Behind the scenes in health care improvement: The complex structures and emergent strategies of Implementation Science
Section snippets
Complex adaptive systems
Until recently, organizational theorists conceived of organizations as machines. Like clocks or heating systems, organizations were thought to consist of moving parts that worked together in an orderly fashion. Organizational machines might be complicated and dynamic, but they were also predictable. This was because mechanical parts have no agency; nothing novel can take place.
As Plsek notes, however, in regard to health care quality improvement (Plsek, 2001; see also Plsek, 2003), according to
Methods
Data were collected using a focused ethnographic approach that included key informant interviews and immersion within the host IS unit. This approach can be likened to ‘institutional ethnography’ (Campbell & Gregor, 2004), which focuses on explicating social relations as they are realized in people's activities, including relations that are trans-local, extend across time, entail authority and subordination (however implicit), and are mediated by organizational texts (e.g., policy statements
Findings
Relevant themes highlighted by the respondents in regard to IS, and their associated meanings and implications, are described and discussed below. The themes are identified in section subheads. Participants quoted2 are identified with a systematically scrambled interviewee number (e.g., ‘[103]’); general job titles are provided only where needed for clarity.
Discussion and implications
The IS unit that formed the central focus of this study is one of nine such units in a large, integrated health care system. The centers are physically located at specific facilities throughout the USA, but core staff (including IS Coordinators) report to the organization's central office. Work is carried out by core center staff, whose work is funded by program grants, and center-affiliated researchers, whose work is funded by project researchers.
Acknowledgements
The project described here was supported by a Veterans Healthcare Administration (VHA) Academic Expert Collaboration Supplement grant (#IMA 04-4117). Institutional Review Board approval was granted by the VHA, University of California San Diego, and San Diego State University.
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