understanding change and innovation in healthcare settings: reconceptualizing the active role of...

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Understanding Change and Innovation in HealthcareSettings: Reconceptualizing the Active Role of ContextSue Dopson a , L. Fitzgerald b & Ewan Ferlie ca Said Business School, University of Oxford , UKb Department of HRM , De Montfort University , Leicester, UKc School of Management, Royal Holloway University of London , UKPublished online: 08 Dec 2008.

To cite this article: Sue Dopson , L. Fitzgerald & Ewan Ferlie (2008) Understanding Change and Innovation in HealthcareSettings: Reconceptualizing the Active Role of Context, Journal of Change Management, 8:3-4, 213-231, DOI:10.1080/14697010802133577

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Understanding Change and Innovationin Healthcare Settings: Reconceptualizingthe Active Role of Context

SUE DOPSON�, L. FITZGERALD�� & EWAN FERLIE��

�Said Business School, University of Oxford, UK, ��Department of HRM, De Montfort University, Leicester,

UK, ��School of Management, Royal Holloway University of London, UK

ABSTRACT This article discusses the ways in which ‘context’ has been formulated and explored inhealthcare settings. We contend that context is an important, but poorly understood mediator ofchange and innovation and that there is a dearth of empirical work in healthcare studies thatadequately deals with context. Drawing on extensive empirical data exploring the career of‘evidence based’ healthcare innovations, we illustrate that context should not be seen as abackcloth to action but as an interacting element in the change process.

KEY WORDS: Context, change, healthcare innovation

Introduction

Many analyses of attempts to change individual and organizational practices referto ‘context’ as an important influence, but we believe that the time is right toreconsider the role of context in change processes within healthcare settingsin greater depth. The precise analytic status of context is often glossed over inmuch of healthcare studies. We contend that context is an important, but poorlyunderstood mediator of change and innovation and that a more rigorous analysisof the term is now helpful.

In this article, we will discuss the theoretical foundations upon which the termcontext has been formulated and explored within studies of healthcare change andinnovation and we put forward possible building blocks for a more sophisticatednotion of context. Empirically, the article draws on some six years of reflection on

Journal of Change Management

Vol. 8, Nos. 3–4, 213–231, September–December 2008

Correspondence Address: Sue Dopson, Said Business School, University of Oxford, OX11HP, UK. Email:

[email protected]

1469-7017 Print/1479-1811 Online/08/03-40213–19 # 2008 Taylor & FrancisDOI: 10.1080/14697010802133577

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49 separate case studies that examined the diffusion of ‘evidence based’ innovationsin UK healthcare settings. By way of background, the evidence based healthcare(EBHC) movement centres on research that suggests a significant gap existsbetween what evidence is available and what is done in clinical practice. It advocatesensuring that clinical practice should change so as to be based on such evidence.More than 1400 interviews were carried out across the studies. A more detailed dis-cussion of the research methods used in the studies is presented later in the article.

Context and Healthcare Studies: Review of the Present Literature

Explaining organizational change and innovation has been an enduring quest ofscholars in many disciplines. Studies of change and innovation in healthcarestudies draw on diverse theoretical preferences and methods. It is not proposedto provide a detailed overview of that work here (others have done that verywell, see Rogers, 1995; Poole et al., 2003), however we do note that a commonfeature of the commentaries on the literature is that whilst the word context isused a lot in discussions of the complexity of achieving change, it is a poorlyunderstood mediator.

In considering the social phenomena of ‘context’, those theorists preferring amore positivist outlook see context as a reality that can be observed and measured.Contingency theory (Burns and Stalker, 1961; Woodward, 1965) is a well-knownschool in sociological studies that explores context in positivistic terms. This per-spective assumes attributes of the environment (including assorted technologies)in which organizations sit, interact to restrict the range of viable or appropriateorganizational forms. At the other extreme, those adopting a more phenomenolo-gical approach (Burrell, 1994) argue that context is complex and not easilyassessed and probably not quantifiable. Indeed, an extreme example of thislatter perspective would argue context is a socially constructed phenomenonand can only be understood by exploring the power relationships that shapewhat is perceived by organizational actors as relevant contexts.

Context has often been considered within healthcare studies of change and inno-vation in terms of ‘levels of analysis’ (for example: Stewart et al., 1980; Harrisonet al., 1992; Iles and Sutherland, 2001), usually encompassing the environment inwhich the organization sits, the organization, group and individual level. The‘level of analysis’ view of context is in evidence in much of the existing scholar-ship on healthcare change and innovation and is helpful in so far as it underlinesthe sources and range of influences are variable and widespread and, as a conse-quence, managers and clinicians need to scan outwards and understand theimpetus for changes. However, these ideas are conceptually limiting, becausethey do not sufficiently stress the interactions between the elements of context.More significantly, the delineation of levels or layers retains the separationbetween the individual, actors and the facets of context.

A significant challenge to the uni-directional view of context is offered by thepioneering work of Andrew Pettigrew and his colleagues. Drawing on structura-tion theory (Giddens, 1984), the Centre for Corporate Strategy and Change atthe University of Warwick, led by Pettigrew (1985, 1987) in the late 1980s andearly 1990s, provided an important contribution to the discussion of context

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within strategic organizational change in healthcare. Pettigrew encouragedresearch which is contextual and processual in character (Pettigrew et al.,1992). In Pettigrew’s terms, a contextualist analysis of a social process ‘drawson phenomena at vertical and horizontal levels of analysis and the interconnec-tions between those levels through time.’ Here, the vertical level refers to the inter-dependencies between higher or lower levels of analysis phenomena, for examplethe impact of a changing socioeconomic context on features of intraorganizationalcontext and interest-group behaviour. The horizontal level refers to the sequentialinterconnectedness among phenomena in historical, present and future time. Pet-tigrew’s starting point for the analysis of change is that any new initiative inevi-tably involves managing both an outer and inner context and process. Outercontext refers to the social, economic, political, and competitive environment inwhich the organization operates. Inner context refers to the structure, corporateculture, history and political context shaping the organization within whichideas for change have to proceed. This perspective sensitizes us to the need tostudy the context, process and content aspects of change simultaneously. It use-fully draws attention to the importance of paying attention to historical eventsas a crucial mediating force on current contexts. However, it suffers becauselike the levels of analysis view of context, the ways in which actors interactwith and mobilize aspects of context is again underplayed.

McNulty and Ferlie (2002) continue work in this tradition. They reflect on theanalysis of complex new public management style reforms to the National HealthService (NHS), and offer a more detailed analysis of the vertical levels mentionedby Pettigrew in a healthcare context. They posit three broad dimensions of contextand argue that all three need to be considered:

1. The macro context of the public sector where three new public managementrelated contextual forces are stressed as being of particular importance,namely: the strength and impact of quasi market forces, the growth of manage-rial and clinical managerial roles and the growth of strategic management.

2. The meso level of context, which draws attention to the dynamics of the inter-mediate level, for example the organizational form of a hospital.

3. The micro level of context, where the emphasis is on the history and dynamicsof activity within particular clinical settings in the hospital.

McNulty and Ferlie use these three levels of context to explore the career andimpact of a Business Process Re-engineering change programme in a NHS trusthospital and ‘trace the downward links between them’. An example of the wayin which the perception of macro context shaped hospital-wide action was inthe managerial assessment that the introduction of the internal market as a newnational policy would create local conditions of severe competition, in which tra-ditional incremental savings would be insufficient and that more radicalapproaches to redesign would be needed (in fact, this assessment of the macrocontext proved in the end to be over pessimistic). Empirically, this study revealedthe way in which the perception of wider context influenced the corporateresponse, which then influenced the response of the intermediate tier (clinicaldirectorate) and, then, the clinical setting. It did not, however explore ways in

Understanding Change and Innovation in Healthcare Settings 215

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which the people acted – or might have acted – to reshape the wider environ-mental context.

There are three difficulties that we would highlight in adopting such a uni-directional view of context. Firstly, organizations, groups and individuals are por-trayed as passive recipients subject to aspects of context that shape behaviour, butwith no leeway in choosing which aspects of context to bring into the organizationand with no influence with which they could reshape the context. Secondly,aspects of these contexts are somehow separated out rather than treated as an‘integrated configuration’. Thirdly, such a view implies a static view of context,that is to say, context is seen as a particular setting at a particular point in timerather than as evolving and changing over time. A final general observation onthis approach is that the ways in which actors interact with and mobilizeaspects of context is underplayed and is often not treated in a sustained way.

Increasingly, healthcare studies scholarship looks to organizational studies forinsights on how to study the impact of context on change and innovation. Organ-izational theorists have suggested selected contextual forces can cause organiz-ational attributes to cluster systematically (Meyer et al., 1993). Organizationalecologists (Hannan and Freeman, 1989) for example, have investigated theimpact of a variety of contextual factors on organizational outcomes, especiallyrates of organizational founding, failure and growth. They have placed particularemphasis on aspects of the institutional and competitive context. Institutionalfactors have included the extent to which an organizational form has become insti-tutionalized, conformity to normative pressures, and formal accreditation. Thisperspective is very selective as to the contextual variables that influencechange. The same selective strategy is also in evidence in institutional theory(Dimaggio and Powell, 1983), which offers another explanation for uniform con-figurations. A central argument of this perspective is that the adoption of inno-vation and change is not a means of improving performance but is rather ameans of achieving legitimacy within the organizational field. The choice toadopt or change may therefore relate more to institutional pressures associatedwith certain fads and fashions, than with well-founded evidence to support theiruse. This perspective assumes that conditions of uncertainty in relation to environ-mental goals and technical efficiencies, will lead organizations to imitate otherorganizations. Here the implication for the study of change and innovation inhealthcare is that organizations are more likely to adopt what is perceived to bebest practice recommendations where there are highly visible models of successwithin their institutional environment, and where there is significant competition.

Another explanation for the clustering of organizational attributes lies in theschool of social constructionism. Here, context is seen as the result of the replica-tion of time honoured practices that become what people know as reality in theireveryday lives (Berger and Luckmann, 1966). Change and innovation is, there-fore, crucially mediated by existing power relationships, where the most powerfulshape is, what is regarded as legitimate practice and what is credible knowledgeand desired outcomes. Power relationships are the most important aspect ofcontext selected to be studied.

Social network theories are increasingly in evidence in studies of healthcarechange (West et al., 1999). The importance of social relationships, seen as


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nodes and ties, is put forward as the relevant context for investigation and a keyaspect for the analysis of change and innovation. In this perspective, the attributesof individuals are less important than their relationships and ties with other actorsin the network. Communities of practice (Lave and Wenger, 1991) is a variant ofthis theory and involves the study of ways in which people work together and arebound to one another in their pursuit of the solving of common issues. In actor-network theory (Latour, 1987), both actors and actants are considered importantin the reconstruction of the network of interactions leading to the stabilizationof the ‘system’. Social network theories major on local interactions and powerissues but largely neglect the wider networks of power as an aspect of context.

Figuration sociology (Elias, 1977) extends the idea of the importance of thestudy of networks as an important element of context and has been recentlyapplied to the study of healthcare change (Dopson, 2005). An Eliasian approachencourages the consideration of change in terms of a temporal dimension, andseeks to understand the impact of the asymmetrical interdependency networksin which the innovation or change has been developed and deployed. It isargued that contemporary ideas or practices are not static or timeless but representthe product of generations of interdependent networks. Furthermore, in Elias’sdiscussion of issues of involvement and detachment (Elias, 1987), we arereminded of the importance of human emotion in processes of change (somethingthat is surprisingly overlooked in the literature on healthcare change and inno-vation); and that codes of emotional engagements within organizations do notoccur in a historical vacuum but occur in relation to wider social processes, ofwhich professionalization and managerialism are particularly important in health-care change and innovation.

Organizational studies also offer a social psychological perspective on context.For example Weick (1969) argues that ‘external conditions only become knownthrough the perceptions of organizational members’, so that context is fundamen-tally a mental concept. For Weick (1969, p. 64) ‘the human creates the environ-ment to which the [organizational] system then adapts’. This perspectiveemphasizes the need to understand the individual’s explanation or view of relevantcontextual issues and the impact on change and innovation.

It is clear that organizational studies are increasingly being drawn upon byhealthcare researchers as a way of exploring context, however many of thegeneral perspectives privilege a selection of contextual variables as being import-ant. Existing studies seem not to effectively address what we perceive to be themajor lacuna in discussions of the role of context, that is the ways in which indi-viduals can influence context and bring aspects of context into change initiatives,thus shaping action.

Fitzgerald et al. (2002) is a recent attempt to reconceptualize the bringing in ofcontext into organizational action using healthcare data. Their data draws attentionto the interplay of features of the outer and inner context and note multiple differ-ences of value, structures, education and relationships between the acute andprimary sectors of healthcare. They conclude by arguing:

Ultimately, the behaviour of the stakeholders and the features of context are inter-

locked. The combination of multilayered, two-way influences, multiple stakeholders


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with interpretative schemes, innovation seeking behaviour by individuals and

groups, and differing absorptive capacity in organizations, produces a situation in

which context is an actor. (Fitzgerald et al., 2002, p. 215)

Fitzgerald et al., set out to argue that context is not merely ‘external’ and thatmany interactions occur between elements of the context and actors. It emphasizesthat influence is two-way and proposes that all aspects of context should form partof the analysis. However, this increases the complexity of the analysis. This studyis limited in its ability to explain this complexity, because it does not attempt toanalyze the processes of interplay in detail, nor the mechanisms by which influ-ence is exerted.

Methods and Data

We draw on Dopson and Fitzgerald (2005) which studied the careers of evidence-based innovations (that is, their trajectories over time from invention to implemen-tation or non implementation). The data comprise a linked set of seven studieswhich provide 49 NHS case studies (Yin, 1999) which are themselves based on800 semi-structured face-to-face interviews with clinical and managerial respon-dents, as well as nearly 600 telephone interviews, written questionnaires and docu-mentary analysis. Table 1 provides more details.

There were methodological challenges in comparing results across the sevenstudies which were handled as follows. In stage 1, we took the seven finalproject reports – rather than the raw interview transcripts – for more refined the-matic analysis, given that the final reports alone contain about 200,000 words intotal. In addition, candidate themes were starting to emerge in the studies’ fullreports which would now be examined in greater depth. Each researcher re-readthe reports and produced summary points of their own studies. We developedan initial overview of the findings, identifying candidate common themes. Instage 2, we undertook a pilot analysis of one theme by one researcher (that is,the impact of clinical opinion leaders), using the list of key points and the fulltexts of the final reports. Other researchers commented and we then assessedthe feasibility of pursuing this method for other themes. Each researcher under-took their analysis of each theme.

In stage 3, we prepared a draft coding structure of themes. This was, first of all,applied to one theme (the nature of the research evidence) by each team memberworking through all the reports. This led to a collective discussion and simul-taneous analysis, using one report as an illustration. Draft coding categorieswere checked and refined, and a further interim analysis produced. This overviewexercise produced a checklist of 10 core themes (see Table 2) evident across thestudies.

In stage 4, each researcher individually applied the coding structure to allthemes and reports, looking for differences and convergence. Each researcherassessed the comparative importance of the 10 themes and ranked them interms of their importance on a three-point scale and then a group ‘score’ wasderived from these individual rankings. Context was assessed as being of verystrong importance in six studies and as of strong importance in a seventh.


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Table 1. An overview of the research design and methods across the seven sites

DesignNo. of case

studies Face-to-face interviews�Telephoneinterviews�

Writtenquestionnaires

Documentanalysis Dates

Dopson andGabbay,1995

Single stage case studieson four clinical topics 4

58 (RHA and purchasingmanagers, cliniciansand public health)

3

2 years,1993–1994

Two stages:Wood et al.,

19981. Overview survey

across whole region71 (mainly front-line

clinicians)3

2 years,1995–1997

2. Case studies, oneper clinical topic,selected onevidence of clinicalchange elicitedfrom first stage

4

48 (mainly cliniciansand clinical managers)

3

2 years,1995–1997

Dawsonet al.,1998

Embedded case studies,two clinical topics ineach of four hospitals

8

256 (clinical staff ofvarious professionsand grades) plus 20informal interviewswith trust and HAmanagers

256 (samegroup asinterviews)

3

2 years,1995–1997

CSAG,1998

Single stage case studydesign, full in sevensites, telephone andquestionnaire only insix

13(7þ6)

250 (front-line cliniciansand managers)

321

1317 GPs 256hospitalclinicians 3

6 months1996–1997

Three stages:Fitzgerald

et al.,1999

1. Overview acrossfour healthauthorities ondiffusion ofinnovation

38 (senior HA managersand GPs)

3

2 years1997–1999

(Table continued)

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Table 1. Continued

DesignNo. of case

studies Face-to-face interviews�Telephoneinterviews�

Writtenquestionnaires

Documentanalysis Dates

2. Overview withsame group,concentrated onparticularinnovations

35

3. Case studies on fourinnovations inprimary care

4

40 (GPs and otherprimary care andphysiotherapy staff)

3

2 years1997–1999

Two stages:Dopson

et al.,1999

1. Initial round ofinterviews half-waythrough project

16

7 (staff from King’sFund and DoH)

51 (project teammembers –managers andclinicians)

3

2 years,1997–1998

2. Second round atend of project,using themeselicited during firststage

122 (project teammembers, othersenior managersand clinicians)

150 (front-lineclinicians)

3

2 years,1997–1998

Lococket al.,1999

Single stage casestudies, after projectcompletion

6

18 (front-line clinicians) 65 (project teammembers, othersenior managersand clinicians,Welsh Officereps)

238 (front-lineclinicians)

3

6 months,1998–1999

Note: All interviews were indepth and semi-structured.

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In order to explore the importance of the ways individuals can influence contextand the active role of context in healthcare change and innovation, we offer twovignettes. We wish to draw attention to a complementary process of interactionfrom within the organization in which organizational actors reach outwards,actively seeking out information from the external environment because italigns and supports their internal interests.

Vignette 1: Services for Heart Failure

In this vignette, local health groups were invited to apply for funding and facili-tation in implementing research-based evidence to improve their chosen area ofclinical practice. Several of the key actors in this case study site had already pin-pointed a need to improve the provision of services for patients with congestiveheart failure, a very serious heart condition that affects up to 10% of elderlypeople and is a large user of NHS resources (nationally greater than £360 m peryear). Research evidence, combined with data about local patients, had suggestedthat a substantial proportion of patients were likely to be receiving inappropriatedrugs. Discussions had already been taking place locally when some of the

Table 2. Original meta analytic themes – ratings of comparative strength and importance

Theme

Dopsonand

Gabbay,1995

Woodet al.,1998

Dawsonet al.1998

CSAGGabbayet al.,1998

Fitzgeraldet al., 1999

Dopsonet al.,1999

Lococket al.,1999

1. Evidence is notsufficient 3 2 3 3 3 3 3

2. Evidence issociallyconstructed 2 3 3 2 3 3 3

3. Evidence isdifferentiallyavailable 2 3 2 3 3 1 2

4. Hierarchies ofevidence exist 3 3 3 3 2 3 3

5. Other sources ofevidence 2 2 3 3 3 2 3

6. The importanceof professionalnetworks 2 3 3 3 3 3 3

7. The role ofprofessionalboundaries 2 3 3 3 3 2 2

8. Context as aninfluence 3 2 3 3 3 3 3

9. The role ofopinion leaders 2 2 3 3 3 3 3

10. The enactmentof evidence 3 3 3 3 3 3 3

Notes: 1. Theme is present; 2. Strong evidence of theme; 3. Very strong evidence of presence.


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protagonists heard about the national initiative and recognized that it gave them anopportunity to obtain help in implementing this already desired change.

Key local opinion leaders in primary care had been arguing for two mainchanges to improve services for people with heart failure locally. The first wasan increase in the prescription of a new type of drug, ACE inhibitors, to replaceinappropriate and often less effective use of the more simple established treatmentwith diuretics. The research evidence for this was very clear and uncontroversial,although the team found when it looked more closely that there was little clarityabout clinically important details such as the dosages required. The secondsuggested change was an increase in direct, open access to a specialist diagnosticprocedure, echocardiography, which research had shown to improve the manage-ment and, therefore, prognosis of patients with this condition.

Local resource constraints (and perhaps some failure to engage the managerssufficiently to persuade them of the need for this service) meant that an adequateechocardiography service was not available locally.

There was no professional defensiveness about the new service that wasbeing suggested nor any argument with the research evidence showing thatACE inhibitors would be superior. Nor, interestingly, was there any significantquestioning about the need for open access echocardiography services, eventhough the evidence that open access was the best form of provision wasslim and could have been easily debated. There were several possible contex-tual reasons why the case for change was so readily accepted. First, the projectwas fronted by a group of highly respected local GPs who had good relationsboth with the Hospital Trust cardiologists and with public health, who werealso closely involved and held in relatively high regard. Having this weightof key opinion leader views behind the scheme, facilitated by their good infor-mal networks, was a potent combination for ensuring the acceptance of the pro-posals that they supported. Secondly, sound clinical leadership was already wellestablished, with good relationships between the acute and primary care sectorsand this gave a strong professional impetus to improve the service. Thirdly, thelocality had developed, in the recent past, some enthusiasm for clinical audit inprimary care, with a degree of involvement by GPs in reviewing their perform-ance against agreed standards. It was, therefore, less difficult to persuade GPsto undertake an audit of the management of heart failure, and this showed theGPs that there was considerable room for improvement in the services for heartfailure. Fourthly, before the project had started, there had been frustration at theinadequacy of the available echocardiography services. Finally, the bid forfunding provided additional resources and attracted support from the pharma-ceutical companies.

By itself, this congruence mainly at the top of the organization might not havebeen enough to spread the new practice among the rank and file clinicians.Crucially, the team from the public health department recently assembled wereexperienced, had the backing of their executives, and had good local networksamong clinicians who respected their views, and were quick to co-opt the localopinion leaders in primary care and hospital cardiology. The team were also stra-tegic thinkers and worked with and through the existing professional structures.There were many alternatives that they might have used – major educational


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events, the development and promulgation of guidelines, or the use of the purchas-ing contracts as a lever for change, for example. But they chose none of these.They recognized the crucial role of the practice managers and practice nurses ingaining entree into the very disparate primary care practices in the vicinity. So,rather than only working directly with GPs, the team used meetings with theseother practice staff members to ‘warm up’ the practices and get them involvedin educational events, so that they could spread the word through the informalcommunication networks within the practices. The team also recognized thatthere was almost no chance of reaching the GPs by sending general advice con-taining information about the evidence for, and benefits of, the new ways of mana-ging heart failure. Such letters needed to be personalized and individually namedto each GP and be clearly identifiable as linked to this well-received project.Written communications needed to be backed up with educational sessions tai-lored to the ways that the practices worked day-to-day and that the education,to have maximum persuasive effect, needed to be delivered by respectedopinion leaders within the existing professional networks.

It was as a result of understanding these complex circumstances that the smallbut skilled team from the public health department, given relatively limited timeand resources, were able to get the proposals known about, accepted, andimplemented. By the end of the two year project, the team were reporting substan-tial shifts in clinical behaviour by the GPs; acceptance of the information pack,reinforced with a well accepted educational programme; funding (eventually)for a new echocardiogram; the establishment of new referral systems; and wide-spread commitment to a continuing audit of the developing service and thedirect engagement of patients through information leaflets and local health groups.

There was a fall in mortality from heart failure, and a substantial fall in readmis-sions to hospital once patients were sent back into the community to be cared forby GPs. They also had good process measures of success. All but a handful ofpractices were signed up to the new service and audit, and more than three quartersof the GPs were using the new referral protocols for echocardiography. The rise ofaround 20% in the prescriptions of ACE inhibitors and a fall of one-third in theprescriptions of some diuretics (despite a continued steady increase in ‘loop’diuretics) also pointed to the success of the project.

This vignette demonstrates that robust evidence alone would not have affecteddiffusion. Change was achieved even though the evidence for one aspect of theproposal was slim. The exercize of local, skilled influence and the process ofdebate were as important as robust evidence. This vignette also underlines howstakeholders may reach out and use characteristics of the context to achievetheir own objectives. Stakeholders made use of targets set by higher tiers andthe incentives and finance available within a government regime to implementimprovements.

Vignette 2: Glue Ear

This second vignette demonstrates the nuanced understanding of the local contextthat is required to engage professional staff in any organizational setting. It con-cerns a project where there was a difference of opinion as to whether it had


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succeeded or not. The project was attempting to persuade ENT surgeons toimplement evidence that suggested they should undertake fewer grommet inser-tions when treating glue ear – a very common problem consequent upon ear infec-tions in children and which can lead to hearing loss. It therefore represents aninteresting example of where innovation requires the suspension of a clinical inter-vention. The three main organizational protagonists in this case were the regionalhealth authority (the strategic body mentoring local trusts and purchasers), the pur-chaser, which was the health authority acting as commissioner of health services,and was largely led in this project by the public health department, and the localbody of consultant ENT surgeons. All three parties were responding to a widelypublicized report, the Effective Health Care Bulletin (EHCB) on glue ear,which was a summary of available research.

The region was developing processes whereby purchasers, as part of their per-formance objectives, could make demands about improving local hospital care. Ascarrots, they offered to fund pilot schemes to explore methods of changing clinicalpractice and used a long history of local meetings and networks in an atmosphereof joint endeavour to invoke friendly competition between purchasers. The stickswere the increasing monitoring of performance, where future financial allocations,not to mention their personal career advancement, depended partly on performingwell in this exercise.

The purchaser in this case study picked a topic that would fit their local agendawith minimum effort and maximum local benefit. They chose grommets becausethis was perceived to be unnecessary clinical intervention, they were also con-cerned about their inability to curb the activities of their surgeons, and they hadpublic health staff who were well placed to work with ENT surgeons. Thepublic health physicians wanted to capitalize on the availability of a newmember of staff, who had enjoyed especially good relations with ENT surgeons,and for career purposes needed to complete some research. This confluence oforganizational and personal motivation and skills led the purchaser to grasp theopportunity to implement research evidence which they believed would reduceunnecessary surgery, saving costs and improving services and health outcomes.

From the purchaser’s viewpoint, as they had no means of direct performancemanagement, they needed to appeal on the one hand, to the surgeons’ pride andcompetitiveness in leading the way in ENT and, on the other hand, to their fearof being seen to allow a high profile project to fail.

The surgeons viewpoint was that they knew about the EHCB because their peergroup nationally regarded it as highly controversial. They felt they might findthemselves being dictated to by poorly informed bureaucrats, and were anxiousto demonstrate that the evidence was seriously misleading. They agreed to takepart in the project and work alongside the local public health physician theyknew and respected. They believed that by doing so, they had the best chanceof showing that the simplistic assumptions made by the EHCB, and then byregion and purchaser were dangerously wrong.

The place of evidence in this initiative was thus deeply embedded in severalstrands of context: a national/ regional desire to introduce an evidence-basedculture; the purchaser’s initial conviction that the evidence demanded fewer grom-mets; the shared view that the evidence needed to be critically examined, and the


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surgeons conviction that rational dialogue would result in their favour. The sur-geons standpoint was to reject the principle of blanket clinical policies, becauseclinical work, they claimed, required individualized judgement based on tacitknowledge that could not be codified. For the region and the purchaser,however, it was equally anathema to allow opaque decision making rules thatallowed unexplained deviations from agreed best practice. The subsequent nego-tiations of acceptable explicit policy partly stemmed from conflicting organiz-ational requirements such as these, and the resulting detailed tussles madevarying demands on the use of evidence.

Over several months, this initial set of conditions involved the purchaser and thesurgeons in a constructive, if tense and detailed, blow by blow negotiation overeach aspect of care.

Whether certain types of evidence were regarded as relevant depended on themotives of the actors considering them, and the negotiations often saw a strugglebetween incompatible sets of requirements. For example, the clinicians wantedevidence on how to safely identify dangerous conditions that might be confusedwith or complicate glue ear, while the EHCB, the region and the purchaserwere seeking evidence that would help to limit unnecessary interventions forstraightforward cases of glue ear. Evidence about costs was another example.The region were very concerned about, and prepared to invest in, ways toreduce costs while improving quality; evidence on costs therefore mattered tothem. Yet when confronted with evidence on costs, the surgeons and purchasers,who were more concerned about improving the processes of clinical care and itsquality, were disinclined to pay it much attention. These different perspectives onthe evidence depended, in part, on the targets which differing parties wereexpected to achieve. Furthermore, because the various stakeholders were attempt-ing to achieve different targets they sought different forms of evidence, none ofwhich was available from the published research, and most of which wascontestable.

For the contextual reasons set out above, both the purchaser and the surgeonswanted the negotiations to succeed and so they sustained their difficult dialogueover several months, each manoeuvring and weaving their way towards makingjoint sense and producing local practice guidelines. From the region’s perspective,the result amounted to a collusion to reject the clear thrust of the EBHC evidencefor excessive grommet insertions. From the local protagonists point of view, thenew evidence-based guidelines were a good result, representing the best way tomake sense of ambiguous and conflicting evidence and to improve local practice.

In reflecting on this vignette, a number of concluding points may be noted. If theevidence is contestable and there are differences between the stakeholders, thenany negotiated solution will take a long time. It can be observed that there isonly one clinical professional group involved in this case, so there are fewer pro-fessional boundary factors here. Nevertheless, the surgeons’ negative views of theinnovation are a critical inhibiting factor. Combined with the contestability of theevidence, this negative factor alone is sufficient to ensure that this innovation doesnot diffuse quickly. Money is seen as an important underpinning factor whichallows resources, in terms of skilled people to be accessed, in order to start offthe initiative. Again, however, money is not the critical factor. We also observe


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the important role played by local knowledge. The exercise of local, skilled influ-ence has been a major factor and contributes to the processes of local debate.

The Building Blocks of a More Sophisticated Notion of Context

Both vignettes demonstrate the complex configuration of healthcare contexts,which plays an integral part in the judgements made by stakeholders. The vign-ettes also demonstrate the complexity of the mediating role of context and theactive role it can play. Our experiences of researching change issues in healthcarecontexts is that it is very dangerous to assume uniform conceptualizations ofcontext. Organizational change has to be understood as contextually specific.We can detect major trends or key influencers, but we have to recognize changeis played out differently in each local context.

In our view there are a number of building blocks that help develop a more soph-isticated and active notion of context. Firstly, we should acknowledge that localcontexts are multidimensional, multifaceted configurations of forces. Forexample, in healthcare settings, the hospital trust is crucially influenced by thearrangements for primary care and social services. Furthermore, no ‘context’ isdiscrete. There are complex connections, interdependencies and interactionsthat individuals often are not aware of that impact on change initiatives. Formalstructures may exist, however the networks of relationships are far morecomplex and actors often have only a very limited understanding of the ways inwhich peoples’ actions are constrained by broader social processes. Forexample in healthcare, the media, the Royal colleges, the Department of Healthand Ministries play a significant role in shaping local action although they arenot actors locally. Studies of change and innovation need to locate local actionsin the wider social context rather than, as often happens, local actions beingseen to involve only those actors who have face-to-face contacts.

Secondly, a more helpful way of viewing context in our view is to conceiveof context as exerting influence through combinations or configurations of factorsat differing levels of organizational analysis, themselves impacted by ‘history’,which together generate consequences, many of which will be unintended. Goldstone(2003) describes the significance of combinations of factors as ‘conjunctural causa-tion’. In complex organizations such as healthcare organizations, no single factor islikely to be responsible for causing an effect. Moreover, more than one combinationof factors may lead to similar outcomes.

A more sophisticated notion of context must also acknowledge the capacity ofindividuals to influence context. Actors perceive and interpret aspects of context indifferent ways. In practice, individuals do not view the facets of context as separ-ate; rather they experience them as a maelstrom, or at least a morass. Individualsseek to make sense of multiple contexts drawing on a mixture of cognitive andemotional judgements to create an ‘integral context’ and it is with this in mindthat action takes place. So perceptions of context are influenced by the motivationsof actors. Individuals may pay attention to an event, a target or a characteristic ofthe context, selectively to achieve a desired end. Our data as presented in the vign-ettes demonstrates that, on some occasions, clinical staff engaged with govern-ment targets and ‘used’ the targets to justify actions. On other occasions, they


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might ignore, downplay or argue against adhering to such targets. The ways inwhich actors construe and interpret their environment is a social act. Collectively,they draw out the social, collective agreement aspect which precedes action theymake sense of their context and thereby create or ‘enact’ (Weick, 1995) thatenvironment which then, in turn, impacts upon the actors’ ability or willingnessto effect change. So it is crucial to understand the form and processes of operationof these social contacts.

Importantly, the micro context should not just be seen as a backcloth to action(as too often portrayed). Local behaviour and context are strongly interlocked –for example, the presence of a clinical product champion is a feature of microcontext but also strongly linked to purposive action (Locock et al., 2001).Actors draw on aspects of local context to legitimate their proposals for action:they draw context in.

In addition to the influence of social and cognitive forces, actors have been andcontinue to be, influenced by the shadow of past periods and historic decisions,which they have inherited. This aspect of the creation and development ofcontext has been under-researched but, in our data, it has been demonstrated tobe critical and crucially needs to inform a more sophisticated notion of context.‘History’ may help to explain the differentiation and the variations betweenhealthcare units of organization which are nominally performing the same tasksin the same circumstances.

Conceptually, there unfolds from this analysis a view of the interrelationshipsbetween the actors and the characteristics of the context. The emerging picturedoes not display a set of multiple, linear two-way relationships. Considering theconfigurations of characteristics and the selective perceptions of actors, developedover time through debate and confirmation with colleagues, we can perceive aseries of loops. The analogy might be of a swirling tornado, building force to avortex and then hitting the ground for action.

This conceptualization of the interrelationships between context and actorsmight be seen as a form of path dependency theory, but related to micro processes.Theorists such as Thelan (2003) and Poole et al. (2003) argue the flow of eventsand outcomes are influenced by initial conditions and critical events. Theyacknowledge the influence of actors in reinforcing the flow of events if thepathway is perceived to be beneficial. Here we illuminate the importance ofmicro processes. We delineate both the characteristics of context which mayform the most common initial conditions for positive diffusion processes andwe illustrate the ways in which actors interpret these conditions.

Conclusion

In this article, we aim to contribute to an improved understanding of the role ofcontext in healthcare change and innovation. We argue on the basis of significantempirical evidence that it is possible to offer a more nuanced view of the mech-anisms involved, and the processes leading to action, extending beyond listingthe key elements of context influencing change. It is apparent that combinationsof positive characteristics account for the diffusion and successful uptake of inno-vations. Thus, one can argue that it is the cumulative effect of a conjunction of


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factors which leads to diffusion and adoption processes. This line of thinking shiftsattention from a view of local context as the ‘external’ influences acting onto anorganization and also underlines the temporal elements of the processes. Accumu-lation involves the gradual build-up of pressures, and the combined impact of aconjunction of factors from different organizational sources to generate anoutcome. Identifying the key factors does not enable one to predict because thefactors may form into different combinations in various organizational units,but it facilitates action to be taken on the basis of probabilities.

However, the core contribution to re-conceptualizing context we seek to make isto suggest that context is an active component in the processes of change and inno-vation. We have suggested in this article that context should not be seen as a back-cloth to action but as an interacting element in the diffusion process. These dataconfirm and develop the view put forward by Fitzgerald et al. (2002) and othersthat context needs to be better integrated into the analysis of change and inno-vation processes. Configuration and structuration theories highlight the interplaybetween structure and process; however they do not acknowledge the role ofhuman action as fully as is needed. Our data raises the need to address this chal-lenge for it indicates that health professionals do not simply apply abstract, disem-bodied scientific research rigidly to the situation around them. Instead theycollaborate in discussion, select, and engage in work practices which activelyinterpret and (re)construct its local validity and usefulness. That activity israrely carried out by individuals in isolation and often includes the redefinitionof the context within which the practitioners will assess the evidence.

What are the policy implications of our argument? It is an uncontroversialobservation that the response to innovation or change depends fundamentallyon the context in which it sits. While there were no laws about what constituteda receptive context, our large-scale comparative database enables us to tease outa cluster of commonly found features of receptivity:

. The availability and engagement of local, credible and skilled opinion leaders.

. The presence of a foundation of sound or good inter-professional relationships.

. The structural characteristics of the locations and configuration of the variousorganizational components.

. The support of senior management, although this may be at a distance.

. Project and change management skills available.

These features of contextual receptivity mix indicators of structure and process(structural features included the degree of system complexity and level ofvolume of clinical work; more processional indicators included the historicaldevelopment of services and a foundation of good prior relationships), withsome features of action (credible opinion leaders; presence of change managementand project management skills, support from senior management). Just as there areno magic bullets, equally there are no magic contexts. Those planning and mana-ging change need to interrogate contexts as carefully as interventions areinterrogated.

The vignettes on EBHC also make it clear that social structure still matters aswell as action, and they suggest that powerful and skilful senior leadership can


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make a difference in helping to reshape or develop local contexts. Legitimateauthority in healthcare organizations will often be more sapientially and profes-sionally based, than power and management led. This calls for the exercise of ‘softleadership’ from well placed clinicians. More thought needs to given to thedefinition and identification of clinical opinion leaders by senior management,as well as ensuring their effective engagement in leading change.

Dopson and Mark (2003) take an overview of current issues in leadershipresearch in healthcare organizations. We know that leadership is more likely tobe effective where: (i) it is distributed throughout the organization; (ii) issues ofprofessional power are understood; (iii) the complex social relationships foundin healthcare organizations are acknowledged and discussed; (iv) efforts aremade to harness talent from all the quarters; and (v) the contribution of differentperspectives is valued and utilized. This is essentially a pluralist view of leader-ship in healthcare. The effectiveness of a collective leadership in introducingchange in healthcare is reinforced by research by Denis et al. (1996). Withinthe pluralist view, however, the power of the professional subsystem clearlyremains considerable and needs to be handled explicitly – especially throughclinical leaders who also retain credibility in the management domain. We con-clude that the development of clinical leaders to support EBHC is a key areafor policy and, indeed, research in the future.

We need to consider the possible mechanism for moving evidence and newworking practises more effectively across the social and cognitive boundariesidentified. In many cases, appropriate flora for identifying, debating and sharingsuch knowledge are either totally lacking or, at the very least, poorly integratedinto clinical or organizational decision making. A foundation of well-developedprofessional and even more importantly, inter professional flora which generatesengagement and high attendance levels (as opposed to the operation of papermachinery which is unable to engage in healthcare workers), was needed forthe effective debate and processing of knowledge within and across healthcareprofessionals. Such foundations were built up over time, but represent criticaladvantages for the most promising sites.

Sometimes bridging or facilitation roles could be helpful in reducing the time-scale for shared learning and changing the negative perceptions that sometimesbuilt up between different professional groups. At the strategic level, senior man-agement or clinical opinion leaders can play a creative role in designing richerorganizational settings which display the key features of receptivity. Groups ofsenior managers, both clinical and general managers could also model collectiveprocesses of sharing.

References

Berger, P.L. and Luckman, T. (1966) The Social Construction of Reality. A Treatise in the Sociology of

Knowledge (London: The Penguin Press).

Burns, T. and Stalker, G.M. (1961) The Management of Innovation (London: Tavistock Publications).

Burrell, G. (1994) Modernism, post modernism and organisational analysis, Organisational Studies, 15(1).

Dawson, S., Sutherland, K., Dopson, S., Miller, R. and Law, S. (1998) The Relationship between R&D and Clini-

cal Practice in Primary and Secondary Care: Cases of Adult Asthma and Glue Ear in Children: Final


Dow

nloa

ded

by [

The

Uni

vers

ity o

f M

anch

este

r L

ibra

ry]

at 0

3:31

12

Oct

ober

201

4

Report. Judge Institute of Management Studies. University of Cambridge and Saıd Business School, Univer-

sity of Oxford.

Denis, J.L., Langley, A. and Cazale, L. (1996) Leadership and strategic change under ambiguity, Organisational

Studies, 17(1), pp. 673–699.

Dimaggio, P.J. and Powell, W.W. (1983) The iron cage revisited: institutional isomorphism and collective ration-

ality in organizational fields, American Sociological Review, 48(April), pp. 147–160.

Dopson, S. (2005) The diffusion of medical innovations: can figurational sociology contribute? Organizational

Studies, 26(8), pp. 1125–1144.

Dopson, S. and Fitzgerald, L. (2005) Knowledge to Action? Evidence Based Health Care in Context (Oxford: OUP).

Dopson, S. and Gabbay, J. (1995) Evaluation of the National Initiative Getting Research into Practice and Policy.

(Oxford: Oxford Region, Department of Health).

Dopson, S., Gabbay, J., Locock, L. and Chambers, D. (1999) Evaluation of the PACE Programme: Final Report.

Templeton College, University of Oxford and Wessex Institute for Health Research and Development, Uni-

versity of Southampton.

Dopson, S. and Mark, A. (eds) (2003) Leading Healthcare Organisations (Basingstoke: Palgrave Macmillan).

Elias, N. (1977) What is Sociology? (London: Hutchinson).

Elias, N. (1987) Involvement and Detachment (Oxford: Basil Blackwell).

Fitzgerald, L., Hawkins, C. and Ferlie, E. (1999) Achieving Change Within Primary Care: Final Report (Univer-

sity of Warwick: CCSC).

Fitzgerald, L., Ferlie, E., Wood, M. and Hawkins, C. (2002) Interlocking interactions: the diffusion of innovations

in health care, Human Relations, 55(12), pp. 1429–1449.

Giddens, A. (1984) The Constitution of Society: Outline of the Theory of Structuration (Cambridge: Polity).

Goldstone, J.A. (2003) Comparative historical analysis and knowledge accumulation in the study of revolutions,

in: J. Mahoney and D. Rueschemeyer (eds) Comparative Historical Analysis in the Social Sciences,

pp. 41–90 (Cambridge: Cambridge University Press).

Hannan, M.T. and Freeman, J. (1989) Organizational Ecology (Cambridge, MA: Harvard University Press).

Harrison, S., Hunter, D., Marnoch, G. and Pollit, C. (1992) Just Managing: Power and Culture of NHS (London:

Macmillan).

Iles, V. and Sutherland, K. (2001) Organisational Change. A Review for Health Care Mangers, Professionals and

Researches (London: London of School of Hygiene).

Latour, B. (1987) Science in Action (Cambridge, MA: Harvard University Press).

Lave, J.C. and Wenger, E. (1991) Situated Learning: Legitimate Peripheral Participation (New York: Cambridge

University Press).

Locock, L., Chambers, D., Surender, R., Dopson, S. and Gabbay, J. (1999) Evaluation of the Welsh Clinical Effec-

tiveness Initiative National Demonstration Projects: Final Report. Templeton College Oxford and the

Wessex Institute for Health Research and Development, University of Southampton.

Locock, L., Dopson, S., Chambers, D. and Gabbay, J. (2001) Understanding the role of opinion leaders in improv-

ing clinical effectiveness, Social Science and Medicine, 53(6), pp. 745–757.

McNulty, T. and Ferlie, E. (2002) Reengineering Health Care: The Complexities of Organizational Transform-

ation (Oxford: Oxford University Press).

Meyer, A.D., Tsui, A.S. and Hinings, C.R. (1993) Configurational approaches to organizational analysis,

Academy of Management Journal, 36(6), pp. 1175–1195.

Pettigrew, A.M. (1985) The Awakening Giant: Continuity and Change imperial Chemical Industries (Oxford:

Basil Blackwell).

Pettigrew, A.M. (1987) Context and action in the transformation of the firm, Journal of Management Studies,

24(6), pp. 649–670.

Pettigrew, A.M., Ferlie, E. and McKee, L. (1992) Shaping Strategic Change: Making Change in Large Organ-

izations: The Case of the National Health Service (London: Sage).

Poole, M.S., Van de Ven, A.H., Dooley, K. and Holmes, M.E. (2003) Organizational Change and Innovation

Processes: Theory and Methods for Research (Oxford and New York: Oxford University Press).

Rogers, E. (1995) The Diffusion of Innovations, 4th edn (New York: Free Press).

Stewart, R., Smith, P., Blake, J. and Wingate, P. (1980) The District Administrator in the NHS, London (London:

King Edwards Hospital Fund).

Thelan, K. (2003) How institutions evolve: insights from comparative historical analysis, in: J. Mahoney and

D. Rueschemeyer (eds) Comparative Historical Analysis in the Social Sciences, pp. 208–240 (Cambridge:

Cambridge University Press).


Dow

nloa

ded

by [

The

Uni

vers

ity o

f M

anch

este

r L

ibra

ry]

at 0

3:31

12

Oct

ober

201

4

Weick, K. (1969) The Social Psychology of Organizing (Reading, MA: Addison-Wesley Pub. Co).

Weick, K. (1995) Sensemaking in Organizations (London: Sage).

West, E., Barron, D.N., Dowsett, J. and Newton, J.N. (1999) Hierarchies and cheques in the social networks of

health care professionals. Implications for the design of dissemination strategies, Social Science and Medi-

cine, 48(5), pp. 633–646.

Wood, M., Ferlie, E. and Fitzgerald, L. (1998) Achieving Change in Clinical Practice: Scientific, Organizational

and Behavioural Processes (University of Warwick: CCSC).

Woodward, J. (1965) Industrial Organization (Oxford: Oxford University Press).

Yin, R. (1999) Enhancing the quality of case studies in health services research, Health Services Research, 34(5),

pp. 1209–1224.

Notes on Contributors

Sue Dopson is Rhodes reader in Organizational Behaviour at Said BusinessSchool, University of Oxford. She has published several books and articles onchanges in the management of the NHS, the changing nature of middle manage-ment, management careers and developments in public sector management. She isinvolved in the development of courses for the NHS and a number of research pro-jects exploring the role of networks in healthcare and the impact and role ofsupport workers in the NHS.

Louise Fitzgerald is Professor of Organization Development, Department ofHRM, Leicester Business School, De Montfort University. Her research centreson the management of change in the professional organizations and she is cur-rently working on a major empirical project on organizational networks. Shehas published in a range of journals, such as Academy of Management Reviewand Human Relations, and has co-authored several books including Knowledgeto Action? Evidence Based Health Care in Context (2005) and The Sustainabilityand Spread of Organizational Change, Modernizing Health Care (2007). She haspreviously worked at City University; Warwick University and SalfordUniversity.

Ewan Ferlie (MA Oxon., MSc, PhD) is Professor of Public Services Manage-ment; Director of the Centre for Public Services Organizations and Head of theSchool of Management at Royal Holloway, University of London. He previouslyworked at the Universities of Kent and Warwick and Imperial College. He haspublished widely on aspects of organizational change and restructuring in publicservices, including healthcare in referred journals. He is also co-author of NewPublic Management in Action (OUP, 1996) and Oxford Handbook of Public Man-agement (OUP, 2005). He has also been a non-executive of Warwickshire HealthAuthority.


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