Reconfiguring the Ecosystem for Sustainable Healthcare: Volume 4

The chapter redefines the focus of the changes required to create sustainable healthcare away from fixing healthcare organizations and toward reconfiguring the constituent elements of the healthcare ecosystem and redefining how they interrelate to yield value more sustainably.

Based on a review of recent literature on healthcare reform, we argue that unlike other sectors, healthcare organizations cannot change themselves without changing their connections to the rest of the healthcare ecosystem, including other healthcare organizations, patients, governments, research institutions, vendors, and the citizenry at large. This is because these are not only stakeholders but also integral parts of healthcare processes.

Interventions intended to create more sustainable healthcare must bring together knowledge and perspectives from across the ecosystem, and must converge different sources of information and analysis to generate novel ways of connecting across the ecosystem. Change within a healthcare system cannot achieve the magnitude of transformation needed to become sustainable.

If the healthcare ecosystem evolves in the manner described in this chapter, the healthcare ecosystem will no longer center around particular institutions and doctors’ offices but rather be defined by flexible and variable interactions between co-acting elements of the ecosystem.

The chapter treats the context as the focus of change in order to change the healthcare system. It proposes three kinds of flows: knowledge, clinical, and resource that are already beginning to change and that will eventually result in fundamentally different approaches to healthcare.

This chapter integrates organization design and sustainability concepts to describe an accelerated transformational change at the Fairview Medical Group (United States).

A case study of the transformation at Fairview Medical Group’s primary care clinics was developed from interviews and first-person accounts of the change. Objective data regarding outcomes was used to evaluate the effectiveness of the redesign process.

The Fairview Medical Group developed an innovation and change capability to transform 35 primary care clinics in six months. All of the clinics were certified by the state of Minnesota as complying with their healthcare standards. Clinical outcomes, costs, and employee and physician engagement also increased. All of the improved measures are sustained.

Healthcare reform in the United States struggles because the organization design challenges are great and the change difficulties even greater. Fairview’s experience provides important evidence and lessons that can help advance our understanding of effective healthcare and create more sustainable healthcare systems. This chapter provides healthcare system administrators evidence and alternatives in the pursuit of implementation.

This chapter examines why managed clinical networks are an appropriate approach to sustainable healthcare, and discusses the conditions for the effectiveness of these multi-stakeholder, clinician-led modes of organizing. It describes the development of a national clinical network to achieve system-wide improvement in the provision of publicly funded cardiac surgery services in New Zealand, and the subsequent evolution of a broader network encompassing the whole cardiac care patient pathway.

The case study of the two cardiac clinical networks focuses on the emergence and evolution of the networks over a four-year period from 2009. Data were collected from interviews with key stakeholders of both networks and from internal and published documentary evidence. Analysis of the case study is informed by network theory and prior studies of managed clinical networks.

Progress made towards the achievement of the goals of the initial cardiac surgery network encouraged a broadening of focus to the entire cardiac care pathway and the establishment of the national cardiac network. An important benefit has been the learning and increase in understanding among the different stakeholders involved. Both clinical networks have demonstrated the value of clinician engagement and leadership in improving the delivery of health services, and serve as a best practice model for the development of further clinical networks for health services that require a national population base.

The case study analysis of the two cardiac clinical networks identifies five mutually reinforcing themes that underpin network effectiveness: network structure, management and governance, and internal and external legitimation. These themes encompass a number of factors suggestive of successful managed clinical networks, and offer insights into the use of such networks in organizing for sustainable healthcare.

This chapter presents a framework for an action research based intervention to develop and transform sustainable healthcare in a regional context. The framework is illustrated by the case of the Regional Cancer Centre (RCC) West in western Sweden.

The framework draws upon and develops Pettigrew’s context–content–process model of strategic change and applies it to the unfolding narrative of the change effort. The empirical focus is the activities of a learning platform consisting of the RCC leadership, senior cancer physicians designated as process owners and an action research team. Data were collected from documents, observations of the learning platform, notes from meetings and interviews. Outcome data were obtained via the self-reporting of the physicians.

The learning platform established the capability for wide ranging development and quality improvement on the 23 cancer pathways as well as some support activities around principles of patient-centred care. A clear result is greater inter-organisational collaboration between care professionals as well as the introduction of new medicines, clinical methods, joint learning activities and new forms of measurement and monitoring of care practices. All of the improved measures are sustained.

Whilst there is no shortage of rhetoric on patient-centred care, the reality is that in complex healthcare systems solutions such as process-oriented approaches often fail. This case presents a model and an approach that eschews clear visions for change and instead places an emphasis on dialogue, participation, professional autonomy and collaborative communities as means for achieving the patient-centred ideal. The case also shows the value of seeing sustainable health systems as being grounded on practitioner–scholar collaboration that combines practical knowing with scientific knowledge.

The dynamics of the physician knowledge system in the Southern California Region of Kaiser Permanente are explored. The framing and analysis use concepts from the knowledge management literature and network theory. The criticality of this issue to the establishment of sustainable healthcare relates to the lynchpin nature of embedding evidence-based knowledge in healthcare practice and the simultaneous challenge of combining this with clinical knowledge that derives from practice.

The case study is compiled from longitudinal interviews with over 40 physicians and other stakeholders and an examination of archival information including published articles generated by the learning system.

The socio-technical approach to building this learning system was critical given the expectations of physicians for autonomy in making clinical decisions with respect to their patients. This robust learning system builds on rich professional and organizational networks, is led by physicians, and builds on and extends the foundation of evidence relating to quality and value. The goals of the physician practice and a robust measurement and feedback system provide focus for the learning system.

Accelerating the incorporation of evidence-based practice and increasing the scope and reach of the learning system entails building physician networks, having a robust system for critically examining and extending evidence, and a clear linkage to valued outcomes.

This detailed examination of the dynamics of knowledge absorption extends understanding of the capacity of medical care systems to absorb evidence-based knowledge.

Healthcare policy-makers are implementing practices based on the logic of cost-opportunity to rationalize investments and resource consumption. The successful implementation of these practices depends on policy-makers’ capacity to involve professionals dispersed in the ecosystem, and who are unaccustomed to cooperating. Our case study investigates the institutional work pursued by the Lombardy Region to stimulate a Health Technology Assessment (HTA) program.

This chapter is based on a longitudinal case study of institutional change linked with a HTA program in the Lombardy Region. The HTA program initiatives were implemented during the 2009–2012 period. The case study is based on triangulating data from archival data, contents of the assessment forms and interviews with regional staff and experts.

The Lombardy Region implemented two distinct strategies, with mixed results. A strategy that was based on the formalization of the HTA program in a legislative direct through educational efforts did not obtain the commitment of the key actors in the relevant ecosystem. Subsequently, the Region implemented an ‘institutional work’ design strategy that included a combination of political, cultural, technical and structural work. This strategy stimulated local HTA experiments that might be used in the future to legitimize the full diffusion of the new practice in the ecosystem.

This study highlights a viable strategy of change that policy-makers can use to manage processes of institutional change in a professional ecosystem. The ‘institutional work’ strategy can support the establishment of new practices that incorporate the logic of cost-opportunity, which might rationalize the use of resources and improve investment decisions.

The purpose of this chapter is to describe a method for priority setting that can be used to identify options for disinvestment, and is also meant to serve as a tool for re-allocation of resources to achieve better outcomes with a given pot of resources.

This chapter draws on findings from the application of a priority setting and resource allocation framework known as Program Budgeting and Marginal Analysis (PBMA). Case studies are used to illustrate key points around implementation including factors for success and guidelines for improving priority setting in practice.

PBMA has been applied in over 150 settings over the last 30 years. Purposes varied from focusing strictly on disinvestment to examining opportunities for re-allocation. Many organizations report continued use of the framework and decision makers typically express a desire to not revert to historical allocation or political negotiation in deciding on the funding for programs.

Practical implications of this body of work on priority setting abound in that there are significant opportunities to improve resource allocation practice including better engagement of staff, clinicians and public members, greater use of evidence in decision making and improving process transparency.

As healthcare resources are limited, particularly in predominantly publicly funded health systems, prudent use of resources is critical. Actually applying the appropriate tools to ensure that funding aligns with organizational and system objectives is paramount.

Although there is a large body of literature on priority setting particularly in countries like the United Kingdom and Canada, this chapter serves to highlight key messages specifically in the context of fiscal constraint and in relation to the concept of disinvestment or service reduction.

This chapter provides a reflective synopsis of six cases focused on making healthcare sustainable. The nature and value of an ecosystem perspective is explored. The intent is to apply and generate organizational knowledge to understand and guide purposeful design and learning.

From five countries where healthcare is organized differently, these cases illuminate particular approaches to develop the capabilities for healthcare to deliver greater value to society. Each case is examined through the lens of an appropriate theoretical perspective. This chapter reports the themes that were common in the six case studies.

New approaches are changing the connections in the healthcare ecosystem, including the flows of: medical knowledge, clinical information, and resources. Common themes include: the importance of networks in the emerging healthcare ecosystem; the role of governance mechanisms and leadership to align the diverse ecosystem components; the engagement of dominant ecosystem actors; the need for adaptive change capabilities, and for multi-stakeholder research collaborations to generate actionable knowledge.

Taking an ecosystem perspective enables healthcare leaders to broaden their conceptualization of the changes that will be required to be sustainable in a changing society.

Almost every man, woman and child is affected by the healthcare system. Increasing the sustainability of healthcare is integral to increasing societal sustainability overall.

Viewing the ecosystem as the appropriate focus of purposeful change departs from a traditional approach that focuses on the effectiveness of each element.