scholarly journals Implementation of large-system transformation initiatives in the New Zealand health system

2021 ◽  
Author(s):  
Kanchan Sharma
Keyword(s):  
New Zealand ◽  
Health System ◽  
Continuous Improvement ◽  
Complex Adaptive Systems ◽  
Adaptive Systems ◽  
Contextual Factors ◽  
Learning System ◽  
Successful Implementation ◽  
System Transformation ◽  
System Leaders

<p><b>Health systems worldwide are trying to shift towards a learning system to deliver people-centred, holistic and equitable health care. Large-system transformation (LST) initiatives that capitalise on key features of complex adaptive systems may be more likely to achieve the desired shift.</b></p> <p>By LST initiatives, I mean “interventions aimed at co-ordinated, system wide change affecting multiple organisations and care providers, with the goal of significant improvements in the efficiency of health care delivery, the quality of patient care, and population-level patient outcomes” (p 422) [1].</p> <p>This research had three aims: (1) to identify the key elements that support successful implementation of LST initiatives; (2) to construct a maturity matrix that describes different stages of maturity for each of these elements; and (3) to investigate and report on contextual factors that influence successful implementation of LST initiatives. Collectively, the three aims revealed the programme architecture that underpins efforts to successfully implement LST initiatives in the New Zealand health system.</p> <p>The realist logic of enquiry, nested within the macro framing of complex adaptive systems, formed the overall methodology for this research. This research used insights from a New Zealand LST initiative (the System Level Measures programme), evidence from literature, and evidence from knowledge of those working in the health system, to analyse and describe this programme architecture. </p> <p>The research resulted in three key sets of findings.</p> <p>First, the research found that a set of 10 key elements needs to be present in the New Zealand health system and work in harmony to increase the chances of successful implementation of LST initiatives. These are: (i) an alliancing way of working; (ii) a commitment to Te Tiriti o Waitangi; (iii) an understanding of equity; (iv) clinical leadership and involvement; (v) involved people, whanau and community; (vi) intelligent commissioning; (vii) continuous improvement; (viii) an integrated health information; (ix) analytic capability; and (x) dedicated resources and time.</p> <p>Second, a self-assessment maturity matrix for the key elements was developed with New Zealand health system leaders to provide a practical tool for them and informal trust-based networks (such as Alliances) to improve their understanding of the different stages of maturity for the key elements, to assess their readiness for change, and to develop capacity and capability needed for system transformation. </p> <p>Third, a realist logic of enquiry was used to investigate how the key elements work in different contexts to influence the successful implementation of LST initiatives. At a local level, (i) the history of working together and quality of relationships, (ii) distributed leadership from commissioners of health services, and (iii) the maturity of informal trust-based networks, such as Alliances, emerged as key contextual factors that influenced successful implementation of these initiatives. The key mechanism of trust was triggered with a positive history of working together, which built strong relationships and facilitated a distributed leadership style among health system agents through informal networks. The high-trust environment built and nurtured over time strengthened relationships among health system agents, which then provided the foundation for health system transformation.</p> <p>At a national level, the distributed health system leadership, the application of ‘new power’ approach to design and implementation of LST initiatives, and the system accountability environment emerged as key contextual factors. The existing accountability framework, which solely focussed on financial performance of District Health Boards and outputs, suffocated the notion of a learning system as health system leaders placed more effort on achieving targets and outputs rather than on continuous improvement. A culture of continuous improvement supported the notion of a learning system; it encouraged iterative learning using methods such as plan-do-study-act cycles and fostered innovation. Use of ‘new power’ values such as collaborative policy design and implementation harnessed the intrinsic motivation of health system agents and built trust between policy makers and health service providers, which lead to sustained collective engagement with transformation efforts. A collective engagement to achieve a shared vision built strong and resilient health system leadership.</p> <p>The research concluded that transformation of health systems depended on senior system leaders’ understanding of the programme architecture that underpins efforts to successfully implement LST initiatives.</p>

scholarly journals Implementation of large-system transformation initiatives in the New Zealand health system

2021 ◽  
Author(s):  
Kanchan Sharma
Keyword(s):  
New Zealand ◽  
Health System ◽  
Continuous Improvement ◽  
Complex Adaptive Systems ◽  
Adaptive Systems ◽  
Contextual Factors ◽  
Learning System ◽  
Successful Implementation ◽  
System Transformation ◽  
System Leaders

<p><b>Health systems worldwide are trying to shift towards a learning system to deliver people-centred, holistic and equitable health care. Large-system transformation (LST) initiatives that capitalise on key features of complex adaptive systems may be more likely to achieve the desired shift.</b></p> <p>By LST initiatives, I mean “interventions aimed at co-ordinated, system wide change affecting multiple organisations and care providers, with the goal of significant improvements in the efficiency of health care delivery, the quality of patient care, and population-level patient outcomes” (p 422) [1].</p> <p>This research had three aims: (1) to identify the key elements that support successful implementation of LST initiatives; (2) to construct a maturity matrix that describes different stages of maturity for each of these elements; and (3) to investigate and report on contextual factors that influence successful implementation of LST initiatives. Collectively, the three aims revealed the programme architecture that underpins efforts to successfully implement LST initiatives in the New Zealand health system.</p> <p>The realist logic of enquiry, nested within the macro framing of complex adaptive systems, formed the overall methodology for this research. This research used insights from a New Zealand LST initiative (the System Level Measures programme), evidence from literature, and evidence from knowledge of those working in the health system, to analyse and describe this programme architecture. </p> <p>The research resulted in three key sets of findings.</p> <p>First, the research found that a set of 10 key elements needs to be present in the New Zealand health system and work in harmony to increase the chances of successful implementation of LST initiatives. These are: (i) an alliancing way of working; (ii) a commitment to Te Tiriti o Waitangi; (iii) an understanding of equity; (iv) clinical leadership and involvement; (v) involved people, whanau and community; (vi) intelligent commissioning; (vii) continuous improvement; (viii) an integrated health information; (ix) analytic capability; and (x) dedicated resources and time.</p> <p>Second, a self-assessment maturity matrix for the key elements was developed with New Zealand health system leaders to provide a practical tool for them and informal trust-based networks (such as Alliances) to improve their understanding of the different stages of maturity for the key elements, to assess their readiness for change, and to develop capacity and capability needed for system transformation. </p> <p>Third, a realist logic of enquiry was used to investigate how the key elements work in different contexts to influence the successful implementation of LST initiatives. At a local level, (i) the history of working together and quality of relationships, (ii) distributed leadership from commissioners of health services, and (iii) the maturity of informal trust-based networks, such as Alliances, emerged as key contextual factors that influenced successful implementation of these initiatives. The key mechanism of trust was triggered with a positive history of working together, which built strong relationships and facilitated a distributed leadership style among health system agents through informal networks. The high-trust environment built and nurtured over time strengthened relationships among health system agents, which then provided the foundation for health system transformation.</p> <p>At a national level, the distributed health system leadership, the application of ‘new power’ approach to design and implementation of LST initiatives, and the system accountability environment emerged as key contextual factors. The existing accountability framework, which solely focussed on financial performance of District Health Boards and outputs, suffocated the notion of a learning system as health system leaders placed more effort on achieving targets and outputs rather than on continuous improvement. A culture of continuous improvement supported the notion of a learning system; it encouraged iterative learning using methods such as plan-do-study-act cycles and fostered innovation. Use of ‘new power’ values such as collaborative policy design and implementation harnessed the intrinsic motivation of health system agents and built trust between policy makers and health service providers, which lead to sustained collective engagement with transformation efforts. A collective engagement to achieve a shared vision built strong and resilient health system leadership.</p> <p>The research concluded that transformation of health systems depended on senior system leaders’ understanding of the programme architecture that underpins efforts to successfully implement LST initiatives.</p>

scholarly journals Implementing YouthCHAT – Evaluation and Development of An Implementation Framework

2021 ◽  
Author(s):  
Rhiannon Martel ◽  
Margot Darragh ◽  
Felicity Goodyear-Smith
Keyword(s):  
New Zealand ◽  
Contextual Factors ◽  
National Level ◽  
Trial Registration ◽  
High Rate ◽  
Normalisation Process Theory ◽  
Research Approach ◽  
Successful Implementation ◽  
Digital Tool ◽  
Implementation Framework

Abstract Background Northland, New Zealand has a generally socioeconomically deprived population with a high proportion of indigenous Māori. Māori youth suffer a high rate of mental ill-health, substance misuse, and other risky behaviours. While evidence demonstrates that early detection and management of these issues leads to long-term positive health outcomes, implementation of systematic screening and intervention is challenging. This study aimed to implement YouthCHAT, a self-administered digital tool screening young people for mental health concerns and risky health behaviours, into youth services in Northland using an iterative process of implementation, evaluation, and modification, and to create a framework for national-level rollout and implementation.Methods Normalisation Process Theory and a Māori research approach informed the implementation and its evaluation. Data sources included end-user focus groups, staff surveys, field notes, and informal communications with key stakeholders. Number of YouthCHAT screens completed measured intervention uptake.Results: Ongoing staff and youth feedback led to changes in YouthCHAT which increased acceptability. Facilitating two-way communication between providers and management, providing accessible training, and improved e-health record integration assisted uptake. Contextual factors, such as establishing a bicultural co-design approach and programming remote functionality during COVID-19 lockdown, were important factors in YouthCHAT’s ultimate acceptability and implementation. Other impediments such as staff redeployed during meningococcal and measles epidemics merely required patience. An implementation framework for YouthCHAT was developed which addresses tool acceptance and uptake, requiring ongoing effective communication and coordination, and iterative evaluation.Conclusions Failure to launch may be due to the interplay between the intervention, its users, contextual factors, and wider organisational aspects. Interventions may need to be tailored to a specific context to meet the needs of users, and address organisational and system barriers. Ultimately there will only be uptake where providers see this as worthwhile. Perception that its effective use will reduce their workload serves as a valuable incentive. The participatory research and bicultural Māori approaches employed in this project eventually led to YouthCHAT’s successful implementation in Northland. Full ownership of the Northland YouthCHAT version was transferred to local stakeholders on project completion. An iterative and evaluative strategy is recommended for future implementation. While derived for a specific population, the principles are generic, and our framework should be generalisable to other settings.Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12618000299202p, 16-02-2018; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374532

Using systems thinking to support clinical system transformation

2016 ◽  
Vol 30 (3) ◽  
pp. 302-323 ◽  
Author(s):  
Allan Best ◽  
Alex Berland ◽  
Carol Herbert ◽  
Jennifer Bitz ◽  
Marlies W van Dijk ◽  
...  
Keyword(s):  
Health System ◽  
Complex Adaptive Systems ◽  
Clinical Guidelines ◽  
Large Scale ◽  
Guideline Implementation ◽  
Clear Understanding ◽  
Care Providers ◽  
System Transformation ◽  
Content Type

Purpose – The British Columbia Ministry of Health’s Clinical Care Management initiative was used as a case study to better understand large-scale change (LSC) within BC’s health system. Using a complex system framework, the purpose of this paper is to examine mechanisms that enable and constrain the implementation of clinical guidelines across various clinical settings. Design/methodology/approach – Researchers applied a general model of complex adaptive systems plus two specific conceptual frameworks (realist evaluation and system dynamics mapping) to define and study enablers and constraints. Focus group sessions and interviews with clinicians, executives, managers and board members were validated through an online survey. Findings – The functional themes for managing large-scale clinical change included: creating a context to prepare clinicians for health system transformation initiatives; promoting shared clinical leadership; strengthening knowledge management, strategic communications and opportunities for networking; and clearing pathways through the complexity of a multilevel, dynamic system. Research limitations/implications – The action research methodology was designed to guide continuing improvement of implementation. A sample of initiatives was selected; it was not intended to compare and contrast facilitators and barriers across all initiatives and regions. Similarly, evaluating the results or process of guideline implementation was outside the scope; the methods were designed to enable conversations at multiple levels – policy, management and practice – about how to improve implementation. The study is best seen as a case study of LSC, offering a possible model for replication by others and a tool to shape further dialogue. Practical implications – Recommended action-oriented strategies included engaging local champions; supporting local adaptation for implementation of clinical guidelines; strengthening local teams to guide implementation; reducing change fatigue; ensuring adequate resources; providing consistent communication especially for front-line care providers; and supporting local teams to demonstrate the clinical value of the guidelines to their colleagues. Originality/value – Bringing a complex systems perspective to clinical guideline implementation resulted in a clear understanding of the challenges involved in LSC.

scholarly journals Health system resilience – a conceptual and empirical review of health system literature

2019 ◽  
Vol 29 (Supplement_4) ◽  
Author(s):  
K Wahedi ◽  
L Biddle ◽  
K Bozorgmehr
Keyword(s):  
Health System ◽  
Health Systems ◽  
Complex Adaptive Systems ◽  
Adaptive Systems ◽  
Empirical Studies ◽  
Building Blocks ◽  
Systems Research ◽  
System Resilience ◽  
Analytical Category ◽  
Operational Frameworks

Abstract Background The concept of health system resilience has gained popularity in the global health discourse, featuring in UN policies, academic articles and conferences. The term is commonly used to refer to the ability of health systems to respond to challenges. However, there has been no comprehensive overview of how the concept is understood and assessed in health systems research (HSR). Methods We conducted a conceptual and empirical review in 3 databases using systematic methods. Quantitative and narrative synthesis was used to trace the introduction of the concept to HSR, identify relevant definitions and examine its use in research. Results From 4063 references, we identified 96 articles concerned with health system resilience from 2007 - 2017, with a recent increase in literature (45% of studies published since 2016). Many articles take a general perspective; others focus on specific HSR building blocks (e.g. 28% on service delivery) or a particular type of crisis, such as climate change (12.5%) or natural disasters (10.4%). While the concept was developed from the ecological sciences, its meaning has been adapted in HSR, with a shift towards people-centred and process-oriented definitions. We identify three frameworks operationalising resilience: the “attributes” framework by Kruk et al. (2017), the “everyday resilience” framework by Barasa et al. (2017) and the “complex adaptive systems” framework by Blanchet et al. (2017). However, we find a mismatch between these frameworks and how the concept is assessed in 13 quantitative and 8 qualitative empirical studies. Conclusions The HSR literature has converged around a definition of resilience focusing on the system’s ability to mitigate ongoing challenges. Differences in emphasis remain, resulting in a variety of operational frameworks. The frameworks require further adaptation and testing in empirical studies to demonstrate the usefulness of “resilience” as an analytical category in HSR. Key messages There is a mismatch between conceptualisation and operationalisation of resilience in the HSR literature. Existing operational frameworks of resilience require further adaptation and testing in empirical studies to demonstrate the usefulness of “resilience” as an analytical category in HSR.

scholarly journals A health systems resilience research agenda: moving from concept to practice

2021 ◽  
Vol 6 (8) ◽  
pp. e006779
Author(s):  
Dell D Saulnier ◽  
Karl Blanchet ◽  
Carmelita Canila ◽  
Daniel Cobos Muñoz ◽  
Livia Dal Zennaro ◽  
...  
Keyword(s):  
Health System ◽  
Health Systems ◽  
Complex Adaptive Systems ◽  
Adaptive Systems ◽  
Dynamic Performance ◽  
Performance Outcomes ◽  
Theoretical Research ◽  
Systems Research ◽  
Complex Adaptive ◽  
System Resilience

Health system resilience, known as the ability for health systems to absorb, adapt or transform to maintain essential functions when stressed or shocked, has quickly gained popularity following shocks like COVID-19. The concept is relatively new in health policy and systems research and the existing research remains mostly theoretical. Research to date has viewed resilience as an outcome that can be measured through performance outcomes, as an ability of complex adaptive systems that is derived from dynamic behaviour and interactions, or as both. However, there is little congruence on the theory and the existing frameworks have not been widely used, which as diluted the research applications for health system resilience. A global group of health system researchers were convened in March 2021 to discuss and identify priorities for health system resilience research and implementation based on lessons from COVID-19 and other health emergencies. Five research priority areas were identified: (1) measuring and managing systems dynamic performance, (2) the linkages between societal resilience and health system resilience, (3) the effect of governance on the capacity for resilience, (4) creating legitimacy and (5) the influence of the private sector on health system resilience. A key to filling these research gaps will be longitudinal and comparative case studies that use cocreation and coproduction approaches that go beyond researchers to include policy-makers, practitioners and the public.

scholarly journals Improving New Zealand water governance: challenges and recommendations

2014 ◽  
Vol 10 (3) ◽  
Author(s):  
Elizabeth Eppel
Keyword(s):  
New Zealand ◽  
Water Resources ◽  
Fresh Water ◽  
Complex Adaptive Systems ◽  
Adaptive Systems ◽  
Water Governance ◽  
Overwhelming Majority ◽  
Governance Challenges ◽  
Complex Adaptive ◽  
New Zealanders

Our lives and our livelihoods depend on fresh water. Our cities and the appeal of our countryside to New Zealanders and tourists alike are based on plentiful supplies of fresh water. The overwhelming majority of New Zealand’s exports – not least agricultural and horticultural – require water, and in large quantities. Indeed, in many respects water is New Zealand’s largest export. Yet the management of our fresh water has not been ideal. We have over-allocated, and badly polluted some of our water resources. Such problems point to significant weaknesses in the governance of fresh water in this country. This article explores these governance issues through a complex adaptive systems lens and outlines some possible solutions.

scholarly journals Peer support for socially vulnerable citizens with diabetes: Bridging the gap to the health system

2019 ◽  
Vol 29 (Supplement_4) ◽  
Author(s):  
U Christensen ◽  
SD Garn ◽  
C Glumer
Keyword(s):  
Health System ◽  
Peer Support ◽  
Contextual Factors ◽  
Action Plan ◽  
Qualitative Interviews ◽  
Support Program ◽  
Successful Implementation ◽  
Co Morbidity ◽  
Local Stakeholders ◽  
Peer Support Program

Abstract Problem Despite free universal healthcare, Copenhagen is challenged by inequality in the prevalence and implications of type 2-diabetes (T2D). To address the problem, the Municipality of Copenhagen has initiated a city action plan including a peer support program for socially vulnerable citizens with T2D. Such programs have shown to be an essential supplement to the established health system to reach groups, who have limited contact with the health system. However, research on the implementation of the programs is generally limited. Description of the problem This 6-months peer support program is based on an initial analysis, showing social vulnerability to be associated with co-morbidity, low level of education, unemployment, living in a disadvantaged district and living alone. The peers are matched with a volunteer peer supporter with T2D, who helps out every 14. day with social-, practical- or bridging activities to health services or the municipality. We aim to evaluate the implementation with focus on contextual factors. We conduct in-depth qualitative interviews with peers (N = 12), peer supporters (N = 12), and relevant stakeholders (N = 6). Further, surveys with the peers and peer supporters (N = 45). Results Our preliminary results indicate how the peer supporters can bridge the gap between socially vulnerable citizens with T2D and the health system. However, contextual factors regarding the recruitment of peers have challenged the implementation process as the municipality has difficulty reaching them. Lessons To ensure a successful implementation, it is important to prioritize resources to ensure good collaboration with local stakeholders, who can be gatekeepers in the recruitment and get in contact with this group of citizens. Key messages The program has potential to bridge the gap between socially vulnerable citizens and the health system. The group is hard to reach without collaboration with local stakeholders.

scholarly journals P112: FLO on flow: front line ownership of emergency department, hospital, and health system patient flow a novel approach to ED overcrowding (Part 1)

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S96-S97 ◽  
Author(s):  
D. A. Petrie ◽  
S. Ackroyd ◽  
S. Comber ◽  
K. Mumford
Keyword(s):  
Emergency Department ◽  
Health System ◽  
Complex Adaptive Systems ◽  
Operations Management ◽  
Adaptive Systems ◽  
Patient Flow ◽  
Full Range ◽  
Front Line ◽  
Hospital Access ◽  
Ed Overcrowding

Introduction: Hospital access block, often called Emergency Department (ED) overcrowding when it manifests there, is an important public health issue and seemingly intractable problem in our evolving Health Care system. The multiple, dynamic, and inter-dependent factors influencing its cause (and potential solutions) may best fit a complex adaptive systems analysis and approach. One technique described in similar contexts is Front Line Ownership (FLO) based on the theoretical framework of positive deviance. The aim of this study is to discover where pragmatic bottom-up insights and adaptive work-arounds can be elicited, described, iterated, and potentially implemented at a broader scale to catalyze systems change, in service of improving patient flow. Methods: This is a qualitative study which identified, convened, and surveyed stakeholders representing three components of the system. Purposive sampling was used to gather a full range of perspectives from three groups: 1) patients and or families, 2) front-line providers, and 3) management/leaders. Interviews were recorded and transcribed by a third party, then each transcription was coded independently by two investigators (at least one of which was the PI). Informed consent was obtained from all participants and each was offered the opportunity to review the transcription to ensure accuracy. A framework analysis was used to synthesize, reflect upon, and interpret the data from multiple perspectives using a structured, iterative approach. Results: In part 1 of this study, three broad over-lapping themes emerged from the analysis as being areas of opportunity for reducing hospital access block. They are: 1. Boundary Conditions (the historical, organizational cultural, psychological, economic, and other contexts influencing system performance), 2. Systems Integration (how well the parts interface with each other relate to the whole), and 3. Operations management (the more technical aspects of patient flow). When these three broad themes are cross-analyzed with a more conventional input-throughput-output approach, previously under-emphasized avenues for improvement may become apparent. Conclusion: A front-line ownership analysis of ED overcrowding is feasible. There are adaptive behaviors by some front-line individuals at each “level” of perspective that have been identified and could be modified and implemented locally to improve patient flow in the ED (and the rest of the health system).

Management of Health System Reform: A View of Changes within New Zealand

1998 ◽  
Vol 11 (3) ◽  
pp. 182-191
Author(s):  
D. Ritchie
Keyword(s):  
Health Care ◽  
Transformational Leadership ◽  
New Zealand ◽  
Health System ◽  
Management Style ◽  
Active Management ◽  
Successful Implementation ◽  
System Reform ◽  
Publicly Funded ◽  
Health System Reform

This paper reports on the context and process of health system reform in New Zealand. The study is based on interviews conducted with 31 managers from three Crown Health Enterprises (publicly funded hospital-based health care organizations). A number of countries with publicly funded health services (e.g. UK, Australia and New Zealand) have sought to shift from the traditional ‘passive’ health management style (using transactional management skills to balance historically-based expenditure budgets) to ‘active’ transformational leadership styles that reflect a stronger ‘private sector’ orientation (requiring active management of resources—including a return on ‘capital’ investment, identification of costs and returns on ‘product lines’, ‘marketing’ a ‘product mix’, reducing non-core activities and overhead costs, and a closer relationship with ‘shareholders’, suppliers and customers/clients). Evidence of activities and processes associated with transformational leadership are identified. Success of the New Zealand health reforms will be determined by the approach the new managers adopt to improve their organization's performance. Transformational leadership has been frequently linked to the successful implementation of significant organizational change in other settings (Kurz et al., 1988; Dunphy and Stace, 1990) but it is too early to assess whether this is applicable in a health care context.

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