Article type
Year
Abstract
Background: Theres usually a better way of running services than the one were currently using. The NHS Service Delivery and Organisation Progamme funded a wide-ranging systematic review to identify how we can better capture, transmit and sustain innnovations in health service delivery and organisation. The study raised wider questions about how to undertake literature reviews that require synthesis of data from diffuse and heterogeneous sources.
Methods: The literature was rich in potentially useful information but appeared chaotic, contradictory, and lacking a unifying theoretical framework. Drawing on Kuhns notion of scientific paradigms, we developed a new method - metanarrative mapping - for sorting and evaluating the 6000 sources identified in our exploratory searches. We took as our initial unit of analysis the unfolding story of a research tradition through time. We identified 11 such traditions from disciplines as disparate as rural sociology, clinical epidemiology, organisational behaviour, and marketing. Each tradition had its own theoretical framework, hierarchy of evidence, and methodological idiosyncrasies. Drawing interpretively on all the relevant traditions, and applying a broad range of critical appraisal tools, we developed a unifying analytical model for "spreading good ideas for improving health services". We tested the explanatory power of the model on four case studies of complex innovations (integrated care pathways, GP Fundholding in the UK, the electronic health record, and telemedicine).
Results: By first separating out, and then drawing together, the different research traditions, we were able to build up a rich picture of our field of study and make sense of the seemingly contradictory literature. Seven key areas, which interact in subtle and complex ways, made up our final model: (1) The attributes of the innovation; (2) The adoption process as engaged in (or not) by individuals; (3) Communication and influence (including the impact of opinion leaders, champions, boundary spanners and designated change agents); (4) The inner (organisational) context (including structural determinants of innovativenss, receptive context for change in general, absorptive capacity for new knowledge, and tension for a particular change); (5) The outer (extra-organisational) context (including inter-organisational collaboration and networking, prevailing environmental pressures such as external competition, particular policymaking contexts and streams, and proactive linkage initiatives); (6) The nature of any active dissemination campaign (which incorporates the general principles of social marketing and knowledge construction); and (7) The nature of any active implementation process (which incorporates the general principles of effective management in a changing environment). The model proved a useful analytical tool for considering the four case studies, but like any model, it is a simplificaiton of reality and its predictive value remains unproven.
Conclusion: This extensive review raised important questions about the spread of innovation in particular and about the general methodology of reviewing diffuse bodies of literature. We believe we have produced two key outputs: (a) a robust methodology for approaching the literature with "fuzzy" questions relating to service development and policymaking; and (b) a parsimonious model for considering the spread of innovations in healthcare organisations. Both the review methodology and the model itself should be tested more widely in a range of contexts.
Methods: The literature was rich in potentially useful information but appeared chaotic, contradictory, and lacking a unifying theoretical framework. Drawing on Kuhns notion of scientific paradigms, we developed a new method - metanarrative mapping - for sorting and evaluating the 6000 sources identified in our exploratory searches. We took as our initial unit of analysis the unfolding story of a research tradition through time. We identified 11 such traditions from disciplines as disparate as rural sociology, clinical epidemiology, organisational behaviour, and marketing. Each tradition had its own theoretical framework, hierarchy of evidence, and methodological idiosyncrasies. Drawing interpretively on all the relevant traditions, and applying a broad range of critical appraisal tools, we developed a unifying analytical model for "spreading good ideas for improving health services". We tested the explanatory power of the model on four case studies of complex innovations (integrated care pathways, GP Fundholding in the UK, the electronic health record, and telemedicine).
Results: By first separating out, and then drawing together, the different research traditions, we were able to build up a rich picture of our field of study and make sense of the seemingly contradictory literature. Seven key areas, which interact in subtle and complex ways, made up our final model: (1) The attributes of the innovation; (2) The adoption process as engaged in (or not) by individuals; (3) Communication and influence (including the impact of opinion leaders, champions, boundary spanners and designated change agents); (4) The inner (organisational) context (including structural determinants of innovativenss, receptive context for change in general, absorptive capacity for new knowledge, and tension for a particular change); (5) The outer (extra-organisational) context (including inter-organisational collaboration and networking, prevailing environmental pressures such as external competition, particular policymaking contexts and streams, and proactive linkage initiatives); (6) The nature of any active dissemination campaign (which incorporates the general principles of social marketing and knowledge construction); and (7) The nature of any active implementation process (which incorporates the general principles of effective management in a changing environment). The model proved a useful analytical tool for considering the four case studies, but like any model, it is a simplificaiton of reality and its predictive value remains unproven.
Conclusion: This extensive review raised important questions about the spread of innovation in particular and about the general methodology of reviewing diffuse bodies of literature. We believe we have produced two key outputs: (a) a robust methodology for approaching the literature with "fuzzy" questions relating to service development and policymaking; and (b) a parsimonious model for considering the spread of innovations in healthcare organisations. Both the review methodology and the model itself should be tested more widely in a range of contexts.