Table 2 sets out a summary of the phases, within which IAs sought to enact their knowledge brokering role, and summary data quotes regarding frontline professional responses to their attempts at knowledge brokering, which we detail further below.
Table 2
CONTEXTUAL CONDITIONS, POLICY-LEVEL KNOWLEDGE INTEGRATION ACTIVITIES, AND FRONTLINE KNOWLEDGE BROKERING EXPERIENCES
| Timeline | PHASE 1 (pre-2008) Drivers of change and the beginning of an innovation discourse | PHASE 2 (2008–2011) Early implementation & the problem of legitimacy | PHASE 3 (2012–2015) Adolescent implementation & the problem of coordination | PHASE 4 (2016–2018) Maturing implementation & emergent collaboration |
| Contextual conditions | • Burgeoning interest in QI methods for healthcare, globally; growing interest in organization theory. Business process re-engineering at Royal Leicester Infirmary gains renown. • Rising influence, domestically, of organization theorists & international boundary organizations specializing in improvement (e.g. Institute for Healthcare Improvement). • Domestically, public hospitals in deep financial trouble; rising urgency to curb expenditure & improve value. • Federal domestic performance targets established to improve patient flow through EDs & surgery; Australian hospitals experiment with Lean. | • Influence of organization theorists on healthcare performance improvement organizations grows. • High Performance Work Systems & Lean-inspired healthcare interventions flourish, internationally. • Domestic interest in improving value & efficiency heightens. • Domestic Lean networks and Lean boundary organizations capture policy interest. • Growing local discontent with poor research impact fuels domestic interest in research translation & knowledge integration. A knowledge translation & integration movement emerges. | • Healthcare is fastest growing area of domestic government expenditure; hospital expenditure is greatest within healthcare funding envelope. • Government concern with waste peaks. • Seed funding provided to establish domestic research translation centres and accelerate knowledge translation, particularly in hospitals. • Research translation centres facilitate greater collaboration between universities & health, but integration with government health departments and policy-makers is poor. | • Maturing conversations about knowledge translation, mobilisation, brokering, and integration. • Importance of research translation and knowledge integration gains recognition at Federal policy level. • Additional research translation centres established. • Push for greater transparency of hospital performance across a range of measures; push for innovation, rather than greater capital investment, to solve hospital capacity issues. |
| Policy-level ‘knowledge integration’ activities & events | • Perceived need for hospitals to acquire improvement capabilities. • Perceived need for hospitals to address lack of critical thinking skills in frontline staff, and lack of mechanisms for staff to challenge taken-for-granted, non-value-adding processes. • Perceived need for greater efficiency and waste reduction. • Distant rather than local searches for new knowledge carried out. • Early efforts to build basic process mapping, process redesign, and project management skills, facilitated by the funding of multiple, small improvement projects. | • Policy intervention commences (2008). • Policy strategy is to differentiate the intervention from already well-embedded, potentially synergistic programs and methodologies (e.g. quality improvement). • Rationale for intervention betrays a strong interest in improving efficiency. • Lack of enthusiasm amongst hospitals leads policy-makers to dangle funds untethered to outcomes, to encourage engagement. • Substantial involvement of Lean-inclined industry & consultants in shaping & governing of the intervention. • Improvement leader roles funded & embedded in hospitals; training in Lean techniques commences; performance improvement work carried out via multiple projects within participating hospitals. • Industry internships, site visits & mentoring for improvement leaders commence. • Improvement leader network established. • Extensive suites of Lean-inspired tools developed & shared across improvement advisor network. • Improvement capability framework for hospitals developed. • “My original and to this day strong recommendation, which wasn't taken up, is that the quality managers and the people working in quality in the hospitals should have been the targeted personnel for this [process improvement] training and this capability uplift. Because, to my way of thinking, it's the same family of theories.” (Policy-maker, Participant 43) | • Policy intervention evaluated (2012). Discrete project successes identified, but clinician engagement, organizational capability, fragmented knowledge integration & poor diffusion of ideas identified as issues. • Government restructure brings policy intervention together with clinical networks & leadership development activities. • Organizational improvement capability tool rolled out. Focus on organizational capability intensifies: “It’s complex work, it’s not simple, because we’re trying to change the way organizations run, not just attack [performance] targets.” (Policy-maker, Participant 2) • “We saw ourselves as facilitating and coordinating and supporting the hospitals to build their capability to improve.” (Policy-maker, Participant 9) • Training programs in process improvement for clinicians continue. • Review of public hospital capacity conducted (2015). Improvement capability (rather than capital investment) identified as key to sustainability of hospitals. • Improvement Advisor roles continue, but concerns emerge regarding impact and value of these roles. • Improvement clearinghouse is established. | • Further policy restructure takes place in light of recent reviews. Policy functions of improvement, safety & hospital capacity brought together, as policy integration and synergies are sought. • Intervention survives, with new emphasis placed on: ¬ Clarification of roles and expectations of Improvement Advisor positions. ¬ Appointment of specialized “industry coaches” (specialists in process improvement) to work alongside Improvement Advisors, but with new conversations about knowledge brokering issues. ¬ Engagement with Improvement Advisors to develop individual capability-building framework that extends beyond building technical knowledge and mastery of technical tools. ¬ Engagement with Improvement Advisors to re-develop organizational improvement capability framework for hospitals, so that improvement knowledge can be better exploited. ¬ Facilitation of peer-to-peer mentoring amongst improvement advisors through strengths-appreciation process that teams up experienced & inexperienced Improvement Advisors. ¬ Establishment of an Improvement Advisor community of practice. ¬ Cross-hospital knowledge-sharing via centrally-coordinated, cross-hospital networking & system-wide showcase events. ¬ Use of social media to communicate & enhance profile & discoverability of local improvement learning. ¬ New emphasis placed on looking locally for improvement inspiration and mobilising local know-how. |
| Frontline knowledge brokering experiences | • Hospitals exposed to basic project management skills and rudimentary process improvement tools. • Concept of knowledge brokering and knowledge integration unestablished within jurisdiction. • Basic skills required to prepare workforce for required improvement: “The main goal [from my perspective] was to increase capability and capacity to be able to respond to problems that [front line staff] identified. But the challenge was you didn’t have a workforce that even asked questions and solved problems.” (Executive Sponsor, Participant 1) | • Project approach becomes wearing on front-line staff, with Improvement Advisors bearing the brunt: “Death by a thousand projects” seems to be a familiar refrain among Improvement Advisors. (Field note) • Improvement Advisor network established, and successful in terms of circulating knowledge throughout this network. At the same time, collaboration between health services is seen as unusual: “That network means that there’s a culture in [improvement] of sharing. That’s unusual [here] in health – it’s crazy, but it’s unusual.” (Executive Sponsor, Participant 14) • “I think broadly from [policy-makers, the ICPH in its early days] was [about] seeing health organizations tooling up.” (Improvement Advisor, Participant 7) | • “My experience of watching [hospitals] go Lean is that after a point in time your staff do a backflip and start to resent it: ‘Here come the Lean people’”. (Improvement Advisor, Participant 4). • The Department should actually be building their policy knowledge based on the [local] issues that appear in health systems. And they don’t necessarily to the extent they could. It’s a power shift. So, do with, not to. So that’s the shift that I would see should be made.” (Improvement Advisor, Participant 13) • “I think [the IA network has] run its race in [terms of] being a supportive group, for a group who are thinking about, ‘Maybe I’ll do this [improvement] thing’”. (Improvement Advisor, Participant 7) • Improvement Advisors report difficulties in engaging clinicians in process improvement and encountering receptiveness issues. • Competitive nature of system openly acknowledged by Improvement Advisors, Executive Sponsors, and policy-makers. | • By the time we got to the third [collaboration event] it opened right up because people started talking about their problems. We started to realise that actually, the issue you've got here at [this health service] is the same issue as [over there]. And [that other health service] has just recently solved that same issue as well, and we start to see this more collegiate kind of thing happen. For the most part, I think they've got these relationships now where everyone will pick up the phone and talk to each other. (Improvement Advisor, Participant 48) • Improvement Advisors begin to express mixed opinions about the competitive nature of the system, and can instead point to examples of collaboration that extend beyond the Improvement Advisor cohort. |
Phase 1: Drivers of Change and the Beginning of an Innovation Discourse (Pre-2008)
In the early 2000s, policy-makers responsible for the performance of the state’s public hospitals faced a daunting task: find new ways to make healthcare service delivery more efficient, but keep improving the quality and safety of care. A confluence of factors had sparked this imperative: financial pressures; the imposition of national performance targets; and the enormity of the impending demands of an ageing population. In light of the coming strain, existing models of care were scrutinised, and the seed of an idealised ambition sewn: build the capability of front-line healthcare professionals to fundamentally redesign business-as-usual mindsets and models.
Around this same time, healthcare policy-makers in Europe and the US were already in the process of experimenting with business ideas, and applying these practices and techniques to hospital settings. The promise of these ideas lay in their demonstrated ability in other sectors to create value, deliver efficiency, and improve quality for consumers. Sizeable gulfs existed, however, between the domains of medicine and business, across which bridges needed to be built, to aid the flow of knowledge. At the same time, awareness within healthcare of how to bridge these gaps was nascent. When stories emerged of the successful application of business process reengineering to hospital processes in the UK, pioneering policy-makers in Australia began agitating for funds to build basic project-management capability at the front-line, in preparation for trialing some of the more rudimentary process improvement tools in use overseas. These initial efforts were piecemeal when viewed in the context of the broader healthcare policy machinery; they touched relatively few front-line professionals and were described as “fragmented” and “short-term in approach” (policy document). But from the perspective of policy-makers they crystallised the need for concerted capacity-building approaches for front-line staff, and introduced to the jurisdiction new ideas, a new lexicon, and an awareness, even if peripheral, of improvement movements occurring in other jurisdictions. A process improvement discourse had begun.
Phase 2: Early Implementation and the Problem of Legitimacy (2008–2011)
Redesigning Care commenced in 2008, with funding secured to employ, train, and embed into 16 of the earliest participating health services the first two waves of IAs. While Redesigning Care built on precursor initiatives, it was pitched as a new solution and distinguished from quality improvement (QI), which had been introduced into the jurisdiction many years prior. The declared centrepiece of Redesigning Care was the injection of a new kind of role and capability into health services.
Distinguishing process improvement from QI had important ramifications. It played up, rather than down, the novelty of the intervention, and it failed to leverage complementary skill sets, thereby foregoing crucial psychological and skill economies. It also overlooked, even antagonised, potential QI allies who were well-placed to chaperone the new roles and skills into health services:
There was a real tension when this first came [in] between what was [process] redesign and the bods that are traditionally in that quality space. (IA, Participant 19)
A mesh of difficulties awaited. The new focus on gaining abstract, system-level efficiencies appeared to be of little importance for healthcare professionals, whose core values and training promoted a focus on the singular needs and interests of the presenting patient. Front-line staff correctly perceived Redesigning Care as being animated by a strong “efficiency remit” (IA, Participant 7) and what they saw as bureaucratic concerns about unmet hospital performance targets. In general, IAs and Executive Sponsors reported that process improvement was seen by front-line professionals as a specialisation of little relevance to the skillsets of care provision, and at odds with their core values:
There's a fairly big difference between a patient flow versus a car production flow. (Executive Sponsor, Participant 39)
This proved a challenging context for IAs, who were rarely embedded within medical or QI teams, and whose main sources of advice and expertise came from outside of healthcare contexts, via participation in industry internships, visits to manufacturing sites, and mentoring from consultants embedded in business and manufacturing industries.
Policy-makers had anticipated and sought to counteract these difficulties by untethering the funded IA roles from predetermined outcomes, and granting hospitals considerable “autonomy” (policy document) to choose how they deployed this new resource. Success was mixed. Outcomes were certainly achieved, earning the extension of the programme to more than 30 health services, and the training of Waves 3 and 4 of IAs. But the lived experience of IAs suggested that these successes were hard won. IAs reported frequently encountering resentment (IA, Participant 4), aggression (IA, Participant 15), and defensiveness (IAs, Participants 4 & 16) at the front-line. So peripheral was the role of IAs, they identified being “invited in” (IA, Participant 26) to wards and units by clinical managers as crucial to the success of their improvement efforts. A threshold lay between the conduits of process improvement knowledge, and the intended adopters, the latter of whom sought to erect rather than dismantle knowledge boundaries by actively distancing their work, ideals, and values from the sectors that had given rise to process improvement:
One of the barriers we came across is that [frontline professionals would say], ‘We’re special and different and we don’t need to do it that way because we’re special.’ (Improvement Advisor, focus group)
Ironically, through their training IAs had honed the de-legitimating features of process improvement – the kind of processes, tools, and cultural referents that reinforced rather than dissolved knowledge boundaries (e.g. metaphors that likened hospitals to factory lines and people to widgets).
Phase 3: Adolescent Implementation and the Problem of Coordination (2012–2015)
An evaluation of Redesigning Care in 2012 called for its continuation, but voiced concerns that it had produced few joined-up, systemic outcomes, and that the integration of process improvement knowledge was immensely variable across the hospital system. Whereas the early years of the intervention had focused almost exclusively on building the technical skills of IAs, the middle years of the intervention saw an attempt to rebalance this focus. Effort was invested in building knowledge integration and exploitation capabilities at the organizational level, and in fostering a familiarity and affinity for process improvement among healthcare professionals, via an increased focused on training programmes in improvement for clinicians, and the roll-out of a tool to help health organizations assess and build their knowledge exploitation and process improvement capabilities.
A subsequent hospital capacity review in 2015 reinforced this diagnosis, noting that the intervention had facilitated “important but small projects”, but that there was “no system-wide gain”. The perceived need for centralised coordination to join up improvement efforts across the system, and to do more with less, was a strong undercurrent throughout the report. Healthcare was the fastest growing area of government expenditure at the time, with hospital expenditure the greatest contributor. The need to build improvement capability was identified as key to the sustainability of the healthcare system. The intervention thereby secured a reprieve, and signalled a more active coordination role for policy-makers in the future.
The sector’s readiness for greater policy-making vigour was uncertain. Occasionally, tensions inherent in the devolved governance arrangements would surface between government and health services. Disgruntlement about the competitive nature of the sector (There’s a whole lot of competition [Executive Sponsor, Participant 6]) was cresting, leading to calls for stronger policy intervention to help distribute knowledge across health service boundaries:
“It’s such a pity that [policy-makers] don’t take a leadership role in this sharing across health services. They just don’t.” (Executive Sponsor, Participant 14)
An IA network had earlier been established, but on the face of the two reviews appeared to have yielded little in terms of diffusing improvement successes, probably because IAs wielded little influence within their health services – without internal purchase, strong relational linkages between IAs and meritorious improvement ideas mattered little in terms of knowledge integration. Even those IAs involved in the network in its early, strongest days, conceded it was ineffectual and indicated a need for more directive intervention from policy-makers.
Phase 4: Maturing Implementation and Emergent Collaboration (2016–2018)
The capacity review heralded a policy restructure, and a critical period for policy-makers to review and secure the survival of Redesigning Care. Substantial policy changes and a determination to “rejuvenate” (Policy-maker, Participant 37) the initiative ensued. Redesigning Care was enfolded into the quality and safety policy-making branch, to capitalise on the legitimacy of quality and safety, while maintaining the initiative’s unique value proposition. Crucially, policy-makers reconsidered their own roles as stewards of Redesigning Care, and set about dissolving boundaries between themselves and IAs, and instead creating complementarities by adopting a partnering approach:
“A challenge … is knowing how we work, and try and look at those partnering relationships as opportunities. Also, don’t lose our sense of what our purpose is and how we can add value.” (Policy-maker, Participant 33)
We're starting to get a reputation in being the helper. Linking people together. Leveraging the resource and the expertise that we have in our department. (Policy-maker, Participant 36)
Policy-makers also became more circumspect about allowing themselves to be seduced or “distracted by shiny new stuff – ‘Oh, someone’s just doing this. I’ve just been to England, or Scotland, or America and they were doing this’” (Policy-maker, Participant 33). Disregarding local learning, experience, and needs began to be understood as a distancing and demoralising experience for IAs and front-line staff:
We’re thinking, ‘Don’t discount the in-house and the local expertize that we might have, as well as the value in using local examples of innovation and scaling’, because people relate to that much easier than they would caesareans, [for example], in South America. (Policy-maker, Participant 33)
This reflection led to the development of a “ground-up”, “sector-led” model of collaboration that eschewed didacticism and identified the issue of competition between hospitals as “a really strong theme in terms of what people want to address. I can’t tell you how many times we had doctors, particularly, going, ‘Golly, it was good to find out what our neighbors are doing’” (Policy-maker, Participant 34).
Themed, structured cross-hospital knowledge sharing to enable a more coordinated, wider spread of process improvement ideas became a focus, and emphasis was placed on helping IAs to better integrate process improvement knowledge into hospitals’ operational processes, and to better position hospitals to exploit that knowledge. These initiatives were received enthusiastically by IAs, who reported growing in confidence, moving away from a “fundamentalist”, “quite strict” approach to improvement (Executive Sponsor, Participant 6) that alienates front-line professionals, and learning how to “soften” process improvement methodologies and render them “more adaptable” (IA, Participant 20) to the sensibilities of front-line professionals.