Managing management innovations: Contextual complexity and the pursuit of improvements in healthcare
Doctoral thesis, 2022
In a context characterised by complexity and conflicting demands, healthcare managers at a meso-level struggle to pursue improvements in the quality and efficiency of care operations. An influential approach on how to pursue improvements is quality management (QM). QM adopts the view that systems are centred around a common aim and should be appreciated and managed to reduce undesired variation and improve performance incrementally. Nuancing this view, complexity science propels the idea of healthcare as a complex adaptive system (CAS), which refutes prediction and managerial control of development. As one component of the CAS of healthcare, various management innovations (MIs) provide suggestions on how to achieve improvements. However, achieving any improvement is not often as simple as portrayed and MIs can rarely be fully and exclusively applied in practice.
Starting from the practical issue of how to achieve improvements in healthcare, this thesis seeks to explore how healthcare managers at a meso-level can understand and use MIs to handle complexity and achieve improvements. A qualitative and action research-inspired approach is adopted to investigate this issue, concentrating on the context of psychiatric care at the Sahlgrenska University Hospital in Gothenburg, Sweden.
Four studies, resulting in five appended papers, are presented. By investigating contemporary MIs, the studies contribute to an improved understanding of how MIs can be used, and complexity handled, in the pursuit of improvements. Study 1 starts by exploring the concept of value at a time when lean was succeeded by value-based healthcare (VBHC) as the MI in fashion in the context and the study follows the implementation of VBHC in an action research-inspired approach. Study 2 tests the utility of the value configurations framework to handle conflicting logics and pursue improvements in psychosis care. In study 3, literature on network configurations in different healthcare contexts is reviewed. Lastly, study 4 is an action research study focusing on contextualisation of learning health systems (LHS) as yet an example of an MI in healthcare.
Based on the findings of five appended papers and earlier literature from the fields of QM, complexity science, and MIs, a model is developed that points to the centrality and utility of logics to connect MIs and other system components to improve the understanding of both MIs and CASs. By investigating the logics underlying different MIs, actors in the healthcare system (e.g., politicians, physicians, and managers), and technical features of care (e.g., its predictability and inclination to standardised treatments), a relative appreciation of a CAS can be pursued, which can guide managers in how to use MIs and attract change that can lead to improvements. Furthermore, the thesis supports the view that MIs are often ambiguous concepts that can be translated and adapted to fit a local context in a process of contextualisation. For scholars, the thesis also contributes by integrating the perspectives of QM and complexity science, and of QM and MIs in general, as two parallel approaches to pursue improvements in healthcare.
Starting from the practical issue of how to achieve improvements in healthcare, this thesis seeks to explore how healthcare managers at a meso-level can understand and use MIs to handle complexity and achieve improvements. A qualitative and action research-inspired approach is adopted to investigate this issue, concentrating on the context of psychiatric care at the Sahlgrenska University Hospital in Gothenburg, Sweden.
Four studies, resulting in five appended papers, are presented. By investigating contemporary MIs, the studies contribute to an improved understanding of how MIs can be used, and complexity handled, in the pursuit of improvements. Study 1 starts by exploring the concept of value at a time when lean was succeeded by value-based healthcare (VBHC) as the MI in fashion in the context and the study follows the implementation of VBHC in an action research-inspired approach. Study 2 tests the utility of the value configurations framework to handle conflicting logics and pursue improvements in psychosis care. In study 3, literature on network configurations in different healthcare contexts is reviewed. Lastly, study 4 is an action research study focusing on contextualisation of learning health systems (LHS) as yet an example of an MI in healthcare.
Based on the findings of five appended papers and earlier literature from the fields of QM, complexity science, and MIs, a model is developed that points to the centrality and utility of logics to connect MIs and other system components to improve the understanding of both MIs and CASs. By investigating the logics underlying different MIs, actors in the healthcare system (e.g., politicians, physicians, and managers), and technical features of care (e.g., its predictability and inclination to standardised treatments), a relative appreciation of a CAS can be pursued, which can guide managers in how to use MIs and attract change that can lead to improvements. Furthermore, the thesis supports the view that MIs are often ambiguous concepts that can be translated and adapted to fit a local context in a process of contextualisation. For scholars, the thesis also contributes by integrating the perspectives of QM and complexity science, and of QM and MIs in general, as two parallel approaches to pursue improvements in healthcare.
complexity
action research
quality management
value-based health care
learning health systems
healthcare management
logics
psychiatry
quality improvement
management innovations
value configurations
Vasa B, Vera Sandbergs Allé 8
Opponent: Professor Julie Reed, Halmstad University, Sweden / United Kingdom
Author
Christian Colldén
Chalmers, Technology Management and Economics, Service Management and Logistics
From “Invented here” to “Use it everywhere!”: A Learning health system from bottom and/or top?
Learning Health Systems,;Vol. In Press(2022)
Journal article
Value-based healthcare translated: A complementary view of implementation
BMC Health Services Research,;Vol. 18(2018)
Journal article
Value configurations for balancing standardization and customization in chronic care: a qualitative study
BMC Health Services Research,;Vol. 21(2021)
Journal article
A Value-Based Taxonomy of Improvement Approaches in Healthcare
Journal of Health, Organisation and Management,;Vol. 31(2017)p. 445-458
Journal article
Colldén, C; Gremyr, I; Schirone, M; Hjalmarsson, Y; Hellström, A. Networks for healthcare delivery: A systematic literature review
“Bend over, here it comes again!” Det sägs ibland vara inställningen bland många inom vården när de nås av nya managementinnovationer. Lean, Six Sigma och Värdebaserad vård är några exempel på managementinnovationer som har varit på modet inom hälso- och sjukvården under de senaste decennierna, men som har lett till varierande (ofta mycket begränsade) resultat. Vården är en mycket komplex kontext med många skilda krav och aktörer, vilket gör utvecklingen svår att styra för chefer och politiker. Men vården är samtidigt en sektor i desperat behov av förbättringar i kvalitet och effektivitet för att möta ökande behov. Så hur kan löftena från managementinnovationer förverkligas? Hur kan förbättringar uppnås? Kan denna gordiska knut lösas?
Mitt i denna komplexa kontext kämpar chefer på organisatorisk mellannivå i vården med att inte bara upprätthålla verksamheten, utan att också förbättra den. Avhandlingen undersöker hur dessa chefer trots vårdsystemets komplexitet kan driva förbättringsarbete – med eller utan hjälp av managementinnovationer. Resultaten visar att chefer snarare bör försöka översätta managementinnovationer än att implementera dem för att de ska matcha behoven i den lokala kontexten. Det innebär att managementinnovationer bör hanteras ”vanvördigt”, så att delar av dem kan brytas ut, anpassas och kombineras med andra koncept. Som en grund för att genomföra översättningar kan chefer i vården identifiera de underliggande logikerna (idéer om roller, mål och arbetssätt kopplade till hur en organisation uppnår sitt syfte) hos olika managementinnovationer och aktörer i den lokala kontexten. På så sätt kan man som chef skapa sig en (om än begränsad) bild av det komplexa system man befinner sig i, som i sin tur kan utnyttjas för att översätta managementinnovationer och attrahera de förändringar man önskar.
Avhandlingens slutsats är att nya managementinnovationer inte är några snabba genvägar till förbättringar i vården, men att ducka för utifrån kommande idéer och koncept inte heller är någon framgångsrik inställning. I stället kan strävan efter förbättringar ses som ett hantverk. För att behärska detta hantverk bör vårdens chefer skapa sig en holistisk uppfattning av det system de agerar i och försöka göra de önskade förändringarna attraktiva och logiska för medarbetare och andra aktörer i vårdsystemet.
Mitt i denna komplexa kontext kämpar chefer på organisatorisk mellannivå i vården med att inte bara upprätthålla verksamheten, utan att också förbättra den. Avhandlingen undersöker hur dessa chefer trots vårdsystemets komplexitet kan driva förbättringsarbete – med eller utan hjälp av managementinnovationer. Resultaten visar att chefer snarare bör försöka översätta managementinnovationer än att implementera dem för att de ska matcha behoven i den lokala kontexten. Det innebär att managementinnovationer bör hanteras ”vanvördigt”, så att delar av dem kan brytas ut, anpassas och kombineras med andra koncept. Som en grund för att genomföra översättningar kan chefer i vården identifiera de underliggande logikerna (idéer om roller, mål och arbetssätt kopplade till hur en organisation uppnår sitt syfte) hos olika managementinnovationer och aktörer i den lokala kontexten. På så sätt kan man som chef skapa sig en (om än begränsad) bild av det komplexa system man befinner sig i, som i sin tur kan utnyttjas för att översätta managementinnovationer och attrahera de förändringar man önskar.
Avhandlingens slutsats är att nya managementinnovationer inte är några snabba genvägar till förbättringar i vården, men att ducka för utifrån kommande idéer och koncept inte heller är någon framgångsrik inställning. I stället kan strävan efter förbättringar ses som ett hantverk. För att behärska detta hantverk bör vårdens chefer skapa sig en holistisk uppfattning av det system de agerar i och försöka göra de önskade förändringarna attraktiva och logiska för medarbetare och andra aktörer i vårdsystemet.
“Bend over, here it comes again!” It is a poorly kept secret that managers and professionals in healthcare does not always embrace new management innovations. Lean, Six Sigma, and Value-based healthcare are a few examples of management innovations that has been promoted within healthcare during the last decades, but that have shown varying (often poor) results. Healthcare is a characterised by vast complexity and many conflicting demands, which makes development difficult to control from a managerial or political perspective. But healthcare is also a business in desperate need of improvements in quality and efficiency to meet increasing demands. So, how can the promises of management innovations ever be realised? How can improvements be achieved? Can this Gordian knot be cut?
Situated in the middle of this complex context, managers at an organisational meso-level struggle to not only maintain the care operations, but to improve them. This thesis investigates how these managers can pursue improvements with – or without – the use of management innovations, despite the complexity of healthcare systems. It suggests that rather than implementing management innovations, managers can translate these concepts to fit the needs of their local contexts. Thus, elements of management innovations can disrespectfully be omitted, adapted, or combined with other concepts. As a foundation for successful translations, managers can identify what logics (i.e., dominant ways of thinking about the roles, goals, and practices connected to how an organisation achieves its aims) that underpins different management innovations and actors in the local context. In that way, managers can achieve an appreciation of their complex systems, which can be used to translate management innovations and attract desired change.
Hence, this thesis suggests that new management innovations are no shortcuts to improvements, but neither is bending over to avoid external suggestions a productive approach. Instead, the pursuit of improvements can be seen as a craft. To master this craft, healthcare managers are advised to holistically appreciate the larger system that they act in and try to make the desired change attractive to the actors in the system.
Situated in the middle of this complex context, managers at an organisational meso-level struggle to not only maintain the care operations, but to improve them. This thesis investigates how these managers can pursue improvements with – or without – the use of management innovations, despite the complexity of healthcare systems. It suggests that rather than implementing management innovations, managers can translate these concepts to fit the needs of their local contexts. Thus, elements of management innovations can disrespectfully be omitted, adapted, or combined with other concepts. As a foundation for successful translations, managers can identify what logics (i.e., dominant ways of thinking about the roles, goals, and practices connected to how an organisation achieves its aims) that underpins different management innovations and actors in the local context. In that way, managers can achieve an appreciation of their complex systems, which can be used to translate management innovations and attract desired change.
Hence, this thesis suggests that new management innovations are no shortcuts to improvements, but neither is bending over to avoid external suggestions a productive approach. Instead, the pursuit of improvements can be seen as a craft. To master this craft, healthcare managers are advised to holistically appreciate the larger system that they act in and try to make the desired change attractive to the actors in the system.
Subject Categories
Health Care Service and Management, Health Policy and Services and Health Economy
Driving Forces
Sustainable development
Areas of Advance
Health Engineering
ISBN
978-91-7905-679-7
Doktorsavhandlingar vid Chalmers tekniska högskola. Ny serie: 5145
Publisher
Chalmers
Vasa B, Vera Sandbergs Allé 8
Opponent: Professor Julie Reed, Halmstad University, Sweden / United Kingdom