both quantitative and qualitative materials to explore brilliance in health care. Pockets of brilliance have been previously identified as catalysts for changing health care systems. Both quality, seen as driven from the outside, and excellence, driven from within individuals, are necessary to produce brilliance. What is known about the topic? The quest for brilliance in health care is not easy but essential to reinvigorating and energising health professionals to pursue the highest possible standards of health care delivery. What does this paper add? Using an innovative methodology, the present study identified the key drivers that health care professionals believe are vital to moving in the direction of identifying brilliant performance. What are the implications for practitioners? This work presents evidence on the perceptions of leadership and management practices associated with brilliant health management. Lessons learned from exceptionally well-delivered services contain different templates for change than those dealing with failures, errors, misconduct and the resulting negativity.

Hospital employees' perceptions of fairness and job satisfaction at a time of transformational change.

Objective This study examines the relationships between job satisfaction and organisational justice during a time of transformational change. Methods Data collection occurred immediately before a major regional hospital's move to a greenfield site. Existing measures of job satisfaction and organisational justice were used. Data were analysed (n=316) using descriptive, correlation and regression methods together with interactions between predictor variables. Results Correlation coefficients for satisfaction and organisational justice variables were high and significant at the P<0.001 level. Results of a robust regression model (adjusted R(2)=0.568) showed all three components of organisational justice contributed significantly to employee job satisfaction. Interactions between the predictor variables showed that job satisfaction increased as the interactions between the predictor variables increased. Conclusions The finding that even at a time of transformational change staff perceptions of fair treatment will in the main result in high job satisfaction extends the literature in this area. In addition, it was found that increasing rewards for staff who perceive low levels of organisational justice does not increase satisfaction as much as for staff who perceive high levels of fairness. If people feel negative about their role, but feel they are well paid, they probably still have negative feelings overall. What is known about the topic? Despite much research highlighting the importance of job satisfaction and organisational justice in healthcare, no research has examined the influence of transformational change, such as a healthcare organisational relocation, on these factors. What does this paper add? The research adds to academic literature relating to job satisfaction and organisational justice. It highlights the importance of organisational justice in influencing the job satisfaction of staff. What are the implications for practitioners? Financial rewards do not necessarily motivate staff but low rewards do demotivate. Shortages of health professionals are often linked to a lack of job satisfaction, and recruitment and retention strategies are often based on salary.

Finding brilliance using positive organizational scholarship in healthcare.

PURPOSE: Positive organizational scholarship in healthcare (POSH) suggests that, to promote widespread improvement within health services, focusing on the good, the excellent, and the brilliant is as important as conventional approaches that focus on the negative, the problems, and the failures. POSH offers different opportunities to learn from and build resilient cultures of safety, innovation, and change. It is not separate from tried and tested approaches to health service improvement--but rather, it approaches this improvement differently. The paper aims to discuss these issues. DESIGN/METHODOLOGY/APPROACH: POSH, appreciative inquiry (AI) and reflective practice were used to inform an exploratory investigation of what is good, excellent, or brilliant health service management. FINDINGS: The researchers identified new characteristics of good healthcare and what it might take to have brilliant health service management, elucidated and refined POSH, and identified research opportunities that hold potential value for consumers, practitioners, and policymakers. RESEARCH LIMITATIONS/IMPLICATIONS: The secondary data used in this study offered limited contextual information. PRACTICAL IMPLICATIONS: This approach is a platform from which to: identify, investigate, and learn about brilliant health service management; and inform theory and practice. SOCIAL IMPLICATIONS: POSH can help to reveal what consumers and practitioners value about health services and how they prefer to engage with these services. ORIGINALITY/VALUE: Using POSH, this paper examines what consumers and practitioners value about health services; it also illustrates how brilliance can be theorized into health service management research and practice.

Trialability, observability and risk reduction accelerating individual innovation adoption decisions.

PURPOSE: The purpose of this paper is to provide a retrospective analysis of computer simulation's role in accelerating individual innovation adoption decisions. The process innovation examined is Lean Systems Thinking, and the organizational context is the imaging department of an Australian public hospital. DESIGN/METHODOLOGY/APPROACH: Intrinsic case study methods including observation, interviews with radiology and emergency personnel about scheduling procedures, mapping patient appointment processes and document analysis were used over three years and then complemented with retrospective interviews with key hospital staff. The multiple data sources and methods were combined in a pragmatic and reflexive manner to explore an extreme case that provides potential to act as an instructive template for effective change. FINDINGS: Computer simulation of process change ideas offered by staff to improve patient-flow accelerated the adoption of the process changes, largely because animated computer simulation permitted experimentation (trialability), provided observable predictions of change results (observability) and minimized perceived risk. RESEARCH LIMITATIONS/IMPLICATIONS: The difficulty of making accurate comparisons between time periods in a health care setting is acknowledged. PRACTICAL IMPLICATIONS: This work has implications for policy, practice and theory, particularly for inducing the rapid diffusion of process innovations to address challenges facing health service organizations and national health systems. Originality/value - The research demonstrates the value of animated computer simulation in presenting the need for change, identifying options, and predicting change outcomes and is the first work to indicate the importance of trialability, observability and risk reduction in individual adoption decisions in health services.