Redesign and innovation in hospitals: foundations to making it happen

This paper describes key features of hospital redesign processes in Australia by analysing Victorian, NSW and other models. It discusses frameworks and drivers of large scale change in health systems including challenges and barriers to success.  The use of systems thinking and institutional entrepreneurship to support achieving change is described.   Insights are provided to enable policy development that can support innovation and system redesign. What is the problem? Australia\u27s demand for healthcare services is escalating, driven by an ageing population with complex health care needs, rising rates of chronic illness, increasing health care costs and rapid information technology innovation. These pressures may not be adequately met within the health system\u27s current and future economic capacity. Therefore, healthcare services and systems must achieve wide-ranging reform and redesign if they are to meet these challenges. The key questions for those working as health services leaders are: how can we support the innovation and change required to address this reality? and what should national policy makers do to support this work? What does the evidence say? Considerable evidence describes overlapping aspects of successful redesign in hospitals. These include: leadership to achieve change; the use of data to monitor and evaluate change; coherent alignment to organisational strategic plans; the development of organisational culture that is ready for change; and ensuring integration of change into routine practice. Systems thinking and institutional entrepreneurship offer approaches to change and redesign that take into consideration networks and relationships of individuals, teams and clinical disciplines working within it, resources and current processes and the cultural context of the organisation. What does this mean for health service leaders? In order to fully meet the requirements for redesign and innovation, health service leaders will need to address a number of key areas. First and foremost, leaders need to develop their organisational strategic vision around the concept of redesign and innovation and build staff understanding of the importance of these concepts. Staff must be given the capacity and confidence to pursue meaningful change in their everyday operations. Leaders must recognise the benefits of data and analytics and support the development of systems to utilise these tools. Innovative practices from outside of the health sector should be studied and adapted, and partnerships with industry and academia must be pursued. What does this mean for policy makers? Policy makers need to commit to investment in the concept of redesign and innovation. They should consider funding models that reward health services for innovation. Policy makers must support health services to pursue and sustain meaningful change while recognising that transformation requires time, perseverance and willingness to learn from success and failure

Examining ‘institutional entrepreneurship’ in healthcare redesign and improvement through comparative case study research:a study protocol

INTRODUCTION:Healthcare service redesign and improvement has become an important activity that health system leaders and clinicians realise must be nurtured and mastered, if the capacity issues that constrain healthcare delivery are to be solved. However, little is known about the critical success factors that are essential for sustaining and scaling up improvement initiatives. This situation limits the impact of these initiatives and undermines the general standing of redesign and improvement activity within healthcare systems. The conduct of the doctoral research detailed in this study protocol will be nested within a broader parent study that seeks to address this problem by drawing on the theory of 'institutional entrepreneurship'. The doctoral research will apply this idea to understanding the capacities and capabilities required at the organisation level to bring about transformational change in healthcare services. METHODS AND ANALYSIS:The parent study is predominantly qualitative, is multilevel in nature and has been codesigned with five partner healthcare organisations. The focus is a sector-wide attempt in an Australian state jurisdiction to transfer new redesign and improvement knowledge into the public healthcare system. The doctoral research will focus on the implementation of the sector-wide approach in one healthcare service in the jurisdiction. This research involves interviews with project team members and stakeholders involved in two improvement initiatives undertaken by the health service. It will involve interviews with redesign and improvement leaders and senior managers responsible for the overall health service improvement approach. The methods will also include immersive fieldwork, interviews and focus groups. Appropriate methods for coding and thematic extraction will be applied to the qualitative data. ETHICS AND DISSEMINATION:Ethical approval has been granted by the health service and Monash University Human Research Ethics Committee. Dissemination will be facilitated via academic publication, industry reports and workshops and dissemination events as part of the broader project.Angela Melder, Prue Burns, Ian Mcloughlin, Helena Teed

Integrating the complexity of healthcare improvement with implementation science:a longitudinal qualitative case study

BACKGROUND: Implementation science seeks to enable change, underpinned by theories and frameworks such as the Consolidated Framework for Implementation Research (CFIR). Yet academia and frontline healthcare improvement remain largely siloed, with limited integration of implementation science methods into frontline improvement where the drivers include pragmatic, rapid change. Using the CIFR lens, we aimed to explore how pragmatic and complex healthcare improvement and implementation science can be integrated. METHODS: Our research involved the investigation of a case study that was undertaking the implementation of an improvement intervention at a large public health service. Our research involved qualitative data collection methods of semi-structured interviews and non-participant observations of the implementation team delivering the intervention. Thematic analysis identified key themes from the qualitative data. We examined our themes through the lens of CFIR to gain in-depth understanding of how the CFIR components operated in a ‘real-world’ context. RESULTS: The key themes emerging from our research outlined that leadership, context and process are the key components that dominate and affect the implementation process. Leadership which cultivates connections with front line clinicians, fosters engagement and trust. Navigating context was facilitated by ‘bottom-up’ governance. Multi-disciplinary and cross-sector capability were key processes that supported pragmatic and agile responses in a changing complex environment. Process reflected the theoretically-informed, and iterative implementation approach. Mapping CFIR domains and constructs, with these themes demonstrated close alignment with the CFIR. The findings bring further depth to CFIR. Our research demonstrates that leadership which has a focus on patient need as a key motivator to engage clinicians, which applies and ensures iterative processes which leverage contextual factors can achieve successful, sustained implementation and healthcare improvement outcomes. CONCLUSIONS: Our longitudinal study highlights insights that strengthen alignment between implementation science and pragmatic frontline healthcare improvement. We identify opportunities to enhance the relevance of CFIR in the ‘real-world’ setting through the interconnected nature of our themes. Our study demonstrates actionable knowledge to enhance the integration of implementation science in healthcare improvement. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12913-022-07505-5

Vitamin D Supplementation Does Not Impact Resting Metabolic Rate, Body Composition and Strength in Vitamin D Sufficient Physically Active Adults

Supplementation with the most efficient form of Vitamin D (VitD3) results in improvements in energy metabolism, muscle mass and strength in VitD deficient individuals. Whether similar outcomes occur in VitD sufficient individuals’ remains to be elucidated. The aim of this study is to determine the effect of VitD3 supplementation on resting metabolic rate (RMR), body composition and strength in VitD sufficient physically active young adults. Participants completed pre-supplementation testing before being matched for sunlight exposure and randomly allocated in a counterbalanced manner to the VitD3 or placebo group. Following 12 weeks of 50 IU/kg body-mass VitD3 supplementation, participants repeated the pre-supplementation testing. Thirty-one adults completed the study (19 females and 12 males; mean ± standard deviation (SD); age = 26.6 ± 4.9 years; BMI = 24.2 ± 4.1 kg·m2). The VitD group increased serum total 25(OH)D by 30 nmol/L while the placebo group decreased total serum concentration by 21 nmol/L, reaching 123 (51) and 53 (42.2) nmol/L, respectively. There were no significant changes in muscle strength or power, resting metabolic rate and body composition over the 12-week period. Physically active young adults that are VitD sufficient have demonstrated that no additional physiological effects of achieving supraphysiological serum total 25(OH)D concentrations after VitD3 supplementation

Sustainability in Health care by Allocating Resources Effectively (SHARE) 8: developing, implementing and evaluating an evidence dissemination service in a local healthcare setting

Abstract Background This is the eighth in a series of papers reporting Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The SHARE Program was a systematic, integrated, evidence-based program for disinvestment within a large Australian health service. One of the aims was to explore methods to deliver existing high quality synthesised evidence directly to decision-makers to drive decision-making proactively. An Evidence Dissemination Service (EDS) was proposed. While this was conceived as a method to identify disinvestment opportunities, it became clear that it could also be a way to review all practices for consistency with current evidence. This paper reports the development, implementation and evaluation of two models of an in-house EDS. Methods Frameworks for development of complex interventions, implementation of evidence-based change, and evaluation and explication of processes and outcomes were adapted and/or applied. Mixed methods including a literature review, surveys, interviews, workshops, audits, document analysis and action research were used to capture barriers, enablers and local needs; identify effective strategies; develop and refine proposals; ascertain feedback and measure outcomes. Results Methods to identify, capture, classify, store, repackage, disseminate and facilitate use of synthesised research evidence were investigated. In Model 1, emails containing links to multiple publications were sent to all self-selected participants who were asked to determine whether they were the relevant decision-maker for any of the topics presented, whether change was required, and to take the relevant action. This voluntary framework did not achieve the aim of ensuring practice was consistent with current evidence. In Model 2, the need for change was established prior to dissemination, then a summary of the evidence was sent to the decision-maker responsible for practice in the relevant area who was required to take appropriate action and report the outcome. This mandatory governance framework was successful. The factors influencing decisions, processes and outcomes were identified. Conclusion An in-house EDS holds promise as a method of identifying disinvestment opportunities and/or reviewing local practice for consistency with current evidence. The resource-intensive nature of delivery of the EDS is a potential barrier. The findings from this study will inform further exploration

Semistructured interviews regarding patients\u27 perceptions of Choosing Wisely and shared decision-making: an Australian study.

OBJECTIVES: This study aimed to examine how patients perceive shared decision-making regarding CT scan referral and use of the five Choosing Wisely questions with their general practitioner (GP). DESIGN: This is a qualitative exploratory study using semistructured interviews. SETTING: This study was conducted in a large metropolitan public healthcare organisation in urban Australia. PARTICIPANTS: Following purposive sampling, 20 patients and 2 carers participated. Patient participants aged 18 years or older were eligible if they were attending the healthcare organisation for a CT scan and referred by their GP. Carers/family were eligible to participate when they were in the role of an unpaid carer and were aged 18 years or older. Participants were required to speak English sufficiently to provide informed consent. Participants with cognitive impairment were excluded. FINDINGS: Eighteen interviews were conducted with the patient only. Two interviews were conducted with the patient and the patient\u27s carer. Fourteen participants were female. Five themes resulted from the thematic analysis: (1) needing to know, (2) questioning doctors is not necessary, (3) discussing scans is not required, (4) uncertainty about questioning and (5) valuing the Choosing Wisely questions. Participants reported that they presented to their GP with a health problem that they needed to understand and address. Participants accepted their GPs decision to prescribe a CT scan to identify the nature of their problem. They reported ambivalence about engaging in shared decision-making with their doctor, although many participants reported valuing the Choosing Wisely questions. CONCLUSIONS: Shared decision-making is an important principle underpinning Choosing Wisely. Practice implementation requires understanding patients\u27 motivations to engage in shared decision-making with a focus on attitudes, beliefs, knowledge and emotions. Systems-level support and education for healthcare practitioners in effective communication is important. However, this needs to emphasise communication with patients who have varying degrees of motivation to engage in shared decision-making and Choosing Wisely

Sustainability in Health care by Allocating Resources Effectively (SHARE) 7:Supporting staff in evidence-based decision-making, implementation and evaluation in a local healthcare setting

Abstract Background This is the seventh in a series of papers reporting Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The SHARE Program was a systematic, integrated, evidence-based program for resource allocation within a large Australian health service. It aimed to facilitate proactive use of evidence from research and local data; evidence-based decision-making for resource allocation including disinvestment; and development, implementation and evaluation of disinvestment projects. From the literature and responses of local stakeholders it was clear that provision of expertise and education, training and support of health service staff would be required to achieve these aims. Four support services were proposed. This paper is a detailed case report of the development, implementation and evaluation of a Data Service, Capacity Building Service and Project Support Service. An Evidence Service is reported separately. Methods Literature reviews, surveys, interviews, consultation and workshops were used to capture and process the relevant information. Existing theoretical frameworks were adapted for evaluation and explication of processes and outcomes. Results Surveys and interviews identified current practice in use of evidence in decision-making, implementation and evaluation; staff needs for evidence-based practice; nature, type and availability of local health service data; and preferred formats for education and training. The Capacity Building and Project Support Services were successful in achieving short term objectives; but long term outcomes were not evaluated due to reduced funding. The Data Service was not implemented at all. Factors influencing the processes and outcomes are discussed. Conclusion Health service staff need access to education, training, expertise and support to enable evidence-based decision-making and to implement and evaluate the changes arising from those decisions. Three support services were proposed based on research evidence and local findings. Local factors, some unanticipated and some unavoidable, were the main barriers to successful implementation. All three proposed support services hold promise as facilitators of EBP in the local healthcare setting. The findings from this study will inform further exploration