Analysing organisational context:case studies on the contributionof absorptive capacity theory tounderstanding inter-organisationalvariation in performanceimprovement

Gill Harvey,1 Pauline Jas,2 Kieran Walshe3

▸ Additional material ispublished online only. To viewplease visit the journal online(http://dx.doi.org/10.1136/bmjqs-2014-002928)

1Health Management Group,Manchester Business School,University of Manchester,Manchester, UK2School of Sociology and SocialPolicy, University of Nottingham,Nottingham, UK3Health Management Group,Manchester Business School,University of Manchester,Manchester, UK

Correspondence toDr Gill Harvey, HealthManagement Group, ManchesterBusiness School, University ofManchester, Booth Street West,Manchester M15 6PB, UK;gill.harvey@mbs.ac.uk

Received 13 February 2014Revised 19 September 2014Accepted 30 September 2014Published Online First21 October 2014

To cite: Harvey G, Jas P,Walshe K. BMJ Qual Saf2015;24:48–55.

ABSTRACTBackground Organisational context is frequentlycited as an important consideration whenimplementing and evaluating quality improvementinterventions in healthcare, but limited guidance isavailable on which aspects of context are mostinfluential or modifiable. This paper examines howinternal and external contextual factors mediateorganisational-level performance improvementthrough applying the knowledge-based theory ofabsorptive capacity (AC).Methods Three healthcare case studies arepresented. Each case is a UK National HealthService organisation that had been identified ashaving performance problems. Qualitative datawere collected through semi-structured interviewswith general and clinical managers within theorganisation and members of external teamssupporting or overseeing performanceimprovement (n=22). Interview data were analysedusing an existing AC framework from theliterature.Results The organisation with the highest ACshowed the quickest and most comprehensiveperformance improvement. Internal characteristicsincluding strategic priorities, processes formanaging information, communication andorientation to learning and development impactedon the organisation’s ability to engage successfullywith external stakeholders and make use ofavailable knowledge. This enabled theorganisation to thrive despite the challengingexternal environment. Lower levels of AC appearedto delay or limit the improvement trajectory.Conclusions Developing a more detailed andnuanced understanding of how context influencesimprovement is an important step towards

achieving more effective and sustainable qualityimprovement programmes in healthcare. AC, withits focus on knowledge and organisationallearning, provides a useful way to explore therelationship between context and qualityimprovement and represents a potentially valuablearea for future research and development.

INTRODUCTIONIt is increasingly recognised that contextmatters in relation to the success ofpatient safety and quality improvementinitiatives in healthcare. There are well-documented variations in the success ofthe same improvement interventionswhen they are used in different organisa-tions.1 Contextual influences may explainsuch inter-organisational (and in somecases, intra-organisational) variation inperformance improvement.2–4

But what do we mean by organisationalcontext? Why is it so important and howdoes it exert an influence? Is it internal orexternal to the organisation? Is it context ata micro-organisational, meso-organisationalor macro-organisational level? Or do ele-ments of all these operate in an inter-connected way? And are there certainaspects of context that are more or lessamenable to intervention to increase thelikelihood of success in implementingimprovements? These are all importantquestions to address in order to maximisethe impact of time, effort and resourcesinvested into developing and implementingimprovement programmes in healthcare.5 6

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This paper aims to extend and develop our under-standing of how ‘organisational context’ affects theimplementation and effectiveness of improvement inhealthcare organisations. We focus on performanceimprovement at an organisational level and on the useof knowledge to inform and implement improvement.Our starting premise is that context matters throughdetermining the organisational capacity to make effect-ive use of available knowledge to improve perform-ance. This line of argument draws on the relevantbusiness and management literature. In particular, wefocus on the theory of absorptive capacity (AC), whichsuggests that contextual factors—both external andinternal to the organisation—mediate the way in whichthe organisation is able to manage and process knowl-edge to improve performance.The paper starts by briefly exploring what is already

known about the contextual factors that influence theimplementation of improvement initiatives in health-care and the role of knowledge management andorganisational learning in performance improvement.We then describe the theory of AC, drawing on recentdebates and applications in the public sector, includ-ing our own empirical research in healthcare.

CONTEXTUAL FACTORS INFLUENCING THESUCCESS OF QUALITY IMPROVEMENT INHEALTHCAREIncreasing awareness of the variable progress andsuccess of quality improvement initiatives in health-care has driven interest in trying to understand andexplain the reasons for such variation. While someresearchers question the efficacy of the improvementinterventions themselves,7 a growing number ofstudies highlight the influence of context on determin-ing the process and outcomes of quality improve-ment.2 8 Even in projects that can be described as anoverall success,9 10 variation between individualproject sites and teams is not uncommon. In exploringcontextual influences, researchers have adopted differ-ent approaches, such as systematic reviews of existing

empirical studies,2 in-depth case studies of organisa-tions that have successfully implemented and sus-tained quality improvement11 and using expertpanels.4

Ovretveit (ref. 3, p.i18) defines context as ‘allfactors that are not part of a quality improvementintervention itself ’, and various authors have devel-oped taxonomies, theoretical and conceptual frame-works to delineate key elements of context thatinfluence the success of quality improvement initia-tives.2 4 12 Typical aspects of context highlighted insuch frameworks include leadership, organisationalculture, teamwork, resources, organisational character-istics and various external environmental factors. Themechanisms by which such factors exert an influenceand the relationships between different factors aregenerally less clear.

THE ROLE OF KNOWLEDGE ANDORGANISATIONAL LEARNING INPERFORMANCE IMPROVEMENTThe importance of knowledge management andorganisational learning has been previously recognisedin the literature on patient safety and quality improve-ment.13–15 Theories used to frame these discussionsand analyses include Senge’s learning organisation16 17

and Argyris and Schon’s ideas of single, double andmeta-loop learning.18 Studies of performance failurehave attributed the root cause of failure to a dysfunc-tion in organisational learning19 20 while other theor-ies link knowledge and learning to the achievement ofcompetitive advantage. These latter theories, specific-ally dynamic capabilities and AC, derive from theresource-based view (RBV) of the firm and originatein the for-profit sector. At the heart of RBV is theview that distinctive performance differences betweenorganisations is determined by the nature and combin-ation of assets on which these organisations candraw.21

DEFINING ACSince early seminal work to describe the concept ofAC,22 23 it has received considerable attention in themanagement literature on learning, innovation andperformance; over 1200 publications on AC appearedin the literature between 1992 and 2005.24 Lane andcolleagues25 undertook a critical review of the litera-ture on AC, describing it as a three-componentprocess of exploratory learning, transformative learn-ing and exploitative learning (table 1). Exploratorylearning is a process through which an organisationcomes to recognise and understand new knowledge.Transformative learning refers to those processes thataffect the way in which new knowledge is assimilatedand combined with prior knowledge at different levelswithin the organisation. Exploitative learning is theprocess by which the new knowledge that has beenassimilated is translated into actions that will benefit

Table 1 Defining absorptive capacity (after Lane et al25)

KnowledgeacquisitionExploratory learning

The process by which the organisation recognisesand understands new knowledge. The priorknowledge of the organisation will be importantbecause the functioning of existing mental modelswithin the organisation will influence valuejudgements about any new knowledge thatappears externally.

KnowledgeassimilationTransformativelearning

A process by which valuable external knowledge isassimilated at multiple levels within theorganisation, involving several processes that shapethe way that newly acquired knowledge iscombined with existing knowledge.

KnowledgeapplicationExploitative learning

The process by which the knowledge that has beenassimilated by the organisation is transformed andused to produce changes that benefit theorganisation’s performance.

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the organisation, for example, through the implemen-tation of agreed plans or policies and the introductionof necessary changes.This same review proposed that AC is determined

by two sets of antecedents that are external andinternal to the organisation25 (figure 1). Externalfactors include the environmental conditions,characteristics of knowledge and characteristics oflearning relationships. Internal factors relate to mentalmodels, organisational strategies, and structures andprocesses within the organisation. Interaction betweenthese factors influences the way in which the organisa-tion approaches the key stages of AC; in turn, thisdetermines the performance outcomes of the organ-isation, in terms of management focus, governanceand improved services.In order to understand how AC can be influenced

by contextual factors—and how those factors couldpotentially be modified to improve AC—it is import-ant to briefly consider how organisations develop,maintain and improve their stock of AC. Key pointsthat emerge from the literature are that AC is path-dependent and cumulative.26 Consequently, an organ-isation that invests in AC is more likely to facilitatefurther development because it is aware what add-itional knowledge it needs and how to access andexploit it, and so becomes more effective at anticipat-ing and predicting change. Mechanisms that enableformal and informal exchange of knowledge promotethe development of organisational AC.27

Although much of the literature on AC focuses onachieving competitive advantage in industrial andcommercial organisations, there is a growing interestin its application to the study of public sector organi-sations.28–32 Market reforms coupled with an increas-ing focus on external performance assessment andregulation has accentuated the need for organisationsto achieve and maintain high levels of quality in anincreasingly competitive environment.

METHODSQualitative data were collected as part of a largerresearch study examining performance failure in theUK public sector.33

In this paper, we focus on three healthcare casestudies we conducted, two in England and one inScotland. Each organisation had been identified ashaving performance problems through external inspec-tion or review of their performance data and a formalimprovement programme had been put in place.Primary data collection involved semi-structured inter-views with middle-level and senior-level managersexploring the history of the performance problem andhow it was being addressed. Interviewees included amix of general and clinician managers and at least oneexternal stakeholder involved in managing the perform-ance of the organisation or providing external improve-ment support. Twenty-two interviews were conducted

in total; 7 in two of the cases and 8 in the third case.The interviews were conducted by two members of theresearch team (GH and PJ), and each participant wasinterviewed once only.The interviews were digitally recorded, transcribed

and analysed using the Lane et al25 conceptualisationof AC (figure 1) as an analytical framework.Supplementary documentation in the form of inspec-tion reports and agreed action plans for improvementwas also made available to the research team; this wasused to inform the background description of thecases and the organisational response to performancedata.

FINDINGSCase ACase A was a small organisation with a small manage-ment team, operating within a financially challengedhealth economy. The organisation did not immedi-ately respond to the evidence about the need toimprove performance and could best be described asan organisation in denial. It had failed an externalclinical governance review and not met nationalresponse-time performance targets. An externalimprovement team had been appointed to work withthe organisation over a 12-month period. The boardand senior leaders of the organisation initially rejectedthe evidence that their performance was poor andrefused to cooperate with the external improvementteam.From an AC perspective, case A never got beyond

the point of acquiring evidence about its perform-ance; this evidence was not accepted, which removedthe potential for assimilating and acting upon the evi-dence to bring about improvement. Case A typified anorganisation with a low level of AC.In terms of external contextual factors, there was a

history of poor relationships with the local healtheconomy and the local media. Although the perform-ance information from external agencies was rejectedby the senior management, staff within the organisa-tion identified with it and felt it confirmed what theyalready knew.

…. when the reports came out I don’t think therewere any surprises I think people knew it was comingand it had to be managed within the health economy… We didn’t particularly have a good relationshipwith our health economy partners either …. which iswhen certainly the external review side of things whenthe stakeholders were then given the opportunity tooffer their concerns and comments ….. they gavethem, quite strongly. (Lead quality manager)

Internal contextual variables related to the predom-inant leadership and management style of senior staff,strategic priorities, organisational resources andculture. The external review of the organisation iden-tified the management structure and regime as a

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major problem; it was perceived as very controllingand top-down. The board was seen to be rather ‘outof touch’, they were not engaged with the clinical/patient care agenda and did not see issues such as clin-ical governance to be relevant.

… they buried their head in the sand, I think in thehope that it would go away, they had a managementstructure with more rank markings than you couldshake a stick at really, very hierarchical and a boardthat I don’t think understood what the new world wasall about. (Member of external improvement team)

In terms of managing performance, senior managersprioritised achieving financial balance and meetingkey national targets, but had failed to do this. Anumber of senior management posts were vacant, buta freeze on recruitment meant several people were inacting-up roles. Senior managers did not push forgrowth or investment of additional funds and staffwere not given access to training and development,including some mandatory training. It was not per-ceived to be a happy organisation; staff worked insilos, they did not feel able to question, morale waslow and they described their feeling of being down-trodden and disempowered.

oh my goodness the morale was very low, staffwouldn’t question just didn’t feel empowered to doanything, didn’t feel it was their place and were gener-ally downtrodden …. it was very antagonistic veryreminiscent of what I imagine the 70s would havebeen like, everybody out on strike that sort of thing soit was very difficult and there was a lot of mistrust ….

there didn’t appear to be any transparency or open-ness. (HR director)

The net effect of these external and internal con-textual factors was a low level of AC, which left theorganisation unable to improve without external inter-vention to replace the chief executive and chair andappoint new individuals into these key roles. Oncethese and other vacant posts were filled, the approachto performance improvement changed considerably. Aclose collaboration with the external improvementteam was established and a range of strategies wereintroduced to support service improvement and staffand leadership development. Correspondingly, ACbegan to develop, although from a very low startingpoint:

…. they are engaging with other [NHS] trusts so theyare wanting to improve which I guess is the biggesthurdle to overcome. They realise they are not perfect,they are engaged in change, they’re open to any sug-gestion and are willing to have support … (Member ofexternal improvement team)

Case BCase B was a recently merged, large acute trust man-aging complex change, including a new hospital build-ing programme. When presented with externalevidence that they had failed to meet national waiting-time targets, the organisation was devastated and ini-tially felt it was unfair. They agreed to work with anexternal improvement team for a year, recognising thevalue of the help on offer. They began to investigatethe performance problem, which was initially

Figure 1 Absorptive capacity (AC) framework (adapted from Lane et al25).

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attributed to an administrative error, and uncoveredother potential mistakes in the wider organisation.

…. it was only when we were galvanising to turn overevery stone to see what other admin issues there werethat we discovered many things that were wrong. Ithink we are a much much stronger organization as aresult of that and we would have been carrying on inblissful ignorance thinking that we were doing fine.(Operations director)

Compared to case A, case B exhibited higher levelsof AC. Although the external context presented sig-nificant challenges, good working relationships withwider health economy partners were apparent. Theorganisation was committed to using external net-works to develop their learning, as evidenced by theestablishment of benchmarking visits to other organi-sations dealing with similar issues and their willing-ness to work with the external improvement team.

[The external intervention team] … worked collabora-tively with us and they were a resource and we usedthem …. Although it was a very uncomfortableprocess, if you use them constructively and say OKthese are people that are going to focus on this and dothis and we are going to get a project plan and getsome structure into it we want to improve anyway thisjust gives us an added chance with some other peopleto help us with keeping focused on what we have gotto do to achieve it. (Medical director)

Internally, the management took steps to investigatethe quality problems that had been identified, despitetheir initial feelings of shock and disbelief. Theystarted to develop structures and systems to manageinformation more effectively and as a result reportedthey felt they were no longer jumping into solutionswithout adequately understanding the problem.

I think what it probably highlighted was issues aroundhow performance management information isrecorded and understood at the highest level and itprobably highlighted that in a really large complexorganization like this one not bringing that informa-tion together into a single place where problems couldbe identified and deficiencies in systems anticipatedand overcome was really what let the organizationdown. (Divisional manager)

This illustrates the steps the organisation took toimprove their AC through introducing internalsystems and processes to address the assimilation ofnew knowledge and its application. This was sup-ported by other internal factors such as developmentprogrammes for staff to support the changes that werebeing introduced and new communication systems todisseminate information from the chief executive tostaff throughout the organisation. Over a relativelyshort time frame, this resulted in a clear improvementin organisational performance.

Case CCase C was one of the largest health organisations inthe country. It had recently been created from themerger of a number of smaller organisations, whichleft it with a significant financial deficit. When thenational government introduced standards for cancerreferral and treatment, the organisation failed to meetthe standards across a wide range of cancer types.Achieving the required standards presented the organ-isation with significant challenges. However, theorganisation considered itself to have a ‘can do’culture, a philosophy driven from the top of theorganisation. The targets acted as a catalyst and focusfor improvement and meeting the cancer targets wasseen to be an absolute priority.

I think the organization is a can do. I think the direc-tors are all generally quite driven people who wantedto make service improvement and who recognise theirobligations…. [The] Chief executive is of that nature. Ithink underneath that, our service managers andgeneral managers do want to make things better, dounderstand that and have got a kind of can do atti-tude. (Clinical director)

Of the three cases studied, case C demonstrated thehighest level of AC, immediately recognising the evi-dence that it was failing to meet external standardsand initiating a concerted effort to address the under-lying issues. Help from an external improvement teamwas readily accepted; this team was seen to bringuseful learning and experience from outside theorganisation, enabling them to draw on best practicefrom elsewhere.

We need to be receptive to best practice, you know, ifthey’re doing it well somewhere then …. we don’twant to reinvent the wheel. …. I think we do not needto be insular…. we need to be absolutely receptive tohow others do things and I’m trying to encourage myteam at the moment to go out. (Clinical director)

Numerous changes were introduced in an effort tomeet the cancer targets. Multidisciplinary teams wereestablished as a vehicle for change and clinical nursespecialists took on a key role as facilitators of change.In lieu of an adequate information technology (IT)infrastructure, a team of ‘trackers’ was appointed tomanually manage the process from referral to treat-ment whilst the organisation invested in a new ITsystem to improve data management. Escalation pol-icies were developed to deal with blockages in thesystem, accountability and reporting systems were putin place and significant energy was invested intogetting clinicians on board through promoting thepatient-centred benefits of the changes.

We were very clear about what the main objective was…. that this was about improving access for patientsand shortening their journey …. there was actually apatient gain and if they were to put themselves in the

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shoes of patients and their families they would seewhere it’s not reasonable for us to not have plannedprocesses that allow patients to fall through the net.(General manager 1)

As a result of this package of changes, the organisa-tion witnessed improvement in achievement of thetargets; rates increased from <50% to >90% within12 months. The prevailing view was that the improve-ment programme had sharpened the organisation’sthinking about the need to ‘drive a process’ ratherthan ‘letting the process meander around’, which inturn created organisational learning beyond cancerservices.

DISCUSSIONThe cases demonstrate how varying levels of ACresulted in different processes and outcomes ofimprovement; they also begin to shed light on howcontextual factors can influence the improvement tra-jectory. All three cases experienced a challengingexternal environment with financial constraints andchanging external conditions. Cases B and C had bothexperienced recent mergers, resulting in larger, morecomplex organisations, bringing together differentcultures and different ways of working. Yet these twoorganisations displayed higher levels of AC than caseA, suggesting other external and internal factorsexerted a more significant influence on AC (figure 2).In case A, most of the internal and external factors

inhibited the development of AC. In a challenging exter-nal environment, the organisation had poor externaland internal relationships, a closed culture, an autocraticstyle of management and high numbers of managementvacancies. Equally subject to difficult environmentalconditions, cases B and C displayed contextual factorsthat promoted AC, including a willingness to engage inlearning and external partnerships, management com-mitment to improve, investment in better IT and com-munication systems and support for staff engagementand development. Therefore, a difficult or challengingexternal context is not in itself sufficient to limit orinhibit the development of AC. Rather, a number ofother internal and external factors can create andenhance higher levels of AC. Important internal con-textual factors include the strategic focus and prioritiesof senior managers, the organisational culture and will-ingness to learn, the establishment of systems and pro-cesses to more effectively manage information andcommunication within the organisation and attention tonecessary staff support and development processes. Inturn, these impact upon external factors such as theextent to which organisations engage with wider stake-holders and are willing and able to make use of knowl-edge from external sources.It follows, therefore, that efforts to increase AC

need to assess and then address the internal and exter-nal contextual factors that influence the processes of

knowledge acquisition, assimilation and applicationand consider the order or sequencing in which spe-cific issues are addressed. For example, if an organisa-tion displays significant internal contextual barriers toAC (as in case A), then providing additional externalinformation or access to external networks andexpertise is unlikely to have much impact. Attentionto the contextual factors within the organisation is anecessary first step to building AC and improving per-formance. This highlights the need for detailed assess-ment of organisational capacity to improve, andtailoring interventions appropriately, rather thanseeking a generic solution to the issue of organisa-tional improvement in healthcare.Developing our knowledge and understanding of

AC in relation to performance improvement couldhelp to build a more detailed picture of how organisa-tions, and subunits within organisations, make use ofavailable information to achieve and maintain moreeffective improvement programmes, including assess-ment of the contextual factors that influence AC. Apossible way forward could be to produce self-assessment diagnostic and evaluative tools for use bysenior leaders and managers within the organisationto review the level of AC and identify important areasfor future development and on-going vigilance.Within this agenda, a closer examination of the rela-tionship between leadership, AC and context wouldbe worthwhile, building on related research in thisarea.34 35

In our view, the distinctive and important contribu-tion of AC is that it provides a conceptual frameworkthat can be used to understand and even address thecauses of variation in performance improvement,beyond simply describing or ascribing it all as a matterof organisational context. It promotes a view of theorganisation as a knowledge processing entity thatcomplements or even counters two more prevalentnarratives: the actor-driven view in which organisa-tional change and improvement comes about becauseof individuals and their leadership; and the methods-driven view in which organisational change andimprovement are produced by following a particularprocedural process of measurement, metrics andtools. Understanding the way knowledge is used inorganisations may be particularly important inknowledge-intensive sectors or settings, such ashealthcare.At an external/regulatory level, thinking about

improvement from an AC perspective could enablethose charged with performance management or sup-porting external improvement interventions to establisha more nuanced understanding of performance-relatedissues by looking at the organisation from a knowledge-processing perspective. This would enable interventionsto be targeted towards building organisational learningcapacity, an important consideration given that the rootcause of performance failures is often attributed to a

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dysfunction in organisational learning.19 In turn, thisleads to organisational behaviour that is typicallyinward-looking, distracted and short-sighted,20 as evi-denced by recent examples of major failures inhealthcare.36

Further exploration of the contribution of AC tohealthcare improvement, from both an organisationaland a regulatory perspective, represents a promisingarea for research and development in the future.Equally, it is important to acknowledge the limitationsof our research, which largely relies on interviews at asingle point in time. Longitudinal observation of orga-nisations as they attempt to manage and improve per-formance would provide richer data and help tofurther refine our understanding of AC.

CONCLUSIONA better understanding of the relationship betweencontext and quality and safety is an important priorityon the agenda to learn from failures and both scaleand speed up the implementation of effectiveimprovement in healthcare. A better understanding of

the contextual factors and processes involved in man-aging and improving organisational performance isimportant for a wide range of stakeholders through-out the healthcare system, including patients, clini-cians, managers, policymakers and regulators. In thispaper, we have discussed the application of a knowl-edge processing theory, AC, to analyse the concept oforganisational context and its relationship to perform-ance improvement. In doing so, we hope that we havecontributed to the debate on why context matters inhealthcare. We believe that by adopting a knowledge-centred approach to organisational learning forimprovement we can move beyond the acknowledgedview that ‘context matters’ to develop a deeper, morerounded picture of why performance varies withinand between organisations and, more importantly,what can be done to facilitate improvement.

Acknowledgements We particularly acknowledge thecontribution of Professor Chris Skelcher to the design andconduct of the study on performance failure in public sectororganisations, from which the empirical data in this paper werederived.

Collaborators Chris Skelcher.

Figure 2 Summary of cases from an absorptive capacity perspective.

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Contributors All authors contributed to the conception anddesign of the paper. GH prepared the initial draft andcoordinated the process of editing and revision. All authorswere involved in the reviewing process and read and approvedthe final manuscript.

Funding ESRC Public Service Programme (grant number:RES-166-25-0020).

Competing interests None.

Ethics approval Leeds (East) Research Ethics Committeereference 07/H1306/125.

Provenance and peer review Not commissioned; externallypeer reviewed.

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