Four System Enablers of Large‐System Transformation in Health Care: A Mixed Methods Realist Evaluation.
Policy PointsThe implementation of large‐scale health care interventions relies on a shared vision, commitment to change, coordination across sites, and a spanning of siloed knowledge.Enablers of the system should include building an authorizing environment; providing relevant, meaningful, transpare...
| Published in: | Milbank Quarterly Vol. 102; no. 1; pp. 183 - 212 |
|---|---|
| Main Authors: | , , , , , , , , , , |
| Format: | Article |
| Published: |
Wiley-Blackwell
Mar2024
|
| Subjects: | |
| Online Access: | View this record in EBSCOhost |
| fields | @attributes: recordID: 1 pdfLink: plink: https://search.ebscohost.com/login.aspx?direct=true&db=ssf&AN=176037768&site=ehost-live header: @attributes: shortDbName: ssf uiTerm: 176037768 longDbName: Social Sciences Full Text (H.W. Wilson) uiTag: AN controlInfo: bkinfo: jinfo: jid: 0887378X MIQ jtl: Milbank Quarterly issn: 0887378X maglogo: Y pubinfo: dt: Mar2024 vid: 102 iid: 1 pid: 480 pub: Wiley-Blackwell artinfo: ui: 176037768 10.1111/1468-0009.12684 ppf: 183 ppct: 29 formats: tig: atl: Four System Enablers of Large‐System Transformation in Health Care: A Mixed Methods Realist Evaluation. aug: au: FRANCIS‐AUTON, EMILIE LONG, JANET C. SARKIES, MITCHELL ROBERTS, NATALIE WESTBROOK, JOHANNA LEVESQUE, JEAN‐FREDERIC WATSON, DIANE E. HARDWICK, REBECCA HIBBERT, PETER POMARE, CHIARA BRAITHWAITE, JEFFREY affil: Australian Institute of Health Innovation, Macquarie University Centre for Primary Health Care and Equity, University of New South Wales Bureau of Health Information, St. Leonards Peninsula Medical School, University of Plymouth su: New South Wales Corporate culture Patient safety Diffusion of innovations Leadership Interviewing Decision making Learning Uncertainty Organizational effectiveness Communication Organizational change Health facilities Authority Employee retention Public hospitals Research funding Value-based healthcare Descriptive statistics Health care reform Research methodology Quality assurance sug: subj: Corporate culture Patient safety Diffusion of innovations Leadership Interviewing Decision making Learning Uncertainty Organizational effectiveness Communication Organizational change Health facilities Authority New South Wales All Other Outpatient Care Centers General Medical and Surgical Hospitals Employee retention Public hospitals Research funding Value-based healthcare Descriptive statistics Health care reform Research methodology Quality assurance keyword: complex adaptive systems enablers of transformative change health care reform implementation science innovation organizational change realist evaluation complex adaptive systems enablers of transformative change health care reform implementation science innovation organizational change realist evaluation ab: Policy PointsThe implementation of large‐scale health care interventions relies on a shared vision, commitment to change, coordination across sites, and a spanning of siloed knowledge.Enablers of the system should include building an authorizing environment; providing relevant, meaningful, transparent, and timely data; designating and distributing leadership and decision making; and fostering the emergence of a learning culture.Attention to these four enablers can set up a positive feedback loop to foster positive change that can protect against the loss of key staff, the presence of lone disruptors, and the enervating effects of uncertainty. Context: Large‐scale transformative initiatives have the potential to improve the quality, efficiency, and safety of health care. However, change is expensive, complex, and difficult to implement and sustain. This paper advances system enablers, which will help to guide large‐scale transformation in health care systems. Methods: A realist study of the implementation of a value‐based health care program between 2017 and 2021 was undertaken in every public hospital (n = 221) in New South Wales (NSW), Australia. Four data sources were used to elucidate initial program theories beginning with a set of literature reviews, a program document review, and informal discussions with key stakeholders. Semistructured interviews were then conducted with 56 stakeholders to confirm, refute, or refine the theories. A retroductive analysis produced a series of context‐mechanism‐outcome (CMO) statements. Next, the CMOs were validated with three health care quality expert panels (n = 51). Synthesized data were interrogated to distill the overarching system enablers. Findings: Forty‐two CMO statements from the eight initial program theory areas were developed, refined, and validated. Four system enablers were identified: (1) build an authorizing environment; (2) provide relevant, authentic, timely, and meaningful data; (3) designate and distribute leadership and decision making; and (4) support the emergence of a learning culture. The system enablers provide a nuanced understanding of large‐system transformation that illustrates when, for whom, and in what circumstances large‐system transformation worked well or worked poorly. Conclusions: System enablers offer nuanced guidance for the implementation of large‐scale health care interventions. The four enablers may be portable to similar contexts and provide the empirical basis for an implementation model of large‐system value‐based health care initiatives. With concerted application, these findings can pave the way not just for a better understanding of greater or lesser success in intervening in health care settings but ultimately to contribute higher quality, higher value, and safer care. pubtype: Academic Journal doctype: Article src: R language: English refInfo: copyright: @attributes: flag: N holdings: @attributes: islocal: N |
|---|