CHIR produces research which supports practitioners, policy-makers, and other stakeholders facing the complex challenges of embedding healthcare innovations; that is, implementing innovations sustainably and at scale.
Our work connects the introduction of innovations to the shifting work patterns and organizational changes required to scale and sustain them in practice. By drawing on the expertise of two highly ranked Schools at City, University of London - CASS Business School and the School of Health Sciences – the Centre provides the interdisciplinary approach needed to analyse, evaluate and improve this dynamic process of embedding innovation. This involves the deployment of a range of methodological tools, including both the tracking of innovation journeys over time, and cross-sectional comparison of innovations.
Our research aims to develop the evidence base for improving the sustainable implementation and spread of healthcare innovations by identifying generalisable aspects and mechanisms of the way such innovations are adopted, adapted and embedded across different contexts. Our work therefore involves multiple projects which reflect the major themes of our approach as being;
- Evidence-based and interdisciplinary;
- Encompassing different types of innovation across multiple levels of healthcare systems;
- Addressing different national and organizational contexts for innovation spread and implementation;
- Assessing patient and public involvement in embedding innovations.
A selection of current projects are outlined below:
Systematic reviews conceptualising implementation depth and innovation diffusion
Healthcare innovations are often not sustained after adoption and vary in their effectiveness when scaled-up across different sites. Diverging research strands focus on either implementation or scale-up/diffusion. These strands typically have different analysis levels, focus on different implementation phases and are conducted in different research fields, e.g., health research (implementation), organisation studies (diffusion). This systematic review aims at synthesising evidence on implementation depth and innovation diffusion published in these diverging research fields. It is expected to shed light on the blind spot in our understanding of how to achieve both, the widespread and sustainable implementation of innovations, or the ‘embedding of innovations’.
System innovation scale-up in China
A system level innovation - Medical Alliance (MA) – was established throughout China in recent years following the 2009 health care reform, and has received considerable attention from policy makers, academics and international development organisations. MAs are collaborative alliances involving the integration of primary and community care organisations with secondary and tertiary care hospital providers. The objective of MAs is to promote the usage of the newly established Community Health Centres (CHCs) and to reduce demand for hospital-based secondary and tertiary care to achieve more effective healthcare delivery. However, there are significant obstacles to adopting and scaling up such a large-scale change or system innovation. This project allow us to gain an ‘insider look’ at a few MA models across three different cities in China to examine the scale up and spread of such complex system-level innovation.
Spread of a social prescribing tool in the NHS
GP practices in the UK face significant increases in workload due to a combination of staff shortages and the escalating pressures posed by chronic conditions and illness. In response to this growing demand, the NHS long-term plan mandates much greater use of digitally-based services in the coming period. The widespread popularity of social media as a means of exchanging information also indicates the potential acceptability and benefits of new digital services for patients. The primary aim of the study is to understand how such a digitally-based service – a social prescribing tool, is being adopted and applied in GP practices by multiple health professionals working in the practice. Greater understanding of the factors enabling or constraining effective adoption and implementation will be of benefit to the developers and users of this particular service by helping to improve its further development, and supporting take up amongst patient groups. The study will also serve a wider need in the UK healthcare community by showing how an innovative tool can be more effectively embedded into existing healthcare organizations and practices to secure significant benefits for staff and patients.
The Startback tool is an innovative triage screening tool. It is developed for GPs and physiotherapists to help assess patients with lower back pain, stratify them into low, medium, or high risk categories, and provide them with matched treatments. We follow the journey of the tool diffusion from 2015 to 2018, and show the variation in different professional groups’ responses (GPs, physiotherapists) to the innovation and the way it is adapted. In doing so, we are able to demonstrate dynamics of distributed leadership in the spread of innovations and the interplay between innovation adaptation and professional practice. This project not only contributes to the literature on innovation diffusion in public service, but also provides valuable implications for policy and practice.
The role of implementation process in shaping technology innovation outcomes in healthcare
The outcome of a technological innovation is dependent upon the way in which the innovation is implemented. The process of implementation interacts with other contextual factors, at multiple levels, and also with the innovation itself. This study aims to contribute to a more systematic and integrated understanding of the role of the implementation process for healthcare innovations. It employs a two-phased in-depth analysis investigating 34 technology implementation journeys across 12 NHS trusts. In phase I, through 121 interviews we unpack rich implementation process dynamics within each of the specific organizational cases. In phase II, by applying Qualitative Comparative Analysis (QCA), we identify which configurations of characteristics of the innovation, the implementation process and the organisational context are linked to innovation outcomes.
Contextualised adaptation of social care innovations spreading from high to low- and middle-income countries
Given the cost and time involved in developing and testing new interventions, low- and middle-income countries are adopting proven interventions from elsewhere. The challenge remains how to adapt and implement such interventions to fit the local context. This project develops a new practical implementation framework to support the adaptation of social work interventions in low- and middle-income countries through a scoping review and workshops with international experts and local practitioners in South Africa and Tanzania. The framework is expected to allow for the development of practical guidance and tools targeting social care practitioners to facilitate and evaluate the adaptation process in the future.
Understanding external implementation context – A best-fit framework synthesis
Variations in the external context such as the political and funding environment, cultural context, location, historical developments or population demographics can influence implementation outcomes but this influence is little understood. We aim to develop a framework conceptualising the influence of external contextual factors on the implementation of health and social care interventions. The framework is developed based on a two-stage systematic review following the ‘best fit’ framework synthesis approach. The first stage of the review examines existing frameworks, models, and theories on external contextual factors and their influence on implementation from a variety of sectors and disciplines such as health and social care, education, environmental studies, and international development. The resulting meta-framework is then tested and refined in the second review stage by synthesising evidence from empirical studies focusing on the implementation of health and social care interventions that spread within or across countries. The final framework can be used to identify factors explaining the decline and variability in effectiveness of interventions but also the prospects of implementation success when spreading interventions within or across countries.
The influence of external context on the implementation of the London Ambulance Service’s Maternity Screening and Action Tool
This spread of an innovation often results in large variation of how well the innovation works in different areas. There is only a limited understanding of what role the characteristics of these different places or external contexts (e.g. political and financial context, geography and location, demographics of the service population, networks between service providers, historical developments) play when implementing an innovation in different areas. This study will explore the impact of external context characteristics on implementation outcome using the Maternity Screening and Action Tool (maternity card) developed by the London Ambulance Service NHS Trust (LAS) as an example. The LAS introduced the maternity card as a prompt for frontline staff to improve the delivery of emergency maternity care. The card was rolled out across London in 2016. This qualitative realist evaluation study aims at understanding what it is about the external context that make the maternity card work in different areas in London. The study is expected to result in a middle range theory formulated as context-mechanism-outcome construct(s) which can inform the spread and implementation of similar innovations. The results of the study are also intended to inform the refinement of a conceptual framework on the influence of external implementation context which is currently being developed.
Role of patient and public involvement in embedding innovations in healthcare – A scoping review
Substantial evidence exists regarding patient and public involvement in research, but it is less clear what we know about patient and public involvement in the later stages of the innovation journey when innovations are implemented and spread in healthcare practice. This scoping review aims at identifying and mapping the currently available evidence regarding the role, influence or impact of patient and public involvement during different healthcare innovation stages from research and development via implementation, to scale-up and spread. Such mapping will identify current evidence gaps to derive new research objectives.
Ziemann, A. , Brown, L., Sadler, E., Ocloo, J., Boaz, A. and Sandall, J. (2019). Influence of external contextual factors on the implementation of health and social care interventions into practice within or across countries - A protocol for a 'best fit' framework synthesis. Systematic Reviews, 8, 258. DOI: 10.1186/s13643-019-1180-8
Chen, Y. and Reay, T. (2019). Responding to imposed job redesign: the evolving dynamics of work and identity in restructuring professional identity. Human Relations. "