Mobilizing pilot-based evidence for the spread and sustainability of innovations in healthcare: The role of innovation intermediaries.

An endemic challenge facing healthcare systems around the world is how to spread innovation more widely and sustainably. A common response to this challenge involves conducting pilot implementation studies to generate evidence of the innovation's benefits. However, despite the key role that such studies play in the local adoption of innovation, their contribution to the wider spread and sustainability of innovation is relatively under-researched and under-theorized. In this paper we examine this contribution through an empirical examination of the experiences of an innovation intermediary organization in the English NHS (National Health Service). We find that their work in mobilizing pilot-based evidence involves three main strands; configuring to context; transitioning evidence; and managing the transition. Through this analysis we contribute to theory by showing how the agency afforded by intermediary roles can support the effective transitioning of pilot-based evidence across different phases in the innovation journey, and across different occupational groups, and can thus help to create a positive feedback loop from localized early implementers of an innovation to later more widespread adoption and sustainability. Based on these findings, we develop insights on the reasons for the unnecessary repetition of pilots - so-called 'pilotitis'- and offer policy recommendations on how to enhance the role of pilots in the wider spread and sustainability of innovation.

Identifying core strategies and mechanisms for spreading a national medicines optimisation programme across England-a mixed-method study applying qualitative thematic analysis and Qualitative Comparative Analysis.

BACKGROUND: Achieving widespread adoption of innovations across health systems remains a challenge. Past efforts have focused on identifying and classifying strategies to actively support innovation spread (replicating an innovation across sites), but we lack an understanding about the mechanisms which such strategies draw on to deliver successful spread outcomes. There is also no established methodology to identify core strategies or mechanisms which could be replicated with fidelity in new contexts when spreading innovations. We aimed to understand which strategies and mechanisms are connected with successful spread using the case of a national medicines optimisation programme in England. METHODS: The study applied a comparative mixed-method case study approach. We compared spread activity in 15 Academic Health Science Networks (AHSN) in England, applied to one innovation case, Transfers of Care Around Medicines (TCAM). We followed two methodological steps: (1) qualitative thematic analysis of primary data collected from 18 interviews with AHSN staff members to identify the strategies and mechanisms and related contextual determinants and (2) Qualitative Comparative Analysis (QCA) combining secondary quantitative data on spread outcome and qualitative themes from step 1 to identify the core strategies and mechanisms. RESULTS: We identified six common spread strategy-mechanism constructs that AHSNs applied to spread the TCAM national spread programme: (1) the unique intermediary position of the AHSN as "honest broker" and local networking organisation, (2) the right capacity and position of the spread facilitator, (3) an intersectoral and integrated stakeholder engagement approach, (4) the dynamic marriage of the innovation with local health and care system needs and characteristics, (5) the generation of local evidence, and (6) the timing of TCAM. The QCA resulted in the core strategy/mechanism of a timely start into the national spread programme in combination with the employment of a local, senior pharmacist as an AHSN spread facilitator. CONCLUSIONS: By qualitatively comparing experiences of spreading one innovation across different contexts, we identified common strategies, causal mechanisms, and contextual determinants. The QCA identified one core combination of two strategies/mechanisms. The identification of core strategies/mechanisms and common pre-conditional and mediating contextual determinants of a specific innovation offers spread facilitators and implementers a priority list for tailoring spread activities.

Making Digital Health "Solutions" Sustainable in Healthcare Systems: A Practitioner Perspective.

Digital health solutions have the potential to bring about great improvements in the delivery and quality of services in healthcare systems. In this paper, we draw on the extensive experience of NHS (National Health Service) England to develop a practitioner perspective on the challenges of effectively implementing and sustaining such solutions. We argue that a properly sustainable approach requires a shift in both thinking and practice when it comes to the spread and adoption of such technologies. Our thinking needs to shift from a focus on the technology itself to how we bring about the changes needed to deliver more efficient and effective care for patients. In practical terms, this means focussing on the changes involved to integrate digital health solutions into the delivery of services. In particular, it requires greater attention to the motivations, constraints and specific contexts that influence users and patients. The technical expertise of innovators therefore needs to be complemented by other forms of insight into change processes, including clinical and behavioral insight, process engineering and knowledge management. In this paper, we show how these different pillars of the NHS Sustainable Healthcare approach help to ensure the effective implementation and use of digital solutions. We draw out the implications of this approach for policy-makers in healthcare systems, highlighting the need to give greater attention and resources to the downstream challenges of implementing digital health solutions.

From spreading to embedding innovation in health care: Implications for theory and practice.

ISSUE: In broad terms, current thinking and literature on the spread of innovations in health care presents it as the study of two unconnected processes-diffusion across adopting organizations and implementation within adopting organizations. Evidence from the health care environment and beyond, however, shows the significance and systemic nature of postadoption challenges in sustainably implementing innovations at scale. There is often only partial diffusion of innovative practices, initial adoption that is followed by abandonment, incomplete or tokenistic implementation, and localized innovation modifications that do not provide feedback to inform global innovation designs. CRITICAL THEORETICAL ANALYSIS: Such important barriers to realizing the benefits of innovation question the validity of treating diffusion and implementation as unconnected spheres of activity. We argue that theorizing the spread of innovations should be refocused toward what we call embedding innovation-the question of how innovations are successfully implemented at scale. This involves making the experience of implementation a central concern for the system-level spread of innovations rather than a localized concern of adopting organizations. INSIGHT/ADVANCE: To contribute to this shift in theoretical focus, we outline three mechanisms that connect the experience of implementing innovations locally to their diffusion globally within a health care system: learning, adapting, and institutionalizing. These mechanisms support the distribution of the embedding work for innovation across time and space. PRACTICAL IMPLICATIONS: Applying this focus enables us to identify the self-limiting tensions within existing top-down and bottom-up approaches to spreading innovation. Furthermore, we outline new approaches to spreading innovation, which better exploit these embedding mechanisms.

Academic health science networks' experiences with rapid implementation practice during the COVID-19 pandemic in England.

The COVID-19 pandemic offered a "natural laboratory" to learn about rapid implementation of health and social care innovations in an altered implementation context. Our aim was to explore implementation practice of Academic Health Science Networks (AHSN) in the English National Health System during the first wave of the COVID-19 pandemic through a rapid implementation lens. We organized three 90-min, online, semi-structured focus groups with 26 operational and senior managerial staff from 14 AHSNs in June-July 2020. Participants were recruited purposefully and on a voluntary basis. Participants presented a case study about their approaches to implementing innovations between March-June 2020 and discussed their experiences and lessons learned. The focus groups were audio-recorded and transcribed verbatim. Transcripts and other documents were analyzed using qualitative thematic analysis following a combination of grounded theory and framework analysis approach. AHSNs increased the pace of their implementation work to support the response to the COVID-19 pandemic. The disruptive event changed the implementation context which enabled rapid implementation through an urgency for change, the need to adhere to social distancing rules, new enabling governance structures, and stakeholders' reduced risk averseness toward change. AHSNs achieved rapid implementation through: (1) An agile and adaptive implementation approach; (2) Accelerating existing innovations and building on existing relationships/networks; (3) Remote stakeholder engagement; and (4) Ensuring quality, safety, rigor and sustainability, and generating new evidence through rapid evaluations. AHSNs aimed at sustaining implementation pace and efficiency after the acute phase of the pandemic mainly through remote stakeholder engagement and flexibility of implementation strategies.

Professionals' responses to the introduction of AI innovations in radiology and their implications for future adoption: a qualitative study.

BACKGROUND: Artificial Intelligence (AI) innovations in radiology offer a potential solution to the increasing demand for imaging tests and the ongoing workforce crisis. Crucial to their adoption is the involvement of different professional groups, namely radiologists and radiographers, who work interdependently but whose perceptions and responses towards AI may differ. We aim to explore the knowledge, awareness and attitudes towards AI amongst professional groups in radiology, and to analyse the implications for the future adoption of these technologies into practice. METHODS: We conducted 18 semi-structured interviews with 12 radiologists and 6 radiographers from four breast units in National Health Services (NHS) organisations and one focus group with 8 radiographers from a fifth NHS breast unit, between 2018 and 2020. RESULTS: We found that radiographers and radiologists vary with respect to their awareness and knowledge around AI. Through their professional networks, conference attendance, and contacts with industry developers, radiologists receive more information and acquire more knowledge of the potential applications of AI. Radiographers instead rely more on localized personal networks for information. Our results also show that although both groups believe AI innovations offer a potential solution to workforce shortages, they differ significantly regarding the impact they believe it will have on their professional roles. Radiologists believe AI has the potential to take on more repetitive tasks and allow them to focus on more interesting and challenging work. They are less concerned that AI technology might constrain their professional role and autonomy. Radiographers showed greater concern about the potential impact that AI technology could have on their roles and skills development. They were less confident of their ability to respond positively to the potential risks and opportunities posed by AI technology. CONCLUSIONS: In summary, our findings suggest that professional responses to AI are linked to existing work roles, but are also mediated by differences in knowledge and attitudes attributable to inter-professional differences in status and identity. These findings question broad-brush assertions about the future deskilling impact of AI which neglect the need for AI innovations in healthcare to be integrated into existing work processes subject to high levels of professional autonomy.

Coproduction in commissioning decisions: is there an association with decision satisfaction for commissioners working in the NHS? A cross-sectional survey 2010/2011.

OBJECTIVES: To undertake an assessment of the association between coproduction and satisfaction with decisions made for local healthcare communities. DESIGN: A coproduction scale was developed and tested to measure individual National Health Service (NHS) commissioners' satisfaction with commissioning decisions. SETTING: 11 English Primary Care Trusts in 2010-2011. PARTICIPANTS: Staff employed at NHS band 7 or above involved in commissioning decisions in the NHS. 345/440 (78%) of participants completed part of all of the survey. MAIN OUTCOME MEASURE: Reliability and validity of a coproduction scale were assessed using a correlation-based principal component analysis model with direct oblimin rotation. Multilevel modelling was used to predict decision satisfaction. RESULTS: The analysis revealed that coproduction consisted of three principal components: productive discussion, information and dealing with uncertainty. Higher decision satisfaction was associated with smaller decisions, more productive discussion, decisions where information was readily available to use and those where decision-making tools were more often used. CONCLUSIONS: The research indicated that coproduction may be an important factor for satisfaction with decision-making in the commissioning of healthcare services.

Supporting knowledge translation through collaborative translational research initiatives: 'bridging' versus 'blurring' boundary-spanning approaches in the UK CLAHRC initiative.

Recent policy initiatives in the UK and internationally have sought to promote knowledge translation between the 'producers' and 'users' of research. Within this paper we explore how boundary-spanning interventions used within such initiatives can support knowledge translation between diverse groups. Using qualitative data from a 3-year research study conducted from January 2010 to December 2012 of two case-sites drawn from the CLAHRC initiative in the UK, we distinguish two different approaches to supporting knowledge translation; a 'bridging' approach that involves designated roles, discrete events and activities to span the boundaries between communities, and a 'blurring' approach that de-emphasises the boundaries between groups, enabling a more continuous process of knowledge translation as part of day-to-day work-practices. In this paper, we identify and differentiate these boundary-spanning approaches and describe how they emerged from the context defined by the wider CLAHRC networks. This highlights the need to develop a more contextualised analysis of the boundary-spanning that underpins knowledge translation processes, relating this to the distinctive features of a particular case.

The enactment of knowledge translation: a study of the Collaborations for Leadership in Applied Health Research and Care initiative within the English National Health Service.

OBJECTIVES: We contribute to existing knowledge translation (KT) literature by developing the notion of 'enactment' and illustrate this through an interpretative, comparative case-study analysis of three Collaborations for Leadership in Applied Health Research and Care (CLAHRC) initiatives. We argue for a focus on the way in which the CLAHRC model has been 'enacted' as central to the different KT challenges and capabilities encountered. METHODS: A comparative, mixed method study created a typology of enactments (Classical, Home-grown and Imported) using qualitative analysis and social network analysis. RESULTS: We identify systematic differences in the enactment of the CLAHRC model. The sources of these different enactments are subsequently related to variation in formative interpretations and leadership styles, the implementation of different governance structures, and the relative epistemic differences between the professional groups involved. CONCLUSIONS: Enactment concerns the creative agency of individuals and groups in constituting a particular context for their work through their local interpretation of a particular KT model. Our theory of enactment goes beyond highlighting variation between CLAHRCs, to explore the mechanisms that influence the way a particular model is interpreted and acted upon. We thus encourage less focus on conceptual models and more on the formative role played by leaders of KT initiatives.

Evidence-based commissioning in the English NHS: who uses which sources of evidence? A survey 2010/2011.

OBJECTIVES: To investigate types of evidence used by healthcare commissioners when making decisions and whether decisions were influenced by commissioners' experience, personal characteristics or role at work. DESIGN: Cross-sectional survey of 345 National Health Service (NHS) staff members. SETTING: The study was conducted across 11 English Primary Care Trusts between 2010 and 2011. PARTICIPANTS: A total of 440 staff involved in commissioning decisions and employed at NHS band 7 or above were invited to participate in the study. Of those, 345 (78%) completed all or a part of the survey. MAIN OUTCOME MEASURES: Participants were asked to rate how important different sources of evidence (empirical or practical) were in a recent decision that had been made. Backwards stepwise logistic regression analyses were undertaken to assess the contributions of age, gender and professional background, as well as the years of experience in NHS commissioning, pay grade and work role. RESULTS: The extent to which empirical evidence was used for commissioning decisions in the NHS varied according to the professional background. Only 50% of respondents stated that clinical guidelines and cost-effectiveness evidence were important for healthcare decisions. Respondents were more likely to report use of empirical evidence if they worked in Public Health in comparison to other departments (p<0.0005, commissioning and contracts OR 0.32, 95%CI 0.18 to 0.57, finance OR 0.19, 95%CI 0.05 to 0.78, other departments OR 0.35, 95%CI 0.17 to 0.71) or if they were female (OR 1.8 95% CI 1.01 to 3.1) rather than male. Respondents were more likely to report use of practical evidence if they were more senior within the organisation (pay grade 8b or higher OR 2.7, 95%CI 1.4 to 5.3, p=0.004 in comparison to lower pay grades). CONCLUSIONS: Those trained in Public Health appeared more likely to use external empirical evidence while those at higher pay scales were more likely to use practical evidence when making commissioning decisions. Clearly, National Institute for Clinical Excellence (NICE) guidance and government publications (eg, National Service Frameworks) are important for decision-making, but practical sources of evidence such as local intelligence, benchmarking data and expert advice are also influential. New Clinical Commissioning Groups will need a variety of different evidence sources and expert involvement to ensure that effective decisions are made for their populations.

Mind the gap: Understanding utilisation of evidence and policy in health care management practice.

PURPOSE: The paper aims to take a reflective stance on the relationship between policy/evidence and practice, which, the authors argue, is conceptually under-developed. The paper aims to show that current research perspectives fail to frame evidence and policy in relation to practice. DESIGN/METHODOLOGY/APPROACH: A qualitative study was conducted in the English NHS in four Primary Care Trusts (PCTs). Seventy-five observations of meetings and 52 semi-structured interviews were completed. The approach to data analysis was to explore and reconstruct narratives of PCT managers' real practices. FINDINGS: The exploratory findings are presented through two kinds of narratives. The first narrative vividly illustrates the significance of the active involvement, skills and creativity of health care practitioners for policy implementation. The second narrative elucidates how problems of collaboration among different experts in PCTs might emerge and affect evidence utilisation in practice. PRACTICAL IMPLICATIONS: The findings exemplify that policies are made workable in practice and, hence, policy makers may also need to be mindful of practical intricacies and conceive policy implementation as an iterative process. ORIGINALITY/VALUE: The contribution of this paper lies in offering an alternative and important perspective to the debate of utilisation of policy/evidence in health care management and in advancing existing understanding of health care management practice. The paper's rich empirical examples demonstrate some important dimensions of the complexity of practice.

'Best practice' development and transfer in the NHS: the importance of process as well as product knowledge.

A core prescription from the knowledge management movement is that the successful management of organizational knowledge will prevent firms from 'reinventing the wheel', in particular through the transfer of 'best practices'. Our findings challenge this logic. They suggest instead that knowledge is emergent and enacted in practice, and that normally those involved in a given practice have only a partial understanding of the overall practice. Generating knowledge about current practice is therefore a precursor to changing that practice. In this sense, knowledge transfer does not occur independently of or in sequence to knowledge generation, but instead the process of knowledge generation and its transfer are inexorably intertwined. Thus, rather than transferring 'product' knowledge about the new 'best practice' per se, our analysis suggests that it is more useful to transfer 'process' knowledge about effective ways to generate the knowledge of existing practice, which is the essential starting point for attempts to change that practice.