Integrating new practices: a qualitative study of how hospital innovations become routine

Background

Hospital quality improvement efforts absorb substantial time and resources, but many innovations fail to integrate into organizational routines, undermining the potential to sustain the new practices. Despite a well-developed literature on the initial implementation of new practices, we have limited knowledge about the mechanisms by which integration occurs.

Methods

We conducted a qualitative study using a purposive sample of hospitals that participated in the State Action on Avoidable Rehospitalizations (STAAR) initiative, a collaborative to reduce hospital readmissions that encouraged members to adopt new practices. We selected hospitals where risk-standardized readmission rates (RSRR) had improved (n?=?7) or deteriorated (n?=?3) over the course of the first 2 years of the STAAR initiative (2010–2011 to 2011–2012) and interviewed a range of staff at each site (90 total). We recruited hospitals until reaching theoretical saturation. The constant comparative method was used to conduct coding and identification of key themes.

Results

When innovations were successfully integrated, participants consistently reported that a small number of key staff held the innovation in place for as long as a year while more permanent integrating mechanisms began to work. Depending on characteristics of the innovation, one of three categories of integrating mechanisms eventually took over the role of holding new practices in place. Innovations that proved intrinsically rewarding to the staff, by making their jobs easier or more gratifying, became integrated through shifts in attitudes and norms over time. Innovations for which the staff did not perceive benefits to themselves were integrated through revised performance standards if the innovation involved complex tasks and through automation if the innovation involved simple tasks.

Conclusions

Hospitals have an opportunity to promote the integration of new practices by planning for the extended effort required to hold a new practice in place while integration mechanisms take hold. By understanding how integrating mechanisms correspond to innovation characteristics, hospitals may be able to foster integrating mechanisms most likely to work for particular innovations.

     

Modeling technology innovation: How science, engineering, and industry methods can combine to generate beneficial socioeconomic impacts

ABSTRACT: BACKGROUND: Government-sponsored science, technology, and innovation (STI) programs support the socioeconomic aspects of public policies, in addition to expanding the knowledge base. For example, beneficial healthcare services and devices are expected to result from investments in research and development (R&D) programs, which assume a causal link to commercial innovation. Such programs are increasingly held accountable for evidence of impact--that is, innovative goods and services resulting from R&D activity. However, the absence of comprehensive models and metrics skews evidence gathering toward bibliometrics about research outputs (published discoveries), with less focus on transfer metrics about development outputs (patented prototypes) and almost none on econometrics related to production outputs (commercial innovations). This disparity is particularly problematic for the expressed intent of such programs, as most measurable socioeconomic benefits result from the last category of outputs. METHODS: This paper proposes a conceptual framework integrating all three knowledge-generating methods into a logic model, useful for planning, obtaining, and measuring the intended beneficial impacts through the implementation of knowledge in practice. Additionally, the integration of the Context-Input-Process-Product (CIPP) model of evaluation proactively builds relevance into STI policies and programs while sustaining rigor. RESULTS: The resulting logic model framework explicitly traces the progress of knowledge from inputs, following it through the three knowledge-generating processes and their respective knowledge outputs (discovery, invention, innovation), as it generates the intended sociobeneficial impacts. It is a hybrid model for generating technology-based innovations, where best practices in new product development merge with a widely accepted knowledgetranslation approach. Given the emphasis on evidence-based practice in the medical and health fields and "bench to bedside" expectations for knowledge transfer, sponsors and grantees alike should find the model useful for planning, implementing, and evaluating innovation processes. CONCLUSIONS: High-cost/high-risk industries like healthcare require the market deployment of technologybased innovations to improve domestic society in a global economy. An appropriate balance of relevance and rigor in research, development, and production is crucial to optimize the return on public investment in such programs. The technology-innovation process needs a comprehensive operational model to effectively allocate public funds and thereby deliberately and systematically accomplish socioeconomic benefits.     

Crop changes from the XVI century to the present in a hill/mountain area of eastern Liguria (Italy)

Background

Until recently, little attention has been paid to local innovation capacity as well as management practices and institutions developed by communities and other local actors based on their traditional knowledge. This paper doesn't focus on the results of scientific research into innovation systems, but rather on how local communities, in a network of supportive partnerships, draw knowledge for others, combine it with their own knowledge and then innovate in their local practices. Innovation, as discussed in this article, is the capacity of local stakeholders to play an active role in innovative knowledge creation in order to enhance local health practices and further environmental conservation. In this article, the innovative processes through which this capacity is created and reinforced will be defined as a process of "ethnomedicine capacity".

Methods

The field study undertaken by the first author took place in India, in the State of Tamil Nadu, over a period of four months in 2007. The data was collected through individual interviews and focus groups and was complemented by participant observations.

Results

The research highlights the innovation capacity related to ethnomedical knowledge. As seen, the integration of local and scientific knowledge is crucial to ensure the practices anchor themselves in daily practices. The networks created are clearly instrumental to enhancing the innovation capacity that allows the creation, dissemination and utilization of 'traditional' knowledge. However, these networks have evolved in very different forms and have become entities that can fit into global networks. The ways in which the social capital is enhanced at the village and network levels are thus important to understand how traditional knowledge can be used as an instrument for development and innovation.

Conclusion

The case study analyzed highlights examples of innovation systems in a developmental context. They demonstrate that networks comprised of several actors from different levels can synergistically forge linkages between local knowledge and formal sciences and generate positive and negative impacts. The positive impact is the revitalization of perceived traditions while the negative impacts pertain to the transformation of these traditions into health commodities controlled by new elites, due to unequal power relations.     

Steering vaccinomics innovations with anticipatory governance and participatory foresight

Vaccinomics is the convergence of vaccinology and population-based omics sciences. The success of knowledge-based innovations such as vaccinomics is not only contingent on access to new biotechnologies. It also requires new ways of governance of science, knowledge production, and management. This article presents a conceptual analysis of the anticipatory and adaptive approaches that are crucial for the responsible design and sustainable transition of vaccinomics to public health practice. Anticipatory governance is a new approach to manage the uncertainties embedded on an innovation trajectory with participatory foresight, in order to devise governance instruments for collective "steering" of science and technology. As a contrast to hitherto narrowly framed "downstream impact assessments" for emerging technologies, anticipatory governance adopts a broader and interventionist approach that recognizes the social construction of technology design and innovation. It includes in its process explicit mechanisms to understand the factors upstream to the innovation trajectory such as deliberation and cocultivation of the aims, motives, funding, design, and direction of science and technology, both by experts and publics. This upstream shift from a consumer "product uptake" focus to "participatory technology design" on the innovation trajectory is an appropriately radical and necessary departure in the field of technology assessment, especially given that considerable public funds are dedicated to innovations. Recent examples of demands by research funding agencies to anticipate the broad impacts of proposed research--at a very upstream stage at the time of research funding application--suggest that anticipatory governance with foresight may be one way how postgenomics scientific practice might transform in the future toward responsible innovation. Moreover, the present context of knowledge production in vaccinomics is such that policy making for vaccines of the 21st century is occurring in the face of uncertainties where the "facts are uncertain, values in dispute, stakes high and decisions urgent and where no single one of these dimensions can be managed in isolation from the rest." This article concludes, however, that uncertainty is not an accident of the scientific method, but its very substance. Anticipatory governance with participatory foresight offers a mechanism to respond to such inherent sociotechnical uncertainties in the emerging field of vaccinomics by making the coproduction of scientific knowledge by technology and the social systems explicit. Ultimately, this serves to integrate scientific and social knowledge thereby steering innovations to coproduce results and outputs that are socially robust and context sensitive.     

From Legal Transplants to Sustainable Transition

Extended producer responsibility (EPR), which assigns significant responsibility to producers to take back their end‐of‐life products to create incentives for redesign of products with lower life cycle environmental impacts, has come to a crossroad facing a trade‐off between the original innovation‐oriented regime design and the cost‐efficiency challenges in practice. This is particularly true in its implementation in non‐Organization for Economic Co‐operation and Development (OECD) countries as they are trying to transplant the “best practices” from OECD countries, for there is increasing skepticism as to whether EPR is suitable for developing countries at all. As an important producer of electronic products and destination of electronic waste (e‐waste) flows in the world, China has been expected to play a vital role in the evolution of global governance based on the idea of EPR, either to create new ways for producers to perform their end‐of‐life strategies, or to reshape the mode of production and consumption with its fast‐growing market. However, the establishment of EPR in China has been long and full of difficulties. This article reviews the status and trends in the establishment of an EPR system for waste electrical and electronic equipment (WEEE) management in China. We use the framework of a multilevel perspective of transition theory in our analysis to characterize the complex interactions among various agents in the evolution of the Chinese system from initial innovation‐oriented design to the current efficiency‐oriented version. An ongoing research framework for evaluation of the EPR program in China is outlined as the research agenda in coming years.     

The domestic struggle for traditional medical knowledge rights

In China, the local communities and various ethnic minorities still hold, sustain and develop traditional medicial knowledge (TMK), innovations, and practices within the original communities. TMK also has pharmaceutical option value, which has attracted interests in commercial use of TMK for pharmaceutical innovation in China. However, the increased use of TMK for non-traditional purposes might lead to a change in the customary treatment of TMK as common goods of relevant communities and peoples, and may lead to significant tension faced by both providers and users of TMK in China. We find there is a significant gap in literature analysing the phenonmenon of domestic biopolitics concerning TMK in China. Closely connected problem is the contradictory relationship between providers and users of TMK, especially between the indigenous and local communities, and corporate and industrial actors. Therefore, urgent research is needed to fill this literature gap.     

Community-based participatory research and integrated knowledge translation: advancing the co-creation of knowledge

Background

Better use of research evidence (one form of “knowledge”) in health systems requires partnerships between researchers and those who contend with the real-world needs and constraints of health systems. Community-based participatory research (CBPR) and integrated knowledge translation (IKT) are research approaches that emphasize the importance of creating partnerships between researchers and the people for whom the research is ultimately meant to be of use (“knowledge users”). There exist poor understandings of the ways in which these approaches converge and diverge. Better understanding of the similarities and differences between CBPR and IKT will enable researchers to use these approaches appropriately and to leverage best practices and knowledge from each. The co-creation of knowledge conveys promise of significant social impacts, and further understandings of how to engage and involve knowledge users in research are needed.

Main text

We examine the histories and traditions of CBPR and IKT, as well as their points of convergence and divergence. We critically evaluate the ways in which both have the potential to contribute to the development and integration of knowledge in health systems. As distinct research traditions, the underlying drivers and rationale for CBPR and IKT have similarities and differences across the areas of motivation, social location, and ethics; nevertheless, the practices of CBPR and IKT converge upon a common aim: the co-creation of knowledge that is the result of knowledge user and researcher expertise. We argue that while CBPR and IKT both have the potential to contribute evidence to implementation science and practices for collaborative research, clarity for the purpose of the research—social change or application—is a critical feature in the selection of an appropriate collaborative approach to build knowledge.

Conclusion

CBPR and IKT bring distinct strengths to a common aim: to foster democratic processes in the co-creation of knowledge. As research approaches, they create opportunities to challenge assumptions about for whom, how, and what is defined as knowledge, and to develop and integrate research findings into health systems. When used appropriately, CBPR and IKT both have the potential to contribute to and advance implementation science about the conduct of collaborative health systems research.

     

Some Considerations on Data Integration for the Next-Generation Flora (iFlora) and Flora Revision—— A Case Study of Gaultheria (Ericaceae)

The next-generation intelligent Flora (iFlora) is designed to integrate current botanical knowledge, with molecular biology information and computer technology. The most important and urgent task for iFlora development is to search for an approach to incorporate all useful data into an accurate, most up-to-date and complete information database for a taxon, and hierarchically classify these data to meet different demands from iFlora users, to provide the user an authentic, scientific research based platform for sharing botanic knowledge, and associated valuable information for the benefit of national economy and quality of our life. In this study, we summarized the innovations, hierarchical classifications and functions of data for iFlora, in contrast of that of the previous Floras and the frequently used digital plant databases or eFloras. The innovation and essential of data compilation and integration of the iFlora was emphasized as intelligent assembly of data from DNA barcodes, key morphological characters, digital images and molecular phylogenetics with the support of computer techniques to achieve intelligent plant identification. We attempted to integrate previously assembled research data into the iFlora, and list three hierarchically classified data and their functions, and related issues, with the genus Gaultheria and one of its species, G.hookeri, as test case.     

iFlora与植物志修订的若干思考——以杜鹃花科白珠树属为例

结合现代植物学、DNA测序与信息等关键技术而产生的新一代智能植物志（iFlora）,其研发中最首要和迫切的任务之一就是如何将前沿、准确和完善的植物数据信息进行特色整合及智能化处理,为用户提供一个客观而科学的,具理论和实际应用为一体的植物学知识共享平台,并有效地为国民经济发展提供有价值的植物资源信息渠道。本文简要介绍了与传统植物志和目前常用的电子植物志数据库相区别的iFlora数据信息的分级内容、特点和功能,并强调了作为iFlora的核心数据信息,即用于物种鉴定的植物DNA条形码、关键形态学分类特征、植物图像等识别数据,以及分子系统发育数据等。以杜鹃花科（Ericaceae）白珠树属（Gaultheria）和其属下红粉白珠（G.hookeri）为例,介绍了iFlora采用的三类数据（核心数据、基础数据和拓展数据）构成的三级信息及其功能,同时探讨了信息整合时可能遇到的问题。     

Molecular phylogeny of Harpactorini (Insecta: Reduviidae): correlation of novel predation strategy with accelerated evolution of predatory leg morphology

Much research and discussion have focused on the effects of key innovations on lineage diversification, whereas little has been done to investigate their role in morphological evolution using phylogenetic approaches. Here we present the first comprehensive molecular phylogeny of the Harpactorini (Insecta: Reduviidae), the largest assassin bug tribe, sampling 229 terminal taxa and using five gene segments (28S D2, D3–D5, 16S, COI, and Deformed). Employing comparative phylogenetic methods, we demonstrate the correlation of a putative key innovation, the sticky trap predation strategy, with accelerated rates of morphological evolution of the predatory fore leg in assassin bugs. We show that bugs exhibiting sticky trap predation have evolved more slender and longer fore femora than non‐sticky bugs. Using phylogenetically independent contrast analyses, we document correlated evolution between femoral thickness and length. We argue that the novel sticky trap predation strategy may allow sticky bugs to alleviate functional constraints on the fore femur and thus to attain a higher rate of evolution than other Harpactorini or Reduviidae. We discuss the possibility that sticky bugs represent a case of adaptive radiation. We also test historical supra‐generic groups within the Harpactorini, and show that most of them are not monophyletic. We confirm the paraphyly of Harpactorini with respect to Rhaphidosomini.     

Long Term Effect on Professionals’ Knowledge,Practice and Attitudes towards User Involvement Four Years after Implementing an Organisational Development Plan: A Controlled Study

Background

Health service organisations are increasingly implementing user involvement initiatives according to requirements from governments, such as user representation in administrational boards, better information to users, and more involvement of the users during treatment. Professionals are vital in all initiatives to enhance user involvement, and initiatives to increase involvement should influence the professionals’ practice and attitudes. The implementation of a development plan intending to enhance user involvement in a mental health hospital in Central Norway had no effect on the professionals after 16 months. The objective was therefore to investigate the long term effect on the professionals’ knowledge, practice and attitudes towards user involvement after four years.

Methods

This was a non-randomized controlled study including professionals from three mental health hospitals in Central Norway. A development plan intended to enhance user participation was implemented in one of the hospitals, including establishing a patient education centre and a user office, purchasing of user expertise, appointing contact professionals for next of kin, and improving of the centre’s information and the professional culture. The professionals at two other hospitals constituted the control group. All professionals were invited to answer the Consumer Participation Questionnaire (CPQ) and additional questions, at a four year interval.

Results

A total of 399 professionals participated (43% response rate). Comparing the changes in the intervention group with the changes in the control group, the results showed that the plan had improved some aspects of the professionals’ knowledge about the user involvement taking place in the hospital. In addition, some parts of the professionals’ practice of providing information to the service users was improved, and the development plan might have raised their awareness about insufficient involvement of next of kin.

Conclusions

This is the first controlled study on the long term effect on professionals from implementing a development plan to enhance user participation in a mental health hospital. Since there was more effect after four years than after 16 months, this study indicates that it takes time before the effect of complex interventions to enhance patient participation in organisations can be detected among the professionals. More long-term studies are thus warranted.     

Cheating on the edge

We present the results of an individual agent-based model of antibiotic resistance in bacteria. Our model examines antibiotic resistance when two strategies exist: "producers"--who secrete a substance that breaks down antibiotics--and nonproducers ("cheats") who do not secrete, or carry the machinery associated with secretion. The model allows for populations of up to 10,000, in which bacteria are affected by their nearest neighbors, and we assume cheaters die when there are no producers in their neighborhood. Each of 10,000 slots on our grid (a torus) could be occupied by a producer or a nonproducer, or could (temporarily) be unoccupied. The most surprising and dramatic result we uncovered is that when producers and nonproducers coexist at equilibrium, nonproducers are almost always found on the edges of clusters of producers.     

Evidence use in decision-making on introducing innovations: a systematic scoping review with stakeholder feedback

Background

A range of evidence informs decision-making on innovation in health care, including formal research findings, local data and professional opinion. However, cultural and organisational factors often prevent the translation of evidence for innovations into practice. In addition to the characteristics of evidence, it is known that processes at the individual level influence its impact on decision-making. Less is known about the ways in which processes at the professional, organisational and local system level shape evidence use and its role in decisions to adopt innovations.

Methods

A systematic scoping review was used to review the health literature on innovations within acute and primary care and map processes at the professional, organisational and local system levels which influence how evidence informs decision-making on innovation. Stakeholder feedback on the themes identified was collected via focus groups to test and develop the findings.

Results

Following database and manual searches, 31 studies reporting primary qualitative data met the inclusion criteria: 24 were of sufficient methodological quality to be included in the thematic analysis. Evidence use in decision-making on innovation is influenced by multi-level processes (professional, organisational, local system) and interactions across these levels. Preferences for evidence vary by professional group and health service setting. Organisations can shape professional behaviour by requiring particular forms of evidence to inform decision-making. Pan-regional organisations shape innovation decision-making at lower levels. Political processes at all levels shape the selection and use of evidence in decision-making.

Conclusions

The synthesis of results from primary qualitative studies found that evidence use in decision-making on innovation is influenced by processes at multiple levels. Interactions between different levels shape evidence use in decision-making (e.g. professional groups and organisations can use local systems to validate evidence and legitimise innovations, while local systems can tailor or frame evidence to influence activity at lower levels). Organisational leaders need to consider whether the environment in which decisions are made values diverse evidence and stakeholder perspectives. Further qualitative research on decision-making practices that highlights how and why different types of evidence come to count during decisions, and tracks the political aspects of decisions about innovation, is needed.

     

Beyond Participation: Politics,Incommensurability and the Emergence of Mental Health Service Users’ Activism in Chile

Although the organisation of mental health service users and ex-users in Latin America is a recent and under-researched phenomenon, global calls for their involvement in policy have penetrated national agendas, shaping definitions and expectations about their role in mental health systems. In this context, how such groups react to these expectations and define their own goals, strategies and partnerships can reveal the specificity of the “user movement” in Chile and Latin America. This study draws on Jacques Rancière’s theorisation of “police order” and “politics” to understand the emergence of users’ collective identity and activism, highlighting the role of practices of disengagement and rejection. It is based on interviews and participant observation with a collective of users, ex-users and professionals in Chile. The findings show how the group’s aims and self-understandings evolved through hesitations and reflexive engagements with the legal system, the mental health system, and wider society. The notion of a “politics of incommensurability” is proposed to thread together a reflexive rejection of external expectations and definitions and the development of a sense of being “outside” of the intelligibility of the mental health system and its frameworks of observation and proximity. This incommensurability problematises a technical definition of users’ presence and influence and the generalisation of abstract parameters of engagement, calling for approaches that address how these groups constitute themselves meaningfully in specific situations.     

Myth of independence: caring for house and residential facilities with care for the elderly

The innovations in the field of housing and care for elderly people often emphasize the concept of independence. Older people in these days are expected to competently and smoothly manage their own lives in a housing and care environment, that encourages self-help and selfsufficiency. Architects, care managers and politicians often are optimistic on the translation of independence into every-day practice of housing and care arrangements. By means of participating observations and interviews we explored how this translation is realised in an innovative project of 'lifetime' housing. Our results point out that strong and unexpected social factors develop in the use of space and caregiving that hinder personal fullfillment of autonomy. These problems were especially seen when every-day dependency failed to be noticed because of a too strongly emphasized autonomy.     

INTER‐ETHICS: TOWARDS AN INTERACTIVE AND INTERDEPENDENT BIOETHICS

Since its origin bioethics has been a specialized, academic discipline, focussing on moral issues, using a vast set of globalized principles and rational techniques to evaluate and guide healthcare practices. With the emergence of a plural society, the loss of faith in experts and authorities and the decline of overarching grand narratives and shared moralities, a new approach to bioethics is needed. This approach implies a shift from an external critique of practices towards embedded ethics and interactive practice improvement, and from a legal defence of rights towards fostering interdependent practices of responsibility. This article describes these transitions within bioethics in relation to the broader societal and cultural dynamics within Western societies, and traces the implications for the methodologies and changing roles of the bioethicist. The bioethicist we foresee is not just a clever expert but also a relationally sensitive person who engages stakeholders in reciprocal dialogues about their practice of responsibility and helps to integrate various sorts of knowledge (embodied, experiential, visual, and cognitive‐scientific). In order to illustrate this new approach, we present a case study. It concerns a project focusing on an innovation in elderly care, based on the participation of various stakeholders, especially older people themselves.     

Federal communication about obesity in the Dietary Guidelines and checkoff programs

The new Dietary Guidelines for Americans focus on obesity prevention. They recommend increased consumption of whole grains, fruits, vegetables, fish, and low-fat dairy products, within a balanced diet whose total calories have been moderately reduced. Meanwhile, other well-known and well-funded federally sponsored consumer communications promote increased total consumption of beef, pork, and dairy products, including energy dense foods such as bacon cheeseburgers, barbecue pork ribs, pizza, and butter. These latter communications are sponsored by the federal government's commodity promotion programs, known as "checkoff" programs. The programs are established by Congress, approved by a majority of the commodity's producers, managed jointly by a producer board and the U.S. Department of Agriculture, and funded through a tax on the producers. The federal government enforces the collection of more than 600 million US dollars annually in mandatory assessments, approves the advertising and marketing programs, and defends checkoff communication in court as the federal government's own message-in legal jargon, as its own "government speech." Federal support for promoting fruits and vegetables is small by comparison. The checkoff programs recently have become more clearly identified as federal programs. After a recent decision by the U.S. Supreme Court upholding the constitutionality of the checkoff programs, calls for consistency with the Dietary Guidelines may get louder. The current inconsistencies in federal communication undermine the effectiveness of the Dietary Guidelines as an antidote to the shortcomings of the private sector market for information about weight and obesity.     

OTO: Ontology Term Organizer

Background

The need to create controlled vocabularies such as ontologies for knowledge organization and access has been widely recognized in various domains. Despite the indispensable need of thorough domain knowledge in ontology construction, most software tools for ontology construction are designed for knowledge engineers and not for domain experts to use. The differences in the opinions of different domain experts and in the terminology usages in source literature are rarely addressed by existing software.

Methods

OTO software was developed based on the Agile principles. Through iterations of software release and user feedback, new features are added and existing features modified to make the tool more intuitive and efficient to use for small and large data sets. The software is open source and built in Java.

Results

Ontology Term Organizer (OTO; http://biosemantics.arizona.edu/OTO/) is a user-friendly, web-based, consensus-promoting, open source application for organizing domain terms by dragging and dropping terms to appropriate locations. The application is designed for users with specific domain knowledge such as biology but not in-depth ontology construction skills. Specifically OTO can be used to establish is_a, part_of, synonym, and order relationships among terms in any domain that reflects the terminology usage in source literature and based on multiple experts’ opinions. The organized terms may be fed into formal ontologies to boost their coverage. All datasets organized on OTO are publicly available.

Conclusion

OTO has been used to organize the terms extracted from thirty volumes of Flora of North America and Flora of China combined, in addition to some smaller datasets of different taxon groups. User feedback indicates that the tool is efficient and user friendly. Being open source software, the application can be modified to fit varied term organization needs for different domains.