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Factors that shape the development of interprofessional improvement initiatives in health organisations
  1. David Greenfield,
  2. Peter Nugus,
  3. Joanne Travaglia,
  4. Jeffrey Braithwaite
  1. Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, Australia
  1. Correspondence to Dr David Greenfield, Australian Institute of Health Innovation, University of New South Wales, Sydney 2052, Australia; d.greenfield{at}unsw.edu.au

Abstract

Background Quality and safety improvement programmes advance the standard of care delivered by health organisations but have been shown to be less effective than anticipated. Implementing improvement programmes require a greater understanding of the impact of the social context and strategies that engage staff.

Objective To investigate factors that shaped the development of interprofessional improvement initiatives in a health organisation.

Methods Data are drawn from a large-scale longitudinal action research study examining interprofessional learning and practice. The setting is an autonomous bounded health jurisdiction in Australia. Within the study, health professionals have conceptualised more than 111 interprofessional improvement projects, of which 76 have evolved into ongoing activities. Textual data were analysed using emergent coding and descriptive statistics.

Results Initiatives were shaped by six determinants: site receptivity; team issues; leadership; impact on healthcare relations; impact on quality and safety issues; and extent to which the projects became institutionally embedded. Initiatives that engaged participants and progressed were characterised by and displayed flexible leadership, and ongoing refinement and maturity over time. The local organisational context and initiatives coevolved.

Conclusions Improvement initiatives are necessary for improved quality of care and patient safety but are difficult to implement and sustain. The factors identified to develop them are constantly under challenge in health services. Improving healthcare quality will, in part, depend upon the ability to provide more flexible and supportive social contexts.

  • Quality improvement
  • interprofessional learning
  • interprofessional practice
  • quality and safety
  • collaborative
  • healthcare quality
  • healthcare quality improvement
  • qualitative research

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Introduction

In order to address recognised deficits in safety and quality in healthcare, there is the need for continuous improvement projects and programmes.1–5 Organisations, services and professionals are called upon to demonstrate efforts to improve and develop. This requirement is institutionalised through accreditation, improvement projects, educational seminars and professional development activities. Quality improvement in health organisations is most effectively achieved by combining the skills of both managers6 and frontline clinicians.7 We know that engaging and maintaining the focus of staff at any level on improvement initiatives is challenging.8–10 Quality-improvement programmes have been shown to enhance organisational performance.11 12 However, their limitations have been recognised.13–15 Investigations into programmes have shifted focus from appreciating how improvement initiatives manifest to investigating the determinants of their effectiveness.15–17 Greater understanding of the impact of the social context,18 19 that is, the interpersonal, team and organisational factors, and strategies that engage staff,20 are essential to further endeavours to implement practice changes successfully. Taking up this challenge, the aim of this research was to investigate which factors shaped the development of interprofessional improvement initiatives in a health organisation.

Methods

Setting

Evidence to accomplish the aim is drawn from a large-scale longitudinal study seeking to improve interprofessional practice (IPP) through increased interprofessional learning (IPL).21 22 The setting is a politically autonomous jurisdiction providing healthcare to a population of nearly 500 000 people, encompassing three domains: a health service, incorporating 5000 managers, clinicians and policymakers; some 400 health academics in university settings; and 71 professional associations with an estimated 300 staff. A purpose-designed study protocol22 and research tool21 to engage participants have been developed for the longitudinal study. As detailed in the protocol, the longitudinal study is seeking to achieve improvements in communication, collaboration, professional relationships, team work and the integration of services.22 The partners are using action research to drive a process of collaborative enquiry.23 That is, ideas from the literature were integrated into a research tool21 that was used with participants to stimulate examination of their individual or collaborative learning and practice behaviours, and improve them.24

Data and analysis

The university research team and health service participants have used action research to stimulate IPL and IPP change conversations25 across physical, professional and service boundaries. Over a 2-year period from 2008 to 2010, participants conceptualised more than 111 interprofessional improvement projects; examples of proposed projects are listed in table 1. As projects emerged, the researchers collected data comprising ethnographic field notes of discussions, meetings and activities about the improvement projects. In mid-2010, three researchers collated and, using emergent coding, thematically analysed26 27 the ethnographic data relating to the 111 initiatives to identify factors that promoted or inhibited their development. Descriptive statistics about the initiatives were developed. Independently, the researchers reviewed the data to identify potential coding categories. They met to refine and determine a common set of codes, and then used the agreed codes to analyse the data. The researchers then regrouped to discuss and synthesise their results. The analysis determined that six categories of factors, with associated subcategories, shaped the progress of the interprofessional improvement initiatives. Activities were noted as having made ‘positive progress’ if the participating health professionals reported they achieved their self-defined aim, and those that had not were recorded as ‘limited progress.’

Table 1

Example list of proposed initiatives

Results

Outcomes of the initiatives

Analysis of the 111 proposed initiatives showed that 76 developed into ongoing activities, and 35 did not progress beyond an initial proposal or discussion (see figure 1). Scrutiny of the initiatives' progress with respect to the three domains in the study setting revealed significant variations (see table 2). A very small minority, four initiatives, were at the boundary between the health organisation and university domains; no progress was achieved in a majority (three) of these. The overwhelming majority of initiatives, that is 88, were sponsored by and conducted within the health service. They were spread across acute services, subacute services, community health and mental health settings, and a number spanned multiple divisions. Progress was achieved in a majority of cases. The exception was community health, where as many initiatives achieved progress as did not. Similarly, a greater proportion of the 14 initiatives conducted in the university domain made progress. By contrast, only one of the five initiatives within the domain of professional associations made progress.

Figure 1

Breakdown of the outcomes of proposed initiatives.

Table 2

Breakdown of the initiatives progress across the study domains

Analysis of factors associated with the initiatives development

Our analysis concluded that development of the initiatives was shaped by six determinants: site receptivity; team issues; leadership; impact on healthcare relations; impact on quality and safety issues; and extent to which the projects became institutionally embedded. There are up to six subcategories associated with each determinant (table 3).

Table 3

Determinants that shaped the interprofessional initiatives

Together, the six determinants shaped the extent to which, or if at all, progress in quality of care and interprofessional practice was achieved. The six determinants are summarised as follows.

Site receptivity

The site receptivity refers to the context within which initiatives are situated. The organisational commitment to the IPL–IPP project established a working environment which encouraged identification and development of initiatives. The health organisation, through the Chief Executive's endorsement, executive sponsor and a project officer, was an active collaborative partner in the IPL–IPP action research project. The organisational commitment was displayed by the development and implementation of an IPL–IPP policy, which is believed to be an international first for a public health service.

Team issues

Team issues are about the amenability of local contexts to progress or hinder initiatives. Individual and teams collective responses shaped if and then how initiatives developed. The organisational environment being receptive was insufficient in itself to generate or sustain activities. In a majority of teams, there was the preparedness to attempt proposed ideas. However, as noted, for one-third the willingness was not apparent—conflicts, ambivalence and waning interest over time, and competing work demands were cited by participants, and discerned by the researchers in field observations, as reasons for not proceeding.

Leadership

Within a local context, the evolution of an initiative was shaped by the presence and ability of a leader or a ‘champion’ for an idea. Successful leadership was characterised by enthusiasm, persistence, the ability to overcome resistance and prosecute an initial idea over time through engaging the support and involvement of colleagues; such leaders remained positive, facilitating collaborative discussions that evolved and revised original proposals. People who were able to specify concrete aims for initiatives, using terms that resonated with professional and organisational concerns of their colleagues, were more effective at progressing their ideas into ongoing projects.

Impact on healthcare relations

Healthcare relations is a term coined to encompass collaboration, teamwork, communication, trust, morale and integration of learning opportunities. There is a self-reinforcing effect from healthcare relations; positive relations encourage further improvements, and poor relations promote distrust. Initiatives that received team support, built momentum and progressed were those that were reported to improve healthcare relations.

Impact on quality and safety issues

The progress of an initiative was influenced by its association to organisational quality and safety activities. Initiatives that were couched as responding to quality and safety issues were more likely to gain support and achieve progress than those that did not. Two-thirds of initiatives that were recognised as impacting on these issues made positive progress.

Institutionally embedded

Institutionally embedded activities were those that were recognised by the organisation in an ongoing way. That is, they were conferred an additional form of organisational legitimisation. A small minority of initiatives became classified as role responsibilities or quality improvement projects for individuals or teams. Most, but not all, achieved positive progress.

Discussion

This study has shown that the development of interprofessional improvement activities is shaped by six determinants: site receptivity; team issues; leadership; impact on healthcare relations; impact on quality and safety issues; and being institutionally embedded. Site receptivity along with team issues referred to how amenable the broad and local settings were to proposals. Positive leadership, particularly through sponsorship, added to the acceptance and actioning of the project. If an initiative positively affected healthcare relations or quality improvement activities, it was more likely to succeed. Additionally, becoming embedded institutionally provided a further level of legitimisation that promoted progress. Improvement activities that displayed multiple determinants received an accumulative congruence that helped promote and sustain their development.

Even in an environment positively orientated to achieving change in IPP, only half of the initiatives achieved positive progress. Engaging health professionals to improve patient care is a significant challenge; this reflects experience from other studies.4 8 10 18 Nevertheless, the determinants provide practical strategies to engage staff and achieve progress. Both of these have been identified as important lessons for healthcare organisations.15 17 Flexibility is required by those leading improvement projects. It appears to promote and sustain participation.16 Ideas need to be matured into ongoing projects. In a majority of cases, the original idea proposed by an individual changed and evolved through the participation of their colleagues. The collaborative development process contributed to the sustainability of initiatives.16 Furthermore, the refinement process takes time.10 This was the norm for those initiatives that made positive progress. Initiatives were actively sustained when reinforced through connecting to other organisational priorities. Multiple sources of legitimacy encouraged and institutionalised ongoing actions.

The findings demonstrate that depending upon other factors, when health staff perceive projects are relevant to their immediate work they are more likely to participate to make improvements. The lesson is reinforced by considering the initiatives where progress was limited or not achieved. Activities more removed from the immediate work context, for example concerning issues at the intersection of the health organisation and university domains, or university or professional association domains, struggled to make progress.10 Overall, in a study site with the characteristics of a complex adaptive system,28 local social contexts and initiatives coevolved and were self-reinforcing. The context determined to a considerable degree whether an initiative thrived or did not evolve, and the emergence, or not, of an initiative evolved the context within which it is located. In positive contexts, initiatives progressed, and in negative ones they had difficulty doing so.

The importance of the determinants can be explained by a combination of three theories: community of practice,29 distributed leadership30 and collaborative power.31 The theory of communities of practice highlights the fusing of individual, team and organisational priorities to drive improvements. Distributed leadership theory argues that change is achieved by actively engaging people at all levels within an organisation. Collaborative power complements these two ideas by emphasising how local settings shape participation, promoting inclusion and mutual negotiation of care arrangements. Taken together, the three theories offer an insight into the significance of the determinants for progressing improvement initiatives.

Limitations and strengths

The defining characteristics of this study are its limitations and strengths.18 The study is unique. It is a large-scale longitudinal investigation, using action research to investigate IPL and IPP in and across multiple agencies. That the factors identified are drawn from one setting is a limitation. However, they are likely to be applicable to other healthcare organisations, as the setting is similar to environments elsewhere—for example, a National Health Service Trust in England. The action research process has engaged participants and provided the research team with in-depth access across a broad range of organisational contexts for an extended period. The research team used accepted methods, rigorously applied to examine the issue.18 We employed multiple investigators and independent analysis to triangulate findings.

Conclusion

Implementing practice change is both a complex and necessary undertaking. Improving quality and patient safety in healthcare necessitates improvements via clinical and managerial efforts.18 Being able to commence and sustain improvement initiatives requires considerable effort, attention and perseverance, particularly when the results do not meet expectations.13–15 The findings from our study add to our understanding about which factors influence the development of improvement programmes. The results offer practical strategies to engage staff and how progress is accomplished, both of which have been called for in the literature.15 17 Future studies could examine the interactional dynamics of the determinants identified, as well as other important issues such as team functioning on initiative development.

The study insights give rise to a significant challenge for health policy makers, managers and clinicians. Health organisations operate in environments characterised as resource-constrained, time-pressured and highly political. Only half of improvement activities made positive progress. How do we provide health professionals the opportunity, and flexibility, to identify and refine ideas into successful improvement projects? The six determinants we have identified will be important catalysts. For health professionals to maximise the potential of improvement programmes, it will be necessary to provide a supporting environment that displays these factors. How, and the extent to which, organisations respond to these determinants will shape their efforts to improve the quality and safety of healthcare.

References

Footnotes

  • Funding This research was supported under Australian Research Council's Linkage Projects funding scheme (project number LP0775514).

  • Competing interests None.

  • Ethics approval Ethics approval was provided by the UNSW/Health Research Human Research Ethics Advisory panel, approval number 09-10-006.

  • Provenance and peer review Not commissioned; externally peer reviewed.