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WHAT ‘SPARKS’ INNOVATION IN RURAL
HEALTH SETTINGS: A CASE STUDY
Sheree Lloyd
B (Bus) QUT, MTM Griffith
Submitted in fulfilment of the requirements for the degree of
Doctor of Philosophy
School of Public Health and Social Work
Faculty of Health
Queensland University of Technology
October 2019
What ‘sparks’ innovation in rural health settings: A case study ii
What ‘sparks’ innovation in rural health settings: A case study iii
Keywords
rural health, innovation, performance, high reliability, organisational factors,
contextual factors
What ‘sparks’ innovation in rural health settings: A case study iv
Abstract
The case study is an empirical inquiry that investigates the ‘case’ in depth and
within its real-world context and relies on multiple sources of evidence (Yin, 2014).
Through a case study the researcher can gain rich picture to analyse institutions,
persons, decision, events or other systems by one or more methods (Thomas, 2016).
Approximately 30% of the Australian population live in rural locations, and population
health is impacted by poor access to health services, higher rates of disease and poorer
health outcomes. Effective health care delivery is influenced by difficulties in
recruiting and retaining staff, fewer resources and less infrastructure. Innovation, the
use of evidence-based decision-making and the adoption of technology are
government priorities. Commonwealth and state health departments’ values and
mission statements focus on the identification of innovative solutions to rising health
costs, health system sustainability, an aging population, workforce and to address
health disparity.
The aim of this research was to investigate the organisational and contextual
factors that influence the adoption and sustainability of innovation and high
performance in rural health settings. A case study conducted in a rural health service
in northern New South Wales, Australia was the research methodology applied. Three
independent studies were conducted using a mixed-method approach. The studies
collected concurrently, qualitative and quantitative data. Data analysis from
interviews, surveys and publicly reported performance data and documents was
completed by the researcher to understand how innovation in rural health settings
occurs, how performance can be measured and described, and to ensure that the study
findings were reliable and valid.
This research has established how innovation can occur in rural health settings.
The research has identified the unique contextual and organisational factors that
support innovation in a rural health setting. The case study organisation was found to
have a culture receptive to innovation, and 78% of the innovations identified have been
sustained. Innovation is occurring despite many of the factors that theory suggests are
necessary, such as size (large), ‘slack resourcing’, administrative intensity and
departmental differentiation. Further, new knowledge regarding performance
measurement using publicly available information and how that might be used to
What ‘sparks’ innovation in rural health settings: A case study v
understand performance in rural health services has been obtained. The performance
study identified that currency of the data and the ability to compare similar peers is
important, and further work is needed on performance data sets to enhance usability.
The research results provide much needed evidence to understand rural health
organisations and to assist health service leaders to determine what could enable
further innovation and to harness that innovation to improve rural health services.
What ‘sparks’ innovation in rural health settings: A case study vi
Table of Contents
Keywords ................................................................................................................................ iii
Abstract ................................................................................................................................... iv
Table of Contents .................................................................................................................... vi
List of Figures ......................................................................................................................... ix
List of Tables ........................................................................................................................... xi
List of Appendices ................................................................................................................ xiii
Glossary and Abbreviations .................................................................................................. xiv
Statement of Original Authorship ........................................................................................ xvii
Acknowledgements ............................................................................................................. xviii
Chapter 1: Introduction............................................................................................. 1
1.1 Background to the research ............................................................................................ 1 1.1.1 Purpose ................................................................................................................ 5 1.1.2 Study design ......................................................................................................... 6
1.2 Context and setting for research ..................................................................................... 6
1.3 Aim of the research ........................................................................................................ 8 1.3.1 Research questions ............................................................................................... 8
1.4 Scope and definitions ..................................................................................................... 9
1.5 Research gap and contribution to knowledge .............................................................. 10 1.5.1 Impact ................................................................................................................ 11
1.6 Thesis outline ............................................................................................................... 13
Chapter 2: Literature Review ................................................................................. 14
2.1 Introduction .................................................................................................................. 14 2.1.1 Structure and scope of the literature review ...................................................... 14 2.1.2 Rural health challenges and the disadvantage in rural health services .............. 16
2.2 Factors driving innovation ........................................................................................... 18
2.3 Innovation and innovation theory ................................................................................ 19 2.3.1 History, types and definitions for innovation .................................................... 19 2.3.2 Determinants and antecedents of innovation ..................................................... 23 2.3.3 Sustainability and diffusion of innovation ......................................................... 25
2.4 Context and the role of place in innovation ................................................................. 26
2.5 Link between performance and innovation .................................................................. 28
2.6 Measurement of innovation and performance .............................................................. 29 2.6.1 Measures of innovation ...................................................................................... 29 2.6.2 Measurement of performance ............................................................................ 31 2.6.3 Challenges in the measurement of performance ................................................ 36 2.6.4 Examples of high performing health care organisations in the literature .......... 38
2.7 Case study research ...................................................................................................... 39
2.8 Rural health service research ....................................................................................... 42
What ‘sparks’ innovation in rural health settings: A case study vii
2.9 Theoretical and conceptual frameworks .......................................................................42
2.10 Research gap .................................................................................................................44
2.11 Summary and implications ...........................................................................................45
Chapter 3: Research Design .................................................................................... 47
3.1 Introduction ..................................................................................................................47 3.1.1 Research design framework ...............................................................................47 3.1.2 Approach to critical inquiry and rationale for case study approach ...................48 3.1.3 Context of the case study location ......................................................................50
3.2 Methodology .................................................................................................................52 3.2.1 Research design for the case study .....................................................................52
3.3 Participants and informants ..........................................................................................54
3.4 Instruments, sampling and data collection procedures .................................................55 3.4.1 Study 1 ................................................................................................................55 3.4.2 Study 2 ................................................................................................................56 3.4.3 Study 3 Workplace Innovation Scale Survey .....................................................57
3.5 Analytical methods .......................................................................................................58 3.5.1 Overview ............................................................................................................58 3.5.2 Data analysis Study 1 .........................................................................................59 3.5.3 Data analysis Study 2 .........................................................................................59 3.5.4 Data Analysis Methods Study 3: Workplace Innovation Scale Survey .............64 3.5.5 Corroboration of methods and studies ................................................................64
3.6 Ethics and data management ........................................................................................65 3.6.1 Ethics ..................................................................................................................65 3.6.2 Backup, retention data storage, privacy and confidentiality ..............................66
3.7 Bias and trustworthiness ...............................................................................................67
3.8 Conclusion ....................................................................................................................68
Chapter 4: Study 1 Results: Performance and Measurement of Performance in
the Case Study .......................................................................................................... 69
4.1 Introduction ..................................................................................................................69
4.2 Results ..........................................................................................................................69 4.2.1 Stream 1: Publicly reported performance data ...................................................70 4.2.2 Streams 2 and 3: Analysis of strategic documents and organisational data .......84 4.2.3 Summary of Streams 1, 2 and 3 ..........................................................................87
4.3 Conclusion ....................................................................................................................88
Chapter 5: Study 2 Results: Semi-Structured Interviews .................................... 92
5.1 Introduction ..................................................................................................................92
5.2 Results ..........................................................................................................................93 5.2.1 Dimensions of innovation culture ......................................................................94 5.2.2 Intention to be innovative ...................................................................................95 5.2.3 Context to support implementation of innovation ...........................................104 5.2.4 Knowledge and orientation of employees to support the thoughts and
actions necessary for innovation ......................................................................111 5.2.5 Infrastructure to support innovation .................................................................124
5.3 Conclusion ..................................................................................................................132 5.3.1 Enablers and barriers in the rural context .........................................................134
What ‘sparks’ innovation in rural health settings: A case study viii
Chapter 6: Results – Measurement of Innovation Culture ................................ 138
6.1 Introduction ................................................................................................................ 138
6.2 Analytical tools .......................................................................................................... 139
6.3 Demographics ............................................................................................................ 139
6.4 Survey results ............................................................................................................. 141 6.4.1 Organisational Innovation ................................................................................ 142 6.4.2 Innovation climate ........................................................................................... 144 6.4.3 Individual innovation ....................................................................................... 146 6.4.4 Team innovation .............................................................................................. 148 6.4.5 Workplace Innovation Scale ............................................................................ 149 6.4.6 Scale reliability ................................................................................................ 152
6.5 Conclusion ................................................................................................................. 152
Chapter 7: Analysis and Discussion ..................................................................... 154
7.1 Introduction ................................................................................................................ 154
7.2 Validity and reliability of methods and studies .......................................................... 155 7.2.1 Performance in rural health settings and its measurement ............................... 156 7.2.2 Corroborating the findings of Study 2 and Study 3 ......................................... 159 7.2.3 Organisational context/climate for innovation ................................................. 160 7.2.4 Infrastructure .................................................................................................... 161 7.2.5 Intention to be innovative ................................................................................ 161 7.2.6 Knowledge and learning .................................................................................. 162
7.3 Organisational and contextual factors in the case study organisation enabling and
sustaining innovation ............................................................................................................ 162
7.4 How can we unleash further innovation in rural health settings? .............................. 165
7.5 Conclusion ................................................................................................................. 168
Chapter 8: Conclusions and Recommendations .................................................. 170
8.1 Introduction ................................................................................................................ 170
8.2 Measurement of performance and performance in rural health settings .................... 170
8.3 How innovation occurs in rural health settings .......................................................... 172
8.4 Impact ........................................................................................................................ 175 8.4.1 Knowledge Impact ........................................................................................... 175 8.4.2 Health Impact ................................................................................................... 175 8.4.3 Social Impact ................................................................................................... 176 8.4.4 Economic impact ............................................................................................. 176 8.4.5 Impact for the case study organisation............................................................. 177 8.4.6 Reach ............................................................................................................... 177
8.5 Researcher reflections ................................................................................................ 178
8.6 Limitations ................................................................................................................. 179
8.7 Opportunities for future research ............................................................................... 181
8.8 Contribution to practice ............................................................................................. 181
8.9 Conclusion ................................................................................................................. 182
References ............................................................................................................... 184
Appendices .............................................................................................................. 209
What ‘sparks’ innovation in rural health settings: A case study ix
List of Figures
Figure 2-1 Structure of literature review topics examined......................................... 15
Figure 2-2 Domains of innovation culture as identified by Dobni (2008) ................. 44
Figure 2-3 Identified research gap for this study ....................................................... 45
Figure 3-1 Research framework and methodological approach ................................ 49
Figure 3-2 Research design for the case study ........................................................... 54
Figure 3-3 Publicly reported indicators of performance examined ........................... 56
Figure 3-4 Four dimensions of innovation (Dobni, 2008) and the codes used to
analyse narrative data ................................................................................... 62
Figure 3-5 Analytical techniques applied in Study 2 ................................................. 63
Figure 4-1 Publicly reported indicators of performance examined for the case
study organisation ........................................................................................ 70
Figure 4-2 Comparison of NSW Major Regional Hospitals Cost per NWAU .......... 75
Figure 4-3 Hand hygiene compliance rates for case study hospital compared
with national benchmark .............................................................................. 78
Figure 4-4 Admitted patient survey 2017 most positive and fewest negative –
10 peer group C hospitals ............................................................................ 81
Figure 4-5 Number of significant positive and negative responses to patient
survey peer comparisons .............................................................................. 82
Figure 4-6 Hospital budget and NWAUs by year for case study site ........................ 86
Figure 5-1 Dobni’s (2008) innovation culture dimensions and factors ..................... 95
Figure 6-1 Workplace Innovation Scale Survey responses (n = 66) by age and
gender. ........................................................................................................ 140
Figure 6-2 Workplace Innovation Scale response by professional discipline ......... 140
Figure 6-3 Identification as a manager in the workplace innovation survey
results ......................................................................................................... 141
Figure 6-4 Seven-point Likert scale used for the Workplace Innovation Scale ...... 142
Figure 6-5 Workplace Innovation Scale organisational innovation level of
agreement, neutral responses and level of disagreement ........................... 143
Figure 6-6 Workplace Innovation Scale innovation climate level of agreement,
neutral responses and level of disagreement .............................................. 146
Figure 6-7 Workplace Innovation Scale individual innovation level of
agreement, neutral responses and level of disagreement ........................... 147
Figure 6-8 Workplace Innovation Scale team innovation level of agreement,
neutral responses and level of disagreement .............................................. 149
What ‘sparks’ innovation in rural health settings: A case study x
Figure 6-9 Spider graph Workplace Innovation Scale’s 24 items across all
dimensions ................................................................................................. 150
Figure 7-1 Innovation types described by informants in the case study site ............ 165
Figure 8-1 Suggested measures for rural health care organisations’
performance scorecard ............................................................................... 172
Figure 8-2 Leverage points for further innovation ................................................... 174
What ‘sparks’ innovation in rural health settings: A case study xi
List of Tables
Table 1-1 Research impacts ....................................................................................... 12
Table 1-2 Thesis chapter structure ............................................................................. 13
Table 2-1 Determinants with positive and significant association with
organisational innovativeness as adapted from Greenhalgh,
Macfarlane, Bate, and Kyriakidou (2004) ................................................... 24
Table 2-2 Accreditation bodies by country ................................................................ 38
Table 2-3 Selected examples of high performing health systems identified in
the literature ................................................................................................. 39
Table 3-1 Framework for analysis of qualitative data adapted from Gale (2013) ..... 61
Table 3-2 Nodes used to analyse data collected in Study 2 ....................................... 63
Table 3-3 Ethics approvals for research ..................................................................... 66
Table 4-1 Median wait time to surgery at case study hospital compared with
peers ............................................................................................................. 71
Table 4-2 Percentage of patients who waited more than 365 days for surgery by
specialty ....................................................................................................... 72
Table 4-3. Percentage of patients who waited more than 365 days for intended
surgery by procedure.................................................................................... 73
Table 4-4. Emergency department data percentage of patients seen on time by
triage comparison with peers ....................................................................... 74
Table 4-5. Emergency department patients treated and discharged within 4
hours comparison with peers ....................................................................... 74
Table 4-6 Length of stay comparison with peer hospitals ......................................... 76
Table 4-7 Staphylococcus aureus bacteraemia infections comparisons to peer
by year .......................................................................................................... 77
Table 4-8 Blood stream infections rate per 10,000 bed days comparison with
peers ............................................................................................................. 77
Table 4-9 Results for the case study site for the questions related to safety and
quality with comparisons to a close peer hospital ....................................... 79
Table 4-10 Results from the admitted patient survey for the case study hospital
and a peer rural hospital for access and timeliness ...................................... 80
Table 4-11 Case study site and Griffith and the total number of significantly
higher agreement and significantly lower agreement across all 86
questions ...................................................................................................... 80
Table 4-12 Case Study Hospital People Matter Culture Index results compared
to Local Health District and Health Cluster (NSW Public Service
Commission, 2017) (NSW Public Service Commission, 2018b) and
(NSW Public Service Commission, 2018a) ................................................. 84
What ‘sparks’ innovation in rural health settings: A case study xii
Table 4-13 Documents analysed by the research and discoveries around
innovation and performance ......................................................................... 85
Table 4-14 Overall picture of performance in the case study organisation ............... 87
Table 4-15 Indicators sourced, data collection and peer grouping ............................ 89
Table 5-1 Breakdown of the 25 interview informants by gender and
identification as a manager .......................................................................... 93
Table 5-2 Professional backgrounds of the interviewees and management
responsibilities ............................................................................................. 94
Table 6-1 Workplace Innovation Scale organisational innovation descriptive
statistics ...................................................................................................... 142
Table 6-2 Level of agreement to statement on organisational innovation from
the Workplace Innovation Scale ................................................................ 143
Table 6-3 Level of agreement to statement on organisational climate from the
Workplace Innovation Scale ...................................................................... 144
Table 6-4 Workplace Innovation Scale innovation climate level of agreement,
neutral responses and level of disagreement .............................................. 145
Table 6-5 Individual innovation descriptive statistics .............................................. 146
Table 6-6 Workplace Innovation Scale individual innovation level of
agreement, neutral responses and level of disagreement ........................... 147
Table 6-7 Team innovation descriptive statistics for the Workplace Innovation
Scale ........................................................................................................... 148
Table 6-8 Workplace Innovation Scale team innovation level of agreement,
neutral responses and level of disagreement .............................................. 148
Table 6-9 Highest levels of agreement and lowest agreement for the Workplace
Innovation Scale ......................................................................................... 151
Table 6-10 Results of Cronbach’s alpha test for the Workplace Innovation
Scale ........................................................................................................... 152
Table 7-1 Case study organisation performance on publicly reported indicators
compared with peers .................................................................................. 159
Table 7-2 Summary of innovations identified in the rural case study hospital ........ 164
What ‘sparks’ innovation in rural health settings: A case study xiii
List of Appendices
Appendix A Examples of high performing health organisations health
organisations identified in the literature .................................................... 209
Appendix B Letter of Support from Chief Executive of Case Study Site .............. 211
Appendix C COREQ Checklist: Consolidated criteria for reporting qualitative
studies (Tong et al., 2007).......................................................................... 212
Appendix D Instruments identified to measure innovation in the literature ............ 216
Appendix E Performance measures and indicators analysed, time periods and
analysis conducted by researcher ............................................................... 218
Appendix F Northern NSW Local Health District Ethics Approval ....................... 219
Appendix G Northern NSW Local Health District Ethics Site Specific
Assessment Approval................................................................................. 221
Appendix H Queensland University of Technology Ethics Approval ..................... 223
Appendix I Semi-structured interview questions posed to informants in the case
study site .................................................................................................... 225
Appendix J Participant Information Sheet used in Studies 2 and 3 ......................... 229
Appendix K Workplace Innovation Scale (McMurray & Dorai, 2003) .................. 231
Appendix L Participant Consent Form Study 2 – Interviews .................................. 235
Appendix M Participant Consent Form Study 3 – Workplace Innovation
Survey ........................................................................................................ 237
Appendix N Core values of the for the case study site ............................................ 239
Appendix O Study 2: Semi-structured interview codes developed for analysis
within NVIVO ........................................................................................... 240
Appendix P Mapping of study 2 and 3 data for corroboration purposes and to
understand commonalities and variances................................................... 241
Appendix Q Innovations identified by informants in the case study site ................ 244
Appendix R Comparisons of key factors identified in the literature as linked to
successful innovation compared to study findings .................................... 248
What ‘sparks’ innovation in rural health settings: A case study xiv
Glossary and Abbreviations
Term Explanation
Accreditation Public recognition awarded by a health care accreditation
body of the achievement of standards by the health care
organisation. An independent external peer assessment
reviews the health care organisation’s level of performance
against set standards (Australian Commission on Quality and
Safety in Healthcare, 2018).
ADEPT Advanced Emergency Performance Training (ADEPT) is a
two-day course teaching non-technical skills to critical care
doctors and nurses (Adept Faculty, 2018).
Agency for
Clinical
Innovation (ACI)
This Agency was established to work with health services,
clinicians and consumers to design better health care for NSW
(Agency for Clinical Innovation, 2019a).
Average Length
of Stay (ALOS)
The average time spent in hospital for a condition or treatment
episode.
Bureau of Health
Information NSW
(BHI)
An independent, statutory authority responsible for reporting
on the performance of the health system in New South Wales
(Bureau of Health Information, 2018a).
CAQDAS Computer-Assisted Qualitative Data Analysis Software.
Case study The study of an issue, examined in one or more cases within a
bounded system such as a setting or particular context
(Liamputtong, 2013).
Clinical
Excellence
Commission
(CEC)
Independent government agency in New South Wales (NSW).
The Commission is a board-governed statutory body
established under the NSW Health Services Act 1997. The
role of the CEC is to driving programs and initiatives with
clinicians, managers, health services and the consumers of
health. The purpose of the CEC is to provide ‘leadership in
safety and quality in NSW to improve health care for
patients’.
Content analysis The identification of codes and then searching for those codes
in the qualitative or quantitative data (Liamputtong, 2013).
Deductive method of data analysis.
Context the circumstances relevant to something under consideration
(Australian Oxford Dictionary) and the circumstances or facts
that surround a particular situation, event, etc. (Macquarie
Dictionary, 2017).
EMR Electronic Medical Record.
What ‘sparks’ innovation in rural health settings: A case study xv
Term Explanation
Health Education
and Training
Institute (HETI)
Division within NSW Health that is a provider of training and
education to support clinical and non-clinical staff, trainers,
managers and leaders across the NSW health system (NSW
Ministry of Health, 2018).
High performance ‘High performing hospitals consistently attain excellence
across multiple measures of performance, and multiple
departments’ (Taylor, Clay-Williams, Hogden, Braithwaite, &
Groene, 2015, p.1).
The achievement of specified targets, either clinical or
administrative (Dias & Escoval, 2013).
Pronovost (2017) suggests that a high performing health
system is one able to achieve its purpose.
Hospital
associated
infections (HAI)
Hospitals aim to have as low a rate as possible and it is used as
a measure of quality and safety.
Innovation The ‘generation, development, and implementation of new
ideas or behaviours’ (Damanpour, 1996, p.694). Innovations
might be new products, processes or services, technologies,
organisational structures or administrative systems, or new
plans or programs (Damanpour, 1996, p.694).
Key Performance
Indicator (KPI)
An indicator, that measures whether an organisation is
achieving goals in health, be that access to services, quality and
safety, effectiveness and sustainability, to mention a few.
MyHospitals A website that provides performance information on public and
private hospitals in Australia. The information is sourced from
the Australian Institute of Health and Welfare’s data
collections.
NWAU National weighted activity unit. Used to compare the costs and
complexity of activity in acute health care organisations.
Organisational
context
Contextual factors such as size, organisational structure,
economic and financial constraints, policy settings and
organisational strategy.
Organisational
climate
‘Climate is an aspect of culture and it represents the team’s
shared perceptions of organisational policies, practices and
procedures’ (Bower et al., as cited in Eriksson et al., 2015, p.5).
Organisational
culture
Many definitions identified and can be broadly described as the
shared rituals, values, beliefs and the expected behaviours with
an organisation (Dobni, 2008).
What ‘sparks’ innovation in rural health settings: A case study xvi
Term Explanation
Positive
organisational
climate
A climate exhibiting cohesion, collaboration, inclusion and
supports colleagues in their work (Braithwaite, Herkes,
Ludlow, Testa, & Lamprell, 2017).
Staphylococcus
aureus (S. aureus)
Bacterium (SAB).
Healthcare-associated bloodstream infections caused by a
bacterium called Staphylococcus aureus (S. aureus).
Semi-structured
interview
Interview based on questions with some probing (United
States Department of Health and Human Services, 2018).
Thematic analysis Identification of themes through analysis of data. Described as
an inductive method of data analysis (Liamputtong, 2013).
Triangulation A process of analysis that seeks convergence, corroboration,
correspondence of results from different methods.
Comparing different kinds of data (e.g. numbers and text,
narratives, images) and/or different collection methods (e.g.
survey, polls, document analysis and interviews) to see whether
they corroborate one another (Thomas, 2016; United States
Department of Health and Human Services, 2018).
Workplace
Innovation Scale
(WIS)
A scale developed by Adela McMurray and colleagues and
tested nationally and internationally. This scale is used to
measure innovation propensity in organisations. The scale
measures team innovation, individual innovation,
organisational innovation and innovation climate. This tool was
selected as it has been widely validated, has a reasonable
number of questions (24) and is suited to the health
environment.
What ‘sparks’ innovation in rural health settings: A case study xvii
Statement of Original Authorship
The work contained in this thesis has not been previously submitted to meet
requirements for an award at this or any other higher education institution. To the best
of my knowledge and belief, the thesis contains no material previously published or
written by another person except where due reference is made.
Signature:
Date: 12/10/2019
QUT Verified Signature
What ‘sparks’ innovation in rural health settings: A case study xviii
Acknowledgements
I would like to thank the important people who have assisted me to complete this PhD
research. First, to my supervisors, who have not only guided my research but mentored
and coached me to completion. Their interest in my research and scholarly direction
and input into my academic development is acknowledged. Professor Gerry
FitzGerald, Dr Cynthia Cliff and Assoc Professor Jean Collie – thank you for your
unwavering support and enthusiasm. Second, my family are the foundations and
strength for all that I achieve, and without their resolute support and freedom to
immerse myself in the learning, this research would not have been achieved.
During this time, the support from Queensland University of Technology
through the ethics and applied information skills for research modules were both useful
and informative. Supervisor wisdom and the motivation they provided has been
invaluable. Research support staff from QUT Faculty of Health have provided timely
and helpful guidance. My colleague Dr Patricia Lee from Griffith Health has assisted
with guidance on SPSS and statistical approaches.
Rebecca Lavery, A/Executive Officer and Alexandre Stephens, Director of
Research of Northern NSW Local Health District, thank you for the guidance and
encouragement through the ethical and site-specific assessment processes.
I would also like to extend my appreciation to Ms Roberta Blake who edited this
thesis, complying with Queensland University of Technology’s guidelines for editing
research theses. Alexandra Stevenson also for graphic design input into Figure 8-2
Leverage points for further innovation.
Finally, to the enthusiastic Case Study Hospital and Case Study Health Service
managers, clinicians and administrative staff who agreed to be interviewed and who
gave their time freely to participate. To those who completed the workplace innovation
survey I am grateful for the insights that this study has provided. To those I may have
forgotten – without their interest in my research, completion of this PhD would not
have been possible.
What ‘sparks’ innovation in rural health settings: A case study xix
Prologue
The origins of this research began when I worked in a rural health setting in the city
where I lived. My career in health up to that point had been carried out in large teaching
hospitals, a State Health Department, Regional Health Authority Office and working
with small- to medium-sized hospitals in metropolitan locations. Working in a rural
health setting, it was clear to me that there were anecdotal and observed disparities in
the physical, financial and human resources available. Yet patients are seen, treated
and cared for, and staff work hard to deliver services to their community year after
year. I could also see potential for improvements, new ways of working and
simplification of processes, many that had remained unchanged over long periods of
time. Working in a rural health setting you get to know all the actors, hear repeatedly
the ‘blame game’ between professions and clinicians and managers. You also see the
impact of historical alliances and professional siloing, but are witness to individuals
working together despite adversity and at times very difficult situations.
Rural health settings are fascinating (and sometimes frustrating) organisations to
work in, and new and old staff can see potential for improvement and change.
Innovations such as new models of care, processes and technologies are introduced
and are adapted to suit the particularities of the rural health context. My experience as
a health information manager and postgraduate with a master’s in technology
management, which focussed on strategy, innovation and the application of
technology, also stimulated my interest in understanding the role of innovation in rural
health settings and how performance in rural health settings might be measured and
linked with innovation. This was an ambitious focus of study for several reasons that
will be revealed in the thesis document.
There is no doubt that having worked in the rural health setting that was studied
helped me to secure the access needed to interview clinicians, executives and other
key personnel. Having the credibility and trust of staff to be able to speak frankly and
to gain the high degree of engagement that was attained from the clinical staff, who
were extremely enthusiastic and supportive of research conducted in their rural health
setting, was critical to the success of this research. Managing bias was an issue, and
this was carefully considered in the way that interviews were conducted, the questions
What ‘sparks’ innovation in rural health settings: A case study xx
asked, how they were asked, frameworks selected and the inclusion of a quantitative
study to measure innovation culture in the case study organisation.
In researching in a rural health setting, I wanted to be able to tell a story that was
important to tell and that reflects the potential and drive of rural health workers to
strengthen their health services through innovation. Understanding the factors that
enable innovation in rural health settings and conducting research in rural settings that
focuses on solutions (Bourke, Humphreys, Wakerman, & Taylor, 2010) is necessary
if we are to succeed in addressing rural health inequities.
Rural hospitals are under-utilised settings for health services management, and
this too was a motivator for completing the research for this doctoral thesis. The
enthusiasm of staff and delight that someone was interested in learning how innovation
occurs in rural locations kept me focussed on identifying practical solutions to the
issues that emerged from the findings. This influenced the tone and language of the
thesis document, with a deliberate emphasis on writing for a broad audience. While
conscious of the university requirements and interests of thesis markers, I tried to
incorporate but avoid writing in an overly formal way. I wanted to write so that the
thesis can be read, understood and applied by academics, rural health executives,
managers, clinicians, researchers and students in line with academic writing principles
as suggested by Mewburn, Firth, and Lehmann (2018) and Sword (2012). These
writers advocate that we write to engage, inspire and inform readers, noting that our
work only becomes consequential when it is understood by others (Boyer, as cited in
Sword, 2012).
I have included a prologue for the purposes of transparency and to share with
readers the key influences on the choice of topic and background to my research.
Openness and sharing of these key influences set the scene for the reader of this
dissertation and explain the origins of my interest in pursuing the topics investigated
and the methods applied.
1 Chapter 1: Introduction
Chapter 1: Introduction
The case study is an empirical inquiry that investigates the ‘case’ in depth and
within its real-world context and relies on multiple sources of evidence with data
converging in a triangulating fashion (Yin, 2014) and is good for gaining a rich
picture and analysing institutions, persons, decision, events or other systems by one
or more methods (Thomas, 2016).
This chapter outlines the background for the research and context of the rural setting
where the research was conducted. A compelling justification for the importance of
this research topic on innovation and high performance in rural health settings is
described. In determining the scope and significance of the research, it was identified
that the topics of innovation and performance are vast and have been well researched
in health and other industries. Despite an extensive review of the literature, almost no
research on how innovation in rural health settings occurs could be sourced by the
researcher. This gap in the literature and a paucity of research conducted in rural
settings was the motivation for conducting the study. The chapter describes the
background to the research, defines the questions that this research answers, explains
the scope, methods used, the limitations and an overview of the thesis.
1.1 BACKGROUND TO THE RESEARCH
In Australia and many other countries, rural communities are disadvantaged in terms
of their health outcomes and in their ability to access health services. For the 30% of
Australians who lived in rural and remote areas, the Australian Institute of Health and
Welfare (2014) reported that this group of citizens tend to have shorter lives, higher
rates of disease and poorer health outcomes. These outcomes occur across a range of
social, employment, health, income and educational backgrounds.
Effective rural health delivery is impacted by issues such as lack of staff,
access to health care services, the ‘dark side’ of relationship-based services and
community sustainability (Farmer et al. 2012). While relationships are fundamental
to the delivery of health care (Shelllner, 2007), health workers in rural settings are
particularly impacted, as even outside of work ‘they are never off duty’ (Farmer,
2 Chapter 1: Introduction
Munoz, & Threlkeld, 2012), and their assumptions of individuals with respect to
their health can be limiting (e.g. in delivering care to Indigenous Australians). Other
challenges include shortages of financial and human resources, the ageing of the
local health workforce and a lack of professional development opportunities and the
supporting health services that are necessary to provide comprehensive patient care
(Bourke et al., 2012). Rural communities have particular issues around ageing with
the out-migration of working adults from rural to urban areas and the in-migration of
former urban dwellers at retirement age (Hage, Roo, van Offenbeek, & Boonstra,
2013). This phenomenon is not unique to Australia, and similar issues are
experienced in Canada, the United States, the United Kingdom and Europe (Bourke
et al., 2012; Farmer, Munoz, & Daly, 2012; Hage et al., 2013; Murphy, Hughes, &
Conway, 2018).
Disparity in services, workforce, health status and well-being and health
outcomes is an extensively documented problem for rural communities. Addressing
gaps in rural health is a significant priority for governments in Australia
(Commonwealth of Australia, 2017b; NSW Ministry of Health, 2014). In 2017, the
first Rural Health Commissioner was appointed by the Commonwealth to give advice
on regional and rural health reform, an acknowledgment of its priority on the
government agenda (Commonwealth of Australia, 2017a). The academic and grey
literature documents at length the problems experienced in rural health (Australian
Institute of Health and Welfare, 2017b; Bourke, Humphreys, Wakerman, & Taylor,
2010; Farmer, 2012; Humphreys & Wakerman, 2018). Humphreys and Gregory
(2012) conveyed that rural health is a national priority, and more focus on rural health
and fairer resource allocation would provide the opportunity to support infrastructure,
the workforce and the services needed for rural health and well-being.
Innovation, the use of evidence-based decision-making and the adoption of
technology were mentioned in Commonwealth and State Health Departments’ values
and mission statements and identified as possible solutions to health disparity
(Commonwealth of Australia, 2017b; NSW Ministry of Health, 2014; Queensland
Health, 2015). The values for health services and the strategies in these policy and
strategy documents require health services to be agile and flexible to adapt to new
policies and reforms (Commonwealth of Australia, 2012; NSW Ministry of Health,
2014;Queensland Health, 2013).
3 Chapter 1: Introduction
The Federal Department of Health relates that there is a need to design, deliver
and support rural and remote health services using more flexible, innovative, and
locally appropriate solutions, without compromising the quality and safety of services
(Commonwealth of Australia, 2012). The Australian Productivity Commission (2015)
noted that Australians spend a lot of money on health through tax, private insurance
premiums and direct payment for items such as medication. The Commission further
explains that our health system produces good outcomes by international standards,
but notes that there is room for improvement (Australian Government Productivity
Commission, 2015).
The measurement of performance in the health system is complex, and there is
evidence of performance variation and inefficiency across the Australian health care
system including the following:
• complications as a result of a stay in hospital are common (Duckett, Jorm,
Danks, & Moran, 2018);
• the variation in costs for similar procedures across Australian Hospitals, taking
into consideration differences in hospital and patient characteristics (Duckett
et al., 2014);
• variable and often inappropriate care is provided (Runciman et al., 2012).
‘Within system’ reforms could be made by health services to improve health
outcomes and these include accelerating the creation and diffusion of effective care
delivery innovations (Australian Government Productivity Commission, 2015). Scott
(2014) identified 10 clinician driven strategies, including the need to ‘accelerate
creation and diffusion of value-adding innovation within rapid learning health care
organisations that constantly measure and benchmark outcomes of care, make changes
to improve care and re-evaluate’ (Scott, 2010, p.129). The Productivity Commission
in Australia in 2017 argued that innovation and diffusion of best practice are critical
to a well-functioning health system and that improvements in health could
(conservatively) reap benefits of $8.5 billion over a 5-year period (Commonwealth of
Australia, 2017c). Innovation is now considered essential for Australians to have the
best health system possible, that is sustainable and produces good outcomes for the
population (Australian Healthcare and Hospitals Association, 2017; Duckett et al.,
2014; Duckett et al., 2018).
Innovation and high performance in health care organisations is regarded by the
government funders of health services as vital to confront and address the documented
4 Chapter 1: Introduction
and described differences in health outcomes in rural health communities
(Commonwealth of Australia, 2009; NSW Ministry of Health, 2014). We know that
solving the disparities in rural health outcomes is complex, and the causes can be
related to numerous factors, including workforce issues, organisational culture,
educational, professional, socio-demographic and community issues (Bourke et al.,
2012; Commonwealth of Australia, 2012; Humphreys & Gregory, 2012).
Indicators of health and health outcomes are now regularly and publicly reported
on websites, reports and in data sets and can be examined and analysed to understand
health system performance (Australian Institute of Health and Welfare, 2017a; Bureau
of Health Information, 2018a; Bureau of Health Information, 2017, 2018c). But can
innovation be linked with performance? In a study of a public organisation by Mafini
(2015), a strong positive relationship between organisational performance and
innovation was noted. Likewise, research by Lee, (2015) found that there were positive
relationships between process innovations and organisational performance.
Innovation is required to make improvements in health settings, both in
metropolitan and rural settings, and the literature review identified studies that describe
the antecedents and determinants for innovation in health and characteristics of high
performance health care organisations (Fleuren, Paulussen, Dommelen, & Buuren,
2014; Fleuren, Wiefferink, & Paulussen, 2004; Greenhalgh, Robert, Bate, Macfarlane,
& Kriakryidou, 2005; Taylor et al., 2015). The factors from the literature that enable
innovation have been comprehensively described in Chapter 2, which describes the
literature review undertaken for this research.
Models of care that work well in urban systems may not be applicable to the
rural setting. The simple application of models tested in metropolitan health services
to rural settings is often inappropriate because of variations in health need and service
delivery capability. The access to staff, resources, organisational structures and other
contextual factors can be unique to each health setting. Every organisation also has
their own ‘uniquely patterned’ culture linked to the context and nature of tasks being
performed (Braithwaite, Ellis, Churruca, & Long, 2018). This can be particularly true
in rural health settings where ‘governance, management, level of autonomy, models
of care, the needs of service providers (given recruitment/ retention difficulties) and
local staff, infrastructure and culture. This results in heterogeneous organisations that
both enable and constrain health care, practice and change in different ways’ (Bourke
et al., 2012, p. 500). What is required are innovative approaches that aim to achieve
5 Chapter 1: Introduction
quality health outcomes using methods suitable for the rural context. Some of the
challenges found in rural health settings can be addressed through the adoption of new
technologies, such as e-health, innovative models of care and connected services. So,
it is important for rural health care settings to build organisational cultures that support
the adoption of innovative practices, enable creativity and seek to achieve performance
at a standard to meet the expectations of funders, the community and clinicians.
Performance of health systems is imperative as consumers of health services
want to ensure that they experience safe care, when and where they need it, at a
reasonable cost (Pronovost, 2017). Health expenditure consumes a significant amount
of Gross Domestic Product (GDP) and in countries such as Australia with a growing
burden of chronic disease and an ageing population, performance and cost is of
concern to the consumers and funders of health (Duckett et al., 2014; Duckett &
Willcox, 2015).
The review of the literature conducted for this research revealed that
performance and the measurement of performance for health care organisations is ill-
defined with no consistent definition (Ahluwalia, Damberg, Silverman, Motala, &
Shekelle, 2017; Pronovost, 2017). Performance has been described using measures
such as access, equity, cost, patient experience and the quality of care (Ahluwalia et
al., 2017; Pronovost, 2017). Taylor et al. (2015) defined high performing hospitals as
those that consistently attained excellence across multiple measures of performance
and multiple departments. Dias and Escoval (2013) provided an alternate definition,
that high performance is the achievement of specified targets, either clinical or
administrative. Definitional issues and the reasons for performance reporting, and
challenges in the measurement of performance will be described more fully in the
literature review in Chapter 2.
1.1.1 Purpose
If innovation as outlined above is a possible solution to sustain Australian health care
systems, then it is important to understand how innovation occurs in rural health
settings. The simple application of urban solutions to rural areas is often inappropriate
as the significant variations in health needs and service capability requires novel
solutions. New approaches are necessary to address well documented and described
differences in health outcomes in rural health communities. Some of the challenges
6 Chapter 1: Introduction
can be addressed through the adoption of new technologies, such as e-health,
innovative models of care and connected and integrated care. Others require the
application of existing technologies in new and innovative ways.
The intent of this study was to examine how innovation occurs in rural health
settings and to identify the factors contributing to sustaining them. Second, the
researcher wanted to determine how performance can be measured in rural health
settings and how a comprehensive picture of performance might be described.
1.1.2 Study design
A case study was the selected research methodology concurrently conducting both
qualitative and quantitative studies. A case study methodology was carefully chosen
to provide a rich and deep understanding of the complex and multidimensional topics
under study. The Workplace Innovation Scale (WIS) was used to measure the
innovation culture in the study site. At the same time, the contextual and organisational
factors for innovation were explored using semi-structured interviews with clinicians
and managers. An investigation of what performance might look like in rural settings
and how that might be measured was achieved by examining publicly reported
performance information and key strategic documents from the health service and
local health district website. The reason for combining both quantitative and
qualitative data was to better understand the research problem posed by converging
the broad numeric trends, gathered by the WIS, the study of performance data and the
detailed views reflected in the narrative data collected at interview (Cresswell, 2009a).
1.2 CONTEXT AND SETTING FOR RESEARCH
The case study site was based in a rural health service in northern NSW. The service
studied is approximately four hours south of Brisbane and provides a range of services
to support and treat the health of the population residing in the surrounding valley.
This health service was chosen pragmatically due to its proximity to the researcher and
willingness and support for the research by hospital executives. While undertaking the
research study, in (2016) the hospital was identified as a high performer by the Clinical
Excellence Commission NSW, and staff were interested to understand this further.
7 Chapter 1: Introduction
Three independent studies were conducted using a mixed-method approach. The
studies were conducted concurrently and collected qualitative and quantitative data.
Data analysis from interviews, surveys and publicly reported performance data and
documents was performed by the researcher to understand how innovation in rural
health settings occurs and to ensure that the study findings were reliable and valid.
Case study methodology is about seeing something as a whole (Thomas, 2016;
Yin, 2014). In this research, a case study enabled the researcher to understand how
and why innovation and high performance occurs through an in-depth exploration
(Ketokivi & Choi, 2014; Thomas, 2016; Yin, 2014). The scope of the study was limited
to one identified ‘high performing’ health service (Clinical Excellence Commission,
2016). In addition, due to the volume of data, complexity and possible variables
collected, and to gain a holistic view, it was judicious to study one rural health service.
The service under study was located in a Remoteness Area 2 (RA2) classified city in
NSW (Australian Government Department of Health, 2016a). The Commonwealth of
Australia (2012, p5) noted the importance of inner and outer regional health services,
such as the case study site, as they play ‘a key role in providing a hub for health care
for rural and remote communities, including preventative health care, specialist
outreach and emergency retrieval services, infrastructure and training centres’.
The case study health service studied in this research was chosen pragmatically.
While it could be potentially biased in terms of revealing a leadership willing to adopt
innovation, the barriers and enablers that have been identified in the study are likely
to be consistent across similar health services, although perhaps expressed in different
ways or levels. The findings may be transferable to other settings or could be applied
or adapted in other rural health settings, and to support innovation and efforts to
strengthen performance.
A case study methodology allowed the researcher to carry out a thorough inquiry
of the rural health care organisation. (Crowe et al., 2011; Thomas, 2016; Yin, 2014).
This methodology allowed the researcher to determine what happens when rural health
settings innovate, and how and why it happens (Thomas, 2016). Case studies are
particularly well suited to answering ‘how’ and ‘why’ questions.
Multiple sources of evidence were gathered in line with best practice case
study research (Silverman, 2017; Thomas, 2016; Yin, 2014). Case studies using
multiple sources and evidence types permit data triangulation (Gray, 2014; Yin,
2014). Gathering various sources of evidence and examining the case study
8 Chapter 1: Introduction
organisation from different angles can provide a three-dimensional picture or a
‘polyhedron of intelligibility’ (Foucault, 1981, as cited in Thomas, 2016).
Validity and reliability are critical considerations in any study (Cresswell,
2009; Silverman, 2017). To ensure these attributes, three studies were conducted, and
the researcher applied quantitative and qualitative methods. These studies provide a
broad picture of the contextual and organisational factors that explain how rural
health services innovate.
1.3 AIM OF THE RESEARCH
Using a case study methodology and collecting data in a rural health setting, this
research investigated the organisational and contextual factors that affect the adoption
and sustainability of innovation in rural health settings. The research aimed to provide
an understanding of how innovation occurs in rural health settings and how
performance might be defined and measured, and to discover new knowledge to
inform rural health settings and policy-makers interested in fostering greater
innovation and performance measurement and reporting.
1.3.1 Research questions
The questions that underpin this research were:
1. What factors affect innovation and high performance in rural health
organisations and how do they exert their influence?
o How does innovation occur in rural health settings?
o How can high performance be enabled in rural health settings?
2. How could the factors that are identified be addressed, to unleash
innovative solutions to improve rural health service performance?
The specific research objectives were:
1. To identify the factors that impede or facilitate the adoption of innovation in
rural health settings.
2. To explore how those factors exert their influence in rural health settings.
3. To identify potential for greater adoption of innovation in rural health settings
to contribute to improved performance.
9 Chapter 1: Introduction
1.4 SCOPE AND DEFINITIONS
Case studies collect vast amounts of data (Yin, 2014), and the topics of innovation and
performance have been well described in the literature. Consequently, the management
of the scope of the research was fundamental to the conduct of the study. The purpose
of this study was to understand the contextual and organisational factors that enable
innovation and high performance in rural health settings. Key terms and abbreviations
have been defined in the Glossary. Numerous definitions were identified in the
literature review for innovation and high performance.
While there was no singular definition of what performance in health is or agreed
measures (Ahluwalia et al., 2017; Pronovost, 2017), three definitions were considered.
Dias and Escoval (2013) defined performance as the achievement of specified targets,
either clinical or administrative, and suggested that a high performing health system is
one that is able to achieve its purpose, while Taylor et al. (2015, p. 1) applied the
definition that ‘High performing hospitals consistently attain excellence across
multiple measures of performance, and multiple departments’. Pronovost’s, and Dias
and Escoval’s definitions were considered too oblique, and Taylor et al. (2015)
definition selected. Consequently, multiple measures of performance for the case study
organisation were analysed in this research.
Public reporting of health information for transparency, accountability and for
clinicians to action to improve care is well recognised (Board & Watson, 2010). In
Australia, health information is routinely reported by Commonwealth and state
governments (Bureau of Health Information, 2018a; National Health Performance
Authority, 2016). While this data is publicly available and accessible, presenting this
information in ways that can show performance across multiple measures across time
is not easily achieved. This study has gathered, analysed and tested how this data can
be compiled in ways that can demonstrate to clinicians, health service managers and
patients the performance of a particular health service over time and multiple measures
in line with Taylor et al.'s (2015) definition. Novel methods to present the information
using visualisation tools have been developed and applied.
The critical analysis of the literature revealed that the topic of innovation has
been widely researched. Much has been written about the precursors to innovation,
determinants, antecedents and factors related to the adoption, sustainability and
10 Chapter 1: Introduction
diffusion of innovation (Crossan & Apaydin, 2010; Damanpour & Aravind, 2012;
Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004; Greenhalgh et al., 2017;
Greenhalgh et al., 2005). To manage the scope of the study, the research focussed on
what key authors described as the ‘inner context’ or ‘inner setting’ constructs of
innovation (Allen et al., 2017; Damschroder et al., 2009; Greenhalgh et al., 2004;
Greenhalgh et al., 2005). This is the ‘organisational context as it influences the
adoption, spread and sustainability of innovations’(Greenhalgh, 2005, p. 134).
Greenhalgh et al. (2004) and (2005) explain that the ‘inner context’ is both the ‘hard’
mediums of organisational structure and the softer ways of working, such as climate,
culture, knowledge sharing, leadership, infrastructure and resources. Similarly, Allen
et al. (2017) and Damschroder et al. (2009) mention cultural, networks and
communication and structural factors as characteristics associated with the
implementation and adoption of innovations. The definition for innovation that has
been adopted in this study is that innovation is the ‘generation, development, and
implementation of new ideas or behaviours’ (Damanpour, 1996, p.694). Innovations
might be new products, processes or services, technologies, organisational structures
or administrative systems, or new plans or programs (Damanpour, 1996). Importantly,
these new behaviours or ideas should be directed at improving health outcomes, cost
effectiveness, administrative efficiency and user experiences, and implemented
through coordinated and deliberate actions (Greenhalgh et al., 2004).
1.5 RESEARCH GAP AND CONTRIBUTION TO KNOWLEDGE
This research has established how innovation can occur in a rural health setting. The
critical review of the literature that follows determined that while there is an abundance
of research on the determinants and/or antecedents of innovation, and the
dissemination and sustainability of innovation, there are few empirical studies on
innovation in rural health settings. Studies were identified that linked innovation to
performance; however, there were no studies that explored innovation and
performance and how that occurred in the rural health setting.
In 2011, the public reporting of hospital performance data was mandated in an
effort to increase health care provider accountability and transparency so that
consumers can make decisions about their health; however, until recently this has
attracted little research (Canaway, Bismark, Dunt, & Kelaher, 2017a, 2017b, 2018).
11 Chapter 1: Introduction
Public reporting is also intended for doctors, nurses, academics, health service
managers, journalists and the community (Australian Institute of Health and Welfare,
2018). Research on performance measurement in rural health settings has received
little academic scrutiny.
1.5.1 Impact
In Australia, research impact is now based on the ‘contribution that research makes to
the economy, society, environment or culture, beyond the contribution to academic
research’ (Australian Research Council, 2018). Others note that the impact of
qualitative research should be described in terms of the intellectual, social and political
significance of the research (Lamont & White, 2005, as cited in Silverman, 2017).
The Australian Research Council and bodies such as the United Kingdom’s Research
England emphasise that impact should be considered at the outset of and efforts
focussed on translating research findings into better outcomes for society such as job
creation, policy underpinned by research and new programs (Australian Research
Council, 2018; Research England, 2019). The impacts from this study are shown in
Table 1-1.
Chapter 1: Introduction 12
Table 1-1 Research impacts
Domain Performance Innovation
Knowledge/
Intellectual
The study has identified new ways of analysing and interpreting
publicly reported and available performance information.
This can be used to provide a comprehensive and holistic picture
of performance in other rural health settings. Identification that
sense making of publicly reported data requires consolidation and
visualisation of the data items.
The factors enabling innovation in rural health have
been determined. Rural health settings do not have the
factors that previous studies have concluded as
important such as size (large), dedicated resources and
departmental differentiation (Greenhalgh et al., 2004;
Greenhalgh et al., 2005).
The culture in rural health settings is open to and has
the propensity for further innovation.
Health Measurement of performance can lead to improvements in health
outcomes, accountability and transparency (Canaway et al.,
2017a). A comprehensive scorecard for innovation has been
recommended by this study to support health services in
identifying trends and areas of focus for safety and quality
improvement initiatives.
Sustainability of health systems with an increasing
burden of disease and ageing population is critical for
Australia’s health care system. Determination of the
enabling factors for innovation in rural settings will
enable others to advance innovative practice.
Social Evidence of those wanting to recruit and attract to the rural
environment of the performance of a health service across
multiple measures. Improved performance gained by
understanding measures can lead to higher quality patient
experiences and quality and safety.
Evidence of potential for innovation in rural health
settings and recognition of the intellectual strengths
and creativity of those who live and work outside of
metropolitan cities.
Economic/Political Being rural adds a unique perspective, depth of understanding of
expressed experiences and perspectives and allows rural
researchers to achieve more informed or advanced study (Farmer,
Munoz, & Daly, 2012). This study was conducted by a researcher
who collected a comprehensive set of data drawn from informants
who live and work in the rural context.
Innovation and the uptake of innovation in rural health
settings can reap economic benefits to health care
organisations and rural health communities.
Innovations can reduce costs through the adoption of
technology, new processes and services or involve the
introduction of more efficient models of care delivery.
Chapter 1: Introduction 13
1.6 THESIS OUTLINE
The introduction has explained the background and reasons for the research and
presents the case for the research on how innovation occurs and is enabled in rural
health settings. Gaining a further understanding of meaningful performance
measurement and reporting in rural health settings has also been studied. The thesis
has been organised using chapters that include an extensive and critical review of
seminal and current literature. A significant proportion of the thesis describes the
research methodology, analysis and conclusions. The thesis concludes with a set of
recommendations and a process for disseminating the findings of the research. Table
1-2 shows the chapter structure for the thesis.
Table 1-2 Thesis chapter structure
Chapter Content
1 Introduction to the research and overview of the study
2 Literature review
3 Research methodology and design
4 Results Study 1: Analysis of publicly reported performance information
and documents
5 Results Study 2: Semi-structured interviews
6 Results Study 3: Workplace Innovation Scale
7 Analysis and discussion
8 Recommendations and conclusions
To understand the research gaps and to inform the design of the research, a
critical review of the literature is provided in Chapter 2. The chapter that follows has
critically analysed and synthesised current and seminal literature related to
innovation and high performance.
Chapter 2: Literature Review 14
Chapter 2: Literature Review
‘Success depends on intuition, on seeing what afterwards proves true but
cannot be established at the moment.’ Joseph A. Schumpeter, credited as the father
of innovation.
2.1 INTRODUCTION
Chapter 1 outlined the rationale for the research. A critical analysis of the literature
was used by the researcher to ‘frame’ the problem studied and to determine the scope
of inquiry (Cresswell, 2009; Gray, 2014). This chapter synthesises the literature and
describes the relevant theories in innovation, the enablers and barriers to innovation
adoption and sustainability, and the determinants and antecedents to innovation. The
literature review identified the dimensions of innovation culture. Factors such as
intention, resources, human infrastructure for innovation, the cultural environment and
support for innovation, and the knowledge and orientation of employees towards
adoption and their propensity for creativity and learning can all impact upon the degree
to which organisations successfully innovate. To understand performance
measurement in rural health settings the literature review examined the argument for
performance reporting, definitions of high performance and determined the status of
performance measurement.
The results of the literature review informed the design of the research, scope of
inquiry, definitions, confirmed the research gaps and provides an overview of previous
research.
2.1.1 Structure and scope of the literature review
The literature review was structured around the research and secondary research
questions and gaps in researcher knowledge about methods and data collection tools.
This is shown below in Figure 2-1, and the scope of the literature review is focussed
around these topics.
Chapter 2: Literature Review 15
Figure 2-1 Structure of literature review topics examined
Scope
The literature review focused on the topics listed below.
• Innovation, high performance and performance measurement in health
• Contextual and organisational factors in rural health
• Barriers and enablers of innovation
• Antecedents and determinants of innovation
• Measures of innovation and performance
• Case study as a research methodology.
To inform the conduct of this research the following approaches to locate
relevant sources from the literature were applied:
• Systematic search of Scopus and Emerald databases for academic studies
• Snowballing from significant articles
• The literature review was also informed by the grey literature as the subject
matter of this study is an emerging area of inquiry.
• A weekly alert from BMC Health Services Research was reviewed and
relevant articles included.
Additional papers were sourced to inform the researcher on case study
methodology and the contextual and organisational challenges in rural health service
delivery.
Chapter 2: Literature Review 16
The literature review discusses the background to the research, the factors
driving innovation, innovation theory, determinants and antecedents of innovation,
links between performance and innovation, measurement of performance and
innovation, and the key theories that will be used in this study.
2.1.2 Rural health challenges and the disadvantage in rural health services
Rural communities are disadvantaged in terms of health outcomes and their access to
health services. For the 30% of Australians who lived in rural and remote areas in
2012, the Australian Institute of Health and Welfare (2014) reported that this group of
citizens tend to have shorter lives, higher rates of disease and poorer health outcomes.
These outcomes occur across a range of social, employment, income and educational
opportunities and backgrounds.
Challenges in rural settings are also exacerbated by issues such as lack of health
professional staff, access to health care, relationship-based services and community
sustainability (Farmer et al. 2012). While relationships are fundamental to the delivery
of health care (Shelllner, 2007), health workers in rural settings are particularly
impacted, as even outside of work ‘they are never off duty’ (Farmer, Munoz, &
Threlkeld, 2012, p. 187) and their assumptions of individuals with respect to their
health can be limiting (e.g. in delivering care to Indigenous Australians). Workforce
shortages in rural and remote locations are extensively described in the literature
(Bourke, Humphreys, Wakerman, & Taylor, 2010; Bourke, Waite, & Wright, 2014;
Humphreys & Gregory, 2012; Schoo, Lawn, & Carson, 2016). Other challenges
include a lack of financial and human resources, the ageing of the local health
workforce, and the professional development and supporting health services necessary
to provide comprehensive patient care (Bourke et al. 2012). Hage et al. (2013) relate
that rural communities have unique issues associated with ageing with the out-
migration of working adults from rural to urban areas and the in-migration of former
urban dwellers at retirement age. Humphreys and Gregory (2012) argue that rural
health is a national priority and more focus on rural health and fairer resource
allocation would provide the opportunity to support infrastructure, work force and the
services needed for rural health and well-being. These issues are not unique to
Australia, and similar issues are experienced in Canada, the United States, the United
Kingdom and Europe.
Chapter 2: Literature Review 17
Bourke et al. (2012) noted that solutions to rural health challenges tend to be
reactive and suggest a conceptual framework to better understand specific rural and
remote health situations. In particular, they focus on power and spatial isolation, and
state that comprehending rural health ‘requires understanding geographic isolation and
the rural space as it impacts on and is constructed by the rural locale (the local services
shaped by geographic isolation, local actors and broader systems)’ (Bourke et al.,
2012, p. 501). Similarly, Schoo et al. (2016) propose that solutions should move away
from narrow strategies and policy and focus on integrated approaches that
acknowledge the interplay of the organisation, community and the roles of professions
in rural health settings.
Others suggest that rural health research is ‘stuck’ on the challenges
experienced by rural health settings (Farmer et al., 2012). They state that researchers
need to look further than ‘how do we get doctors’ as the key solution to rural health
(Farmer, Munoz, & Daly, 2012). Humphreys (as cited in Farmer, Munoz, &
Threlkeld, 2012) notes that there is a need to progress rural health research from
simply more study of how to recruit doctors to intellectually challenging, robust and
future-oriented studies that fundamentally address the roots of the challenges of
improving health and providing services in rural locations. Bourke et al. (2010) argue
that remote and rural health researchers have greater opportunities to understand
community level factors. These researchers argue that a ‘problem-describing’ rather
than ‘problem-solving’ approach to remote and rural health that focuses on a deficit
approach leads to a narrow and singular focus on what rural and remote lacks. They
also convey that ‘there has been scant attention to the innovative health care models
and systems that are working well in rural and remote areas’(Bourke et al, 2010, p.
206). A deficit approach is challenged by Bourke et al. (2010), who state that
solutions might be found by comprehensively understanding rural identities,
activities, models of care and the potential for change through innovation.
When examining the grey literature, key government bodies and stakeholders
have had a focus on rural health and the challenges in delivering services to rural
communities. Innovation was also observed as a topic of interest. Innovation, use of
evidence-based decision-making and the adoption of technology is mentioned in
Commonwealth and state health departments’ values and mission statements. These
values for the health services and the documented strategies in policy and strategy
documents require health services to be agile and flexible to adapt to new policy and
Chapter 2: Literature Review 18
reform requirements. The Commonwealth Department of Health related that the
challenge is to design, deliver and support rural and remote health services using more
flexible, innovative, and locally appropriate solutions, without compromising the
quality and safety of services (Commonwealth of Australia, 2012).
Australians spend a lot of money on health through tax, private insurance
premiums and direct payment for items such as medication (Australian Government
Productivity Commission, 2017; Duckett et al., 2014; Productivity Commission,
2015). While it is agreed that the Australian health system generally produces good
outcomes by international standards, it has been observed that there is room for
improvement (Australian Government Productivity Commission, 2017; Duckett et al.,
2014; Duckett & Willcox, 2015). The measurement of performance and efficiency in
the health system is complex. Variations and opportunity for improvement in the
Australian health care system are evidenced by:
• complications as a result of a stay in hospital (Duckett et al., 2018);
• the variation in costs for similar procedures across Australian Hospitals,
taking into consideration differences in hospital and patient
characteristics (Duckett et al., 2014);
• variable and often inappropriate care (Runciman et al., 2012)
Successive reports by the Productivity Commission describe areas for efficiency
gains, including the introduction of a quality and safety dimension to pricing and
payment of health services within activity-based funding (Australian Government
Productivity Commission, 2015, 2017). A further area examined by the Productivity
Commission (2015) was workforce reform actions that involve role expansions to
create greater workforce flexibility, potential for reduced labour costs, improved
patient access and higher workforce satisfaction. Managing costs, volumes and
sustaining the quality of health services is a key driver for innovation in the health
industry.
2.2 FACTORS DRIVING INNOVATION
In Australia, the sustainability of our health system is of concern as the population
ages and the burden of chronic disease continues to increase. Changing patient needs,
technological advances, budgetary cuts, sustainability issues, the growth in chronic
diseases and an unstable operational landscape have been identified as drivers for
Chapter 2: Literature Review 19
innovation in the health sector (Akenroye, 2012). There is no shortage of ideas for
improvement in the highly professionalised and educated health industry (Tomson,
2009). Akenroye (2012) cites Berwick’s observation that in health it is not the scarcity
of innovation but the adoption and dissemination of innovation concepts that is the
problem.
In 2015, the Australian Government announced a National Innovation and
Science Agenda that recognised that innovation is important in every sector of the
economy including health care (Commonwealth of Australia, 2015). Technological
and other innovations could have huge potential to improve health, attract and retain
rural physicians, and strengthen access in rural and remote locations (Snowden &
Cohen, 2012).
In a study conducted by Akenroye (2012), the factors driving innovation in the
National Health System (NHS) in the United Kingdom were examined. A conceptual
framework was derived for exploring the forces for innovation in the health sector,
including sustainability, technological changes, budget cuts, long-term health
problems and changing patient needs. In Canada, the United Kingdom, Germany,
Australia and globally, shifts in population demographics and costs and fragmentation
in health care delivery models are driving innovation and health reform (Snowden &
Cohen, 2012). Reforms to the Australian health care system has long been touted to
strengthen and ensure the viability of health systems and funding (Duckett & Willcox,
2015). If the health system is to reform as suggested, new ways of working and
innovation will be required to successfully translate from policy to practice.
2.3 INNOVATION AND INNOVATION THEORY
The literature identified many academic papers on innovation and innovation theory.
This part of the literature review critically examines the history of innovation and
identifies key definitions to be used in this research.
2.3.1 History, types and definitions for innovation
The topic of innovation is vast, and innovation has been of interest since the 1770s
with new ways of business emerging (Salter & Alexy, 2013). Salter and Alexy (2013)
note that the French Revolution confirmed the impressions of Samuel Johnson that
innovation was a compelling force through a significant innovation introduced in the
Chapter 2: Literature Review 20
early 1790s, the ‘guillotine’. Innovations that are sustained usually make an
improvement to the way that ‘things are done’. This is true in the health sector where
innovations will be sustained if the new ways of working make it easier or reduce
workloads. The guillotine has been described as a very successful innovation as it was
used until 1977 – 200 years after it was developed. The guillotine was a successful
innovation as it was regarded as being more efficient than previous execution methods
as it was instantaneous in action and pain free (Salter & Alexy, 2013).
Innovation has been studied at the level of industry, the firm and the individual,
and many factors impact upon the uptake and sustainability of innovation and
innovation behaviours (Damanpour, 1996; Greenhalgh et al., 2005). Innovation has
been identified by many authors as a driver of economic growth and necessary for
creating value for patients and the consumers of health care (Dobni, 2008; Wilson-
Evered, Härtel, & Neale, 2001). Damanpour (1996, p. 694), an early and seminal
researcher on innovation, defined innovation as the ‘generation, development, and
implementation of new ideas or behaviours’. We often think of innovations as new
technologies or breakthroughs; however, the literature review revealed that there are
many different types of innovation. Innovations might be new products, processes or
services, technologies, organisational structures or administrative systems, or new
plans or programs (Damanpour, 1996). Johannessen (2013, p. 1195) used a definition
for innovation, first coined by Wyckoff (2004), as the ‘application of new ideas with
the aim of creating value’. Importantly, these new behaviours or ideas should be
directed at improving health outcomes, cost effectiveness, administrative efficiency
and user experiences, and implemented through coordinated and deliberate actions
(Greenhalgh et al., 2004).
The health industry provides millions of services each year in general practices,
hospitals, pathology and imaging centres, pharmacies, aged care, primary health and
other settings (Australian Institute of Health and Welfare, 2014). Service innovation
has wide appeal and application in health and the potential to have huge impact.
Johannessen (2013) notes that service innovation has two categories – tangible and
intangible service products. In the health industry this might be new treatments or
models of care, and intangible products, such as change of attitude, change in service
experiences for patients and consumers, or change in communication styles or
methods. During the literature review numerous examples of innovation in health
were described and include the adoption of checklists to reduce infections, hospital in
Chapter 2: Literature Review 21
the home, day of stay surgery, e-government/ehealth and of course technological
innovation such as robotics. These innovations have reduced complications, allowed
hospitals and health care settings to manage increased demand for services, reduced
length of stay and provided greater accessibility through enabling technology such as
teleconsultations.
In the literature, it has been noted previously that the pursuit of innovation is a
worldwide agenda. In Europe, governments interested in innovation in public sector
organisations describe a typology of innovations (Bloch & Bugge, 2013). According
to the Oslo Manual (OECD/Eurostat, 2005), there are service innovations, service
delivery innovations, administrative and organisational innovations, conceptual
innovations that involve new ideas and views, policy innovations and systemic
innovations (Bloch & Bugge, 2013).
Damanpour in (1996, p. 693) noted that empirically developed theories of
organisational innovation are not adequately descriptive ‘despite continued scholarly
effort in the past three decades to understand both the innovation process and the
conditions under which innovation is facilitated’. Rogers’ model of innovation
adoption has over the past 30 years been widely used and discussed since the theory
was first described in 1962 (Kapoor, Dwivedi, & Williams, 2014; Pashaeypoor,
Ashktorab, Rassouli, & Alavi-Majd, 2016; van Oorschot, Hofman, & Halman, 2018).
Rogers’ work identified five characteristics of innovation that influence whether they
are adopted (Rogers, 1983). Rogers’ innovation adoption curve with early adopters
and laggards is widely known (Rizan, Phee, Boardman, & Khera, 2017) and still taught
in business and other schools. Studies have described how in the health industry
innovation is disseminated, the processes for adoption, the determinants and
antecedents for innovation (Chaudoir, Dugan, & Barr, 2013a; Crossan & Apaydin,
2010; Fleuren et al., 2004), and the factors that support innovation uptake and spread
(Greenhalgh et al., 2004; Greenhalgh et al., 2005). Early work by Greenhalgh (2005)
on innovation dissemination in health continues to be extensively referenced today
(Kapoor et al., 2014; National Health System, 2018; Rapport et al., 2018; van Oorschot
et al., 2018) and is recognised as a significant and seminal work. Some aspects have
been updated in her more recent work (Greenhalgh et al., 2017).
The literature review identified that the effectiveness of innovation depends on
the organisational context – culture, leadership, and team dynamics (Dodgson, Gann,
Phillips, & Phillips, 2013; Harrison et al., 2014); Körner, Wirtz, Bengel, & Göritz,
Chapter 2: Literature Review 22
2015). Importantly, these factors can be more important underpinnings for innovation
than resourcing (Rao & Weintraub, 2013). In a pivotal paper by Kimberly and
Evanisko (1981), organisational level variables – size in particular – were determined
to be the best predictors of technological and administrative innovations in a health
care setting. Damanpour and Aravind (2012), Greenhalgh et al. (2004) and Greenhalgh
et al. (2005) all concurred that size (large) of an organisation is a determinant for the
uptake and sustainability of health innovations. These studies document numerous
antecedents and determinants for innovation that may or may not be present in rural
health settings; for example, the size of rural health services (small), little
differentiation/specialisation, a lack of administrative intensity, smaller allocations
and discretion in resourcing, as well as managerial attitudes towards change and risk.
Mariano and Casey (2015) relate that after the introduction of innovation,
organisations can experience increased costs, lowered levels of organisational
performance and reduced competitive advantage, and question whether innovation in
organisations is always a good thing. This study found that to avoid the negative
impacts of innovation, managers need to recognise incompatibilities between
innovation and prior organisational knowledge, and should promote the acquisition of
new knowledge by members of the organisation (Mariano & Casey, 2015).
The literature review elucidated that innovation can be changes to models of
care, services, policy or the introduction of new technologies (Bloch & Bugge, 2013;
Greenhalgh et al., 2005). Schumpeter, who is identified as the father of the study of
innovation, suggests that most innovations are combinations of elements that already
exist. This might involve the development of new technologies and processes or ways
of organising. Innovation may be transformative or incremental, and the literature
outlines the strengths and weaknesses of each approach (Dobni, Klassen, & Nelson,
2015; Witell, Synder, Gustaffson, Fombelle, & Kristensson, 2016). Incremental
innovations can have significant effects (Johannessen, 2013; Salter & Alexy, 2013).
Examples of incremental innovations with large impacts are increased passenger
throughput at ports such as Heathrow from 5 million to 50 million per year over 30
years with only two runways (Salter & Alexy, 2013). Over the last decade, in the
Netherlands, innovations to primary care funding and the introduction of primary care
physician cooperatives has been successful in satisfying patient needs for after-hours
care with 90% of patients visited in their homes within an hour of calling and a
reduction in incidents of suboptimal treatment (Snowden & Cohen, 2012).
Chapter 2: Literature Review 23
Greenhalgh and her colleagues in their major text published in 2005 provided a
comprehensive systematic review of over 1,000 papers. The review was focused on
synthesising research on the diffusion, spread and sustainability of innovation in health
service organisations. This was the most comprehensive and significant work
identified in the literature that specifically examined innovation in health service
organisations. The resulting book provides a conceptual model for understanding
innovation diffusion and notes that inner and outer contextual factors can influence the
success or not of innovation (Greenhalgh et al., 2005). The next section of the literature
review will describe the factors fostering innovation in the health industry and the
antecedents for innovation.
2.3.2 Determinants and antecedents of innovation
Synthesis of the literature identified that successful innovation involves several
factors. Different models and frameworks for innovation in the literature explain how
innovation occurs. Rao and Weintraub (2013) describe six building blocks of an
innovative culture, resources, processes, values, behaviours, success and climate.
Dobni (2008) related that innovativeness is a more complex multidimensional
construct grounded in service, process, cultural and infrastructure aspects. Greenhalgh
and colleagues, in an often cited study, described a multilevel conceptual model for
the determinants of diffusion, dissemination and implementation of innovation
(Greenhalgh et al., 2004; Greenhalgh et al., 2005). Key findings from the critical
analysis of these studies and others describing the determinants and antecedents of
innovation are presented in this section of the chapter.
To foster innovation Rao and Weintraub argue that resources, processes and
the measurement of success are given attention, but lesser attention is given to the
harder to measure people-oriented determinants of innovative cultures such as
values, behaviour and organisational climate (Rao & Weintraub, 2009, 2013).
Dobni's (2008) study ascertained four general dimensions of innovation culture: the
intention to be innovative, the infrastructure to support innovation thrusts, knowledge
and orientation of employees to support thoughts and actions for innovation, and the
context for innovation.
Greenhalgh et al. (2004, 2005) synthesised more than 1,000 papers and found
that in health service delivery organisations certain structural determinants have a
Chapter 2: Literature Review 24
positive and significant association with organisational innovativeness. The
conceptual model derived for the diffusion, dissemination and implementation of
innovation based on this systematic literature review described the system
antecedents for innovation, innovation specific, implementation process, readiness
for innovation and other factors. The model devised was then tested on four case
studies (Greenhalgh et al., 2004) and has been elaborated upon in later work
(Greenhalgh et al., 2017). Table 2-1 shows the determinants having a positive and
significant association with organisational innovativeness.
Table 2-1 Determinants with positive and significant association with
organisational innovativeness as adapted from Greenhalgh, Macfarlane, Bate,
and Kyriakidou (2004)
Determinant Definition
Administrative intensity Indicator of administrative overhead and level of
administrative support
External communication Degree of organisation member’s involvement and
participation in extra-organisational professional
activities
Complexity Specialisation, functional differentiation and
professionalisation of the workforce
Functional
differentiation
Extent to which the organisation is divided into
different units
Internal communication Extent of communication among organisational units
Managerial attitude
toward change
Extent to which manager or members of the dominant
coalition favour change
Professionalism Professional knowledge of an organisation’s members
Slack resources An organisation’s resources beyond minimal
requirement to maintain operations
Specialisation Number of an organisation’s specialties
Technical capacity Reflects an organisation’s technical resources and
potential
Specifically, the inner contextual factors of their model convey that an
organisation will adopt innovations more readily if it is large (in size), is functionally
differentiated into small autonomous departments, is mature, has high quality data
systems and strong leadership with a clear vision, and has resources to channel into
innovation and decentralised decision-making processes. Greenhalgh et al. (2004,
2005) explain that large size and organisational complexity promote the adoption of
innovation as these determinants enable specialised expertise to develop and that there
are critical masses of problems that demand solutions. Similarly, environments that
Chapter 2: Literature Review 25
are changing or heterogenous facilitate innovations as these organisations and their
cultures are exposed to new ideas imposed from outside in contrast to stable
environments (Greenhalgh et al., 2005)
Crossan and Apaydin (2010) describe leadership, managerial levers and business
processes as determinants of innovation as well as impediments to innovation such as
conflict, lack of infrastructure and external disruption. From a systematic review of the
literature they constructed a multidimensional framework for innovation. Their study
identified professionalism, organisational structure, strategy, organisational learning,
positive climate and financial resources as determinants of innovation (Crossan &
Apaydin, 2010).
Johannessen (2013) studied key theorists (Miller’s theory of living systems and
systemic thinking, North’s action theory and Asplund’s moderation theory) to explain
aspects of institutional innovation. The resulting paper describes a systematic
innovation theory based on a series of propositions and their implications for
innovation and entrepreneurship. Johannessen (2013) proposed that innovations could
be promoted by reward systems, a culture supportive of innovation and organisational
learning. The aspects of innovation described were similar to those identified in other
studies (Crossan & Apaydin, 2010; Dobni, 2008; Greenhalgh et al., 2005).
2.3.3 Sustainability and diffusion of innovation
A large study by a research team led by Greenhalgh and published in 2004 and 2005
identified the ‘critical success factors’ for the spread and sustainability of innovations
in an organisational setting (Greenhalgh et al., 2005; Greenhalgh et al., 2004). In their
work they differentiated diffusion (passive spread), dissemination (active and planned
efforts to persuade target groups to adopt an innovation), implementation (active and
planned efforts to mainstream an innovation within an organisation), and sustainability
(making an innovation routine until it reaches obsolescence) (Greenhalgh et al. 2005;
Greenhalgh et al. 2004). Greenhalgh and colleagues showed the linkage between the
outer and inner contexts of organisation and their influence on the diffusion and
sustainability of innovation. Their literature review provided a list of innovation
attributes that predict successful adoption. They also note that research on innovation
in the service sector and the influence of internal politics such as the doctor–manager
Chapter 2: Literature Review 26
power relationship was conspicuously absent in the empirical body of work they had
studied.
Sarto and Veronesi (2016) examined the evidence around the assumption in
health that clinician involvement in governance and management can lead to greater
efficiency and effectiveness in health care organisations. The study examined
scientific papers from studies of health settings from the United States, Germany, Italy
and the United Kingdom. Non-financial and financial performance dimensions were
examined, and the authors concluded that ‘greater clinician participation at the
strategic decision-making level potentially has a wide range of benefits for
hospitals’(Sarto & Vernosi, 2016, p. 85). While acknowledging that their study
focussed on Anglo-American settings and was based on a small number of papers in
the European context, they concluded that benefits of clinician involvement include
improved quality of care and performance (Sarto & Veronesi, 2016).
Lerro (2012) describes an innovation cycle underpinned by managerial actions
and tools and that is reliant upon an organisation’s intellectual capital resources,
innovation capacity and capabilities and ability to translate innovation into actions.
Lerro (2012) assumes that innovation results should lead to improved performance and
acknowledges that the health industry has huge intellectual capital resources; however,
it is renowned for its inability to translate innovation into results.
2.4 CONTEXT AND THE ROLE OF PLACE IN INNOVATION
Context is defined in the Australian Oxford and Macquarie Dictionaries as ‘the
circumstances relevant to something under consideration’ (Australian Oxford
Dictionary) and ‘the circumstances or facts that surround a particular situation, event,
etc.’ (Macquarie Dictionary, 2017)
Numerous studies convey that contextual factors can influence the effectiveness
of quality improvement innovations in hospital systems. Kimberly and Evanisko
(1981) determined that organisational level variables – size in particular – were a good
predictor of innovation. Studies have also identified that inner contextual factors are
responsible for innovation uptake and sustainability; these include size, slack resources
and administrative intensity. However, in rural health settings these factors are not
always present as they are small and can have little redundancy in human and financial
resourcing, and have few administrative support officers.
Chapter 2: Literature Review 27
Studies in the literature report that organisational context influences the adoption
of innovation initiatives such as the implementation of ‘Lean’ (Harrison et al., 2014)
and the uptake of technologies (Greenhalgh et al., 2017). In earlier work, Greenhalgh
et al. (2004, p. 604) related that ‘different organisations provide widely differing
contexts for innovations, and a number of features of organisations (both structural and
“cultural”) have been shown to influence the likelihood that an innovation will be
successfully assimilated (i.e. adopted by all relevant individuals)’. If we think about
rural health services and their context, Wakerman (2009) relate that sustainability
models of rural health service delivery must be appropriate to the context and be able
to change and adapt to new environmental factors.
Kimberly and Evanisko (1981) noted that the literature around innovation and
contextual factors is voluminous and examined the effects of variables from three
different levels: individual, organisational and contextual factors. Their study focussed
on the introduction of innovations and identified that organisational level variables and
size were better predictors than individual or contextual level variables.
Kringos et al. (2015) studied the relationship between effectiveness of hospital
quality improvement strategies and analysed the importance of contextual factors. In
this study of 56 systematic reviews, organisational characteristics were demonstrated
to influence the adoption of quality improvement strategies. They examined a number
of domains, including culture, learning climate and leadership engagement, and
document both facilitators and barriers (Harrison et al., 2014).
Context was demonstrated to shape change outcomes of e-health
implementations in rural settings in a study by Hage et al. (2013). Their study aimed
to identify implementation factors that enable or restrain the adoption of e-Health. This
study concluded that new technology innovations to support rural health sustainability
can fail ‘due to underestimating the implementation factors involved and the
interactions between context, process and content elements of change’ (Hage et al.,
2013, p. 14).
All organisations have unique cultures (Braithwaite et al., 2018), and this will
impact upon their performance and ability to innovate. Contextual factors were shown
to influence the implementation of patient safety interventions (Kringos et al., 2015;
Ovretveit et al., 2011; West & Lyubovnikova, 2013). The extent to which an
organisation can be regarded as innovative will be influenced by contextual influences
(Dobni, 2008).
Chapter 2: Literature Review 28
2.5 LINK BETWEEN PERFORMANCE AND INNOVATION
‘It is essential that health care delivery systems innovate at scale to optimise
performance. Achieving successful and sustainable improvements across complex
health systems is, however, difficult.’ Wutzke et al. (2016 p. 327)
Health care is complex and hospitals have distinctive characteristics when compared
to other industries (Lee, 2015; Wutzke et al., 2016). Lee (2015) conveys that for
hospitals, their goals are to provide the best services to patients and employees,
improve operational efficiency, reduce costs and apply advanced technologies to
internal and external functions. Defining and measuring performance in health was
addressed in the literature review and is discussed later in the chapter. In this section,
the findings from the literature that link innovation with performance are presented.
Few papers were identified that directly linked innovation and performance in
health, and evidence linking innovation to performance is scant (Dias & Escoval,
2013). Surprisingly, ‘little is known about the nature of innovativeness in healthcare
organisations and its relationship with performance’ (Moreira et al., 2017, p. 355).
Mafini (2015) conducted research in a public organisation and demonstrated a strong
positive relationship between organisational performance and innovation, and inter-
organisational systems and quality. Crossan and Apaydin (2010) stated that ‘linking
innovation outcomes with performance is critical in addressing whether and how
innovation creates value’. They cited other management scholars and related that
‘innovation capability is the most important determinant of firm performance’
(Crossan & Apaydin, 2010).
Moreira, Gherman, and Sousa, (2017) conducted a study motivated by a desire
to learn whether innovation influences performance in health care institutions. They
established that service and process innovation influences operational performance but
could not assert that innovation in health care led to improved financial performance
(Moreira et al., 2017). A study by Lee (2015) found that there were positive
relationships between process innovations and organisational performance, supporting
the findings of Moreira et al. (2017). Similarly, work by Dobrzykowski et al. (2015)
that tested innovation orientation to patient satisfaction results found that a hospital’s
innovation orientation positively impacts patient satisfaction, a measure used
Chapter 2: Literature Review 29
internationally as an indicator of health system performance (Hibbert, Johnston, Wiles,
& Braithwaite, 2015).
Dias and Escoval (2013) critically analysed the relationships between innovation
and performance in the public health system in Portugal and explored the drivers of
performance improvement through innovation. Their study used a range of techniques,
including a survey, interviews and nominal group technique to better understand the
relationship between innovation and organisational performance. A conceptual
framework was used in their study and included the variables of flexibility, innovation
and performance (Dias & Escoval, 2013). The framework resulted in four clusters of
health care organisations: innovative and efficient, innovative but not (as) efficient,
not innovative but efficient, neither innovative nor efficient. This study suggested that
the factors necessary to improve performance through innovation in the public health
sector were organisational, financial and cultural changes (Dias & Escoval, 2013). The
authors concluded that it is possible to improve performance through different
organisational structures and processes but that certain organisational principles are
also required. These include an emphasis on the breakdown of hierarchical structures,
fostering cooperation across departments and prominence given to the delegation of
authority (Dias & Escoval, 2013).
When critically evaluating the literature, some authors argued that innovation
does not always have a positive impact upon performance. Organisational
dysfunction can result when innovations are introduced and the new knowledge is
incompatible with previous knowledge (Mariano & Casey, 2015).
2.6 MEASUREMENT OF INNOVATION AND PERFORMANCE
This part of the literature review defines high performance and how performance in
health can be measured. The methods for measuring innovation and performance were
also investigated and the literature review informed the selection of quantitative tools
and the framework for the semi-structured interview questions.
2.6.1 Measures of innovation
Many potential instruments for measuring the organisational determinants and culture
for innovation were found in the literature. Measures include the Innovation Quotient,
Chapter 2: Literature Review 30
WIS, Short Form Learning Organisation Scale, Open Innovation Climate Scale,
Innovation Culture Scale and others (Danks, Rao, & Allen, 2017; Dobni, 2008;
McMurray, Islam, Sarros, & Pirola-Merlo, 2013; Rao & Weintraub, 2009; Singer,
Moore, Meterko, & Williams, 2012). Nelson et al. (2014) suggest that measurement
of innovation is difficult as innovative practices, strategies, and other phenomena are
not always amendable to discrete measurement. Their article questions whether
innovation measures can measure innovation, and while not drawing any definitive
conclusions, they note that it is important to use multiple measures.
Research by Danks et al. (2017) described the existing instruments to define and
measure innovative cultures. This study evaluated the instruments against the criteria
of validity, reliability, parsimony, and interpretation and user-friendliness. The 10
instruments identified measured innovation culture, innovation capability, innovation
climate, innovativeness or a related construct (Danks et al., 2017). Danks et al. (2017,
p 449) tested the Innovation Quotient Survey developed by Rao and Weintraub (2013),
concluding that due to a lack of ‘discriminate validity and reliability across
organisational groups’ additional tools are needed. Research conducted by Allen et al.,
(2017) evaluated innovation measures and concluded that few measures have
demonstrated reliability or validity.
A critical assessment was made of tools and their applicability for this research.
Assessment of identified tools was made based on validity, reliability and a
manageable number of items in the tools to aid completion by clinicians and hospital
staff. Some tools were ruled out for use as they were designed to measure innovation
across systems or sectors or before or after the introduction of innovations.
The work by Dobni (2008) tested an innovation culture scale based around seven
factors designed to be used both descriptively and diagnostically. Four general
dimensions to innovation culture were described, these being an intention to be
innovative, infrastructure to support innovative ideas, orientation and knowledge of
employees to support innovation, and context that supports innovation (Dobni, 2008).
The innovation culture scale produced from this study has been validated with 86 scale
items that can be used to measure an organisation’s innovation culture (Dobni, 2008).
This scale was evaluated for this study; however, it was not applied due to the large
number of scale items. This measurement tool, however, was used to shape the
questions asked of informants in the semi-structured interviews that were conducted.
Chapter 2: Literature Review 31
A validated scale to measure innovation was developed by McMurray and Dorai,
(2003) and the instrument has been widely tested. McMurray et al. (2013) used the
WIS to measure innovation culture in not-for-profit organisations in Australia. The
tool showed high internal reliability of measures. This tool has been used in six
different countries over the past 12 years or so and has demonstrated high reliability
levels (McMurray, 2017). Of the scales assessed, this scale possessed a manageable
number of dimensions and questions and from a pragmatic perspective aided
completion by survey respondents. Based on the findings of the literature review, the
WIS developed by McMurray et al. (2013) was selected for use in this research. All
tools examined and reasons for selection of the WIS are fully explained in the Research
Design chapter of this thesis (Chapter 3:).
2.6.2 Measurement of performance
In the literature, it was evident that there is an interest in protecting patients from harm,
ensuring that our hospitals are delivering safe care at a cost that is acceptable to payers
and sustainable in an environment of rising demand for health care services (Board &
Watson, 2010; Chalmers, Ashton, & Tenbensel, 2017). Measurement of performance
against agreed standards and comparison with peers are ways that hospitals can be
assessed.
While controversial, measurement of performance in health using a range of
indicators is now an accepted practice. Public performance measures are routinely
reported in Australia through the MyHospitals website and organisations such as the
Bureau of Health Information in NSW. This is the picture internationally, as well
(Mannion et al., 2005; Ovretveit, 2011), with Hibbert, Johnston, Wiles, and
Braithwaite (2015) identifying 34 organisations from 12 countries having key roles in
health care performance and public reporting.
Public reporting of health information for transparency, accountability and for
clinicians to action to improve care is well recognised (Board & Watson, 2010). In
Australia, health information is routinely reported by the Australian and state
governments (Bureau of Health Information, 2018a; National Health Performance
Authority, 2016). Reporting of performance has been shown internationally to exert a
powerful effect in accelerating improvements in health services (Canaway, Bismark,
Dunt, Prang, & Kelaher, 2018a; Leeb, 2018). State- or national-level figures average
Chapter 2: Literature Review 32
out the differences between local areas and conceal which hospitals or health providers
are doing particularly well and identify services where improvements may be
necessary. Hospital-level ‘reporting gives health managers, patients and others the
knowledge they need to see where improvements can be made’ (National Health
Performance Authority, 2016). Much has been written in the literature about the types
of performance indicators used, barriers to indicator collection, disincentives to
reporting and how the information can be used (Canaway et al., 2017a, 2017b;
Canaway, Bismark, Dunt, & Kelaher, 2018; Canaway, Bismark, Dunt, Prang, &
Kelaher, 2018b; Leeb, 2018; Lynch, 2015).
The literature review identified a range of definitions for ‘performance’ but no
single definition of what ‘high performance’ constitutes was able to be identified
during the literature review. While there was no singular definition of what
performance in health is, or agreed measures (Ahluwalia et al., 2017; Pronovost,
2017), three definitions were considered. Pronovost (2017) suggested that a high
performing health system is one that is able to achieve its purpose. Dias and Escoval
(2013) conveyed that hospital performance may be defined according to the
achievement of specified targets, either clinical or administrative, while Taylor et al.
(2015, p. 1) used the definition that ‘High performing hospitals consistently attain
excellence across multiple measures of performance, and multiple departments’. This
is the definition adopted, and multiple measures of performance for the case study
organisation were collected and analysed in this research.
In Australia, all public hospitals collect and contribute data to state and national
data sets from which performance data is routinely reported on sites such as the
Australian Institute of Health and Welfare, NSW Bureau of Health Information and
My Hospitals. Australia’s health system performs well when measured against other
health systems (Marchildon, Ludlow, Boyling, Braithwaite, & Philippon, 2018). Since
2009 in Australia, a National Health Performance Framework has been in place and
routinely measures the performance of hospitals against measures of equity, quality,
safety, appropriateness and effectiveness (Australian Institute of Health Innovation,
University of NSW, 2013). While Australia has strong health data collection and data
sets, there is no single data collection to determine whether our health system works
in optimal ways (Srinvasan et al., 2018). Consequently, to measure performance across
multiple measures and time periods requires significant data analysis and manipulation
by consumers, clinicians and researchers.
Chapter 2: Literature Review 33
While their work was focussed around primary health service evaluation, Reeve
et al. (2015) identified that data routinely collected by health services can be used to
develop indicators to evaluate health service performance and be linked to
achievement of health outcomes. Board and Watson (2010, p. S93) implore that we
use the abundant information that we currently collect to ‘focus clinical quality, patient
centredness and safety of care in hospitals’ while Hanson (2011) urges that good health
information is central to informing the delivery of care.
Mannion et al. (2005, p. 431) note that ‘the quality and performance of health
care organisations are receiving increasing scrutiny in most countries’. This includes
both quantitative systems such as report cards, league tables and other rating systems,
and through qualitative assessments such as accreditation and inspections. Their
project used case studies to examine the complex interplay between culture and
performance and sampled both high and low performing Health Trusts in the United
Kingdom. The study conducted by Mannion et al. (2005) examined cultural
characteristics of high and low performing Trusts and focussed on the chief executive,
leadership style, senior management team turnover, accountability, rewards,
information systems, performance management, recruitment policies and taboos.
While they urge caution in the interpretation of their findings, they conclude that
‘strong, information-based systems of accountability, empowered middle management
and pro-performance values seem to be important underpinnings of a clearly
articulated corporate strategy’ (Mannion et al., 2005, p. 438). Importantly, leadership
that can communicate vision and follow through at the transactional level is a
requirement for strong performance in health care organisations. This is supported by
work by Curry et al. (2013), who identified the importance of organisational values
and goals, problem-solving and learning, and senior management involvement as
being present in high performing hospitals caring for patients with acute myocardial
infarction.
Aboumatar et al. (2015) conducted a national study of high performing hospitals
with a focus on patient-centred hospital care. The study reported that leaders and
clinicians actively worked together in the high performing organisations studied.
Further, organisational context and culture emerged as a common theme in their study
and was noted to be linked to success in high performing hospitals. The study
identified selected approaches to drive improvement, including use of data,
communication strategies such as rounding, hospital-wide education programs,
Chapter 2: Literature Review 34
recognition of high performance teams, incentives for high performance and
development of new hiring policies (Aboumatar et al., 2015). Braithwaite et al. (2018)
suggest that hospital performance is related to the pace of hospital life as measured by
length of stay, patient satisfaction and adverse events. This article argues that to
achieve best performance, hospitals need to work under conditions of intermediate
pace, what they referred to as the ‘Goldilocks’ zone, and they are undertaking further
research to validate their theory (Braithwaite et al., 2018).
The literature review identified tools and frameworks for measuring innovation
and innovation culture. In contrast, tools for the measurement of hospital performance
were not considered as robust or plentiful. In Australia, accreditation is a widely
adopted system for certifying the quality of health care organisations. This is a
standards-based rather than an outcome-based approach. Bodies such as the Australian
Council on Healthcare Standards survey health care organisations according to
National Safety and Quality Health Service Standards (ACHS, 2018). The value of
accreditation and linkage to performance was noted in the literature review
(Accreditation Canada, 2015; Braithwaite et al., 2010; Greenfield & Braithwaite,
2008). A study by Braithwaite et al., (2010) observed that leadership behaviours and
cultural characteristics show a positive trend between accreditation and clinical
performance. Australia has a long history of accreditation, dating back to the 1970s,
with improvements and iterations to the process and mechanisms for measurement.
Recently, the standards delineated by the Australian Commission on Quality and
Safety in Healthcare have been refined and now focus on systems and processes that
will reduce harm and drive high quality health outcomes (Australian Commission on
Quality and Safety in Healthcare, 2018).
The literature review uncovered various awards and recognition systems used
internationally for high performing health care organisations. The Malcolm Baldridge
National Quality Award is a program used in the United States to define and measure
the components of quality in efforts to improve organisational performance (Foster,
Johnson, Nelson, & Batalden, 2007; Shields & Jennings, 2013). The Malcolm
Baldridge Award Program surveys health organisations and measures progress
towards defined standards. The results of the surveys are then used to assess the
performance of the organisation, learn what can be improved, and focus on
strengthening cultural and communication aspects that the workforce feels are most
needed (National Institute of Standards and Technology, 2016). Of note, a number of
Chapter 2: Literature Review 35
studies described this award and how it can be used, but the literature review did not
elucidate any empirical validation studies of the survey tools (Foster et al., 2007;
Shields & Jennings, 2013; Van Der Wiele, Millen, Whelan, & Section, 2000).
Taylor et al. (2015, p.1) use the definition that ‘high performing hospitals
consistently attain excellence across multiple measures of performance, and multiple
departments’. Taylor et al. undertook a qualitative systematic review of the literature
to identify high performance hospitals and what ideas and factors are important for
success. Their study utilised a ‘range of process, output and outcome and other
indicators to identify high performing hospitals’(Taylor et al 2015, p. 1). The study
identified seven themes that represent key factors associated with high performance.
These were ‘positive organisational culture, senior management support, effective
performance monitoring, building and maintaining a proficient workforce, effective
leaders across the organisation, expertise driven practice and interdisciplinary
teamwork’(Taylor 2015, p. 7).
In contrast, a study by Shwartz et al. (2011) demonstrated that there are
challenges in identifying high performing hospitals and warns that composite
measures of performance that take into account multiple components may not
recognise individual strengths and strategic priorities of individual organisations. This
study argues that when using multiple performance measures, there are only a small
number of hospitals that can be clearly classified as high performing. The research
concludes that ‘despite the lack of correlation among widely available hospital
performance measures, it is still reasonable to calculate a composite measure of
performance’ (Shwartz et al., 2011, p. 306).
Studies across industries also suggest that the systematic use of high-
performance work practices could improve the quality of care in health care
organisations (Garman, McAlearney, Song, & McHugh, 2011; McAlearney, Robbins,
Garman, & Song, 2013). Garman et al. (2011) and McAlearney et al. (2013) describe
the concept of high performance work practices as those practices that have been
shown to improve the capacity to attract, develop and retain high-performing
personnel. These practices include performance-driven reward and recognition;
information sharing; communicating mission, vision and values; mentoring; teams;
and decentralised decision making with training linked to organisational goals –
similar to the cultural dimensions and factors described by Dobni (2008).
Chapter 2: Literature Review 36
2.6.3 Challenges in the measurement of performance
Lynch (2015) critiqued health system performance measurements and noted that there
is a managerial belief that well-managed health systems lead to the good use of public
funds. The article stated that performance measurement is regarded as a necessary
prelude to performance management and that both activities are considered to be tools
for increasing the effectiveness and efficiency of health systems (Lynch, 2015). A
number of authors have identified concerns with performance measures and
measurement practices that can lead to dysfunctional and unintended consequences
(Lynch, 2015; Mannion & Braithwaite, 2012). International studies have found that
while performance measurement is important and can have benefits such as reducing
waiting times, they can lead to unplanned outcomes in health care organisations such
as bullying and gaming misplaced incentives, and they should be interpreted in light
of ‘local contexts’ (Aryankhesal, Sheldon, Mannion, & Mahdipour, 2015).
Shahian et al. (2016) observed that some performance cards are flawed and that
this fosters cynicism and distrust of performance measurement in general. This article
notes that patients and providers deserve transparent performance measures that are
valid, and that doctors and hospitals should be held accountable for the care they
provide. Flawed measures are meaningless and may harm health stakeholders,
including patients (Shahian et al., 2016). The findings are supported by Mannion and
Braithwaite (2012), who concluded that performance measurement can be
strengthened by the inclusion of different types of measures (process, structure,
clinical outcomes, appropriateness, resource use, patient-reported outcomes and
experience of care), data sources (registry, electronic health record), data quality,
attribution of patients to specific providers, robust risk adjustment, presentation
formats and the ability to monitor for unintended adverse consequences (Shahian et
al., 2016). While performance measurement is currently a topic of interest to the
funders, consumers and providers of health care, it has been claimed that health care
measurement is more than 250 years old (Loeb, 2004). While we know that the
measurement of health care quality seems simple, agreement around appropriate
measures, quality of data, data integrity, consumer perspectives and risk adjustment
are all challenges (Loeb, 2004). Importantly, this author noted that a significant part
of the challenge in measuring performance in health care is the variable perspectives
among key stakeholders. Loeb (2004, p. i5) stated that ‘measurement is not a neutral
activity’ and invokes anxiety and frustration. This is supported by Arnaboldi et al.
Chapter 2: Literature Review 37
(2015) and Mannion and Braithwaite (2012), whose articles both describe pitfalls and
unintended consequences. Arnaboldi et al. (2015) wrote that the single largest pitfall
for performance management systems is the negative side-effect of undermining
motivation and morale and related that further research is required in this difficult,
complex and testing area.
While data quality and integrity may be challenges to performance measurement,
considerable work since the time of Loeb's (2004) paper on measurement and data
quality and integrity has been published in the academic literature. Hanson (2011) and
Board and Watson (2010) argue that we need to use the abundant information that we
have and that this will elucidate quality issues and consequently result in better data to
inform and improve the quality of health care in Australia.
In Australia, broad indicators of health system performance, outcomes, cost and
quality in hospitals and other settings are now routinely and publicly reported. It is
acknowledged that public reporting of information can improve the quality of care that
is provided (Australian Commission on Safety and Quality in Healthcare, 2014;
Australian Institute of Health and Welfare, 2017b; Board & Watson, 2010; Leathley,
Gilbert, Kennedy, & Hughes, 2010).
In 2011, the public reporting of hospital performance data was mandated to
increase health care provider accountability and transparency so that consumers can
make decisions about their health. Until recently, public reporting of hospital
performance has attracted little research (Canaway et al., 2017a, 2017b; Canaway,
Bismark, Dunt, & Kelaher, 2018). Public reporting is also intended for doctors, nurses,
academics, health service managers, journalists and the community (Australian
Institute of Health and Welfare, 2018). An evidence check conducted by the Sax
Institute, prepared by Hibbert et al. (2015), analysed 34 organisations from 12 studies
and examined how health care performance was conducted, how data were presented,
what was presented, timeliness of data and presentation styles. This study showed a
wide range of approaches to public reporting of health performance data.
The Australian Institute of Health and Welfare collects a vast amount of health
information and routinely reports on the health of Australians and their health systems.
Publicly reported data on hospital performance is accessed via the MyHospitals
website, but it is still a work in progress with some of the planned indicators not in use
and not all hospitals are reported (Hibbert et al., 2015; National Health Performance
Authority, 2016). Studies by Freeman (2002) and Hibbert et al., (2015) have also
Chapter 2: Literature Review 38
documented the unintended consequences and key lessons for public reporting. This
includes gaming, pursuit of short-term targets, deliberate manipulation of data, the
need for clarity and different reports depending on the intended audience, and the need
for timely data.
Accreditation and standards-based measures
In addition to the performance measures described above, there are many examples of
standards-based processes used to assess health care systems. These approaches have
been comprehensively documented and well-argued and were not in scope for the
literature review but are included for completeness. Examples are shown in Table 2-2.
Table 2-2 Accreditation bodies by country
Body Description Country
Australian Council on
Healthcare Standards
(Australian
Commission on Quality
and Safety in
Healthcare, 2018)
EQUip and National Safety and
Quality Healthcare Standards
developed by the Australian
Commission on Safety and
Quality in Health Care
(ACSQHC).
Accreditation standards
Australia/International
National Institute of
Standards and
Technology
Baldridge Performance
Excellence (Foster et al., 2007;
National Institute of Standards
and Technology, 2016; Shields
& Jennings, 2013)
United
States/International
Accreditation Canada
(Accreditation Canada,
2017)
Qmentum Accreditation
Standards
Canada
Joint Commission on
Accreditation in
Healthcare (Joint
Commission, 2017)
Accreditation standards United
States/International
European Foundation
for Quality
Management (Shaw,
2000)
Accreditation standards
International standards
organisation
Europe
2.6.4 Examples of high performing health care organisations in the literature
During early phases, the researcher was interested to determine which health care
organisations had been identified as high performing and the measures on which that
determination was made. Papers in the literature were examined, and Appendix A
Chapter 2: Literature Review 39
shows all health care systems recognised as examples of high performance located in
the literature review. This analysis and the evidence from the literature reviewed
showed that there is no single agreed measure for performance for hospitals and health
care systems. Organisations mentioned in this synthesis are listed in Table 2-3.
Table 2-3 Selected examples of high performing health systems identified in the
literature
Examples of high performing health
care organisations in the literature
Measures of performance
Jonkoping County Council Efficiency, timeliness, safety, patient
centredness, equity and effective
(Baker, 2011b; Scoville, Little,
Rakover, Kuter, & Mate, 2016).
Intermountain Health Care Reduction of mortality and readmission
rates of congestive heart failure and
ischemic heart disease (Baker, 2011b;
Scoville et al., 2016).
Mayo Clinic Hospital
Duke University Hospital
Vanderbilt University Medical Centre
Virginia Mason Medical Centre
Process of care measurements together
with Hospital Consumer Assessment of
Healthcare Provides and Systems and
mortality scores (Chatfield & Byrd,
2017).
Mayo Clinic
Massachusetts General Hospital
Henry Ford Health System
Scripps Clinic
Intermountain Health Care
Award winners and measured high
performance, literature citations,
Previous research and field experience,
Expert opinion, best within best (E.
Nelson et al., 2002).
2.7 CASE STUDY RESEARCH
In health service research, Rapport and Braithwaite, (2018) boldly predict that
qualitative research will move from a third paradigm of multimethods to a fourth
paradigm characterised by research conducted in real-time settings using exploratory
approaches and emerging data types.
Case study research is one type of social science research and the preferred
method when the main research questions are how or why questions (Yin, 2014). Case
studies investigate a single or a small number of cases (Thomas, 2016; Yin, 2014). A
case study allows a holistic and multifaceted view and is a valid scientific form of
inquiry provided that the research is carried out rigorously (Gray, 2014; Silverman,
2017; Thomas, 2016; Yin, 2014). What distinguishes case studies from other forms of
Chapter 2: Literature Review 40
inquiry is that they study naturally occurring cases where the aim is not to control
variables (Gray, 2014; Thomas, 2016). A case study uses many different methods and
sources of data, looking at relationships and processes to enable the researcher to see
something in its completeness and allowing the researcher to gain a rich picture of the
case (Thomas, 2016; Yin, 2014).
Yin and others describe different types of case study design and methods for
categorisation of cases (Gray, 2014; Silverman, 2017; Thomas, 2016; Yin, 2014). Case
studies can be based upon single or multiple case designs (Gray, 2014; Thomas, 2016;
Yin, 2014). Robert Stake, a seminal author in this area in 2000, as cited in Yin (2014)
and Silverman (2017), related that there are three categories of cases: intrinsic,
instrumental and collective. The intrinsic case study is of interest and is an in-depth
exploration of the complexity and uniqueness of a particular organisation in a real-life
context (Simons, as cited in Thomas, 2016); and this assertion is supported by Yin
(2014) and Gray (2014). The intrinsic case is often exploratory in nature: through
seeing the depth and breadth of a case the researcher obtains a deep understanding
(Grandy, 2010). The intrinsic case is not without critics, and Silverman (2017) argues
that a single case is resisted by many qualitative researchers. The researcher can
alleviate concerns through the use of multiple sources of evidence to create a ‘chain of
evidence’, linking the study of the case to theoretical concepts and ensuring that the
researcher asks ‘what’ and ‘how’ (Silverman, 2017). To ensure rigour in case study
research, the design and methodology are important. Triangulation is one way that case
study researchers design for rigour and quality, and involves seeing things from
different viewpoints (Thomas, 2016), using multiple data sources and applying a range
of methodologies (Yin, 2014).
Case studies in health service performance and innovation have provided many
insights to inform policy and management (Mannion et al., 2005). The value of case
studies is well recognised in law, business and policy but less so in health services
research (Crowe et al., 2011). Crowe et al. (2011) argue that this approach can be well
suited in health and that the illustrative ‘case report or grand round’ has a long tradition
in health. Presentation of a detailed critique provides insights into aspects of the case
and can exemplify broader lessons that may be learnt (Crowe et al., 2011). According
to Thomas (2016), good case study research will comprise the subject or case and
apply an analytical framework.
Chapter 2: Literature Review 41
By using a case study research technique and by undertaking a detailed analysis
in the study site, valuable insights into the antecedents of innovation in rural health
setting have been identified. Limitations have been noted to the case study
methodology and include the generation of large volumes of data and the need to leave
adequate time for data management and analysis (Thomas, 2016; Yin, 2014). Debate
in the literature was evident regarding the merits of qualitative versus quantitative
methodologies and their rigour, validity and reliability (Baker, 2011a; Crowe et al.,
2011; Gillham, 2010). Academic texts and papers published on the topics of case study
and qualitative methods convey that case study research and qualitative methods can
be rigorous, valid and reliable provided that the risks are managed and proven
strategies are included in research study design (Gray, 2014; Liamputtong, 2013;
Silverman, 2017; Thomas, 2016; Yin, 2014).
To uphold one of the important characteristics of scientific research – that is,
transparency – case research must be made transparent by demonstration of what the
researcher has done and declaration that a formalised process was followed (Holton,
2007, as cited in Ketokivi & Choi, 2014). Other authors state that this clear and visible
‘chain of evidence’ ensures the validity and reliability of findings from case study
research (Thomas, 2016; Yin, 2014). The quality of a case study is dependent upon the
design and conduct of the study (Thomas, 2016; Yin, 2014). The rationale, theoretical
concepts and construction of the research will be fully described in the chapter on
research methods.
Setting aside the criticisms of case study research (Arundel & Huber, 2013),
there is strong support for its application to understand how and why certain
phenomena occur (Silverman, 2017; Thomas, 2016; Yin, 2014). Flyvbjerg (2006, p.
241) summarises this by stating that the ‘case study is a necessary and sufficient
method for certain important research tasks in the social sciences and is a method that
holds up well when compared to other methods in the gamut of social science research
methodology’. Other authors support this, noting a ‘renaissance’ in its use as a research
methodology (Crowe et al., 2011; Ketokivi & Choi, 2014). Proponents of case study
methodology argue that seeing something in its completeness and looking at
something deeply and from many angles is in fact the essence of good science
(Thomas, 2016). By getting up close and examining the case in detail, this kind of
research inquiry is now recognised as a valid research methodology (Cresswell, 2009;
Silverman, 2011, 2017; Yin, 2014).
Chapter 2: Literature Review 42
However, while case study research is well established in organisational
research, it is less common in health services organisational research ( Baker, 2011).
The case study approach does lend itself to complex health service research, and
Crowe et al. (2011) argue that it should be more widely considered in spite of the
challenges in conducting this type of research. Furthermore, case studies can be used
in health service research to explore and successfully understand the specific
experiences in particular contexts (Baker, 2011a).
2.8 RURAL HEALTH SERVICE RESEARCH
Health services research is an emergent field where currently there is a paucity of
research studies (Fox et al., 2014). Fox et al. (2015) argue that the findings from health
research should be synthesised to develop a health service research paradigm. Funding
of health service research by large funding bodies is limited in both support and grant
size, although there are some signs that this is changing. In 2017, it was noted that
there is now funding for centres of health service research excellence (National Health
and Medical Research Council, 2017a).
Bourke et al. (2010) stress the importance of rural research being based in the
rural setting. Through a detailed analysis of a health service located in a rural health
setting, this thesis will contribute to the research body of knowledge in health service
management, take a ‘problem-solving’ rather than’ problem-describing’ approach, and
provide a unique and authentic perspective to rural health research (Bourke et al.,
2010; Farmer, Munoz, & Daly, 2012).
2.9 THEORETICAL AND CONCEPTUAL FRAMEWORKS
Theories are used in mixed methods research to provide an orienting lens to shape the
types of questions that the researcher asks, to determine how data are collected and the
implications of the study (Cresswell, 2009a). Theories can be used in qualitative
studies to define and explain phenomenon (Silverman, 2011, 2017).
The comprehensive literature review identified theoretical frameworks that
explain rural health research, health innovation sustainability and diffusion, and
innovation determinants. Bourke et al. (2012) proposed a framework to better
understand specific rural and remote health situations. This is intended to provide a
Chapter 2: Literature Review 43
comprehensive understanding of rural health challenges unique to each setting. The
framework covers six concepts: geographic isolation, the rural locale, local health
responses, broader health systems, social structures and power (Bourke et al., 2012).
Fox et al. (2014) note that health services research is an emergent field and as such
requires strong theoretical links, and they suggest a framework for innovation
sustainability around five factors that include innovation specific, workforce,
organisation, political and financial factors.
A number of frameworks to analyse innovation and the determinants of
innovation were located in the literature (Chaudoir et al., 2013; Crossan & Apaydin,
2010; Dobni, 2008; Larisch, Isis, & Hidefjall, 2013). Dobni’s framework for
innovation culture was used to underpin and formulate the research questions directed
to known innovators, managers and clinicians in study 3. Larisch et al. (2013) studied
health care innovation systems in the Stockholm region. This study, while focused on
innovation in information systems, found mechanisms that block innovation include
the intrinsic fragmentation of health systems, lack of clear leadership, and inadequate
involvement of patients and health care professionals. The framework described how
product, process, and organisational and business innovations can be translated into
health care outcomes such as improved health, elevated safety, reduced inequalities
and higher efficiency (Larisch et al., 2013). Their study related that health care
innovations ‘aim to improve measurable indicators of healthcare, including quality,
health disparities, effectiveness, patient centredness, safety, timeliness’ (Larisch et al.
2013, p. 1223). They argue for stronger collaboration on innovation and the
involvement of academia, industry and institutional reform as necessary to successful
innovation (Larisch et al., 2013). Kimberly and Evanisko (1981) determined that
organisational-level variables – size in particular – was a good predictor of innovation;
they identified that inner contextual factors that are responsible for innovation uptake
and sustainability and explicitly mentioned size, slack resources and administrative
intensity. In rural health settings, these factors are not present as they are small, and
they have little redundancy in human and financial resourcing and few administrative
officers.
Dobni (2008) conveys that there are four general dimensions of innovation
culture. These dimensions are: (1) the intention to be innovative; (2) the infrastructure
to support innovation thrusts; (3) influence, or the knowledge and orientation of
employees to support thoughts and actions necessary for innovation; and (4) an
Chapter 2: Literature Review 44
environment or context to support implementation. The literature review has informed
the research study design and used the dimensions of innovation culture as described
by Dobni (2008). Dobni (2008) relates that innovativeness is a multi-dimensional
construct grounded in service, process, cultural and infrastructure aspects. Further, he
argues that the literature provides a very strong relationship between innovativeness
and culture. Dobni's (2008) study reported on a broad model of innovation informed
by other studies. To understand the cultural factors that support how and why
innovation occurs in the rural health setting under study, this framework has been used
to underpin the collection and analysis of the qualitative data. The dimensions studied
were based on Dobni’s work (2008) and are shown in Figure 2-2 below:
Figure 2-2 Domains of innovation culture as identified by Dobni (2008)
2.10 RESEARCH GAP
The critical analysis and synthesis of the literature, evidenced in the discussion above,
demonstrates that the body of knowledge on innovation, the factors that underpin
innovation and the diffusion of innovation in health is quite rich. However, significant
gaps in the literature remain. There is a paucity of research on innovation in rural health
settings and a lack of agreement on what constitutes high performance and how
performance can be measured meaningfully for rural health care organisations. While
Chapter 2: Literature Review 45
the literature review identified several articles linking innovation and performance,
there was little published in Australia or for rural health settings.
In recent years, Canaway and colleagues (2018b) have published on public
reporting of hospital performance data; they convey that there has been little research
focusing on this topic in Australia.
A number of authors also noted that while there is an abundance of evidence on
innovation in other industries, there is a scarcity of studies related to the uptake and
sustainability of innovation in health services (Fox, Gardner, & Osborne, 2014;
Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004).
The thorough review of the literature conducted for this doctoral thesis revealed
gaps in the knowledge base. The focus of this study was to determine the contextual
and organisational factors enabling innovation in rural health settings. Understanding
performance measurement and how publicly reported data can be used to gain a
comprehensive overview of performance in a rural health setting was also examined
in this research. The research gap is shown in Figure 2-3 below.
Figure 2-3 Identified research gap for this study
2.11 SUMMARY AND IMPLICATIONS
The contextual and organisational factors for innovation have been described in the
literature review. Performance measurement in health is topical, and there is growing
Chapter 2: Literature Review 46
interest in using hospital performance data to drive improvements and to increase
transparency (Canaway et al., 2017a; Canaway, Bismark, Dunt, Prang et al., 2018b).
The literature review revealed an apparent lack of research conducted in rural health
settings related to innovation and high performance.
This literature review has introduced the broad concepts and theories of
innovation. Why it is necessary for health system managers and funders to focus on
innovation and high performance has been justified. The review has also identified the
determinants of innovation and high performance within health organisations and an
understanding of the role of context in the uptake and adoption of innovative practices.
Context has been identified as an important influence on the dissemination of
innovation and sustainability. Rural health settings display unique contextual factors
that have been studied in this research.
Gaps were identified in the literature and include understanding how rural health
settings can enable and promote further innovation. Measuring performance in rural
health is a topic with scarce academic attention. A case study approach was used in
this research and the literature review has described the strengths and weaknesses of
this methodology. Strategies to ensure that the study is performed without bias or
methodological error were adopted by the researcher.
Chapter 3 describes in detail the design of the research study, methods utilised,
reasons for applying those methods, ethics and data management, analytical methods
and tools used, and approaches to ensuring the validity of the study findings.
Chapter 3: Research Design 47
Chapter 3: Research Design
‘The case study approach lends itself to in-depth, complex health service
research, we believe this approach should be more widely considered by researchers
… though inherently challenging, the research case study can, if carefully
conceptualised and thoughtfully undertaken and reported, yield powerful insights
into many important aspects of health and healthcare delivery.’ (Crowe et al., 2011)
3.1 INTRODUCTION
A case study methodology, collecting qualitative and quantitative data, has been
applied in this research to gain an in-depth appreciation of the organisational and
contextual factors in rural health responsible for innovation and high performance.
Case study is a valid research methodology provided that the design is based on solid
research approaches and that methods and data can be corroborated to ensure the
validity and reliability of the findings (Thomas, 2016; Yin, 2014). Case studies should
be used when researchers wish to answer a ‘how’ or ‘why’ question (Thomas, 2016;
Yin, 2014). A single case was chosen to gain a holistic and comprehensive
understanding of a particular case (Gray, 2014). A rural health setting and an
investigation of the unique factors contributing to innovation and performance justifies
what Stake (2005, as cited in Yin, 2014) describes as an intrinsic case study. The
intrinsic case study is of interest and is an in-depth exploration of the complexity and
uniqueness of a particular organisation in a real-life context (Simons, as cited in
Thomas, 2016, and supported by Yin, 2014, and Gray, 2014). The intrinsic case is
often exploratory in nature and through seeing the depth, breadth and complexity of a
case obtains a deep understanding (Grandy, 2010).
The rationale for the case study, the research methods and analytical
approaches applied in this study are described in this chapter.
3.1.1 Research design framework
Underpinning the study is theory on the antecedents and determinants of innovation,
innovation culture, and innovation sustainability and spread (Dobni, 2008; Greenhalgh
et al., 2005; Greenhalgh et al., 2004). The theory has been discussed in depth in
Chapter 3: Research Design 48
Chapter 2. From the literature review, relevant theory guided the research design and
selection of appropriate measurement tools to collect and analyse data for the three
studies conducted by the researcher.
3.1.2 Approach to critical inquiry and rationale for case study approach
Pragmatism is a philosophical approach to inquiry and has seen a recent resurgence as
it is an method of creating knowledge based on the reality of the world in which we
live and experience (Gray, 2014; Liamputtong, 2013). Pragmatists are concerned with
what works and solutions to problems (Cresswell, 2009). According to Coghlan and
Brydon-Miller (2014), pragmatism can be used to uncover contextual truth. While
critics argue that pragmatism lacks rigour and does not aim to uncover certainty, the
pragmatist can systematically bridge theory and experience (Coghlan & Brydon-
Miller, 2014). Pragmatists agree that research occurs in social, political and other
contexts, and for the mixed-methods researcher it enables analysis of multiple
methods, diverse views and assumptions, as well as different forms of data collection
and analysis (Cresswell, 2009). Prior theory has been used in this study to guide data
collection and analysis and this enables the researcher to confirm, refute or modify
principles (Gray, 2014).
To gain a holistic understanding of how innovation and high performance
occurs in rural health settings, pragmatism was the ideal approach to critical inquiry
for this study. The theory that has informed this research has been well described in
the literature review chapter. The approaches are shown diagrammatically below in
Figure 3-1.
Chapter 3: Research Design 49
Figure 3-1 Research framework and methodological approach
Case studies allow the researcher to explore in depth, people, places or events
at a particular time (Cresswell, 2009; Crowe et al., 2011). A case study approach was
the preferred research method and ‘is particularly useful to employ when there is a
need to obtain an in-depth appreciation of an issue, event or phenomenon of interest,
in its natural real-life context’(Crowe, 2011 p. 1). Case studies in health have been
applied to understand how organisations have implemented technology, governance
and safety systems, and new health services (Crowe et al., 2011). This research
technique can be used to contribute to knowledge of organisational, social and
political phenomena (Yin, 2014).
By using a case study research technique, valuable insights into the antecedents
of innovation in rural health setting were able to be identified. In the literature, case
studies in health have provided many useful insights to inform policy and
management (Edmondson, 2004; Mannion et al., 2005; Vandeusen Lukas et al.,
2010). The case study approach lends itself to complex health service research, and
Crowe et al. (2011) argued that it should be more widely considered in spite of the
challenges in conducting this type of research. Furthermore, Baker (2011) argued
that case study research can contribute to a more detailed understanding and
knowledge as to the ways that innovation can be embedded in organisations.
Limitations have been noted to the case study methodology and include the
generation of large volumes of data and the need to leave adequate time for data
Chapter 3: Research Design 50
management and analysis. Appropriate risk-management strategies were followed to
ensure that enough time to collect, manage and analyse the data were included by the
researcher in the timeline for this study.
The case study site was chosen pragmatically because of its size, location,
accessibility and the preparedness of service leaders to support the research. Support
from the Chief Executive for the research was obtained and there was a high degree of
interest in research of this type being conducted in the rural location chosen (see
Appendix B for letter of support). While this is potentially biasing in terms of revealing
a leadership willing to adopt innovation, the barriers and enablers identified in this
research are likely to be consistent across similar health services, although perhaps
expressed to different levels or in different ways. The cultural antecedents of high
performance and innovation identified by this study may be advanced in other rural
settings.
In addition, the health service had also been identified by the Clinical Excellence
Commission as a high performer, based on patient experience, safety culture and
patient safety metrics (Clinical Excellence Commission, 2016). This had piqued the
interest of staff and clinicians interested to understand further the contextual and
organisational factors responsible so that they could be replicated across the health
service.
3.1.3 Context of the case study location
The Case Study Hospital is part of the Northern NSW Local Health District. The case
study site, located in a rural city in northern NSW, is situated in rich farming country
adjacent to a major river. The population in 2012 was 51,346 for the city and
surrounding locale that the hospital serves. Population growth is slow and projected to
rise by .3% per annum to 2031 (Clarence Valley Council, 2015). Unemployment is
high, with 7.5% unemployed in the September quarter 2013. Health, education and
services are major employers (Clarence Valley Council, 2015). Access to tertiary
education involves travel and there is an out-migration of younger adults. A survey of
residents in 2011 identified that 17.2% of the population self-assessed their health as
fair or poor compared with 14.3% of NSW (North Coast Primary Health Network,
2017). The rate of hospitalisations per 100,0000 population for all causes in 2013–14
was considerably higher than NSW overall (North Coast Primary Health Network.,
2017); in particular, for smoking attributable hospitalisations, diabetes and chronic
Chapter 3: Research Design 51
obstructive pulmonary disease. Two hospitals are located within the Valley. The case
study hospital is the major centre and provider of health services to Valley residents.
A district hospital offers fewer services but is an integral and highly valued part of the
community.
The case study hospital is a level 3/4 base hospital providing care to over 12,500
in-patients every year. The hospital performs over 3,300 surgical procedures and sees
over 24,700 Emergency Department attendances annually. The case study hospital
provides a solid base of services and key specialty areas include surgery, medicine,
paediatrics, anaesthetics, orthopaedic surgery, emergency medicine, intensive care,
and obstetrics and gynaecology. There are no registrars and residents located on wards.
Specialist emergency department clinicians support career and junior medical officers
in the Emergency Department. Recruitment can be challenging, with gaps filled by
locum staff when leave or vacancies occur. The nursing workforce is the largest group
of clinicians, with an ageing workforce and retirement of many senior clinicians, some
of who have worked their whole career and trained in the case study hospital.
In a major planning document produced by the Northern NSW Local Health
District the retention and recruitment of skilled staff was noted to be a challenge across
the NSW health system, especially in rural areas (Northern NSW Local Health District,
2013). The plan stated that this will be compounded in the next 10 to 20 years as the
workforce ages and retires. Accordingly, the plan notes that workforce restructure and
reforms will be necessary as new training regimes are implemented, work practices
change driven by new therapies, models of care, clinical service redesign and
developments in information technologies (Northern NSW Local Health District,
2013). These changes will require health services to adapt, innovate and introduce new
practices and ways of working.
NSW Ministry of Health (2014), the lead government agency in the state where
the case study organisation is located, has an overarching vision to nurture a health
system that is innovative and fosters a learning organisation. The core values for NSW
Health are Collaboration, Openness, Respect and Empowerment (NSW Health
Education and Training Unit, 2018). Authors such as Foster et al. (2007). Rowe and
Cadzow (2014), and West, Lyubovnikova, Eckert, and Denis (2014) convey the
importance of core cultural values in achieving high quality health care. West et al.
(2014) state that to develop and nurture high-performance cultures it is necessary to
have in place leaders, leadership behaviours and leadership collaboration that is
Chapter 3: Research Design 52
aligned around ‘reinforcing the values, behaviours and practices that are core to the
desired culture’.
3.2 METHODOLOGY
3.2.1 Research design for the case study
In accordance with case study principles, multiple sources of evidence were
assembled. Case studies that utilise multiple sources of evidence enable the research
data that has been collected to be triangulated (Yin, 2014). This case study collected
various sources of evidence and examined the case study organisation from different
angles to gain what Foucault (1981, as cited in Thomas, 2016) described as a three-
dimensional picture or a ‘polyhedron of intelligibility’. This case study used both
quantitative and qualitative methods and different approaches to obtain data, and three
studies were conducted. Both quantitative and qualitative data were then analysed to
understand and explain how and why innovation occurs in rural health settings. The
first study was designed to gain background information and to understand how
performance in rural health settings can be measured using publicly available
information. Cross-checking and corroboration of the data collected in Studies 2 and
3 was performed to gain a complete picture of the contextual and organisational factors
responsible for innovation. Through synthesis and analysis of the data, the barriers and
enablers for innovation in the case study site and the issues associated with
performance measurement in the rural health setting were determined and the findings
presented in Chapter 7.
Study 1: Analysis of performance and cultural data publicly available and linked
to performance and innovation. Three streams of data were collected.
1. Performance data from publicly available data sources (MyHospitals and
Bureau of Health Information) were collected for the hospital to demonstrate
the quality and outcomes of care. Data were collected on access, timeliness,
sustainability, quality and cost of services. The data were analysed to identify
any factors that appear to influence performance and outcomes in the rural
health setting under study. Comparisons to peer hospitals of similar size and
service configurations were made.
Chapter 3: Research Design 53
2. Analysis of strategic documents to identify the level of organisational
commitment to performance and innovation and the way in which these
commitments are translated into action through strategic intent and
organisational climate. The Local Health District web-site was searched and
plans and Board minutes examined.
3. Analysis of organisational data from cultural and patient experience
surveys. Data from the NSW Government ‘People Matters’ Survey were
collected and analysed to understand cultural dimensions of performance,
engagement with work and communication compared with State and Local
Health District results (NSW Public Service Commission, 2018).
Study 1 determined the performance of the case study organisation, the focus on
innovation and high performance, and strategic intents around these topics.
Governance and organisational climate reflected in staff surveys was used to provide
insights to the researcher that informed the interviews conducted in study 2.
Study 2: Semi-structured interviews with key informants.
Executives, managers and clinicians were interviewed to identify the factors that may
influence attitudes to innovation and its adoption. The questions in this study were
derived from the work by Dobni (2008), who identified four dimensions associated
with innovation culture. Questions asked of the participants related to the contextual
factors to support innovation, the intention of the organisation to innovate,
infrastructure for innovation, and the knowledge and orientation of employees to
support innovation thrusts (Dobni, 2008). The questions directed to informants in the
case study site are attached in Appendix I.
Study 3: A survey of staff using the Workplace Innovation Scale (WIS;
McMurray et al., 2013)
A validated survey instrument, the WIS (McMurray et al., 2013) was selected to collect
information from staff within the case study organisation. The WIS identifies and
measures the behavioural aspects of innovation practices by individuals in their
workplace (McMurray & Dorai, 2003). The WIS can be used to measure innovation
culture and comprises four dimensions of organisational innovation, innovation
climate, individual and team innovation (McMurray et al., 2013).
Chapter 3: Research Design 54
The literature review identified tools for measuring innovation and innovation
culture, and the WIS chosen. This tool was carefully chosen due to its manageable
number of questions, validation of the scale, and that it had been used in six different
countries over the past 12 years and demonstrated high reliability levels (McMurray,
2017; McMurray et al., 2013). Permission from the author had also been attained in
the early stages of the research (McMurray, 2017). As part of the process of developing
the research protocol for the study, an assessment of tools for measuring innovation
culture was undertaken. The literature review identified many studies that described
tools to measure innovation or the determinants of innovation, such as innovation
culture, and organisational and structural characteristics for measurement. In this
study, the intention was to measure the innovation culture within the case study
organisation.
The linkage between the three studies, the analysis that has been performed and
the original research questions posed are shown diagrammatically in Figure 3-2.
Figure 3-2 Research design for the case study
3.3 PARTICIPANTS AND INFORMANTS
Informants for the interviews were from all disciplines in the case study site, including
executives, administration, medical, nursing and allied health clinicians. In rural
settings most clinicians have management and clinical roles and as such can provide a
unique perspective from both viewpoints. From an initial pool of 22 identified for
Chapter 3: Research Design 55
interview, 29 participants in total were interviewed. This allowed known innovators,
recommended by colleagues during interviews, to be included in the study. Twenty-
five interviews were transcribed for analysis due to technical issues with the quality of
audio recording for four of the interviews. No data was able to be used from the four
recordings due to poor quality of the sound recordings.
Participants in the WIS survey were opportunistically sampled and included
nurses, medical clinicians, allied health staff, managers, administrative and support
services staff in the case study hospital. From a population of 366 staff, a total of 66
surveys were completed.
Interviewees and survey respondents were all provided with a participant
information sheet, explained the risks of participating in the study and that
participation was voluntary, what would occur with the data, the provisions for data
storage, and the approaches to the maintenance of confidentiality and privacy of the
research data collected. The aims and outcomes of the study were presented to all
informants.
3.4 INSTRUMENTS, SAMPLING AND DATA COLLECTION
PROCEDURES
3.4.1 Study 1
Performance data on access and timeliness to care, costs, quality, safety and other
items were downloaded from MyHospitals and the Bureau of Health Information. Key
strategic documents and minutes from Local Health District Board meetings were
analysed with text analysis tools
To collect and manage publicly reported performance data and documents,
spreadsheets were created. The spreadsheets included case study site data as well as
published peer hospital performance. Peer hospitals are those that have shared
characteristics, and provide similar services, organisation and size. Peer groupings
are intended to support valid comparisons, enabling like with like to be compared, as
the groups reflect common purpose, resources and roles (Australian Institute of
Health and Welfare, 2015). The datasets have been analysed to establish the profile
of performance, measurement descriptors and comparative data. A profile of
performance for the rural health case study site has been created using known and
currently used performance measures.
Chapter 3: Research Design 56
To examine documents, text analysis tools were used to identify word
frequencies. Appendix E shows the full list of publicly reported performance measures
examined in this study, and the time periods and analysis conducted by the researcher.
Figure 3-3 shows the domains that were measured and the indicators collected. No
sampling was required for this study.
Figure 3-3 Publicly reported indicators of performance examined
3.4.2 Study 2
The data-collection instrument used to conduct the interviews for Study 2 was
designed based on the four dimensions of innovation culture described by Dobni
(2008). A full copy of the questions asked of participants is attached in Appendix I.
An email was circulated by the Chief Executive explaining the study and that
staff would be invited to be interviewed. The organisational phone book was used to
identify all executives, department and clinician managers, who were then approached
by phone and email. The initial pool of 22 participants was extended when
interviewees identified or referred the researcher to known innovators or those who
had been involved in an innovation. This combined sampling approach of purposive
and snowball sampling is appropriate when the intent is to include participants who
are rich in information and who will reflect the views of the organisation (Gray, 2014;
Liamputtong, 2013).
Chapter 3: Research Design 57
Twenty-nine semi-structured interviews were conducted, based on questions
constructed based on Dobni (2008). Where innovations were identified there was
opportunity to delve into matters further and to elicit information about the
organisational behaviours and processes around innovation and performance
(DiCicco-Bloom & Crabtree, 2006).
The interviews were conducted to ascertain the contextual and cultural
determinants for innovation in the case study organisation. During the interviews, the
participants were asked to identify the barriers and facilitators to innovation in the
organisation where they work. Questions for the interviews were focussed on the
context of the organisation for innovation, infrastructure available for innovation,
knowledge and orientation of the organisation towards innovation, and intention to
innovate (Dobni, 2008).
Each interview took approximately 30–45 minutes to complete. The interviews
were conducted face to face, and permission to record the interviewees and to
participate was gained from each staff member interviewed. The final number of
interviews analysed was 25 due to poor quality audio-recordings of four interviews.
3.4.3 Study 3 Workplace Innovation Scale Survey
To understand the propensity for innovation in the case study site, a validated survey
tool was used to measure innovation culture. The WIS, developed by McMurray et al.
(2013), has been tested and validated in national and international studies.
The WIS is a 24-item scale that can be used to measure innovation and comprises
four dimensions of organisational innovation, innovation climate, organisational
innovation, and individual and team innovation (McMurray et al., 2013). The WIS,
used to collect data for Study 3, is attached as Appendix K.
The scale was used to complement the data elicited from informants in Study 2,
which sought views concerning the case study organisation’s intention to innovate,
infrastructure available for innovation, context, knowledge and orientation to
innovation. The WIS was designed to identify and measure the behavioural aspects of
innovation practices by individuals in their workplace and comprises four dimensions
of an innovation culture: organisational climate, organisational innovation, individual
innovation, and team innovation (McMurray et al., 2013; McMurray & Dorai, 2003;
Moussa, McMurray, & Muenjohn, 2018). A Likert-type scale with responses ranging
from 1 (strongly disagree) to 7 (strongly agree) was applied.
Chapter 3: Research Design 58
Due to the nature of work at the case study site, such as weekend, 24/7 and shift
workers, a paper-based survey was considered the most appropriate way to administer
the survey. An email was circulated by the Chief Executive explaining the study and
that staff would be invited to complete the survey. Surveys were circulated widely to
staff employed in the case study health service. Participants were invited to contribute
to the study and were provided with an information sheet. The participant information
sheet explained the purpose and benefits of the study and outlined the aims and
objectives. Participation in the survey was voluntary and subjects completed a consent
form. While not a random sampling technique, and this can limit the generalisability
of the results (Gray, 2014), the methodology applied gathered responses from a
different population to the semi-structured interviews. This is considered a valid
approach in mixed-method research where converging data and examining trends from
quantitative and the detail of qualitative studies is achieved to answer a research
problem (Cresswell, 2009a; Gray, 2014). From a total full time-equivalent of 366 staff,
66 surveys were returned to the researcher.
Paper-based surveys, once completed, were entered into a Google form and
downloaded into an Excel spreadsheet and Tableau for further analysis.
3.5 ANALYTICAL METHODS
3.5.1 Overview
Both qualitative and quantitative data were collected for this research. Quantitative
data were analysed using SPSS and Tableau. SPSS was used to analyse the quantitative
data collected using the WIS (McMurray et al., 2013). The Tableau software package
was used to visualise results from the WIS and to present performance data collected
in Study 1. Tableau allowed the researcher to visualise data in a way that makes the
data easy to interpret and digest using a ‘traffic light’ system (Hoelscher & Mortimer,
2018; Tableau Software Inc, 2018). Visualisation of data is a powerful information
management reporting tool as it enables large amounts of data to be summarised in
ways that tell a story (Brigham, 2016; Ertug, Gruber, Nyberg, & Steensma, 2018).
SPSS was used to calculate descriptive statistics for the sentiments of staff
(agree/disagree) to questions on innovation climate, organisational innovation, team
innovation and individual innovation in the study site. The WIS measured the
Chapter 3: Research Design 59
organisational climate and factors contributing to innovation culture within the case
study organisation.
Qualitative analysis of the interview data was undertaken using NVIVO v12, a
computer-assisted qualitative data-analysis software (CAQDAS) tool. This software
was used to organise the qualitative data collected and to code the data according to
the factors under study in this research.
3.5.2 Data analysis Study 1
Performance data were analysed based on measures for cost, timeliness, access, quality
and safety. Text searching tools were applied to count terms in strategic documents.
Tableau software was used to analyse routinely reported performance data and
patterns in the data identified to show performance across time for each indicator. To
demonstrate variation in performance, traffic light colours were used (Red:
performance not better than peers, and Green: performance better than peers). Data
visualisation and business intelligence tools are used widely by health care
organisations. Tableau and similar software packages are used to present data in
meaningful ways with high visual appeal and to enable intuitive interpretations
(Chorpita, Bernstein, & Daleiden, 2008; Ghazisaeidi et al., 2015). Tableau is used by
the NSW Bureau of Health Information and Queensland Health as a means to present
large volumes of data in meaningful ways in an environment of increased transparency
and reporting (Kirk, 2012).
3.5.3 Data analysis Study 2
Once interviews had been conducted, they were recorded and transcribed into Word
documents. Documents were printed and read by the researcher prior to uploading to
NVIVO. This was performed to gain an understanding of the narrative data collected.
The CAQDAS and NVIVO were used to manage qualitative data and to assist
with the analysis of data collected from Study 2. Coding was used to manage and
organise the data around key themes and the questions posed. Matrixes, charts and
diagrams were used to identify links and patterns, abstracting ideas from data and to
help offer explanations (Liamputtong, 2013; Thomas, 2016).
Each interview was set up as a case in the NVIVO software and interviewee
attributes were assigned. Coding of each interview was undertaken using the domains
Chapter 3: Research Design 60
for innovation culture as described by Dobni (2008). Interviews were also coded and
aligned with the specific questions posed to informants. Additional codes were added
when interviewees described the specific organisational enablers and barriers to
innovation. When interviewees gave examples of innovations that they had been
involved with, these were coded to enable the identification and quantification of
innovations in the case study site. Interview files were also linked to their case
descriptors. Once coding was completed, this allowed the researcher to review
participant insights grouped according to each of the innovation culture domains
identified by Dobni (2008).
Tools have been developed to assist in strengthening the quality and
transparency of health research. The COnsolidated criteria for REporting Qualitative
research (COREQ) checklist developed by Tong, Sainsbury, and Craig (2007) was
recommended as a suitable tool for reporting to ensure transparency of qualitative
methods and reporting (Fitzgerald, 2019). This 32-item checklist was applied and
assessment of the conduct of this research study against the list is shown as Appendix
C.
Content and thematic analysis
The method adapted by the researcher to analyse qualitative data was the Framework
Method documented by Gale, Heath, Cameron, Rashid, and Redwood (2013). The
Framework Method is a popular approach used in the management and analysis of
research in the medical and health fields (Gale et al., 2013). This method was
customised by the researcher and provided a step-by-step approach to the coding and
analysis of qualitative data. The Framework Method for the management and analysis
of qualitative data assisted the researcher to synthesise the large volume of interview
data that was collected (Gale et al., 2013) and was similar to other approaches such as
that recommended by Cresswell (2009). This method was selected due to its ease of
application and logical steps. The Framework Model involves seven clear stages to
guide and support qualitative data management and analysis (Gale et al., 2013).
The seven steps used in this study were:
1. Transcription
2. Familiarisation with the interview
3. Coding
Chapter 3: Research Design 61
4. Developing a working analytical framework adapted from Gale et al
(2013)
5. Applying the analytical framework
6. Charting data into a framework matrix
7. Interpreting the data (Gale et al., 2013).
Table 3-1 explains in further detail how the researcher applied these steps,
informed by the Framework Method (Gale et al., 2013).
Table 3-1 Framework for analysis of qualitative data adapted from Gale (2013)
Step How it was applied by the researcher
1. Transcription Recorded interviews were outsourced to a third-party
transcription service.
2. Familiarisation
with the interview
All interviews once transcribed were printed out and read.
Key terms were circled and highlighted.
3. Coding Interviews in a Word document format were uploaded to
the NVIVO software. NVIVO was used to manage and
assist with analysis of the data.
Several attempts were made by the researcher at coding.
Initial attempts resulted in difficulties in analysis and
lacked consistency.
Finally, the interviews were coded according to the
questions asked in the interview as recommended by
(Bazeley & Jackson, 2013). Further codes were then able
to be assigned.
Codes were then applied to the 25 transcripts in the
NVIVO data base.
Higher level node groupings were added in line with
Dobni’s four dimensions for innovation culture.
4. Developing a
working analytical
framework
Once coding was completed all codes were applied and
queries run to compile all responses, for each code into
separate Word documents that corresponded to the codes.
See Appendix O for list of final codes applied.
Text searching was also used in the NVIVO database to
find where key terms were mentioned.
5. Applying the
analytical
framework
A framework of the dimensions and factors contributing
to an innovation culture and is shown in Figure 3-4
below.
6. Charting data into
a framework
matrix
The separate Word documents created for each code were
copied to an Excel spreadsheet as a matrix of the codes
and identified themes.
7. Interpreting the
data
Themes were then able to be generated from the data set
by reviewing the matrix and making connections within
and between the codes and the interview responses.
Chapter 3: Research Design 62
This framework guided the researcher and provided structure to the task of
managing and analysing the vast amount of narrative data collected from informants
in the case study site.
Coding
Transcribed interviews were printed to familiarise the researcher with the data. The 25
interviews transcribed to Word documents were uploaded as cases in NVIVO. Using
NVIVO, each interview was coded to enable content and thematic analysis. Narratives
were coded using categories based on the questions asked to participants (Bazeley &
Jackson, 2013). Further codes were applied based on key terms derived from the
enablers of innovation. At the second pass, top level tree nodes were added to group
nodes according to the four dimensions of innovation culture. Figure 3-4 shows the
four dimensions of innovation and the codes used to make sense of narrative data
collected in Study 2.
Figure 3-4 Four dimensions of innovation (Dobni, 2008) and the codes used to
analyse narrative data
Additional coding was applied to assist with analysis as shown in Table 3-2 below.
Chapter 3: Research Design 63
Table 3-2 Nodes used to analyse data collected in Study 2
High-
level
node
Context to
support
innovation
Infrastructure
to support
innovation
Intention to be
innovative
Knowledge and
orientation to
innovation
Other
Next
level
nodes
Ease of
modification
of systems
Metrics to
measure
innovation
effectiveness
Quick
turnaround of
ideas into
useable
services
Contextual
factors
enablers and
barriers
Contextual
factors other
Time and
resources for
innovation
Knowledge
sharing systems
in place
Underlying
culture directed
to innovation
Innovative
ideas valued
Organisational
mission reflects
innovation
Support for new
ideas
Individuals
valued
Expectation to
develop skills
directed towards
innovation
Organisational
learning linked to
overall strategy
for improvement
and innovation
Reward for
learning
Patient orientation
Leadership
approaches
Innovation
comments
Example
innovations
Once coded, the two methods considered for examination of the interview data
were thematic analysis and content analysis. Content analysis involves establishing
categories and counting the number of instances when those categories are used, while
thematic analysis attempts to locate themes in qualitative data (Silverman, 2011,
2017). Figure 3-5 shows the analytical methods applied in this study.
Figure 3-5 Analytical techniques applied in Study 2
Chapter 3: Research Design 64
Content analysis
Content analysis is a well-established process in qualitative research and can be
applied by counting instances of a theme or responses in unstructured text (Bazeley &
Jackson, 2013). Content analysis was conducted manually and, where possible,
assisted by use of the NVIVO software package. During the document analysis and
coding, instances were noted and recorded according to the codes assigned; for
example, the number of absolute times when interviewees identified that they were
familiar with the mission of the hospital.
Thematic analysis
Thematic analysis was used by the researcher to locate themes in the qualitative data
(Silverman, 2011). All interviews were coded using NVIVO, based on the questions
that were asked. Additional codes were attributed to each case in the NVIVO database
based on key terms.
3.5.4 Data Analysis Methods Study 3: Workplace Innovation Scale Survey
Two software packages were selected to analyse data collected in this study – SPSS
and Tableau. Survey results were entered in a Google Form, then downloaded to a
spreadsheet for analysis and checked for errors. Once data were cleaned it was
uploaded to SPSS and Tableau software tools.
SPSS was used to calculate descriptive statistics such as means, standard
deviations and percentile rankings for each dimension in the WIS.
Tableau software was used to identify patterns of sentiment connected with
innovation culture in Study 3. Data visualisation tools are used to help understand
patterns, processes and relationships (Glesne, 2016; Thomas, 2016). In this study, the
Tableau package was adopted as this was available to the researcher through the
university and is widely used by health information performance reporting agencies
such as the Bureau of Health Information and MyHospitals.
3.5.5 Corroboration of methods and studies
Data from the three studies were analysed to provide a comprehensive understanding
of the cultural aspects, local organisational factors, human resource, leadership,
Chapter 3: Research Design 65
learning and sustainability requirements for innovation and high performance in the
case study site. Data from the studies have been corroborated and compared, and this
will be fully discussed in Chapter 7 (Gray, 2014; Silverman, 2017).
Mixed-methods research was used to gather data for this study. Qualitative and
quantitative methods were applied. Triangulation of different methods and evidence
increases the reliability and validity of case study findings (Gray, 2014; Silverman,
2017; Yin, 2014). This study has used a concurrent triangulation strategy, as suggested
by Cresswell (2009). Qualitative and quantitative data were collected concurrently and
compared to determine whether there was convergence or differences in the findings.
Combining data and analysis from the three studies has provided a complete
picture of the case study site and the data examined, with items compared, contrasted
and cross-referenced to validate the findings. This corroboration strengthens the
validity and reliability of mixed-methods research (Cresswell, 2009; Silverman, 2011,
2017).
3.6 ETHICS AND DATA MANAGEMENT
3.6.1 Ethics
This research involved interviewing staff and determining their views on the factors
that enabled innovation within the case study site. A survey was used to collect
information about workplace innovation using a validated survey instrument
(McMurray et al., 2013) According to the National Health and Medical Research
Council (2018), this study was considered a low and negligible risk
The study required ethical approvals from all stakeholders impacted by the
research. Table 3-3 shows the ethics bodies and approvals obtained prior to
commencement of the research.
Chapter 3: Research Design 66
Table 3-3 Ethics approvals for research
Body Approvals required Approval Number
North Coast New South
Wales Local Health
District Human Research
and Ethics Committee
(HREC).
Low and negligible risk
(LNR) research
application
LNR 176/17/NCC/127
See Appendix F.
North Coast New South
Wales Local Health
District Human Research
and Ethics Committee.
Site specific assessment
(SSA) research
application is a
requirement for research
conducted in Northern
NSW Local Health
District sites.
LNR SSA/17/NCC/129
See Appendix G.
Queensland University of
Technology
Low and negligible risk
research application
1800000117
See Appendix H.
Interviewees were approached by phone and email and invited to participate in
the research. Interviews were set up at times convenient to the interviewee. Interviews
were initiated with an explanation of the research and an overview of the risks
provided. A participant information sheet was developed for both studies. Written
consent was gained from respondents. See Appendix L and Appendix M.
3.6.2 Backup, retention data storage, privacy and confidentiality
Research data have been managed in line with Queensland University of Technology
(QUT) policy. Data collected during the research study have been stored on internal
university-secured drives and will be retained according to policies.
As a case study methodology was used and in view of the small size of the health
service and that individuals may be identifiable, interview responses were coded in the
NVIVO database and reported in the thesis according to discipline to protect individual
privacy. This has ensured that individual responses have been anonymised in line with
case study research guidelines (Crowe et al., 2011; Yin, 2014). To protect the privacy
of participants interviews were coded, in line with Crowe et al.'s (2011)
recommendations. Glesne (2016) recommends keeping an account of all respondents
and their interviews and to maintain organised records with backups to ensure against
data loss.
Chapter 3: Research Design 67
Survey responses were not identifiable, and no identifiable information was
collected on the WIS survey form.
3.7 BIAS AND TRUSTWORTHINESS
In the literature review, authors noted that the potential for bias was a challenge and
risk to the conduct of case study research (Darke, Shanks, & Broadbent, 1998;
Eisenhardt, Graebner, Eisenhardt, & Graebner, 2007; Flyvbjerg, 2006). A range of
strategies recommended to avoid bias in case study research were applied (Darke et
al., 1998; Eisenhardt et al., 2007; Flyvbjerg, 2006). Eisenhardt et al. (2007), for
example, suggests that a key approach is to use numerous and knowledgeable
informants who have a range of diverse perspectives. These informants can be across
different hierarchical levels, functional groups and areas. In this study, informants
were drawn from staff at the ‘coalface’, executives, managers and clinicians, providing
a wide range of views and perspectives.
The research methodology in this study has used both qualitative and
quantitative methods and collected data from three different studies. While quality in
qualitative research is strongly debated (Thomas, 2016; Yin, 2014), through rigour in
the design, analysis and presentation stages, valid research and results have been
produced (Gray, 2014; Thomas, 2016; Yin, 2014).
Credibility in qualitative approaches can be addressed through repeatable,
documented and accurate data-gathering processes and clearly explained techniques
for interpretation (Gray, 2014; Silverman, 2017). Throughout the study, the researcher
has documented the processes applied, checked and rechecked data, and in Chapter 7
will explain how data from the different studies were combined to create an overall
picture of how innovation and high performance is enabled in the case study site.
To assist with the analysis and interpretation of qualitative data, the framework
devised by Gale et al. (2013) was utilised. Tools developed to assist in strengthening
the quality and transparency of health research were also applied in this research.
These tools can ensure that the researcher documents and reports any potential for bias
and that study design, analysis and findings are transparent. The COREQ checklist
developed by Tong, Sainsbury and Craig (2007) was recommended as a suitable tool
for reporting to ensure transparency of qualitative methods and reporting (Fitzgerald,
Chapter 3: Research Design 68
2019). This 32-item checklist was applied and is shown as Appendix C COREQ
Checklist: Consolidated criteria for reporting qualitative studies (Tong et al., 2007).
Of interest, Flyvbjerg (2006, p. 235) asked the question ‘Do case studies contain
a subjective bias?’ and concluded that the ‘Question of subjectivism and bias toward
verification applies to all methods, not just to the case study and other qualitative
methods’. Boldly, Flyvbjerg asserts that ‘experience indicates that the case study
contains a greater bias toward falsification of preconceived notions than toward
verification’(2006, p, 237). To enhance rigour, the researcher has used multiple
sources of evidence, different methods and sought a range of perspectives. This created
an in-depth set of data to understand the context of a rural health setting and the
organisational factors that affect innovation and high performance.
3.8 CONCLUSION
Undertaking a case study requires the researcher to holistically examine the data
identify patterns of ideas and themes. This research has collected data from three
separate studies. Both quantitative and qualitative data have been collected for
analysis. Quantitative data have been analysed and managed using Excel spreadsheets
and the Tableau software package. Qualitative data were managed and analysed using
NVIVO.
Qualitative data analysis by its nature requires a cyclical and iterative approach
to seek out patterns and themes in the data collected (Liamputtong, 2013; Thomas,
2016; Yin, 2014). NVIVO software and the Framework methodology recommended
by Gale et al., (2013) were applied to aid analysis of the rich data provided through
the interviews. This Framework was chosen due to the logical appeal, ease of
application and provision of a practical example as a supporting file. The framework
selected for use is similar to the steps endorsed by Cresswell (2009a).
The Framework assisted the researcher to examine, categorise, tabulate, review
and explain patterns to assist in answering the questions posed (Crowe et al., 2011;
Yin, 2014). Unstructured information obtained from interviews was analysed using a
thematic approach to demonstrate commonalities and dissimilar views and experiences
(Liamputtong, 2013). The Framework assisted the researcher to see links, notice
patterns, and abstract ideas from the data to offer explanation of how innovation occurs
in the rural case site setting examined (Thomas, 2016).
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 69
Chapter 4: Study 1 Results: Performance and Measurement
of Performance in the Case Study
‘High performing hospitals consistently attain excellence across multiple
measures of performance, and multiple departments.’ Taylor et al. (2015)
4.1 INTRODUCTION
The results of Study 1 are presented in this chapter. This study involved an examination
of routinely reported performance and organisational data available from government
reporting agencies and organisational websites accessed via the World Wide Web.
Performance data routinely reported on NSW and Australian government websites for
the case study organisation were downloaded in spreadsheet format. A software
package, Tableau, was used to present the data. Using text analysis tools to locate key
terms, strategic and other organisational documents were able to be examined.
This study was conducted to understand the performance of the rural health
service under study and how performance in rural health settings might be measured.
This was an exploratory study and the findings of this study informed Studies 2 and 3.
While the results of this chapter reveal that performance can be reported and
accessed with ease, gaining an overall understanding across multiple measures remains
challenging. The analysis shows that the case study hospitals demonstrated evidence
of strong performance for several dimensions measured, including access to some
surgical procedures, timely access to care for those with life-threatening conditions in
the emergency department, cost per weighted separation, hand hygiene, hospital
associated infections and patient feedback on the experience and outcomes of care.
Large volumes of data can be summarised across time and measured to synthesise data
in meaningful ways to demonstrate hospital performance.
4.2 RESULTS
The results for the three streams of data collected are presented. Organisational, human
resource management and publicly reported performance data associated with
performance and innovation were examined. Performance data have been summarised
and displayed in novel ways using a visualisation tool.
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 70
Analysis for the three streams of data are presented:
1. Publicly reported performance data were collected on the service to
demonstrate the cost, quality and outcomes of care. An analysis of the
data to identify any factors that appear to influence performance and
outcomes in this rural health setting was conducted.
2. Analysis of strategic documents was performed to identify the level of
organisational commitment to performance and innovation and the way
in which these commitments are translated into action through decision
making approaches and forums.
3. Analysis of organisational data from cultural surveys, human resource
management and other systems was conducted.
4.2.1 Stream 1: Publicly reported performance data
MyHospitals data were downloaded in Excel for the case study site and compared with
hospitals of similar size, role and service delivery. Griffith Hospital, also in NSW, was
selected as a close peer for some analyses as it has faces many of the challenges, provides
similar services and has approximately the same population as the case study site.
Figure 4-1 summarises the domains of measurement and measures analysed for
Study 1. The full list of indicators – where they were sourced, years examined and the
analysis conducted – is shown in Appendix E.
Figure 4-1 Publicly reported indicators of performance examined for the case
study organisation
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 71
Domain 1: Access and equity
Strong health systems provide the community with services where and when needed.
In Australia, timeliness is regarded as an important indicator of accessibility and
quality care (Australian Institute of Health Innovation University of NSW, 2013).
Access to Emergency Departments and Surgery has been publicly reported since 2011.
Surgery waiting times. Waiting for surgery can have significant impacts on
individuals’ well-being, health and independence, and waiting time by urgency is
routinely reported. Table 4-1 shows the median waiting time for surgery by specialty
in the case study hospital across multiple time periods. The table illustrates the
timeframes in years where the hospital under study performed better (green) or not
better than peers (red) using a traffic light approach. The table demonstrates that for
some specialties (general and other surgery, as well as orthopaedic surgery) better than
peer performance is achieved on a continued basis.
Table 4-1 Median wait time to surgery at case study hospital compared with
peers
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 72
Table 4-2 shows the percentage of patients waiting more than 365 days for
surgery. The case study hospital performed better than peers for ear, nose and throat
surgery, general surgery, gynaecology, ophthalmology and orthopaedics. Urology and
other surgery specialties did not compare well with peer performance, possibly
reflecting a lack of access to urology and or the specific specialties grouped in ‘other
surgery’.
Table 4-2 Percentage of patients who waited more than 365 days for surgery by
specialty
The data by specialty could be further drilled down to specific surgical
procedures. Table 4-3 below shows the percentage of patients waiting for more than
365 days by procedure. This reflects increased waiting for some types of surgical
procedures such as cataract surgery where demand may be high or there is a lack of
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 73
access to surgical services for some procedures (e.g. myringoplasty, myringotomy and
septoplasty).
Table 4-3. Percentage of patients who waited more than 365 days for intended
surgery by procedure
Emergency department waiting times. Australian emergency departments routinely
report to government on timeliness of first seen by triage categories and time for
treatment and discharge within four hours. In emergency departments, timely care,
particularly for seriously ill patients, is an important measure of the performance of
the hospital. The four-hour requirement for treatment and discharge from the
emergency department reflects patient flow of the hospital and timely discharge to the
most appropriate setting for care, be that to a ward, discharge to patient’s home,
transfer to higher level of care, operating theatre or the intensive care unit. Figure 4-4
shows performance for triage category 1 patients at the case study site is better than
peers over a sustained period; however, triage 2–4 does not perform better. For triage
5, the reported data did not meet the criteria needed to calculate this item in the years
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 74
2011–2015, limiting analysis of this group (Australian Institute of Health and Welfare,
2018).
Table 4-4. Emergency department data percentage of patients seen on time by
triage comparison with peers
The National Emergency Performance Target has been used in the United
Kingdom and Australia as a measure for access to timely care in emergency
departments (National Health Performance Authority, 2016). This data item has been
reported on since 2011 in Australia and Table 4-5 shows performance for the case
study site.
Table 4-5. Emergency department patients treated and discharged within 4
hours comparison with peers
Domain 2: Efficiency and sustainability
Two measures were identified in the study for sustainability and efficiency: average
length of stay and cost per national weighted activity unit (NWAU). The cost per
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 75
NWAU is the ‘average’ cost of a public hospital service provided to an admitted
patient. This cost compares the operational costs to government of services provided
at similar hospitals and adjusted for different types of patients. Average length of stay
is widely used as a proxy for efficiency as a shorter stay reduces the cost and shifts
care from inpatient to less expensive care settings (OECD, 2018).
Figure 4-2 below shows the case study hospital compared to peer group hospitals
in NSW for cost per NWAU. The case study site has a budget that in part is based on
an activity-based funding formula. The chart shows that the case study hospital is the
most efficient of its peers in NSW but more expensive than the peer group Australia
wide. Costing information from MyHospitals was not available after 2013–2014. Later
costing data is available through the Independent Hospital Pricing Authority’s
National Benchmarking Portal and access is granted to health organisation employees
through a jurisdiction contact (Independent Hospital Pricing Authority, 2018).
Rural health services tend to be more expensive than metropolitan services due
to economies of scale and the high cost and use of locum medical officers. It has been
acknowledged that rural hospitals have additional costs (The Independent Hospital
Pricing Authority, 2018).
Figure 4-2 Comparison of NSW Major Regional Hospitals Cost per NWAU
2011–12 2012–13 2013–14
Bathurst Health Service 5300 5400 5900
Goulburn Hospital 5500 5600 5100
Case study hospital 5000 4900 4900
Peer Average 4340 4420 4630
$3,500$3,700$3,900$4,100$4,300$4,500$4,700$4,900$5,100$5,300$5,500$5,700$5,900$6,100
Co
st p
er N
WA
U
Comparison of NSW Major Regional Hospitals by NWAU Over Years
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 76
When average length of stay was examined, Table 4-6 shows that the case study
organisation has performed well since 2014 for two categories of patients: Heart failure
and knee replacement have average length of stays better than peer organisations
consistently over time. In the rural health context, alternative settings for post-acute
care for chronic conditions are limited. This performance could reflect local practices
or the inability to refer to alternative post-acute settings.
Table 4-6 Length of stay comparison with peer hospitals
Domain 3 Quality and safety/patient orientation
Performance information on quality and safety was analysed to understand the
organisation’s commitment to quality and safety. The Bureau of Health Information’s
results for the admitted patient survey, accreditation status, hand hygiene data and
hospital acquired infection rates from MyHospitals were analysed.
Accreditation status. The case study hospital is currently accredited by the Australian
Council of Healthcare Standards. Accreditation has been achieved over many years,
with good results. The last survey was conducted in October 2016 and produced full
accreditation, which was granted in January 2017. The next survey is planned for
October 2019, using the new Australian National Safety and Quality Healthcare
Standards. Accreditation is recognition that the organisation is compliant or working
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 77
towards achievement of the National Safety and Quality in Healthcare Standards.
These Standards aim to protect the public from harm and improve the quality of health
care, and describe the systems and processes of care that should be provided by health
service organisations (Australian Commission on Quality and Safety in Healthcare,
2018).
Healthcare-associated infections. Staphylococcus aureus (S. aureus) bacteraemia is
an infection that can be acquired during medical care or treatment in a hospital.
Hospitals aim to have as few cases as possible as contracting an S. aureus bloodstream
infection can be life-threatening (Australian Institute of Health and Welfare, 2018).
Table 4-7 shows trends for health care associated infections over the past seven years.
Five of the seven years reported have shown performance better than peer.
Table 4-7 Staphylococcus aureus bacteraemia infections comparisons to peer by
year
The case study site had consistently performed better than peer on this measure
until 2016. Continued monitoring and further investigation of this indicator is needed
to detect whether this was an aberration or reflects a change in clinical practice.
However, this was outside of the scope of this research study.
Table 4-8 below shows the rate per 10,000 bed days for all bloodstream
infections compared to a similar peer, and large and medium hospitals. Major
hospitals’ data (tertiary referral) have been removed due to differences in case-mix
complexity and staffing. The case study hospital has performed better than peer
hospital, Griffith, and large and medium hospitals consistently over time except for
2016–17.
Table 4-8 Blood stream infections rate per 10,000 bed days comparison with
peers
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 78
Hand hygiene. Correctly performed hand hygiene can minimise the risk of healthcare-
associated infections. Data from the MyHospital site shows that the case study site has
consistently higher than the National benchmark performance for hand hygiene (see
Figure 4-3). More recent data was not available at the individual hospital level.
Figure 4-3 Hand hygiene compliance rates for case study hospital compared
with national benchmark
Adult Admitted Patient Survey. Each year patients admitted to NSW public hospitals
are surveyed and asked over 80 questions. The Adult Admitted Patient Survey 2017
seeks the views of patients and the results reflect the care provided to adult patients
admitted to public hospitals. The survey in 2017 asked 86 questions and addresses a
wide range of the experience and outcomes of care. Results are publicly reported at
the state, Local Health District and hospital level. Results reflecting the experiences of
care of 21,026 adults admitted to public hospitals in 2017 are collated and reported via
the Bureau of Health Information website. Where hospitals results are deemed
significantly different to NSW according to a 95% confidence interval, results are
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 79
shown in green (positive difference) and red (negative difference) (Bureau of Health
Information, 2018b).
Comparisons were made of all hospitals categorised by the Bureau of Health
Information NSW as Peer Group C and a close peer, Griffith Hospital. Peer Group C
includes 40 hospitals across NSW. For each hospital the questions where responses
were significantly less favourable are shown in red and those significantly more
favourable than NSW shown in green. Analyses were performed to understand:
• performance on two important items – Access and Timeliness and Hygiene and
Safety according to the views of patients for two close peer hospitals;
• top 10 hospitals by number of significantly more favourable and less
favourable items according to the views of patients;
• performance across the 90 items according to the views of patients in Peer
Group C – number of significant positive and negative differences.
Table 4-9 shows the results for the case study site for the questions related to
safety and quality with comparisons to a close peer hospital. This shows that the case
study organisation demonstrates superior performance when compared to NSW and a
similar peer.
Table 4-9 Results for the case study site for the questions related to safety and
quality with comparisons to a close peer hospital
Question Text Response NSW
Minimum
Maximum
Case
study
Griffith
Did you see nurses wash their hands,
or use hand gel to clean their hands,
before touching you?
Yes,
always 61 49 80 70 62
Did you see doctors wash their
hands, or use hand gel to clean their
hands, before touching you?
Yes,
always 53 42 65 54 50
Did nurses ask your name or check
your identification band before
giving you any medications,
treatments or tests?
Yes,
always 91 83 98 95 89
Table 4-10 below shows results from the Admitted Patient Survey for the case
study hospital and a peer rural hospital for access and timeliness. Overall response
rates to the survey in 2017 for the case study hospital and a similar peer were 48% (n
= 202) and 33% (n = 149) respectively (Bureau of Health Information, 2017).
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 80
Table 4-10 Results from the admitted patient survey for the case study hospital
and a peer rural hospital for access and timeliness
Question Text Response NSW Minimum Maximum
Case
study Griffith
Do you think the amount of
time you spent in the
emergency department was...?
About right 67 38 93 85 78
Do you think the time you had
to wait from arrival at hospital
until you were taken to your
room or ward was...?
About right 78 63 94 80 76
How long did you have to wait
to see that specialist?
Up to 4
weeks 63 35 81 53 45
From the time a specialist said
you needed the operation; how
long did you have to wait to be
admitted to hospital?
Less than 1
month 28 7 57 21 19
The total time between when
you first tried to book an
appointment with a specialist
and when you were admitted to
hospital was...?
About right 62 43 93 65 59
On the day you left hospital,
was your discharge delayed? No 79 71 98 94 73
For the case study hospital, Table 4-11 shows the case study site and Griffith and
the total number of significantly higher agreement and significantly lower agreement
across all 86 questions. The case study hospital, according to patients surveyed, shows
stronger performance across 20 items than the peer hospital according to patient views
on the experience and outcomes of care.
Table 4-11 Case study site and Griffith and the total number of significantly
higher agreement and significantly lower agreement across all 86 questions
Hospital and positive/negative Case Study Griffith
Number of survey questions
Significant negative difference to survey population 1 10
Significant positive difference to survey population 20 0
No significant difference or insufficient responses 65 55
Total questions 86 86
Comparing the highest positive and least negative responses the graph in Figure
4-4 shows the top 10 hospitals in Peer Group C based on significantly positive
responses to patient survey items.
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 81
Figure 4-4 Admitted patient survey 2017 most positive and fewest negative – 10
peer group C hospitals
Shown graphically below in Figure 4-5 are the results for the whole of NSW for
Peer Group C. The case study organisation is situated in the upper half of the graph.
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 82
Figure 4-5 Number of significant positive and negative responses to patient survey peer comparisons
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 83
Domain 4: Employee engagement/orientation
Each year the NSW government surveys staff and asks employees about experiences
with their work environment, individuals’ own work and working with their team,
managers and their host organisation. A report is produced for each distinct entity and
the results made available to the senior managers of each site to action (NSW Public
Service Commission, 2018).
Results for a statement that asked about senior managers encouraging innovation
in the Local Health District where the case study site is located found only 31% agreed.
This question was identified as one of the lowest scoring statements, along with a
belief that senior managers provide a clear direction for the future of the organisation
(NSW Public Service Commission, 2018). High scoring questions in the District
Survey results reflected clarity and understanding of what is expected of employees,
achievement of patient satisfaction and teamwork environment (NSW Public Service
Commission, 2018).
Table 4-12 shows the Employee Engagement Index from the 2017 and 2018
Culture Survey for the Northern NSW Local Health District. The Index is a weighted
score and significant differences are highlighted in red (requiring attention) and
green (best practice) (NSW Public Service Commission, 2018). Multiple dimensions
are shown in the table for the case study hospital and compared to other sites in the
Local Health District. While 67% of employees are engaged with their work for
some indices, such as engagement with performance, diversity and inclusion were in
2017 and 2018 identified for improvement. In 2017, four areas were identified for
improvement and in 2018, six areas. In 2018, areas identified for improvement
included communication, high performance and organisational values factors related
to this study.
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 84
Table 4-12 Case Study Hospital People Matter Culture Index results compared
to Local Health District and Health Cluster (NSW Public Service Commission,
2017) (NSW Public Service Commission, 2018b) and (NSW Public Service
Commission, 2018a)
Question
groupings
2017 2018
NSW
Health
Local
Health
District
Case
study
NSW
Health
Local
Health
District
Case
study
Employee
engagement
64 57 54 65 59 53
Engagement
with work
45 67 59 73 70 67
Senior
managers
57 32 33 46 32 24
Communication 72 47 38 59 51 43
High
performance
63 54 49 64 56 48
Public sector
values
58 49 45 60 51 42
Diversity and
inclusion
65 56 49 66 59 52
4.2.2 Streams 2 and 3: Analysis of strategic documents and organisational data
A search of the World Wide Web could not locate a strategic plan for the case study
site. However, a strategic plan for the Northern NSW Local Health District for the
period 2013–2018 was able to be located and includes the case study site (Northern
NSW Local Health District, 2013).
The Northern NSW Local Health District web page was searched for documents
and the following identified as suitable for analysis. Table 4-13 shows the documents
analysed by the research and discoveries around innovation and performance. Text
analysis tools were used to search for key terms.
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 85
Table 4-13 Documents analysed by the research and discoveries around
innovation and performance
Document
References made to
Innovation Performance
NSW Rural Health Plan
(NSW Ministry of
Health, 2014)
Strategy 2: Strengthen
rural health
infrastructure, research
and innovation
The Strategic Plan is
underpinned by NSW
Health CORE values that
mentions performance.
See Appendix N.
Health Services Plan
2013 – 2018 (Northern
NSW Local Health
District, 2013)
Innovation was
mentioned 17 times
throughout the Plan.*
Performance mentioned
88 times.
Board Meeting Minutes
(Northern NSW Local
Health District Board,
2018b, 2018a, 2018c)
The specific term
innovation was not
mentioned in the minutes
examined however new
models of care and
initiatives discussed.
Significant discussion on
performance related
agenda items such as
KPIs.
Web page – About us
Executive team
Budget allocation
Service information only.
Insufficient information
to assess.
Description of services
provided.
Insufficient information to
assess.
Note. *The Strategic Plan noted in a section on staff commitment to improving
performance as follows: ‘Staff requested there be a greater focus on systems of
feedback to individual clinicians about service performance … and structured
feedback submitted for new models of care. There are perceived barriers to
service/model innovations…. To maintain a focus on service quality and improvement
… Communication needs to be strengthened …’ (Northern NSW Local Health
District, 2013). This suggests that the Local Health District and Employees recognise
innovation and performance and feedback as important. Strengthened communication
necessary as a focus for service quality and improvement.
Governance for Performance and Innovation
Governance for performance for the case study organisation is influenced by the
principles described in the National Health and Hospital Agreement between the
Commonwealth and the NSW State Government. A professional Health District Board
and Local Health District Chief Executive set the direction and goals for the District.
This is operationalised by general managers for health service groups and the local site
executive officers. Boards have overall responsibility for the operational efficiency
and strategic direction of the Local Health District they oversee and support the
efficient and economic operation of the District, to ensure it manages its budget and
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 86
meets performance targets, and to ensure district resources are applied equitably to
meet the needs of the community (New South Wales Government, 2015).
Local decision making is an important design of NSW Local Health Districts
and explicitly, the Health District Board and the Chief Executive are responsible for
the monitoring of performance for the Local Health District against performance
measures in the LHD Service Agreement and delivering services and performance
standards within an agreed budget (Northern NSW Local Health District, 2018).
Analysis of strategic documents and web pages suggest that governance for
performance and a focus on innovation are in place.
Budget
Budget allocations are reported annually for transparency on the Northern NSW Local
Health District website. Key budget information is shown in the graph in Figure 4-6
and demonstrates continued growth in the budget for the case study site over the six
years analysed. The budget has grown by at least 2% each year and NWAUs increasing
by 10% reflect the opening of a new orthopaedic service in 2015–2016, then remaining
steady in subsequent years. Figure 4-6 shows the budget and NWAUs for the case
study site.
Figure 4-6 Hospital budget and NWAUs by year for case study site
2014-2015
2015-2016
2016-2017
2017-2018
2018-2019
Annualised budget $62,222,000 $63,320,000 67279000 $72,124,000 $73,642,000
NWAU 11903 13080 13028 13375 13368
$0
$10,000,000
$20,000,000
$30,000,000
$40,000,000
$50,000,000
$60,000,000
$70,000,000
$80,000,000
11000
11500
12000
12500
13000
13500
NW
AU
s b
y Ye
ar
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 87
4.2.3 Summary of Streams 1, 2 and 3
The three streams of data have been analysed to provide an overall picture of
performance in the case study organisation as shown in Table 4-14.
Table 4-14 Overall picture of performance in the case study organisation
Streams Indicators Performance of case study
organisation
Stream 1: Publicly reported performance data
Access and
Equity
Median waiting time to
surgery by specialty.
Percentage who waited
more than 365 days for
intended surgery by
specialty.
Time to first seen in the
Emergency
Department.
Treated and discharged
within 4 hours (4-hour
rule).
Not better than peers except for
orthopaedic surgery.
Better than peers for general surgery,
gynaecology, ophthalmology,
orthopaedic surgery.
Better than peer for most urgent
triage category.
Not better than peer across triage
categories 2- 5.
Not better than peer across all triage
categories.
Efficiency and
Sustainability
Average length of stay
(ALOS).
Costs of acute admitted
patient’s data.
Not better than peer except for knee
replacements and heart failure.
Better than peers.
Quality and
safety/Patient
orientation
Accreditation status.
Patient feedback.
SAB rates.
Hand hygiene.
Accredited.
Mid-range performer.
Better than peer.
Better than national benchmark
consistently over time.
Streams 2 and 3: Analysis of strategic documents and organisational data
Strategic focus
and engagement
with innovation
and performance
Number of mentions. Local Health District where case
study site is situated has focus on
innovation and performance.
Governance for
performance and
innovation
Strategic
documentation
Governance
arrangements.
Governance for performance and a
focus on innovation is in place.
Budget Budget for innovation. The budget has grown by at least 2%
each year. No publicly available data
to understand if specific resources
available for innovation.
Employee
engagement/staff
orientation
Yoursay Cultural
Survey.
Not better than peers.
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 88
4.3 CONCLUSION
Publicly available data in the three streams was able to be discovered and analysed by
the researcher. This exploratory study was instigated to understand the performance
and its measurement for the case study organisation. Analysis of the results identified
the following:
Peer comparisons
The peer groupings assigned by the Bureau of Health Information and MyHospitals
are organised for different levels of granularity and bundling depending upon the items
collected. For example, the Acute Admitted Adult Patient Survey from the Bureau of
Health Information bundled two peer groups together: Peer Group C1 (between 4,000
and 10,000 acute weighted separations) and Group C2 (4,000 or less acute weighted
separations) (NSW Health, 2016). This bundled group called Peer C is referred to as
District Hospitals with smaller number of patients (Bureau of Health Information,
2017). MyHospitals data collection, from where most data were sourced, allocated the
case study hospital into a peer group called ‘medium regional hospital with an
emergency department’. Consequently, ‘like with like’ is not able to be compared
across all the indicators identified for inclusion in this study. What this study has tested
is the availability and viability of measuring performance across multiple measures
over time. The useability of the data is limited by the different ways the grouping of
hospitals occurs. Data must be sourced from multiple data collections to provide a
complete picture and for some analysis further granularity is necessary. Table 4-15
Indicators sourced, data collection and peer grouping.
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 89
Table 4-15 Indicators sourced, data collection and peer grouping
Measure Indicators Source Peer
grouping
Access and Equity Median waiting time
to surgery by
specialty
Percentage who
waited more than
365 days for
intended surgery by
specialty
Time to first seen in
the Emergency
Department
MyHospitals
Medium
hospital with
emergency
department:
18 NSW
hospitals
Efficiency and
Sustainability
Average length of
stay
Costs of acute
admitted patients’
data
MyHospitals Medium
hospital with
emergency
department:
18 NSW
hospitals
Quality and
safety/Patient
orientation
Accreditation status Hospital Quality
and Safety
Manager
Not applicable
Patient survey results
on experience and
outcomes of care
Bureau of Health
Information NSW
Peer group C
district
hospitals:
40 NSW
hospitals
SAB rates MyHospitals Medium
hospital with
emergency
department:
18 NSW
hospitals
Hand hygiene results MyHospitals National
benchmark
Employee
engagement
Yoursay Cultural
Survey
NSW Public
Service
Commission,
(2018)
State-wide
and local
health district
comparisons
This is regarded by the researcher as a significant limitation identified through
the conduct of this research. Taken at face value using the data that is reported, the
following conclusions are drawn.
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 90
Access and equity
• The case study organisation performs well in terms of access and
timeliness of care for some inpatient services that are provided by the
hospital under study. Timeliness and access to care for emergency
department in rural settings is impacted by fewer alternatives for lower
acuity Triage 4 and 5 patients, and comprehensive care is provided at no
cost in the case study emergency department.
Efficiency and sustainability
• According to costing data, the case study site is more efficient per
NWAU than NSW peers; however, it is less efficient than peer hospitals
if compared across Australia
• Average length of stay as reported does not indicate efficiency across the
board. Lower than peer lengths of stay observed for knee replacements
and heart failure were observed in the case study site.
Quality and safety/patient orientation
• Patients treated in the case study hospital view their care significantly
positively on 20 measures and negatively on only 1 item when survey
results are compared with all responses across NSW. This is superior to
a similar peer; however, within the overall peer group, the case study site
is situated in the top half of its peer group.
• The case study site actively seeks out standards-based quality assessment
in the form of accreditation according to the National Standards.
Employee engagement/governance
• Robust governance systems are in place at the Local Health District
Board level and the site has experienced growth in activity and budget
over the past 6 years.
• Strategic documents reflect a focus on innovation, new models of care
and performance.
• Board minutes focus on performance and discuss new models of care.
Chapter 4: Study 1 Results: Performance and Measurement of Performance in the Case Study 91
• Staff are engaged with their work, although some indices and concerns
were noted by staff in the cultural survey conducted during 2018.
• Observations of strategic documents from Board meetings are
inconsistent with Employee Cultural Survey data, suggesting a potential
disconnect between strategy, organisational intention and the translation
of this intent as interpreted by employees working at the service under
study.
Data can be analysed and presented in novel ways to provide a picture of
performance and tell a story of what is occurring in rural health settings. However,
there is no single, easy to access dashboard of performance that combines data across
time periods and performance measures. Future clinicians or managers wanting to
understand the performance of a health care organisation in a rural setting would need
to undertake significant analysis to gain an overall picture.
This study has analysed publicly reported data and strategic documents to
understand the status of performance in the case study site. In a study of a public
organisation by Mafini (2015), a strong positive relationship between organisational
performance and innovation was noted. Likewise, research by Lee (2015) found that
there were positive relationships between process innovations and organisational
performance. Innovation and levers to strengthen the uptake of innovation can be
associated with organisational performance, if the findings of Lee (2015) and Mafini
(2015) hold true.
In summary, performance can be measured and assessed using publicly reported
data, but there is no single source where performance on multiple measures over time
can be viewed. Multiple sources and dimensions (access and equity, efficiency and
sustainability, quality and safety, employee/staff engagement) are required to present
a complete picture of organisational performance.
Chapter 5: Study 2 Results: Semi-Structured Interviews 92
Chapter 5: Study 2 Results: Semi-Structured Interviews
‘I think the advantages for a small, rural place, for being able to modify
things quickly, is that you often know all the actors in the implementation process,
and so you can get ideas around very quickly and you can build a case for change.’
Medical clinician
5.1 INTRODUCTION
This chapter presents the results of Study 2 and the analysis of interviews conducted
with known innovators, clinicians, managers and executives employed in the case
study organisation. The purpose of the interviews was to elicit information about the
organisational and context-specific factors contributing to innovation, and understand
the intention to innovate and infrastructure available to support innovative ideas.
Interview questions were based on the four dimensions of innovation culture described
by Dobni (2008) of intention to be innovative, infrastructure to support innovation
thrusts, implementation context and knowledge, and orientation of employees to
support innovation. Questions were asked about metrics for measuring innovation,
creativity and empowerment, mission and culture, resourcing for innovation, and
knowledge and learning systems. Twenty-five interviews were transcribed and
analysed. Whilst twenty-nine interviews were originally conducted four were of poor
quality and not able to be transcribed.
The COREQ checklist developed by Tong et al. (2007) was recommended as a
suitable tool for reporting to ensure transparency of qualitative methods and reporting
(Fitzgerald, 2019). This 32-item checklist was applied and assessment of the conduct
of this research study against the list is shown in Appendix C. NVIVO was used to
manage interview data and codes applied in line with the questions that were asked
about innovation and the factors that enabled change within the case study
organisation. A framework methodology was used to support the analysis of the
qualitative data that was collected. This methodology, described by Gale et al. (2013),
was chosen due to the logical approach, ease of application and provision of a practical
example as a supporting file. The framework selected for use is similar to the steps
endorsed by Cresswell (2009a). Once data were coded (see Appendix O) queries in the
Chapter 5: Study 2 Results: Semi-Structured Interviews 93
NVIVO database was able to be performed. Using queries on the four dimensions, data
analysis was then completed.
This study was initiated to answer the research questions about what factors
affect innovation and to determine how innovation occurs in rural health care settings.
Interviewees revealed innovations that they had been involved with and factors that
contributed to these being sustained or abandoned. The study found that innovation
does occur and identified the specific contextual and organisational factors that support
innovation and whether they can be sustained over time in the case study organisation.
5.2 RESULTS
Twenty-nine interviews were conducted by the researcher; four recordings were of
poor quality and not able to be transcribed. The breakdown of the 25 interview
informants by gender and identification as a manager is shown in Table 5-1. The
gender breakdown for interviews does not reflect the distribution of the employee
population, with more males than females. However, 13 of the interviewees identified
that they also had managerial responsibilities. Management roles across Australia and
in the health industry are male dominated and as such reflect the reality of a lack of
gender diversity in health workplaces (Workplace Gender Equality Agency, 2018).
Table 5-1 Breakdown of the 25 interview informants by gender and
identification as a manager
Gender Female Male Total
6 6 12
7 6 13
13 12 25
Table 5-2 shows the professional backgrounds of the interviewees, which reveals
a range of disciplines and managerial responsibilities reflecting a wide mix of views
across the case study organisation.
Chapter 5: Study 2 Results: Semi-Structured Interviews 94
Table 5-2 Professional backgrounds of the interviewees and management
responsibilities
Professional
background
No management
responsibilities
Management
responsibilities
Total
Administration 2
2
Health Information
Manager
1 1
Medical Officer 5 2 7
Nurse 5 6 11
Occupational
Therapist
1 1
Pharmacist
1 1
Physiotherapist
1 1
Radiographer
1 1
Total 12 13 25
5.2.1 Dimensions of innovation culture
Using thematic and content analyses, responses were studied according to the
constructs of innovation culture: the intention to be innovative (mission and culture),
infrastructure to support innovation thrusts (knowledge systems, time and resources
for innovation), knowledge and orientation of employees to support innovation
(organisational learning, creativity and empowerment, patient value/orientation) and
the implementation context to support innovation (ability to change systems/processes
and metrics for innovation), as described by Dobni (2008). Figure 5-1 below shows
how the constructs and the discussion of the data have been organised around the
constructs and factors.
Chapter 5: Study 2 Results: Semi-Structured Interviews 95
Figure 5-1 Dobni’s (2008) innovation culture dimensions and factors
Each interview was numbered from 1 through 29 as a unique identifier that has
been used when quoting informants.
5.2.2 Intention to be innovative
To measure this dimension, questions were included about the propensity of the
organisation to innovate. Interviewees were asked whether innovative ideas are valued
and about their engagement with innovation in the organisation. Interviewees’ views
on whether the culture and mission of the organisation supports innovation and
organisational culture and mission reflects innovation were elicited. Typically,
organisations with a strong propensity for innovation and business models to support
innovation will reflect and communicate this through the mission and organisational
values of the organisation (Dobni, 2008; Dobni et al., 2015).
Innovation is an underlying culture in the organisation and innovative ideas are
valued
Interviewees were asked whether they believed that innovation was an underlying
culture and not a word. The response to this question was mixed. Eight interviewees
clearly stated that they thought it was just a word. Other responses ranged from those
who believed that innovation occurred within the organisation but was not deeply
entrenched in the culture to those who saw the organisation heading in a direction
Chapter 5: Study 2 Results: Semi-Structured Interviews 96
where innovation was deeply embedded. The following quotations summarise the
range of sentiments and views.
Medical clinician: No. 9
I think that varies quite a bit, I think there’s definitely innovation, a lot of
innovators, but there’s probably quite a few stymiers as well. Because innovation
almost always costs money and there are people that are very, very, they’ve got very
tight budgets to adhere to and they’re stopping us spending every cent possible I guess,
so there’s got to be a little bit of that. But I think overall, it’s an innovative place. I
mean there are more services here now than there were 20 years ago, so that says
something, doesn’t it?
Executive: No. 17
For sure, for sure. We’ve already spoken about that a great deal, that it doesn’t
happen just sporadically, or it doesn’t happen with one individual. It requires both
thought leaders and people who initiate ideas, but it also requires an ecosystem and
an environment within the hospital that can foster it. It’s a seed and soil kind of idea.
So, it certainly has to be an embedded part of the culture if we ever want to take it – if
you ever want to see it fully flourish.
Informants interviewed and who that thought that innovation was just a word felt
strongly that innovation should be further embedded in the organisation. Views
regarding this are exemplified by comments from a surgeon, clinical nurses and nurse
manager.
Medical clinician: No. 11
No, I don’t think so. Again, I don’t think there’s a push from New South Wales
Health or whereever we are [Northern Rivers] Local Health District being inventive.
I guess innovation has got its problems, it’s got potential risks associated. So, I haven’t
– this is really something – our innovations have been inherent in our multiple
stakeholder [unclear] clinical unit, nurses, physiotherapists, anaesthetists, doctors, et
cetera.
That’s something that’s been driven from within and is recognised and
appreciated but certainly hasn’t been – I don’t really feel that’s always pushing
Chapter 5: Study 2 Results: Semi-Structured Interviews 97
innovation. It’s more just I think the hospital is trying – or the health district is trying
to keep its head above water, isn’t it? It’s like the CPD, it’s not really development;
it’s more some sort of metric of being good enough, but there’s not really too much
interest in the need for resources or capacity to try to go beyond being good enough.
Administration support: No. 2
I wouldn’t say it’s an underlying culture. There’s quite a few departments and
individuals that do think innovatively, but it wouldn’t be a big part of the culture, but
definitely not just a word. I believe that most people that I work with anyway
understand what it means to be innovative and can think innovatively but whether or
not they can put it into practice within this organisation is probably the real question,
yeah.
Nurse Manager: No. 5
I don’t think so, yet. No, hm. I know there’s a lot of quality type competitions
that are invested in encouraging people to do well and create new things. That’s – I
don’t know – it seems to be in that – what am I trying to say – in that bubble above us.
Although, we recognise that and we see that, I don’t know that it’s actually the
everyday culture, now. It’s trying to be, but I don’t know that it actually is yet, in
certain fields and certain teams, but not everywhere I don’t think
Clinical nurse: No. 23
I think it’s a word, yeah. I think it’s – innovation, as I said to you before,
everyone’s very keen in the very, very beginning of the thing but I’m not seeing a lot
come to fruition from what I’m hearing across the board. So, I would like to see more,
I’d love to see more. I’d love to see people as passionate as I am about nursing
passionate about innovation and change. Because we could make it so good if they
did, if we could just inspire them to just take that extra step, make that extra mile.
Others saw innovation as just part of continual improvement within the case
study organisation and that improvements for the betterment of patients is a clinical
obligation. This was reflected in the comments below.
Chapter 5: Study 2 Results: Semi-Structured Interviews 98
Clinical nurse: No. 3
I’ve never thought about innovation as an underlying culture, but I have been
nursing since I was 17 years old, so for almost 40 years. Nursing has changed
radically in those 40 years, so that’s basically innovation. So, it’s happened and it’s
just happened on a day-to-day basis. So, I don’t necessarily think the word innovation
is necessarily put up there every day.
But if I look at even the most basic procedures and the way everything from
medication just to monitoring patients to documentation, there’s just been a huge shift
in that 40 years, all of it positive. Pretty much all of it positive for the patients. For the
patient and for staff. So, I think innovation does happen, but I don’t think it’s
necessarily pushed and discussed as innovation.
Allied health manager: No. 14
Yes, I think culture would be a fair word and the best way to describe it as long
as – when we use the word the healthcare service, I’m breaking it down into our
department. Because I know we’re fiercely focussed on learning, we’re fiercely
focussed on development, we’re clearly focussed on maintaining and ensuring our
skills. We’re very conscious that we’re isolated, we’re, I won’t say rural, we’re
regional, but we don’t have an onsite radiological input, we don’t. We have to really
stay driven on all of these things.
I think if it was just a word it would have lost impact, and I’ve seen in some
departments where it is just a word it doesn’t have the drive and the development. I
would love to say within the healthcare service that it is a culture but, look, I am aware
of some areas that it’s not overly promoted. Look, there’s the usual culprits being
resources, staff, timing, all those sorts of things.
But look I feel that from my point of view from our department it’s definitely
something that we value, we strive towards. It is, it’s important and we have to support
the ideas, the creation and change, new concepts, new developments.
Chapter 5: Study 2 Results: Semi-Structured Interviews 99
Mission of the organisation
When asked to explain how innovation was reflected in the mission of the hospital
most of the interviewees struggled to recall the hospital’s mission. Despite this, most
felt that there was a culture within the organisation where improvement was valued.
Both clinicians and managers conveyed this opinion. Interviewees related that as the
base hospital in a rural setting, the focus has been on delivering services to the
community. That innovation was not embedded within the culture has not impeded
innovative ideas and the implementation of innovations, as demonstrated in the quotes
below.
Clinical nurse: No 3
That’s – I think the hospital strives to continue moving forward in all areas.
Whether that’s patient care, whether that’s quality performance, whether that’s
OH&S, I think the hospital is constantly striving to move forward. Innovation that can
help that does come into play and does happen.
She went on to say about the rural setting under study:
I don’t think that it’s a huge lag behind, and I do think that there is a group of
people in this particular organisation that are proactive in different areas in keeping
it moving forward. I see the Emergency Department as a prime example. The NUM 3
there from her role through the years that I’ve worked here at the case study site has
progressively kept, tried to keep the Emergency Department up to speed, up to date
with all of the innovations that are coming across, within reason that you can do as a
country hospital.
Executive: No. 17
So, where innovation has happened through the regular processes of the
organisation, it has been in the pursuit of quality improvement with service delivery.
The sporadic innovation ideas that came up were just serendipitous and that’s not
part of a mechanism.
‘in a proper organisation, every single individual should be able to drop that off
their tongue in an instant.’ Medical clinician
Chapter 5: Study 2 Results: Semi-Structured Interviews 100
Innovation per se has not been a focus for us, and we have mostly seen ourselves
as a service delivery organisation. If you want to make innovation a bigger part of our
portfolio, I think we need to articulate that in our mission statement. We need to
articulate that and explicitly within our core values that we foster and encourage and
look forward to innovation or we see ourselves as an innovative organisation.
I think compared to some of the larger, say, teaching hospitals, where innovation
is an embedded part of what they do – that’s partly because they have a large number
of teachers, trainees, academic staff, professors with university appointments, which
is a very different workforce profile from the one that we have. We pursue innovation
not as an end in itself, but as a consequence of seeking excellence in service delivery,
but to take it one notch higher, we will need to explicitly articulate that.
Individuals are valued and ideas able to be implemented
The literature review identified that cultures that support innovation instil trust and
respect, teamwork, and are quick on the uptake to make decisions (Dobni, 2008). Other
authors identified the importance of a receptive context for change, positive
managerial/staff relations and the motivation to adopt innovation (Greenhalgh et al.,
2005, 2004).
When asked whether interviewees felt their contributions were valued within
the organisation, 22 respondents clearly articulated that they did feel valued.
Particularly, they felt valued within their team and by their direct managers.
Different views were presented as to the extent of how others in the organisation
valued their contribution, with less consensus that individuals were valued outside of
their immediate teams or departments. The second part of this question asked the
participants whether they felt they were able to generate ideas and see these
implemented. In small teams within the case study organisation, innovations could be
implemented and consensus gained quickly if an individual had an innovative idea.
The following extracts from interviews demonstrate the range of views.
Medical clinician: No. 7
Yep. Again, I’m lucky in my small department. Because it’s just me and a couple
of nurses, we rely on each other and we’ve built up a lot of trust over the years and
they can see where these ideas are coming from, that it is about improving patient care
Chapter 5: Study 2 Results: Semi-Structured Interviews 101
and they can see it working and feel proud that it’s coming from their small
department. Then they enjoy seeing it go further and the successes that it’s had.
Administration support: No. 2
By some employees, yes, and by some no. By my direct manager and the health
service, yes, I feel my ideas are valued and I’m able to express my ideas to those
people. Then other people who I work alongside, I’ve had the opposite experience
where I feel undervalued and sort of, I’ve had fellow colleagues attempt to put up
barriers and have made me feel that my ideas weren’t valued by those barriers.
Clinical nurse: No. 3
Okay, colleagues yes, definitely think (I am) valued by colleagues. Expertise,
knowledge, professionalism, ability to get things moving, all those things, definitely
by colleagues. Higher up in management, don’t know, minimal feedback from that.
Clinical nurse: No. 21
Yes, definitely feel valued. In fact, every day; everybody from the nurses to the
relatives and the doctors. I get a lot of referrals now from the GPs in the community
and especially the other end of the valley where there’s no geriatric services and no
physician moving in the hospital.
The generation and implementation of innovative ideas and whether this could
be achieved within the case study was also ascertained during interviews.
Participants were asked whether they can put ideas forward in the organisation
and see them implemented. Innovative organisations will often express innovation
through behaviours that lead to a tangible outcome or action and as such will create an
environment where employees can put ideas forward and see them implemented
‘Yes, I think I can generate (ideas) but it goes back to what I said before. If it has
to go – the further up the management chain it goes the more it seems to, well,
peter out or not come to fruition, basically, or if it does it’s longer. If it’s
something that can be kept at a lower level management and it’s a simple process
it can happen’. Clinical nurse
Chapter 5: Study 2 Results: Semi-Structured Interviews 102
(Dobni, 2008; Dobni et al., 2015; Saunila & Ukko, 2012). Responses indicated that
there were plenty of innovative ideas, but at times implementation was challenging
with barriers such as time and funding. Clinicians passionate about innovative ideas
recognised that to implement their ideas that they needed to be disruptive, use personal
influence and connections and/or work around the ‘system’. The following quotes
from a medical clinician, allied health and nurse manager reflected this.
Medical clinician: No. 27
To a degree. I think I’ve been very fortunate; I’ve had some good platforms to
put my ideas forward, and I guess I haven’t been shy in saying what I think either and
being a bit disruptive, so that’s been – it’s had some ups and downs associated with it,
but yeah, I think I’ve had a good opportunity to put some ideas forward.
Nurse Manager: No. 5
Yes, definitely, definitely, but with any change, it’s often person driven. So, a
systems-driven approach takes years, takes 12 months. But you have your own views
and your convictions, and you keep working on it.
Allied Health Manager: No. 15
Yeah, yeah. I think especially once you’ve worked here a little while and people
know who you are. I certainly think my ideas, and people come to me to comment on
a lot of things they’re working on in their departments, which I find quite enjoyable. I
guess there’s a number of clinical leaders that end up getting everything coming
through them.
Informants also identified issues that enabled or challenged the implementation
or sustaining of innovation. Selected quotes below demonstrate that for some
innovations, sustaining them can be difficult. Trust, experience of team members and
their ability to think independently were identified as important enablers. Time and
funding to develop and implement innovations were also acknowledged by
participants as a challenge to the generation and implementation of innovative ideas.
These were recurrent themes in the qualitative data collected through the interview
process.
Chapter 5: Study 2 Results: Semi-Structured Interviews 103
Nurse manager: No. 22
I think so. Yeah. You see that at committees, you talk about things – it gets to
that implementation stage that then that’s where it has trouble being sustained, I think.
Medical clinician: No. 7
I think the culture in our little department helps, that we – I’m there all the time
during the day but then we have locums after hours and at weekends. Part of it is that
we have very senior, very experienced nurses that have been there for 20 years, and
because you can be a nurse and living in Yamba and work in Maclean it’s a
competitive job to get into so they’re high-level nurses. I try to encourage a lot of
independent thinking in the nurses and a lot of assertiveness to get a really good team
going because I need their help. If I’m the only one there, they need to be helping me
out as I’m trying to help them out. They don’t tolerate poor performance.’
Allied Health Manager: No. 20
So, yes I do think that you’re able to see ideas through and see them
implemented, but I think it can be very hard work to get there. It’s not made easy for
you.
In my case, honestly, I end up doing most of these things in my own time because
I spend my work hours managing the pharmacy and managing the dispensary, and
then I don’t get a chance to actually focus on stuff until 4:30 when everyone else has
gone home. So, there are times when you sort of just start to think, well why am I
bothering? No one else seems to want this to be implemented, so why? It’s not worth
it.
Nurse Manager: No. 4
I would say happy for you to put ideas forward, but whether it progresses or not
is again due to the red tape or the processes to put in place, [whether there’s] financial
support to implement something. I think financial barrier’s a big one as well. Yeah, I
think the bigger picture, sometimes we talk about it, but we don’t often follow through
with it.
Chapter 5: Study 2 Results: Semi-Structured Interviews 104
5.2.3 Context to support implementation of innovation
Participants were asked if they knew whether innovation specific metrics were
routinely reported, whether systems and processes could be modified quickly to
improve services and the contextual factors that enabled or acted as barriers when they
had been involved in an innovation.
Ability to modify systems and processes quickly to improve services
When questioned to determine whether systems and processes could be modified
quickly to improve services, most interviewees thought that it was possible. However,
this was subject to constraints. If the change required additional funding or approval
from Local Health District Executives, then speed could be impacted. Respondents
conveyed that small changes with local impact could be made relatively quickly.
Quotations from interviewees below reflect the views on speed of modification.
Executive: No. 17
I don’t think there’s a quick turnaround because you’ve got to convince people
of the need to do it, the need to change. People – clinicians don’t like change and
they don’t like telling – being told they need to change. I think that’s a – so you’ve
got to make them think it’s their idea. The art to getting change in an organisation is
to present a scenario and you can do that through an audit or adverse events or
viewing adverse events, viewing clinical cases, which is how Medical Quality
Committees work, and then convincing people that there’s a need to change or them
realising that there’s a need to change so it becomes their idea. If it becomes their
idea you’ve got a much better chance of getting change.
Allied Health Manager: No. 16
I would say, no. The system itself is actually geared to working slowly. There’s
many layers within the system and it’s sometimes hard to navigate and actually
‘Depending on how big the change is, that’s the thing. If it’s small changes, then, heck, I
can do that here in the case study site. Anything that’s significant will have to go up’ Nurse
Manager
Chapter 5: Study 2 Results: Semi-Structured Interviews 105
understand how to navigate through those various layers. You know, who you need
to direct questions to. Timeliness of responses is not a problem. But it’s also that
respect and understanding that there needs to be change, and sometimes that’s really
hard to get across, and that’s really hard to get across at the level that we’re talking
about, because things happen up here in the ethos but, in a lot of cases, what we’re
talking about is on-the-ground service provision.’
Nurse manager: No. 18
But I think you can do it quickly. I do think it can be done but there’s a lot of
people that need to be involved in small change.
Barriers to modification suggested by informants were the number of points of
consultation and this caused frustration to those wanting to innovate. This is
exemplified in examples where innovations had tried to be implemented to improve
staff rostering in the Emergency Department and Intensive Care Unit and
strengthening access to cardiac clinical services.
Nurse Manager: No. 5
So, something as simple, like we had just recently a change of roster time,
starting time, of the afternoon staff, because there is a lot of overtime from between 10
pm and 11 pm, people having to stay back because works were not completed, patients
and you go from seven staff to three. So, to change that time, which everyone agreed
to – so, we had to survey, twice, all the staff, put that into a document of what the
responses were, why, majority or not. Then we had to consult the union about it. Then
we had to consult executive. Executive had to consult area executive. It took about
three months, maybe even longer.
Clinical Nurse: No. 23
I wanted to put together a package to be able to improve our cardiac services in
the hospital, but the problem was it needed to be talked to on so many different levels
that I couldn’t get anyone to actually come along with me on the bandwagon to make
the change. I got really, really frustrated.
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Metrics to measure the effectiveness of innovation initiatives
Participants were asked whether there were metrics to measure the effectiveness of
innovation initiatives in the case study organisation. Fourteen of the 25 interviewees
related that they were not aware of explicit metrics used to measure the effectiveness
of innovation initiatives. However, they did note that when changes are made, key
performance indicators would sometimes be reviewed pre- and post-implementation.
Other metrics that interviewees mentioned were patient and staff surveys, audits and
the incident management system. The Quality and Risk Management Committee,
informants related, was the responsible governance body for monitoring metrics.
Recognition for innovation could be made through the Local Health District Quality
Awards program. In response to the question on metrics to measure the effectiveness
of innovation initiatives the only measure was the innovation itself and whether it was
sustained. Interviewees recognised that this was a barrier to evaluation of the
effectiveness of innovation, and quotations below demonstrate how measurement and
data can be used to sustain, measure and identify where problems exist and to spread
innovation.
Nurse manager: No. 22
That’s just monitored by the quality committee – quality risk management
committee – but we don’t go that next stage in measuring the effectiveness. We know
that the project’s there. It’s been done and there’s not a lot of focus on outcomes and
transferability – that wow, this is really good, let’s see if another ward can do it, or
something like that. It’s really at that stage where it’s just an item [laughs].
Medical clinician: No. 27
We had this steering committee at my – it was my suggestion, and at the
steering committee – no one seemed to really have a way of moving forward, other
than some anecdotes. They’d use them as hot points of what we might change. It was
like, what’s our methodology here? So, once you’ve got that, then you get the KPIs,
and then you have a temporal framework but also a structural framework about how
you’re moving forward, and I think a real barrier to that is that we don’t have the
expertise to work to [our] projects. People are left to themselves, and I don’t know if
people left to themselves without an academic basis to how they’re doing these things
very well necessarily. So that’s a real barrier.
Chapter 5: Study 2 Results: Semi-Structured Interviews 107
So KPIs here – it’s often just success, in that the thing is finished. You would
say – with the patient flow, there was a bunch of recommendations, but at the end it
seemed to be a bit all or none, a bit black and white. Oh, well, we’ve done that now
and it wasn’t really this kind of – whether it’s action research or [participatory]
action research or whatever your methodology is moving forward, it just didn’t seem
to be that focused.
Some changes in the case study organisation could be made easily if it did not
involve additional funding and or resources. Within a department or a clinical unit,
changes could be made, and the following quotes reflect how this can be done. Barriers
identified were the levels of bureaucracy, uncertainty about who needs to approve and
how to get approvals – that is, understanding the processes of governance and
authority.
Medical clinician: No. 7
I can do that in my department and I can modify things quickly because there’s
just me and a couple of nurses. If we want to do things a different way, we can crack
on and do that when I’m there. To get it more broad than that is a problem. There’s
various levels of clinical and management buy-in that you need and then both
doctors and nurses like to rely on authorisation from very far above. Not even a local
protocol; until something is state-wide then they’re not keen to use it if it’s a new,
innovative protocol.
Medical clinician: No. 11
Yes, we can, I suppose that’s the key thing, is that it’s a small hospital with a
close-knit regular team of doctors, nurses, allied health. So, if we want to change
something, it usually doesn’t involve too many people. We can talk through what we
might do differently and then basically do it, if we agree that that’s sensible’.
Medical clinician: No. 27
I think the advantages for a small, rural place, for being able to modify things
quickly, is that you often know all the actors in the implementation process, and so you
can get ideas around very quickly and you can build a case for change very quickly. If
you can build that, [that] everyone really is behind that, because there’s only so few
Chapter 5: Study 2 Results: Semi-Structured Interviews 108
actors involved you really can get [unclear] something happening quite quickly.
Barriers to that, however, are about volatility of workforce.
Bureaucracy and the system
Many of those interviewed described ‘the system’ and the bureaucracy as a barrier. If
innovation involved change within the team or clinical department this could be
achieved relatively easily in the case study organisation. Where change involved
approvals from above, this slowed down progress, provided a source of frustration and
was a barrier to innovation. Others emphasised the importance of good communication
and ensuring that a persuasive argument for change was presented. Selected quotes
highlight the key themes from the narratives.
Administration support: No. 2
No, no, there’s too many hoops to jump through, I guess that’s the nature of a
large organisation (NSW Health) perhaps. But if you have a good idea, there’s so
much policy and procedure around everything that you often find that you hit a lot of
barriers. For example, a simple thing like delivering some information to the public,
in terms of like, a simple newspaper article, turns into quite a labour-intensive task
and you have to go through so many, so many different people to – and then it gets so
much back and forth and it turns into quite a bit of work that one might get discouraged
from doing something like that in the future because of the workload involved and the
end is often gets changed so much through the process that it might not be what was
initially intended.
‘But in terms of fitting into the health service system and ever being able to modify anything
there, perhaps it is possible, but in my experience, there’s – the system is – there’s too many
people to go through and the processes aren’t clear enough.
So the work involved to even get to the answer to the question as to how something might be
changed, is the barrier in itself. So you follow the process and then you hit so many
confusing and misinformation from various departments that you often end up just stalling
there before you even find out what the process is to implement some change within the
system.’ Medical clinician
Chapter 5: Study 2 Results: Semi-Structured Interviews 109
Clinical nurse: No. 3
I don’t think you can modify them quickly, they can be modified. You have to,
from my position because I’m just a clinical nurse, I have to follow my line
management. So, if I see something that needs to be changed, I can make a
recommendation or I first approach my nurse manager. Then I can write what I would
like done, write a report or something to validate what I’d like done. Then from her
then it would need to go to the next step.
Allied Health Manager: No. 20
Something was sent to me by my manager to send to PM who is the LHD safety
and quality manager, to get it put up online. Even at that level, and this is Executive A
and Executive B, so Executive A who – I’m sure you’re familiar with – they both had
different ideas about who needed to do the approving to get something put up online.
It was a very frustrating thing to realise – but then at the same time they don’t seem to
see a problem with the way it’s set up. It’s not a reflection of them personally, and
their work, but more the whole organisation, is that the highest level, no one seems to
think that this is a problem.
During interviews, participants did identify innovations that they had been
involved with and there was an acknowledgement that despite the barriers, progress
had been made. NSW Health bodies such as the Agency for Clinical Innovation and
the Clinical Excellence Commission had supported the integration of new and
beneficial models of care, as reflected below.
Medical clinician: No. 28
But having said that, it’s remarkable what changes have occurred in this hospital
and I think having the students here has been a positive for that. The input of places
like the CEC and the ACI has helped run change and they’ve put up – they’ve
developed pathways which can be sort of stamped universally. A good example of that
is the orthogeriatric model that the ACI and CEC both put up and which we’ve
attempted to implement here. It’s still not implemented as well as it should be because
we don’t have the resources. We’re still very much starved compared to larger places.
There’s no registrars, there’s no residents [unclear] but the role has been ill defined.
Management doesn’t seem to have the resources and the capacity to do that.
Chapter 5: Study 2 Results: Semi-Structured Interviews 110
During interviews the importance of champions for change and leadership by
clinicians was identified as an enabler to the implementation and maintenance of
innovation.
Champions and leadership for change
In the case study organisation, many of the innovations identified were initiated and
driven by clinicians rather than direction from the executive. In rural settings, medical
staff are often only supported by the nursing team and allied health workers. The case
study site under study had no junior medical staff, interns or registrars working on the
wards except for orthopaedics, which has one registrar on rotation from a larger centre.
The appetite for risk and innovation by employees is therefore impacted by these
limitations of staff and resources. During interviews it was clear that when clinicians
are implementing innovation, champions and leadership for change was an important
factor. Staff interviewed felt that without support from the clinicians at the coalface
real change was difficult and could be slow. Identification of a clinician to drive and
promote the innovation was identified as an important factor, as reflected in the quotes
from three medical clinicians and an allied health manager.
Medical clinician: No. 7
It’s a matter of – it’s a two-pronged approach; coming in at the grassroots and
trying to convince people on that level but also right at the top, from Minister down,
and getting those people convinced of the innovation and they can drive it and
hopefully meet together in the middle. I think the organisation is, for good reasons,
fairly slow to pick up on innovation.
Medical clinician: No. 28
Then you’ve got to have them agree to the change and that’s how the
orthopaedic (geriatric) model came in. To convince the physicians that they needed
The response was, well then we’d have to get permission from – you know we’d have to
put it out for trial and then we’d have to – so there were a lot of loopholes whereas
down here if Dr A can see there’s a pathway or something that needs to be done, it’s
just implemented, discussed and this is now what we do. Nurse manager speaking about
Dr A the champion
Chapter 5: Study 2 Results: Semi-Structured Interviews 111
to be involved in the orthopaedics was not an easy task. Even when it was
recommended by an organisation such as the CEC and the ACI it still wasn’t an easy
task. That’s partly because of their workload.
Medical clinician: No. 9
It’s quite unusual to be able to do it quickly. There are occasions when something
compelling comes along and it’s carried across the line by champions. But most of the
time when it’s funding dependent it is an exceedingly slow process.
Allied health manager: No. 15
I think we were very fortunate, the usual manager for our department is
extremely motivated, energetic and sees the clinical value in a lot of these things and
puts them in place. So, I think that’s why our department, in particular, is quite
progressive. I guess that energy and change invigorates a lot of the staff.
5.2.4 Knowledge and orientation of employees to support the thoughts and
actions necessary for innovation
Within innovative organisations, employees have the information and strong
knowledge management systems that support them to keep up to date and to introduce
innovations (Dobni, 2008; Lerro, 2012). These organisations will have a coherent
knowledge management system, strategy and direction towards innovation. Questions
were asked about the case study organisation and the learning systems in place, and
the opportunities to develop new skills and knowledge directed towards innovation.
Organisational learning – organisational expectations to develop skills and
knowledge directed towards innovation and connection of an overall strategy for
change, improvement and innovation
When asked whether there is an expectation to develop new skills, capabilities and
knowledge directed toward supporting innovation, most interviewees felt that
‘Oh, towards supporting innovation? I can’t think of any formal channel for that. I
mean HETI encourages you to upskill and maintain skills and accepted standards.’
Medical clinician
Chapter 5: Study 2 Results: Semi-Structured Interviews 112
continual learning for improvement was supported. While innovation and techniques
for translating innovation into practice may not be explicitly covered by the education
courses provided, there was consensus that education was valued. Medical clinicians
expressed that they were well supported to attend conferences and other forums to
ensure that they could keep up to date with knowledge, innovations and contemporary
practice in their respective disciplines. This was exemplified in the responses below
from medical clinicians.
Medical clinician: No. 27
I think there is an expectation. There’s certainly an expectation that things will
change in the right way. So, I would agree with that, yes.
Medical clinician: No. 10
Training, education, and study leave. So, we get five weeks’ salary, five weeks
of leave and ($$$$$) to supplement doing whatever you want, basically. Now, you used
to be able to do whatever you wanted … they’ve cut down on it enormously, which is
annoying.
Nurses, allied health and support staff revealed that they attended mandatory and
hospital and Local Health District training but that other learning opportunities were
limited. Opportunities to attend specific education related to supporting the
organisation to innovate were available through the Health Education Training
Institute (HETI) but these were limited. One project officer interviewed revealed that
they attended training at the Agency for Clinical Innovation (ACI), and others were
members of working groups of the Clinical Excellence Commission (CEC). These
bodies provided corporate knowledge and expertise in innovation and were regarded
as extremely positive and a useful support to strengthen learning and equip staff with
skills to implement innovation and to manage change projects successfully.
Executive: No. 17
What we’ve tried to do over the last few years is engage not only internally but
also with external organisations that can help drive change and improvement and
bring about an environment conducive to creativity. As examples, I will cite the very
involved engagement that we’ve had with the Agency for Clinical Innovation, and
Chapter 5: Study 2 Results: Semi-Structured Interviews 113
we’ve had a number of ACI-driven projects that are running here locally, and that’s
helped us improve, innovate, change, by using the agency as an external change
mediator, which was ACI in this case. Equally, we’ve also worked with the Clinical
Excellence Commission where we’ve been able to leverage some of their
exceptionally good products and innovations and implement them within the
organisation. But to also be not just the passive recipients of these changes but also
be actively involved, I think the LHD has encouraged people to take part in
leadership courses, in training and management courses. Myself, I was sponsored by
the LHD to go and attend a master’s program in clinical leadership of management
and this is just one example of many that the organisation has been involved with in
trying to create an environment that is conducive to providing good leadership and
that fosters creativity within the organisation.
Some staff felt that further training and education to support them to be
innovative would be helpful. The observation from a Nurse Manager (No. 22) reflects
this:
I just don’t think there’s a lot of training around. I think I haven’t had a lot of
training in quality to be honest. I’ve stepped into this role and … got given a whole lot
of information and things but actually applying it to practice – that whole quality
improvement stuff – I know that’s my role but I wouldn’t say I’m overly confident with
the whole process and that I would actually attend training if there was something.
Others felt strongly that more could be done to support staff with training and
education so that they could learn further about innovation and improvement
approaches. The quotation below reflects their impressions concerning the alignment
of the case study organisation’s approach to learning for innovation. Individual
responses also reflected that gaps in learning motivated them to support their own
learning through online courses or other self-directed learning.
Medical clinician: No. 7
No, I don’t think the organisation is trying to get you to be innovative or develop
new skills or anything, quite the opposite. The training is all based on established
credentialled courses, the nurses do their FLECC, you go and do your EMST, which
has been the same for 30 years. They’re not innovative courses, they’re quite the
Chapter 5: Study 2 Results: Semi-Structured Interviews 114
opposite. The organisation is lagging on that; the people themselves see the value and
are queueing up for innovative courses and telling their friends and doing these things
in their spare time.
Administration support: No. 2
No, there’s not the expectation. Within some roles, there probably is, but in other
roles it’s probably more or less becoming a cog in the process and not being inspired
to or required to think innovatively and that’s something that could really be worked
on and would help improve processes within the health service.
Nurse clinician: No. 25
I’ve done as I said a lot of online stuff. I do a lot of reading too, like that
Hardwiring for Excellence course. I did that [student course] a few years ago. Just
leadership and management books in general, I read them just so I can maybe work
differently or think differently or just see it from someone else’s perspective and try
and implement it in my work environment. I think that it’s more self-driven than
actually offered to me here at work.
Nurse clinician: No. 3
I think there is, particularly if you are willing to do it yourself, self-direct your
learning, self-fund your learning [laughs]… There is a certain amount made available,
but I think sometimes that the resources get stretched. I don’t think that’s anybody’s
fault, but all of the yearly mandatory training, all of the things that the whole staff have
to be put through I think that must eat into the education budget. A prime example was
someone was thinking about doing – one of my colleagues was thinking about doing
psychogeriatrics, approached the hospital regarding funding assistance, even just time
off if she was willing to fund herself. Basically well, we’ve got one of those, we don’t
need another one.
Executive: No. 24
There is an expectation that we meet the requirements for providing patient care,
and whilst we would like to see people or staff come forward with innovation of how
we can do that – it’s that old saying, you work smarter not harder, we would like to
think that staff will come forward. On the whole, you’ll find some staff will and they’ve
Chapter 5: Study 2 Results: Semi-Structured Interviews 115
always been the motivated ones, will come forward. It’s a little bit more difficult when
you try to get, probably staff that aren’t as outgoing, trying to get them to participate
because often they have just as good ideas of how things can progress.
Medical clinician: No. 11
I don’t know, I think we more look at – medically we look at continuous
professional development as okay, it’s called continuous development, but it’s more
like continuous status quo, isn’t it? It’s like making sure you’re not going back.
Keeping up to date, okay, things change and keeping up to date, need to learn new
things, but progressing beyond that or being at the forefront of that is not promoted or
too much a part of the picture. Probably, I guess it’s recognised if it occurs again, so
supported or recognised but not effectively.
Administration Support: No. 19
Yeah. Basically, you either do it in your own time, or your sit down and Google
the problem until you actually learn it. That’s basically it. I think it’s just, basically,
self-direct. We have done training in the past, but it’s – I think, really, it’s just been to
tick a box, because it hasn’t been really appropriate to what we use here. We’ve sent
you on training. It’s just like, well, it’s not really relevant to what I do.
Nurse manager: No. 4
Yeah. No, I would say clinically maybe in terms of researching for best practice.
But in terms of organisational change, then no, I would say no. I don’t think there’s
enough time given to look at that. With the structure of the health service, which flows
down from New South Wales Health to each LHD to then each site itself, I think there’s
just – with everything being standardised, I think it makes it more difficult to change
structures.
Chapter 5: Study 2 Results: Semi-Structured Interviews 116
Connection of learning to an overall strategy for change, improvement and
innovation
All participants were asked whether they thought that learning and development in the
organisation was connected to an overall strategy for change, improvement and
innovation. Informants felt that while learning was done well in the case study site
when compared with others in the Local Health District, it was focused around
mandatory training rather than addressing specific areas for improvement or equipping
staff better to make improvements and to implement innovation. Examples were
provided of how the case study site stood out from others in the Local Health District,
such as the Strategic Education and Research Committee, which had been introduced
with a brief to look at educational requirements across the service and in line with
organisational strategy.
Fewer than half (9 of the 25 informants) had the view that the organisation did
connect learning with improvement. Most responses, however, reflected that while
there were learning opportunities the connection between identified areas for
improvement and innovation and learning was not clear.
Executive: No. 17
Yes, yes. I think we – much of what happens by way of change or improvement
or innovation, which is driven by the quality improvement activities that we have and
the quality and risk measures that are being monitored, they are all directed at
making sure that we learn something from it. So, learning and development is
committed to the overall strategy, without a doubt, and are reasonably well
connected. Whether it percolates to the next stage of the implementation effectively, I
think needs to be looked at more thoroughly. I think that’s an area where we can do
better.
Executive: No. 24
Overall, I would like to think it is. They’re – learning and development
sometimes gets hamstrung in having to provide services to meet the mandatory
‘Yes, I do. – it’s necessary to be a lifelong learner. Yeah. If you don’t learn, you
don’t grow. If you don’t grow, nothing changes.’ Nurse Manager
Chapter 5: Study 2 Results: Semi-Structured Interviews 117
requirements in a lot of areas for different types of education. It would be nice to think
that it is, in fact, they’ve got that ability to encourage and promote innovation as well.
Nurse manager: No. 4
It’s meant to be through our strategic education committee meeting, research
and education, although I think that since we’ve set those meetings up, it has certainly
enabled us to liaise more with executive staff so that they can then understand what
we’re doing and then hopefully give them the view that it is important. We’re trying to
coach them basically into knowing that education and research is really important.
Those interviewed who did not agree that learning was connected to an overall
strategy for innovation and improvement perceived that change came as a result of a
reaction to issues arising out of accreditation or to address specific quality and safety
issues. Clinician quotes below summarise the sentiments of those who did not agree.
Nurse manager: No. 29
Everything’s reactive in this hospital, reactive, reactive towards accreditation,
reactive towards the profile, because we have to have this done and because we’ve got
a PICC line now, now you’re reactive, you get these people tested because we’ve got
that patient with this, we’ve got grads in; unfortunately, we are a bit reactive not
proactive.
Nurse clinician: No. 23
No. No I don’t. I think the learning and development – okay, so let me answer
that one. So, with the learning in ED it’s specifically for ED, so we do advance our
skills in that area and A does target our education so that we are continuously at a
high standard of practice, but it’s in a high acuity area and you need to be. But I, yeah,
I don’t feel that – how can I put that? I don’t really feel, with a lot of the education, as
I said, I just don’t feel that nurses have anywhere to go with it.
Nurse non-clinical: No. 18
Sometimes I feel like the education department is just there to sort of tick a box.
It’s not necessarily innovative. I think it could be improved upon. Yeah. I think actually
having educators – because I know that they’re on the ward. But a lot of the time I
Chapter 5: Study 2 Results: Semi-Structured Interviews 118
think patient load or something? I don’t think they’re actually like going around to the
bedside with the nurse and checking what they’re doing. I do think that yeah – I do
think the education department could be improved.
Reward for learning and development
Participants were asked whether learning and development was rewarded and in what
ways. Nine thought that learning was rewarded. While in the case study organisation
there was no monetary reward for learning, individuals attained personal satisfaction
and achievement through learning. Sample views reflecting these responses are
reported below.
Executive: No. 17
Again, in my view, not adequately, because I think to create an awareness that
we encourage this simply by rewarding people through recognition, through
celebration, would be not only useful to drive a change but also to encourage and
motivate other people to come into that space. So, I think we do not celebrate our own
achievements adequately, and that’s an area where we can improve. So, it’s a bit like
you were saying symbols. How does the organisation treat the people who are
innovators and how does it respond to them and how does it celebrate them? Those
can act as powerful symbols that could motivate behaviour in the rest of the
organisation as well. We do reasonably, but I think we can do a lot better.
Medical clinician: No. 7
Again, I think it’s rewarded by your peers that if you’ve gone and learnt
something or become an expert at this or done some research on this or done your
project or whatever then yes, your peers will enjoy that and respect it and adopt it. But
within the organisation it’s not going to change your pay grade, it may help in the eyes
of your manager and you may gain a promotion quicker, but the trouble with those
My first answer would be, no, except for own personal growth. I know, we spent a lot of
time education, not only our staff here, but say, the nursing and the clinical staff about
various things. Whether that’s – well, I don’t know whether that’s rewarded. It’s
expected. It’s more expected and its part of what we do. So, I don’t know.
Administration support.
Chapter 5: Study 2 Results: Semi-Structured Interviews 119
promotions is that you’re moving away from the coalface in that case. If I get promoted
then I don’t see patients anymore, I’ll be sitting at a desk in an office and it’s the last
thing I want.
Administration support: No. 2
Sometimes yes and sometimes no. Learning and development is rewarded when
that learning and development results in a positive outcome in the workplace. So, for
example, if the employee learns a new skill and then brings it back and shares it with
their colleagues and then that results in positive patient outcomes, then that would be
a reward for that learning and development. Then I guess in other cases learning and
development is not rewarded when that sort of additional knowledge or skill can be
seen as a threat to other colleagues and that’s just a reflection of a bad workplace
culture, I guess; but that would be one example of it not being rewarded.
Clinical nurse: No. 25
I wouldn’t say it’s rewarded. I think for yourself internally you feel rewarded. I
feel like especially from being in an acting role for a long time to then actually feel
like you have a valid opinion or a response because of what you know. It’s a bit of a
confidence booster when you go into a meeting and you actually have half an idea of
what you’re talking about. I don’t think it’s – I think it’s not rewarding here either
because there’s no one else seems to be on the same page. I think if you worked in a
culture or an environment that everybody had the same ideas.
Nurse manager: No. 6
Don’t suppose, well you can apply to be paid to go and study. So that’s a reward
isn’t it, really? Not everybody gets the opportunity to be paid while they’re attending
a study day. So yes, we can do that now. They don’t pay our accommodation, don’t
pay our – they might help with course fees or things, but they don’t pay your travel or
your accommodation. But I actually think if the organisation’s willing to pay for my
time to go plus someone to replace me if I’m a nurse on the ward that’s a big enough
commitment from them.
We’re less, we’re a little bit disadvantaged in the country as opposed to the city
because we don’t have that close access to – I can go to uni one day a month or two
days a month or whatever. We have to do a lot by distance ed, but it’s rewarded –
Chapter 5: Study 2 Results: Semi-Structured Interviews 120
there’s an expectation that you would come back and you will, yeah, teach your peers
what you learned at the course.
I suppose the biggest reward you ever get is the self-satisfaction that you know
you’ve got the tools to do your job well. A lot of people who do education do it solely
for that reason, there’s a lot of people who should be doing it and don’t. But yeah,
rewards, I suppose you know what you’re doing with your patients better. But tangible
rewards, you get, if you do a postgraduate course you actually get an allowance, a
fortnightly allowance in your pay.
Creativity
An environment where creativity is promoted can enable innovation to flourish
(Damanpour, 1991; Damanpour & Aravind, 2012; Dobni, 2008; Rao & Weintraub,
2013). The question that was posed to interviewees asked them to consider the
challenges in getting people in the organisation to be creative and to use that creativity.
Interviewees believed that creativity was evident within individuals; however, factors
and challenges impeding creativity that were identified were funding, the bureaucracy,
time waiting for responses, past failure to progress ideas, space, ways of working, lack
of diversity, burnout, and making time with busy clinical workloads. Eight
interviewees explicitly mentioned time for creativity was a factor as clinical work takes
priority. The following vignettes reflect some of the challenges in being creative in the
case study site.
Medical clinician: No. 27
I think it’s just mapping those good (creative) ideas to actually a credible
governance framework and how that actually would be enacted in policy and
operations and what’s involved. So that’s – there’s often a lot of – because it’s exciting,
having new ideas, and then actually getting to that point of getting through all that
other stuff like the process is really quite tedious and is a bit for the long game. So that
might take months, and it takes a lot of persistence.
I would say funding. I’d say that would be one of the challenges. Probably time.
Timeframes. Maybe even actual space Nurse manager.
Chapter 5: Study 2 Results: Semi-Structured Interviews 121
That’s a different idea to do what clinicians do, which is treat what’s happening
in front of them, very spur of the moment. It’s a very different concept to having a good
idea and thinking oh, that’s really quite good, really, I wouldn’t mind doing that, and
actually seeing that through is a really different time frame.
Medical clinician: No. 7
Yeah. I think people don’t believe that they can do it, that they see themselves as
one cog in a huge machine and often based on good experience if they’ve put their
hand up before, nothing happens, nothing improves so they think well, this is just a
stupid system, I’ll just keep turning up at work, banging my head against the wall. It’s
a matter of getting people to think actually no, this is a good idea and let’s expand it
and this is how you take it through the levels.
Administration support: No. 2
Again, it would probably be the overcomplicated policies and procedures and
delegation processes that often are so complicated that it ends up being a barrier to
one’s request to do something creative or outside of the box. It often ends up being in
the too-hard basket.’
Allied health manager: No. 20
I think that’s probably one of the biggest challenges that I’ve seen, is the lack
of diversity in where people have worked … So, I think sometimes that can be a bit
lacking here. Trying – yeah, I think when people – we need people to be creative. If
they haven’t actually seen a whole range of ways of doing things, they just do the
way it’s been taught to them.
Patient orientation and value
When asked whether there was consensus among employees about what is important
to patients and other stakeholders, there were a range of responses. Innovative cultures
are oriented towards customers and providing value, in the case of health patients, for
‘Generally, I would have to say yes. That’s what I like about working here – is
that it’s still got some really good old-fashioned values.’ Clinical nurse
Chapter 5: Study 2 Results: Semi-Structured Interviews 122
carers and families (Dobni, 2008). Health care organisations oriented to excellent
patient care has also been identified by Taylor et al. (2015) to be associated with high
performance. In the case study organisation, patient views are sought through feedback
collected at discharge and through NSW Health routine patient surveys. Results of
these surveys were analysed in Chapter 4 of this thesis. However, satisfaction data is
not collected in real time for immediate feedback to staff working with patients during
their episode of care. Real-time feedback would enable the study site to react and
remedy deficiencies in a timelier fashion. Some of the staff interviewed recognised the
importance of community members’ participation in Local Health District committees.
The Local Health District web page reflected that at this level there was strong
representation of community views.
One innovation identified during interviews that directly supported patient
orientation was the introduction of the ‘safety cross system’, a new way of focussing
and managing quality management processes. This had been introduced by a physician
on the medical ward after returning from a conference; however, it was not sustained
(Flynn, 2014). Some staff interviewed felt that orientation to patients and families
could be better, and one nurse clinician reflected that at times staff ‘second guess what
is important to patients’. Time and patient volumes were identified as a constraint to
addressing patient needs. Views within the organisation on patient orientation are
reflected through the following comments.
Administration support: No. 2
I don’t – I probably don’t feel that there is a consensus among employees about
what’s important to patients and stakeholders. I’m sure there’s a lot of employees who
are very passionate about, you know, communicating what’s – and upholding, in their
work ethic, what’s important to patients and stakeholders but there’s also those that
aren’t. I feel like we could, as a health service, gauge much more frequently and openly
with stakeholders and the patients within this community because the feedback from
the general public when trying to access the health service is that it’s a very confusing
process. So that definitely is a reflection of poor engagement and communication with
the patients.… None of the committees that I sit in have community members. So, I
guess we rely on feedback from the people that do regularly have those sessions with
members of the public, action advocates and the like, as to what we need to be doing
to tailor our service towards patients.
Chapter 5: Study 2 Results: Semi-Structured Interviews 123
Executive: No. 17
Well, there is consensus among employees about – and understanding of what
is important to the patients and the stakeholders. With patients, it is very easy,
because the focus of our care has been patient and service delivery, so it’s an
embedded part of our culture that there is a focus on what the patients need. When
we say stakeholders, stakeholders are much more than just the patients. Stakeholders
is everybody who works within the organisation, patients, their families, community,
the public health network, and all of them are stakeholders in the care we provide.
Whether there is an overarching consensus among this larger group, I suspect
not, but there are nascent efforts or burgeoning efforts to try and bring, for instance,
the public health network into greater dialogue with the public hospital. There are
efforts to engage with the GPs and to create a consensus among the wider group of
stakeholders within the organisation. But amongst the employees, I think there is a
reasonably good understanding and consensus about what is important, and there is
a mechanism to communicate backwards and forwards with employees. So, if the
executive sees a priority, we are able to communicate that to the rank and file staff,
and equally, things can be escalated up to the executive from rank and file staff if
necessary, and the mechanism for generating that consensus does exist.
Nurse manager: No. 29
I think we could do that a lot better. I don’t think there’s the time now, there’s
just not the time. It’s one area we could do a lot better. I am surprised we don’t get a
lot more complaints. But there are some very good clinicians here. If we’re talking
about orthopaedics, they’re very inclusive.
Medical clinician: No. 7
I don’t think we actively engage [with] what they think is important. Patients
don’t know what’s important in terms of emergency care. They may think they do. I’m
sounding condescending here, but they’re not experts on how to treat their chest pain,
all that sort of stuff. No, to be honest, I haven’t engaged with patients on this. I’m very
aware that I’m trying to improve patient care and improve the structures around that
and the teamwork and things but in terms of engagement with patients, that’s not a
Chapter 5: Study 2 Results: Semi-Structured Interviews 124
part of it. The same with the intubation one I’m talking about today and the same with
of course ADEPT with the aviators. No.
Allied health manager: No. 16
I think we’re very much client focused. From a community health point of view,
very, very much client focused. Very much driven by the needs of the community.
Maybe not always able to achieve what needs to happen to meet those needs, but very
much driven by the perception of the community and quite engaged in most instances
with other service providers, be they NGOs, be the council, from a transitional-age
care perspective for example.
Clinical nurse: No. 3
Yeah, yeah. I think yes people do understand, but sometimes I think time
constraints, staffing constraints, medical support because we have a lot of locums. So
that can lead to communication, not necessarily breakdowns and not necessarily
miscommunication but not particularly thorough communication.
Executive: No. 24
I think that there is a general consensus amongst the clinicians, that what
patients expect is to be provided with good quality care. How that’s delivered or to
what volume, is probably the bit that gets debated at times.
5.2.5 Infrastructure to support innovation
In the literature a resource allocation was noted as an important building block to
support innovation (Danks et al., 2017; Dobni, 2008; Rao & Weintraub, 2009, 2013).
Interviewees were asked how they make sure that sufficient time and/or money is
allocated for innovation projects. It was clear from the interviewees that there was a
perception that there was no explicit budget for innovation in the case study site.
‘I can’t answer that, I had no real control of the purse strings at all. We were very
much in a beggar’s position, if we saw something we thought we needed or needed
upgrade we had to ask for it and be at the mercy of those who had the power.’
Medical clinician
Chapter 5: Study 2 Results: Semi-Structured Interviews 125
Discretion on spending for innovation projects was not available nor access to a budget
for innovation in this rural hospital.
Executive: No. 17
Something like this cannot be done at the local level, because most budgetary
decisions – and I’m now speaking with respect to the ‘case study site’ specifically.
The budgetary decisions are taken at the level of the local health district, so to make
sure that sufficient time, money, is allocated for innovation, we will need to get the
LHD involved. I think that has happened and I think evidence of that is the fact that
we have a director of research, for instance, now, so there is a much greater
awareness and a willingness to partake and involve ourselves in research processes.
I don’t think the levers for these are local, except the ability to be advocates for
it and be spokespeople for the idea that money and time needs to be allocated for
fostering innovation within the ‘case study site’. We’ve provided – we’ve showed
results, and I think we should leverage the results that we have shown to motivate the
LHD to believe that resourcing us is worthwhile and there would be a good return on
investment from doing so.
Medical clinician: No. 7
You do it at home, that’s right. I don’t get any time. I had to battle to get today
off; even with two months’ notice they couldn’t cover my day today to come and
present something that you’ve already done in your own time, you still can’t get the
time off so it’s just hopeless, hopeless, yeah. You read about these tech companies
where they get their Wednesday afternoons to do what they want to do and that sort
of stuff.
Allied health manager: No. 16
Most people would be doing projects, in addition to their current roles. Or
again with Leading Better Value Care money, that there’s a Ministry of Health
directive about these programs. So that innovation and that drive is very much part
of that program. The other thing that from a community-health point of view that –
and ‘case study site’ has just been a bit of a fringe dweller in this – is the integrated
model of care which was very much rolled out in Richmond and Tweed.
Chapter 5: Study 2 Results: Semi-Structured Interviews 126
Executive: No. 24
That becomes, ooh, very difficult. There is no specific budget that is allocated
for innovation. Budgets tend to be allocated on actual clinical needs at this point and
requirements to make the system function. There isn’t capacity at this stage, at a
local level, to identify specific amounts of money within our – but in saying that, if
there’s small things, we can usually find some scope, that some funds could be
allocated, but it’s only on a very small scale. Nothing on a larger scale.
Allied health manager: No. 14
That’s a very, very tight question for us. Essentially, we have no scope in our
budget to provide that service. However, as a manager I make time to make that
happen. So, there’s a compromise somewhere within our department, usually that’s a
compromise on my time and that’s my choice. But definitely try to promote and
delegate those things throughout the team. I think as a manager it’s really, really
important to know your staff and the key thing too, is to understand where you can
champion those staff members to take on those extra things.
Allied Health Manager: No. 15
I don’t know. It gets a bit challenging at times because I think there is lots of
encouragement from throughout the organisation to innovate and change practice in
line with evidence and increase your efficiencies. That’s all sort of set. But when it
comes down to getting the resources to implement that, sometimes the walk doesn’t go
with the talk, which is extremely frustrating, especially when you want to try and bring
in change and you think you’ve got a good basis for it. That’s where having lots – a
reasonably big department that are enthusiastic really helps. Everyone can keep
fighting these battles a bit.
Funding
If additional funding was required for innovation, be that new services, technology or
dedicated resources to support the introduction of an innovation, staff conveyed in
interviews that in the current climate it would be unlikely that funding could be made
available.
Chapter 5: Study 2 Results: Semi-Structured Interviews 127
Executive: No. 24
New services … have to go through an approval process from the district with
the Director of Clinical Operations. So, any new services would need to have briefs
prepared, sent to the district for consideration with full costings. The likelihood of any
new services commencing that will cost the district, is unlikely to get approval at this
time.
Allied Health Manager: No. 15
We can, I guess, for minor innovation. It’s very much department and
personnel driven a lot of the time. I think our department has done that quite a lot
and worked very well. There isn’t, I guess, a lot of organisational support in terms of
getting extra funding or staffing is the big issue. We feel for our clinical load we’re
already under-staffed and then we’re trying to add extra services.
Allied health manager: No. 15
I guess in terms of funding, all I can do is continually advocate for our
department and what we’re doing to an executive level. Something A has done very
well, and I’m trying to go through the process at the moment is getting grants, HETI
grants and things like that for – I know there are options there for research but also
for just courses and bring new knowledge to the department. That’s probably the
main thing we do is look for grants and funding that we can use to try and put these
things in place.
Knowledge sharing
Effective knowledge sharing and systems is integral to fostering innovation and
performance improvement (Lerro, 2012) and recognised by (Damanpour & Aravind,
2012; Dobni, 2008) and others as determinants of innovation. Technical knowledge
sharing is particularly important in health, as is the ability to effectively access new
guidelines and recommended evidence in ways that support clinical ways of working
enables clinical staff to ensure that care can be delivered based on this information.
…… you get policy overload and policy fatigue, because every week you’re
getting new ones coming out. Allied health manager
Chapter 5: Study 2 Results: Semi-Structured Interviews 128
During the interviews it was revealed that knowledge is shared in the case study
organisation through email, regular meetings, Grand Rounds, ‘Lunch and Learn’, the
health service ‘shared Z drive’, Northern NSW Local Health District Intranet, NSW
Health, Clinical Excellence or Agency for Clinical Innovation websites, journals,
blogs, social media, the Internet, newsletters and education forums. Information from
the Local Health District or NSW Health often ‘percolated’ down. Increasingly,
videoconferencing or web-casting using tools such as Skype for business have been
adopted as methods of communication and knowledge sharing. It was identified that
there was no one single source of truth for information and that mechanisms for
keeping staff up to date on important policy and procedures was cumbersome. Staff
could easily miss important changes or new policy and procedures and acknowledged
that knowledge sharing, and maintenance was something that could be strengthened.
Policy and procedures were long, and while held in a repository, the information was
often complex to navigate and find. Barriers to knowledge sharing identified in the
interviews were dead links on web pages, the unwieldy nature of procedures, lack of
perceived process and resourcing for document/knowledge management and fewer
opportunities for in-house clinical meetings such as specialist driven Grand Rounds.
A medical clinician (No. 7) conveyed:
That’s right. The protocols themselves are 20 pages long and the first 10 pages
is the history of the development of the protocol and the revision date and who to
contact and who signed this off and da-da-da. They’re wordy and bureaucratic. No
one reads protocols at the moment, they’re absolutely ridiculous. The current method
for disseminating new knowledge is just hopeless. It’s designed by managers for
managers to say yes, we sent this protocol out, you should be using this drug in this
way because there’s a new protocol, and it’s, really?
Information links on the intranet might be broken or out of date without a clear
process for ensuring that knowledge was current. This was described by a pharmacy
manager:
I’ve found here, I’ve brought things to people’s attention about dead links or
things that are still up online that shouldn’t be, it’s not even that people try to – people
don’t even try to take them down. You bring it to their attention and they sort of say,
oh okay, yeah no, that’s a problem. Yeah, so I don’t know how to get that down. That’s
Chapter 5: Study 2 Results: Semi-Structured Interviews 129
the problem. No one knows how to actually take these things down, because there’s no
process.
Medical clinician: No. 7
There’s some teaching events like this or a lot of social media stuff, people are
following different influencers on social media and seeing new ways of coming
through. Particularly in the younger doctors that have joined, chasing up well before
the organisation has got hold of it, that’s the cutting-edge stuff before it’s published,
you’ve got the people around the world doing that. That tends be the way it filters
through, the complete opposite to how the organisation wants to do it.
Allied health manager: No. 20
Yeah, that’s right. You sort of get – but you get policy overload and policy
fatigue, because every week you’re getting new ones coming out. I know that I might
scan it quickly to see if it’s anything to do with pharmacy, and the rest of the time I
don’t go into it. There’s ones that something might relate to pharmacy, but I’ve looked
at it and thought, oh that’s probably pharmacy-related, I don’t have time to look at it.
Then it will come back in a committee or a meeting or someone will specifically say,
well did you see this protocol said to use this drug? I didn’t, because I looked at it and
thought …
Clinicians saw limits to the education forums used to share knowledge, such as
Grand Rounds, in the case study site. The quote below encapsulated this attitude.
So, you have grand rounds once every month or whatever it is, and there will be
the student presentations, they’ll be good, but it won’t be cutting edge research.
There’s no journal club, there’s no radiology meetings. So, it becomes very difficult to
get hold of best practice. (No. 27)
Medical clinician: No. 27
Well, I think this is a real gap between the country and the city. In the city, you’ve
got lots of forums [for weeks] of like a radiology meeting, ECG meeting and the grad
rounds and this and that, and journal clubs and all sorts of things.… So you’ll see
people who are not following something that came up last year that’s changed practice
completely, specialty, and people just don’t know, necessarily, unless they’re staying
Chapter 5: Study 2 Results: Semi-Structured Interviews 130
up-to-date with blogs and mailings and significant things. So, actually quite difficult,
I think, dissemination of knowledge in a small, rural place.
When discussing new protocols and emails an emergency department nurse
clinician (No. 23) related:
They’re not highlighted or they’re not set out, it’s probably not the easiest form
of communication to staff. Because we get so much spam. Our email system in the
hospital, I would get probably 20 emails a day that’s just stuff that’s nonsignificant.
So, something that’s significant about, like that, you really do have to take the time to
break it down and I think that’s where it could get lost.
The volume of communications was repeatedly mentioned as a barrier to
knowledge sharing in the organisation.
Medical clinician: No. 11
There are policy update bulletins that come out, I guess that’s some sort of
useful, but again it’s a drop in the ocean. There might be 50,000 policies out there and
they update about 10 different ones that have been reviewed recently. Even that’s like
every month, 10 different policies a month that are – so there’s lot of information. The
important bits are hidden amongst the less important bits. It’s a problem.
Allied health manager: No. 15
I obviously have meetings with managers and executive above me and there’s
information I can disseminate from those to my department when I have meetings. We
get a sea of emails and it’s nice when we have time to read things like Northern
Exposure and quality awards and all of those things. Again, they’re the first things to
get dropped off when we get busy. You come back from a week’s leave and you’ve got
120 emails to sort through.
Similarly, a medical clinician (No. 7) related:
A new protocol would go on the intranet and it will be in your email that you
receive every day or every week, new protocols for perusal and there’ll be umpteen of
those with all boring names like how to hire a fleet car, so everyone always deletes
that straight off.
Chapter 5: Study 2 Results: Semi-Structured Interviews 131
The most effective methods for knowledge sharing seemed to be face-to-face. A
medical clinician and manager (No. 7) stated:
Whereas the way people work is talking to their colleagues and saying oh look,
I’ve heard of this new way of doing it, here’s some evidence or la-da-da-da-dah, or
I’ve got this protocol, I’ve googled it from San Francisco, they’re doing this, what do
you think, la-da-da, and communicating at the coalface where the people are actually
using it a far more workable way. That tends to be how the knowledge actually gets
around.
Some saw that information and knowledge was at times difficult to access and
often provided on a need to know basis. This could be positional or related to
individual power or relationships within the case study organisation.
Allied health manager: No. 20
I found that interesting, listening to that, because I thought that’s not what I think
we see here in this LHD. I find that we still have very much the old, you’re on a need-
to-know basis. It’s sort of like people that are in whatever group will have all the
knowledge, and they’ll decide when they filter out little bits to the community … that’s
the complete opposite of the way you want that knowledge flowing through your
organisation. You want it to be clear, accurate messages that are coming down from
the top.
Knowledge sharing was also impeded by the nature of shift work and the
multiple mediums for messaging such as newsletters, flyers and emails.
Nurse – Non-clinical: No. 18
The way I see it’s filtered down is through we have like a newsletter that goes
around the hospital staff. We have emails. There’s often flyers printed around. If
there’s a new policy or procedure they’ll be education offered. How else do we do it?
Newsletter. Team meeting. Staff meetings. Things like that. I do feel like it could be
improved upon. I don’t know how. I think there’s still massive gaps on information
sharing. And actually getting down to the staff on the ground. Like the nurses on the
floor. On the night duty.
Chapter 5: Study 2 Results: Semi-Structured Interviews 132
Executive: No. 17
To be brutally honest, I think this is something that we don’t nearly do as well
as we could, because many of the initiatives that happen and are useful do not
adequately percolate through the organisation. When I say organisation, I mean the
‘Case Study site’. Examples I will cite, some of the recommendations that are made
for root cause analyses, for instance. Root cause analyses are very thorough, very in-
grown processes which are very well-funded, and they come up with
recommendations, but sometimes we do not implement them adequately, we do not
make sure that all those recommendations percolate through all our staff. So, we need
a mechanism to make everybody aware of some of these processes and
recommendations and changes that are happening. It tends to exist along the senior
exec, it tends to exist amongst some of the more senior administrators, certainly the
people involved with quality and risk and all of them, but if you took the rank and file
staff, it probably does not percolate through. We need to be able to communicate that
more effectively to them, I think, and that’s an area that we could improve on.
5.3 CONCLUSION
This study has collected rich data from key informants in the case study organisation
and analysed their views on the four dimensions of innovation culture (Dobni, 2008).
The interview questions were based on the dimensions of innovation culture and the
case study site’s intention to innovate, infrastructure for innovation, context to support
innovation and knowledge and orientation of employees to support innovation (Dobni,
2008). Analysis of the qualitative data provided a comprehensive picture of the
contextual and organisational factors within the case study organisation that enables
innovation.
‘So, you can’t just follow the classic escalation frameworks. You have to work
around them, and I think almost anyone who has changed anything in a small
rural hospital, you have to be up and down the ladder a lot, really campaigning at
ministry level and the area executive level. You’d have to be doing things all over
the place.’ Medical clinician
Chapter 5: Study 2 Results: Semi-Structured Interviews 133
Intention to be innovative
Informants within the case study feel valued within their clinical teams and
departments. However, they often conveyed that they did not feel valued by the wider
organisation. If innovative ideas were able to be implemented within the team then
implementation could proceed.
The organisation does not have a mission statement that is explicitly directed
towards innovation. The case study organisation’s intention to innovate is not closely
aligned to mission and culture; however, individuals believe that the organisation is
receptive to innovation. This was evidenced by the depth and breadth of innovations
identified during interviews.
Context to support innovation
Informants conveyed that there are no formal metrics used within the case study
organisation to measure innovation success or outcomes. Informal measures to
evaluate innovation are in place as well as proxies, such as Local Health District
quality awards.
Systems, processes and models of care cannot be easily modified at the case
study site. It can be difficult to make changes quickly and with speed. This is due to
funding, space and other limitations. The ‘system’ and the bureaucracy were identified
as a deterrent to innovation as the approval processes could be long and complicated.
Within clinical teams and departments innovations can be made. Successful change in
the case study organisation was often supported and promoted by respected clinical
champions willing to drive the innovation and work around barriers identified. These
individuals often knew the appropriate channels to gain support for their ideas and how
to advance them at senior and at times State Executive levels.
Knowledge and orientation of employees to support innovation
Continual learning is supported within the case study site but is principally directed
towards mandatory training requirements. A formal and strategic committee is in place
with responsibility for education and research. Medical clinicians are well supported
for ongoing education as this is addressed through their contracts. Nursing, allied
health and other disciplines attend mandatory training or training offered within NSW
health. Informants are motivated to learn by personal satisfaction and requirements to
assure a high level of ongoing professional development. Opportunities to attend
Chapter 5: Study 2 Results: Semi-Structured Interviews 134
training that might be directed towards innovation or change management skills are
zero to non-existent. Within the case study site, there is no overall learning strategy
towards change and improvement or an innovation agenda.
Creative ideas are generated within the case study site but funding, time and the
system were identified as barriers to taking ideas forward to implementation.
Informants within the case study organisation acknowledged that understanding
the requirements and focus of patients, families and carers was important. Some staff
believed that this focus was front and centre of patient management and planning
considerations, while others felt that this was an area where more emphasis could be
placed.
Infrastructure to support innovation
Due to clinical workloads and resourcing on the ground at the case study site there was
no allocated time or budget for innovation. High clinical workloads in rural health
settings limit the time for non-clinical activities. Without time for reflection and
thinking the opportunities for generating new ideas, gaining support and implementing
them are constrained.
Knowledge sharing was clearly an issue in the case study site. Informants
revealed frustration and a sense of overwhelming information overload with no single
source of truth regarding policies, procedures and best practice easily accessible.
Without proper knowledge management information, sharing is difficult and an
impediment to innovation spread and uptake.
Despite these findings, the interviews identified that significant innovation does
occur in the case study organisation. Innovation is predominately driven by clinicians
and supported by administration, with 14 recent innovations across the case study
organisation identified during interviews
5.3.1 Enablers and barriers in the rural context
In summary the following factors impact upon innovation adoption in the rural context.
Clinicians with an idea for safer or more effective patient care or outcomes
initiate innovation
Chapter 5: Study 2 Results: Semi-Structured Interviews 135
If clinicians in the case study organisations believed that an innovation could
make a difference to patients, they were willing to perform their own research and
contribute their own funds to support the project. One clinician had funded website
design and graphic designers to publish and share an innovation in emergency
department protocols. Another funded a research company to evaluate their clinical
innovation.
Successful innovations are also driven and reliant upon champions and those
with a maverick approach. These mavericks will work around standard escalation
and procedural frameworks. They know who to talk to and have the confidence and
ability to campaign at Ministry of Health and Local Health District executive levels.
Not all rural settings may have these individuals, but where good ideas are
generated it is important that we make it easier to implement changes that
communities and workers know are needed (Farmer, 2012b).
External bodies such as the Clinical Excellence Commission (CEC) and Agency
for Clinical Innovation (ACI) play an important role
In NSW in recent years as part of a reform agenda, agencies have been
established to support clinicians, consumers and managers to design and promote
better and safer health care for NSW. The Agency for Clinical Innovation has a
vision of ‘Collaboration. Innovation. Better Healthcare’ (Agency for Clinical
Innovation, 2019b). Clinicians working in rural health settings identified the
important role of these organisations in motivating innovation, providing intellectual
effort in identifying possible innovations for implementations through their efforts,
resources and capacity to research.
Time and resources for innovation could unleash and support further innovation
Innovation and implementation take time and effort. In the rural setting with few
resources, limited access to staff and resources there is an environment of scarcity. In
the case study and most rural settings there is little or no ‘slack’ in the system. The
literature review identified that ‘slack resources’ are a system antecedent for
innovation uptake and dissemination (Greenhalgh et al., 2005, 2004). Further
Chapter 5: Study 2 Results: Semi-Structured Interviews 136
innovation could be unleashed in the rural setting if time was allocated to staff with
innovative and creative ideas to improve services, change processes or introduce new
ways of working.
Understanding the context is important in adapting innovations for the rural
setting
New models of care may need refining or adaptation to work well and to suit the
resources available in a rural health setting. The difference in demographics,
indigenous and socio-economic issues impinge upon how care and services can be
delivered. The quotation below from an allied health manager (No. 14) reflects this.
That’s –- essentially what we have seen has been an important thing is having a
clear understanding of the background. I think that’s one of the key issues that we need
to understand that if we are going to invest in change it needs to meet the genuine
needs of our community. We can’t adhere to a model that’s applied elsewhere because
we have different demographics, we have different rural, remote isolation issues. We
have different Indigenous issues, we have different socioeconomic issues.
Stability and diversity of the workforce
Often there is stability in the workforce over many years with some individuals
interviewed having trained and spent their entire work life in the case study
organisation. Medical and allied staff tended to be more transient in many rural health
settings. The following quote from a medical clinician (No. 27) reflects how this can
impact upon acceptance and reception to innovation.
You have that in the city too, but it’s much more transient and it’s a much
younger workforce often. Particularly in the people who enact policy, like the people
on the ground, they tend to be a lot more junior in the cities, if you could generalise.
I’m sure there’s data to back this up. In the country, if you’re dealing with people that
have been somewhere for 20 or 30 years and you’re coming in and telling them – in
Chapter 5: Study 2 Results: Semi-Structured Interviews 137
telling someone to change or innovate, you’re often – what’s unsaid is that what
they’ve been doing for 20 or 30 years isn’t very good or it could have been better
Chapter 6: Results – Measurement of Innovation Culture 138
Chapter 6: Results – Measurement of Innovation Culture
‘With the right people, culture and values you can accomplish great things.’
Tricia Griffith, Chief Executive Officer
‘Positive organisational and workplace cultures were consistently associated
with a wide range of patient outcomes such as reduced mortality rates, falls, hospital
acquired infections and increased patient satisfaction’ (Braithwaite, Herkes,
Ludlow, Testa, & Lamprell, 2017, p,1).
6.1 INTRODUCTION
This chapter presents the results of Study 3. A validated survey instrument, the WIS,
developed by McMurray & Dorai (2003), was used to collect information from staff
within the case study organisation. The survey was designed to identify and measure
the behavioural aspects of innovation practices by individuals in their workplace
(McMurray et al., 2013; McMurray & Dorai, 2003).
The WIS is a 24-four item scale that can be used to measure innovation culture
and comprises four dimensions of organisational innovation, innovation climate,
individual and team innovation (McMurray et al., 2013). The study was initiated to
measure staff views in the case study organisation regarding these dimensions. This
study contributes to answering Research Question 1, understanding the factors
influencing innovation in rural health settings.
Compliance with online surveys can be low when staff have limited access to a
computer and time to complete them. In the case study hospital, there can be
difficulties gaining access to computer workstations for clinical staff on the ward;
therefore, a paper-based survey was initiated. Blank surveys were handed to all
managers and they were asked to circulate these among their staff. Copies were also
left in the hospital library and education centre. The researcher also hand-delivered
surveys to ward and clinical areas to ensure that after-hours staff had the opportunity
to complete the WIS. Using this opportunistic sampling approach, WISs were
completed by 66 staff across all disciplines in the case study organisation. Full-time
equivalent (FTE) staffing numbers at the time of the survey was 366. This sample size
of 66 from the sample population of 366 full-time equivalent employees and based on
Chapter 6: Results – Measurement of Innovation Culture 139
a confidence level of 95% provides a confidence interval of 10.9 (Holosko & Thyer,
2011). Full-time equivalents do not reflect the total number of employees who work
in the organisation as part-time hours are summated and converted to equate to full-
time employment numbers. This is recognised as a limitation; however, it was the best
data available able to be provided to the researcher by the case study site business
manager.
6.2 ANALYTICAL TOOLS
Survey results were downloaded into a spreadsheet and uploaded into Tableau.
Tableau was selected to aid the analysis and is a data visualisation and business
intelligence tool used widely by health care organisations. Tableau was used to present
raw data in meaningful ways with high visual appeal and to enable intuitive
interpretations (Chorpita et al., 2008; Ghazisaeidi et al., 2015). This tool was selected
as it was available to the researcher and is used by the NSW Bureau of Health
Information and Queensland Health to present large volumes of data in meaningful
ways in an environment of increased transparency and reporting (Kirk, 2012).
SPSS Version 25 was used to calculate descriptive statistics such as mean,
standard deviations and percentile rankings for each dimension in the WIS.
6.3 DEMOGRAPHICS
Most respondents to the survey were female and in the 50–59 age bracket, reflecting
the gender makeup and ageing workforce of the case study site. Seventy-three percent
of the respondents were female and 27% male, reflecting the gender distribution in the
health and social assistance industry of 79.2% in 2015 (Workplace Gender Equality
Agency, 2018). The health industry is an ageing one with the average age for all health
practitioners in NSW, 44.3 (Australian Government Department of Health, 2016b).
The average age for all health workers in outer regional locations was 45.4 years in
2016 (Australian Government Department of Health, 2016b). The age breakdown in
the case study site was not able to be determined by the researcher; however,
anecdotally it conforms with an older age profile in the case study site.
Chapter 6: Results – Measurement of Innovation Culture 140
Figure 6-1 shows the age distribution of the sample, whose average age of 45.3
aligns well with the Australian Government average of 45.4 for health workers in outer
regional locations.
Figure 6-1 Workplace Innovation Scale Survey responses (n = 66) by age and
gender.
Respondents recorded the department where they work, and this was then
grouped to reflect their professional discipline, as shown in Figure 6-2.
Figure 6-2 Workplace Innovation Scale response by professional discipline
Chapter 6: Results – Measurement of Innovation Culture 141
This composition aligns with rural and regional health care organisation with
high numbers of nursing staff, no junior medical staff, interns and registrars with
nurses filling many managerial roles. Nurses in rural and regional areas comprise the
largest proportion of health workers.
Respondents were asked whether they were a manager. More than 86% of
survey respondents did not identify as managers (Figure 6-3). In a small rural site such
as that under study, clinicians often have dual management/clinician roles and few
managerial only roles are in place. On weekends, a senior executive is rostered on call
in the event of significant clinical and/or other events. After-hours nurse managers,
responsible for the smooth running of the hospital out of core business hours will
perform clinical work as required during this time.
Figure 6-3 Identification as a manager in the workplace innovation survey
results
6.4 SURVEY RESULTS
A 7-point Likert-type scale was used in the WIS. Respondents were asked to mark
their level of agreement concerning a statement about innovation for each of the 24
items in the scale.
In this section of the chapter, results will be presented for each dimension in the
WIS: organisational innovation, team innovation, individual innovation and
innovation climate. Descriptive statistics are presented for each dimension and
individual question responses. Each question has been reported as ‘percentage
agreement’ (scores 5–7) and ‘percentage disagreement’ (scores 1–3) by use of colour
coding and a ‘traffic light’ colour coding to show questions of high and low agreement
to the statements posed. Agreement scores are coded in green tones and disagreement
in red tones. A score of 4 is yellow and reflects those who neither agreed or disagreed
with the statement. See Figure 6-4 below.
Chapter 6: Results – Measurement of Innovation Culture 142
Scale 7 6 5 4 3 2 1
Level of
agreement
Strongly
agree
Agree Somewhat
agree
Neither
agree or
disagree
Somewhat
disagree
Disagree Strongly
disagree
Figure 6-4 Seven-point Likert scale used for the Workplace Innovation Scale
6.4.1 Organisational Innovation
Survey respondents were asked five statements relating to organisational innovation.
The statements related to organisational vision and linkage to goals, reward for
innovation and systemised and procedural opportunities for learning, Using SPSS,
descriptive statistics were generated.
Table 6-1 shows the descriptive statistics. The mean of 4.4 suggests agreement from
the respondents for this dimension as the mid-point of the Likert-type scale is 3.5.
Table 6-1 Workplace Innovation Scale organisational innovation descriptive
statistics
Org innov
Mean 4.4030
Std. Deviation 1.54501
Percentiles 25 3.1500
50 4.8000
75 5.4500
Table 6-2 shows the level of agreement and disagreement to the statements.
Chapter 6: Results – Measurement of Innovation Culture 143
Table 6-2 Level of agreement to statement on organisational innovation from
the Workplace Innovation Scale
Statement Positive Neutral Negative Total
In our workplace opportunities to learn are
created through systems and procedures.
70% 3% 27% 100.0%
Innovation in my workplace is linked to its
business goals.
48% 20% 32% 100.0%
Our workplace has a vision that is made very
clear to the employees.
64% 14% 23% 100.0%
Our workplace rewards innovative ideas
regularly.
42% 17% 41% 100.0%
The vision of my workplace often helps the
employees in setting their goals.
58% 9% 33% 100.0%
Figure 6-5 shows respondents’ level of agreement with statements on
organisational innovation using the traffic light approach.
There was a high level of agreement to the statement that within the organisation
opportunities to learn are created through systems and procedures; 70% of survey
respondents reflected a level of agreement with this statement.
Figure 6-5 Workplace Innovation Scale organisational innovation level of
agreement, neutral responses and level of disagreement
Chapter 6: Results – Measurement of Innovation Culture 144
In contrast, 41% of respondents disagreed with the statement that the workplace
regularly rewards innovation.
Thirty-three percent or a third of employees in the sample disagreed with the
statement that the vision of workplace helps employees in setting goals. Of these
respondents, only one was a manager and the remainder were spread across allied
health, site administration, medical and nursing staff. Similarly, 41% of respondents
did not agree that innovation in the workplace was linked to organisational goals.
6.4.2 Innovation climate
Six statements were associated with measuring innovation climate and related to
employees being given opportunities to learn from mistakes and feedback on creative
ideas, peer/leader perceptions on problem solving and leader’s role modelling creative
thinking.
Table 6-3 shows the descriptive statistics. Respondents agreed strongly on
statements related to innovation climate, with the mean of 4.7 much greater than the
mid-point (3.5) of the Likert scale.
Table 6-3 Level of agreement to statement on organisational climate from the
Workplace Innovation Scale
Statistics
Innov_climate
Mean 4.7601
Std. Deviation 1.46005
Percentiles 25 3.7917
50 4.9167
75 5.8750
Table 6-4 shows the level of agreement and disagreement to the statements.
Sixty-two percent of respondents agreed that they are given opportunities to try new
ideas and approaches to problems. As for organisational innovation, respondents
agreed that they could try new ideas and approaches to solve problems. Seventy-one
percent agreed that bosses provided them with the opportunities to learn from
Chapter 6: Results – Measurement of Innovation Culture 145
mistakes. Half of those that disagreed with this statement were from non-clinical
departments. When creative ideas are put forward, 67% of respondents agreed that the
boss provides useful feedback on those ideas.
Table 6-4 Workplace Innovation Scale innovation climate level of agreement,
neutral responses and level of disagreement
Statements Positive Neutral Negative Total
I am always given opportunities to try new
ideas and approaches to problems.
62% 20% 18% 100.0%
I discuss with my boss regularly, on how to
get ahead.
65% 11% 26% 100.0%
My boss and my colleagues perceive me to be
a creative problem solver.
53% 33% 14% 100.0%
My boss gives me an opportunity to learn
from my mistakes.
71% 17% 12% 100.0%
My boss gives me useful feedback regarding
my creative ideas.
67% 11% 23% 100.0%
My boss is our role model in creative
thinking.
58% 12% 30% 100.0%
Figure 6-6 Workplace Innovation Scale innovation climate level of agreement,
neutral responses and level of disagreement using the traffic light colours.
Chapter 6: Results – Measurement of Innovation Culture 146
Figure 6-6 Workplace Innovation Scale innovation climate level of agreement,
neutral responses and level of disagreement
6.4.3 Individual innovation
Survey participants were asked to respond to eight statements about their individual
propensity for innovation. The statements related to opportunities for innovative
decision making, teamwork, originality, ability to express ideas in staff meetings
frankly, ability to think of new ideas to improve the workplace, time to pursue ideas
and projects and linkage of performance measurement to creativity and problem
solving. Using SPSS descriptive statistics were generated.
Table 6-5 shows the descriptive statistics. The mean of 4.6 suggests agreement
from the respondents for this dimension as the mid-point of the Likert scale is 3.5.
Table 6-5 Individual innovation descriptive statistics
Statistics
Indiv innov
Mean 4.6458
Std. Deviation 1.11794
Percentiles 25 4.3125
50 4.8750
75 5.2813
Table 6-6 below shows the level of agreement and disagreement to the
statements. Eighty-six percent of respondents agreed that they work in teams to solve
complex problems. Those who agreed (n = 57) were primarily clinical staff in non-
managerial roles (n = 49). Other high agreement statements were respondents thinking
of new ideas to improve the workplace and ability to express themselves frankly in
meetings, a factor supportive of creative idea generation for innovation.
It is, however, interesting to note that more than a quarter of the respondents to
the survey also indicated that performance measurement is not linked to individual
creativity or initiative in problem solving in their workplace.
Chapter 6: Results – Measurement of Innovation Culture 147
Table 6-6 Workplace Innovation Scale individual innovation level of agreement,
neutral responses and level of disagreement
Figure 6-7 shows respondents’ level of agreement with statements on organisational
innovation using the traffic light approach.
Figure 6-7 Workplace Innovation Scale individual innovation level of
agreement, neutral responses and level of disagreement
Statements Positive Neutral Negative Total
At work I sometimes demonstrate
originality.
74% 17% 9% 100.0%
I am constantly thinking of new ideas to
improve my workplace.
71% 14% 15% 100.0%
I express myself frankly in staff meetings. 76% 8% 17% 100.0%
I make time to pursue my own ideas or
projects.
58% 23% 20% 100.0%
In my workplace performance measurement
of an individual is related to his or her own
creativity.
33% 29% 38% 100.0%
In our workplace performance measurement
is related to one's initiative to solve
problems.
42% 32% 26% 100.0%
I work in teams to solve complex problems. 86% 2% 12% 100.0%
My work requires me to make innovative
decisions.
74% 8% 18% 100.0%
Chapter 6: Results – Measurement of Innovation Culture 148
6.4.4 Team innovation
Survey respondents were asked to reflect their level of agreement with five statements
about team innovation. Statements related to teamwork and team behaviours, freedom
to make decisions and act upon them and an environment that is amenable to risk and
uncertainty. Table 6-7 shows the descriptive statistics. The mean of 4.2 suggests
agreement from the respondents for this dimension as the mid-point of the Likert scale
is 3.5.
Table 6-7 Team innovation descriptive statistics for the Workplace Innovation
Scale
Table 6-8 shows the level of agreement and disagreement to the statements. In
the rural setting, as would be anticipated, agreement with statements welcoming
uncertainty is low with 47% of respondents disagreeing with this statement. Freedom
to make decisions and act upon them without asking permission was agreed with by
49% but disagreed with by 38%. Of those who agreed with this statement, 75% were
not managers. Of those who disagreed, 100% were not managers.There was strong
agreement that respondents work in teams to solve complex problems. More than half
agreed that in the workplace respondents felt a strong sense of membership and support
however 29% disagreed and 18% had neutral feelings. This is shown in Figure 6-8
below and through use of traffic light colours.
Table 6-8 Workplace Innovation Scale team innovation level of agreement,
neutral responses and level of disagreement
Statistics
Team innov
Mean 4.2697
Std. Deviation 1.27436
Percentiles 25 3.3500
50 4.5000
75 5.2000
Chapter 6: Results – Measurement of Innovation Culture 149
Statements Positive Neutral Negative Total
Amongst my colleagues I am the first one to
try new ideas and methods.
40.9% 40.9% 18.2% 100.0%
In my company people feel a strong sense of
membership and support. 53.0% 18.2% 28.8% 100.0%
In our workplace teams have freedom to make
decisions and act on them without needing to
ask for permission. 48.5% 13.6% 37.9% 100.0%
My colleagues welcome uncertainty and
unusual circumstances related to our work. 40.9% 12.1% 47.0% 100.0%
We work in teams to solve complex problems. 78.8% 7.6% 13.6% 100.0%
Figure 6-8 Workplace Innovation Scale team innovation level of agreement,
neutral responses and level of disagreement
6.4.5 Workplace Innovation Scale
To provide an overall picture of the results from the WIS, a spider graph was used.
Mean responses from each of the dimensions, team innovation, individual innovation,
Chapter 6: Results – Measurement of Innovation Culture 150
organisational innovation and organisational climate were graphed and are shown
below. This analysis reveals that within the case study organisation, based on the
sample, there were greater mean scores for innovation climate and individual
innovation and a lower mean for team and organisational innovation. Figure 6-9
graphically show the means for the four WIS dimensions.
Figure 6-9 Spider graph Workplace Innovation Scale’s 24 items across all
dimensions
A further analysis examined the individual questions with the highest levels of
agreement and lowest agreement for the WIS. Table 6-9 shows that there was high
agreement on the questions relating to teams working to solve complex problems and
individuals being able to express themselves frankly in meetings. Individuals are
required to make innovative decisions and think of new ideas and can make mistakes
and learn from them. On the other hand, it was clear that in the rural setting under
study there is low tolerance for uncertainty, no reward for innovative ideas and that
innovative ideas are not recognised as part of performance discussions or linked to an
individual’s performance.
3.94
4.14.24.34.44.54.64.7
Team innovation
Organisationalinnovation
Innovation Climate
Individualinnovation
Mean responses
Chapter 6: Results – Measurement of Innovation Culture 151
Table 6-9 Highest levels of agreement and lowest agreement for the Workplace Innovation Scale
Highest scoring agreement questions Lowest scoring agreement questions
Individual innovation I work in teams to solve
complex problems.
86.4% Team My colleagues welcome
uncertainty and unusual
circumstances related to
our work.
47.0%
Team innovation We work in teams to
solve complex problems.
78.8% Organisational innovation Our workplace rewards
innovative ideas regularly.
40.9%
Individual innovation I express myself frankly
in staff meetings.
75.8% Individual In my workplace
performance measurement
of an individual is related
to his or her own
creativity.
37.9%
Individual My work requires me to
make innovative
decisions.
74.2% Team innovation In our workplace teams
have freedom to make
decisions and act on them
without needing to ask for
permission.
37.9%
Individual At work I sometimes
demonstrate originality.
74.2% Organisational The vision of my
workplace often helps the
employees in setting their
goals.
33.3%
Climate My boss gives me an
opportunity to learn from
my mistakes.
71.2% Organisational Innovation in my
workplace is linked to its
business goals.
31.8%
Individual I am constantly thinking
of new ideas to improve
my workplace.
71.2% Climate My boss is our role model
in creative thinking.
30.3%
Chapter 6: Results – Measurement of Innovation Culture 152
6.4.6 Scale reliability
The WIS was selected as it was a tool to measure innovation culture that had been
tested and validated (McMurray, 2017; McMurray et al., 2013; McMurray & Dorai,
2003). In this research, scale reliability and internal consistency of the results was
tested using Cronbach alpha (George & Mallery, 2007). Cronbach’s alpha was
computed using SPSS, and according to George and Mallory (2003) a common rule of
thumb is ≥.9 Excellent, ≥.8 Good.
For all factors measured (n = 24) using the WIS, the Cronbach’s alpha results
are shown Table 6-10. These results reflect very strong internal consistency and scale
reliability for the WIS.
Table 6-10 Results of Cronbach’s alpha test for the Workplace Innovation Scale
Factor Number of items Reliability Cronbach’s alpha
Organisational innovation 5 .908
Innovation climate 6 .924
Individual innovation 8 .865
Team innovation 5 .844
All items 24 .952
6.5 CONCLUSION
The WIS has been tested nationally and internationally as a measurement tool to
identify and measure the behavioural aspects of innovation practices of individuals in
their workplaces (McMurray et al., 2013; McMurray & Dorai, 2003). The scale is
comprised of four dimensions of innovation culture that have been measured in the
case study organisation.
Findings from this study demonstrate that:
• There is potential for innovation in the organisation as results reflect a
supportive environment for (non-clinical) mistakes and a strong team
working environment. Successful innovation requires an acceptance
and learning from testing and trialling new ideas. Teams within the case
study organisation are constrained by needing to ask permission. Staff
Chapter 6: Results – Measurement of Innovation Culture 153
can generate ideas freely and can express themselves in meetings and
are required to make innovative decisions in their work.
• Climate and risk taking is pivotal to innovation – uncertainty and risk
taking is not readily supported in the case study rural organisation. This
finding is understandable and in line with local practices to ensure safe
services due to staffing and the lack of supporting infrastructure, for
example limited number and access to medical clinicians.
• Support for innovation is not linked to organisational vision and business
goals.
• The work environment in the case study organisation does not regularly
reward innovative ideas, and bosses were not seen by the respondents as
being role models for creative thinking.
• The WIS is a valid and internally consistent tool for measuring
innovation culture and as a 24-item scale is simple and readily applied in
rural health care settings.
Chapter 7: Analysis and Discussion 154
Chapter 7: Analysis and Discussion
‘He who would search for pearls must dive below.’ John Dryden, English poet
and laureate.
7.1 INTRODUCTION
This research was carried out to determine the factors that enable innovation and high
performance in rural health organisations and to describe how they exert their
influence. In this chapter, the results of the three studies will be analysed and discussed
in their entirety to answer the research questions and objectives. The findings from the
three studies will be compared and combined to form an overall picture of how
innovation occurs, the factors identified to enable and sustain innovation, and to
corroborate findings. Performance in the case study organisation, anomalies and issues
in measurement will be presented here.
This case study used frameworks from the literature to inform the study design,
the questions asked of key informants and the tools that were applied. Frameworks for
analysis from the theory such as the cultural dimensions and factors identified in the
literature as enabling innovation and sustaining innovation underpinned the research
(Dobni, 2008; Greenhalgh et al., 2004; McMurray et al., 2013). The case study
methodology was selected by the researcher and enabled an in-depth investigation of
phenomena within a real-world context. Using the data collected, a rich picture and
full understanding of innovation and performance in the case study organisation was
achieved (Silverman, 2017; Thomas, 2016; Yin, 2014). The data collected has been
used to explain how innovation occurs in rural health settings and the measurement of
performance. The literature review identified the antecedents for innovation such as
organisational culture, infrastructure for innovation, knowledge and learning systems,
and intention to innovate (Dobni, 2008; Fleuren, Paulussen, Dommelen, & Buuren,
2014a), as well as the importance of the inner contextual factors in innovation uptake:
size of organisation, functional differentiation, high-quality data systems,
decentralised decision making, strong leadership and resources for innovation
(Greenhalgh et al., 2005; Greenhalgh et al., 2004). In rural health settings, not all these
factors are in place. Despite this, innovation does occur and is initiated by clinicians
seeking new ways to improve patient care. Successful innovation is driven by clinical
Chapter 7: Analysis and Discussion 155
champions and those invested in making improvements. The case study organisation
was identified as high performing by the Clinical Excellence Commission. This study
analysed multiple measures of performance across time and confirmed that this is the
case for some measures but not all. This chapter brings together the results of the three
studies to explain the organisational and contextual factors that enable innovation and
high performance in a rural health setting.
The specific research objectives of the study were:
1. To identify the factors that impede or facilitate the adoption of innovation
in rural health settings.
2. To explore how those factors exert their influence in rural health settings.
3. To identify potential for greater adoption of innovation in rural health
settings to contribute to improved performance.
The chapter will begin by describing how the data from the three studies
corroborate each other and then summarises the key findings from the three studies.
7.2 VALIDITY AND RELIABILITY OF METHODS AND STUDIES
Frameworks and theories from the literature were used to underpin research
approaches. Tools such as COREQ that have been developed to assist in strengthening
the quality and transparency of health research were applied (Tong et al., 2007). To
assist in a structured and methodical approach to analysis of qualitative data, a
Framework developed by Gale et al. (2013) was adopted.
Qualitative and quantitative methods were used to collect data from the three
studies. Triangulation of different methods and evidence increases the reliability and
validity of case study findings (Gray, 2014; Silverman, 2017; Yin, 2014). This study
has used a concurrent triangulation strategy as suggested by Cresswell (2009).
Qualitative and quantitative data was collected concurrently and compared to
determine whether there was convergence or differences between the study findings.
Combining data and analysis from the three studies provides a complete picture
of the case study site and the data examined; items were compared, contrasted and
cross-referenced to validate the findings. This corroboration strengthens the validity
and reliability of mixed-methods research (Cresswell, 2009; Silverman, 2011, 2017).
In the next sections of the chapter, the contribution to understanding innovation and
high performance in the case study organisation will be discussed as well as how the
Chapter 7: Analysis and Discussion 156
findings from the studies supported one another. Resulting from this is a
comprehensive story of how innovation occurs in rural health settings. With regard to
performance, the measurement of high performance across multiple measures over
time (Taylor et al., 2015) can be achieved but requires consolidation, data
manipulation and presentation skills in order to provide a complete assessment.
Study 1 was designed to understand the performance of the organisation as
compared with peers, set the scene and provide an understanding of the rural health
setting under study.
Study 2 utilised an interview technique to elicit information from key staff within
the case study about the culture and contextual factors for innovation, the
organisational intention to innovate, and knowledge and learning systems for
innovation and intention to innovate.
Study 3 collected data from across the organisation using the WIS, a validated
instrument that measures the innovation culture of an organisation.
Studies 2 and 3 collected items that could be directly compared; however, these
should be interpreted with caution as while similar questions were asked, the
respondents were drawn from different population groups within the case study
organisation.
7.2.1 Performance in rural health settings and its measurement
‘High performing hospitals consistently attain excellence across multiple
measures of performance, and multiple departments.’ Taylor et al. (2015, p. 1)
Study 1 provided background information on the case study site and an understanding
of its performance. During the author’s research period, the service had also been
identified as a high performer by the Clinical Excellence Commission NSW and staff
were interested to understand this further (2016).
The literature review ascertained that there was no agreed definition of
performance and how it should be measured. For the purpose of this study, Taylor et
al.'s (2015, p. 1) definition that ‘high performing hospitals consistently attain
excellence across multiple measures of performance, and multiple departments’ has
been used. The research conducted for this study found that publicly reported
performance data is rich and deep. The MyHospitals website makes the data accessible
Chapter 7: Analysis and Discussion 157
and downloadable in spreadsheet formats that include results of all hospitals and peer
benchmarks. The website allows the public to access the results of individual hospitals.
The Bureau of Health Information’s Health Observer produces reports and uses
visualisation tools to enable comparison and interpretation of results at the hospital
level (Bureau of Health Information, 2018c). These reports show comparisons to peers
and information about the Local Health District. While the publicly available data
utilised in this study was relatively current, there were constraints in using historical
data to inform quality improvement and for addressing performance. In addition, the
focus on reporting by these organisations is at the macro level and not available at
clinical department or clinician level. Information about costs, process outcomes and
patient experiences is reported publicly at various levels of aggregation and granularity
(Canaway et al., 2017b). The researcher accessed data from a number of sources
(Australian Institute of Health and Welfare, 2018a; Bureau of Health Information,
2018a; Northern NSW Local Health District, 2017). Utilising data visualisation tools,
a representation of performance across multiple measures and time was able to be
obtained; however, this required a significant amount of work and health information
management expertise. For small rural hospitals such as the case study organisation,
gaining a representation of performance based on an agreed set of measures, collected
(ideally) in real time, could aid them to understand their performance better. This type
of performance data might enable the early identification of potential quality issues
and lead to early intervention or quality improvement initiatives. This is supported by
Canaway and colleagues, who conducted four different studies on the topic of public
reporting of performance data in health (Canaway et al., 2017a, 2017b; Canaway,
Bismark, Dunt, & Kelaher, 2018; Canaway, Bismark, Dunt, Prang et al., 2018b). They
noted that agreement on relevancy of indicators, data granularity, time delays between
collection and reporting and the ability to report for small jurisdictions are all barriers
to the effective implementation of public reporting of hospital performance data in
Australia (Canaway et al., 2017a). The use of different peer groupings across data
collections and benchmarking approaches as identified in this study also limits
possibilities in compiling an overall picture that incorporates multiple measures across
time.
In 2016, the case study organisation was identified as high performing by the
Clinical Excellence Commission of NSW Ministry of Health (Clinical Excellence
Commission, 2016). In Study 1, multiple measures of performance across time were
Chapter 7: Analysis and Discussion 158
analysed and confirmed that this is the case for some measures but not all. Analysis of
reported data and using the definition of performance defined by Taylor et al. (2015)
showed that the case study site did perform well on a number of indicators over time
when compared to peers; for example, costs of acute admitted patients, hand hygiene
audits and accreditation. Table 7-1 below shows in a scorecard format how the case
study organisation performed when compared to peers for the range of measures and
indicators examined for this research.
To produce this scorecard and to gain a representation of performance across
access and equity, efficiency and sustainability, quality, safety, patient orientation and
organisational culture required sourcing data from multiple websites and investment
in analysis and interpretation. Recruitment of clinical staff to rural health settings is
challenging and as such, enabling clinicians to understand the performance and culture
of the organisation prior to commencing employment could be identified as integral to
attracting high quality clinicians to work in the rural setting. Anecdotally, there is a
perception that the workload in rural health settings is high and access to resources
more limited, and this translates into poorer patient outcomes. Scorecard information
across a comprehensive set of measures can demonstrate whether this perception is
accurate.
Chapter 7: Analysis and Discussion 159
Table 7-1 Case study organisation performance on publicly reported indicators
compared with peers
However, during the research it was identified that data reporting bodies
(MyHospitals and Bureau of Health Information) do not consistently apply the same
definitions to group hospitals. For example, the Bureau of Health Information when
reporting on the admitted patient survey combines all Peer Group C hospitals together.
This group consists of 40 hospitals regarded as district hospitals. MyHospitals uses an
alternative peer grouping to report on average length of stay, cost, emergency
performance and other indicators included in this research.
7.2.2 Corroborating the findings of Study 2 and Study 3
Combining data and analysis from the studies provided a comprehensive
understanding of the case study site and the data studied, items compared, contrasted
and cross-referenced to validate the findings. This corroboration strengthens the
Chapter 7: Analysis and Discussion 160
validity and reliability of mixed-methods research (Cresswell, 2009; Silverman, 2011,
2017).
Study 2 interviewed 25 individuals in the case study to determine innovation
culture and identify innovative behaviours and the barriers and enablers to innovation.
Study 3 used the WIS to measure across the organisation’s culture and its propensity
for innovation. As the studies collected different types of data and used different
methods, direct comparison was not able to be achieved; however, to understand how
the findings from Studies 2 and 3 corroborated with one another, several strategies
were used:
1. The questions asked of informants in Study 2 were mapped to similar or like
questions in the WIS. The mapping is shown in Appendix P.
2. Analysis of similarities and differences were then identified.
The validation of findings from the two studies is discussed below.
7.2.3 Organisational context/climate for innovation
The findings from qualitative interviews revealed that in the case study organisation,
while no formal reward processes for innovative ideas or innovations were in place,
successful innovations could be put up for quality awards or informally rewarded. A
similar question was posed in the WIS, which sought views on statements relating to
rewards for innovation and an individual’s ability to make innovative decisions. Less
than 50% of those surveyed agreed with the statement ‘Our workplace rewards
innovative ideas regularly’, concurring with the views revealed by informants.
During interviews, informants disclosed that teams in the case study organisation
could drive innovation. Within teams, innovations were easier to achieve than large
innovations requiring approvals or funding. Findings from the WIS corresponded with
this as 86% responded positively to the question on individual innovation ‘I work in
teams to solve complex problems’, In the WIS, to a question that was posed – ‘I make
my time to pursue my own ideas and projects’ – 20% reflected a negative and 23% a
neutral response. During interviews it was conveyed by informants who had
successfully implemented innovations that they largely did this in their own time at
their own cost as they believed it would make a difference to patients. Time for
innovation, thinking, reflection and innovation implementation was identified as a
barrier to innovation by informants.
Chapter 7: Analysis and Discussion 161
The WIS asked for responses to the statement ‘In our workplace teams have
freedom to make decisions and act on them without needing to ask for permission’.
Less than 50% of respondents agreed with this statement, validating the qualitative
interview data collected where permissions and bureaucratic processes were a limiting
factor and demotivator to individuals with innovative ideas.
In innovative cultures, team members value each other’s contributions and new
ideas can be shared and implemented (Dobni, 2008). A positive environment for team
work in the case study organisation was identified in both Study 2 and Study 3.
Seventy-one percent of respondents to the WIS agreed that they are ‘constantly
thinking of new ideas to improve my workplace’. Informants identified that they felt
valued within their teams.
7.2.4 Infrastructure
The WIS applied in Study 3 asked respondents to convey their level of agreement with
the statement as to whether ‘innovation in my workplace is linked to business goals’.
Thirty-two percent of those who completed the Scale disagreed with this statement and
less than half (48%) agreed. This supported the insights gained from key informants
in Study 2 who conveyed that time and budget for innovation was a barrier to
innovation and implementation of innovative ideas.
7.2.5 Intention to be innovative
The literature recognises that innovative organisations have a clear mission and vision
directed to innovation (Dobni, 2008; Dobni et al., 2015; Greenhalgh et al., 2004;
Greenhalgh et al., 2005). The interview process and the evaluation of corporate
documents identified that there are no formal metrics for innovation in the case study
site. While strategy documents mentioned innovation and performance, the mission
statement of the case study organisation did not include explicit statements related to
innovation.
The WIS survey identified that 71% agreed with the statement that they are
‘constantly thinking of new ideas to improve my workplace’. Study 2 identified that
innovation is occurring in the case study site, and 14 innovations were revealed during
interviews with 25 informants.
Chapter 7: Analysis and Discussion 162
Some informants believed that innovation was an underlying culture and that
there was an explicit focus on patient care within the case study organisation. Most,
however, acknowledged that innovation was still a word. The WIS survey asked
several questions about vision of the workplace, but they were not able to be directly
compared.
When asked in the WIS about the sense of membership and support – ‘In my
company people feel a strong sense of membership and support’ – only 53% of
respondents agreed with this statement. This concurred with informant data where
individuals felt highly valued within their teams but not by others in the wider
organisation.
7.2.6 Knowledge and learning
During interviews it was clear that the case study organisation enables learning for its
employees and this was supported by the finding of the WIS where 70% agreed with
the statement, ‘In our workplace opportunities to learn are created through systems and
procedures’. However, informants disclosed that learning was focussed heavily around
mandatory training requirements and was not linked to an overall strategy for
innovation and improvement.
7.3 ORGANISATIONAL AND CONTEXTUAL FACTORS IN THE CASE
STUDY ORGANISATION ENABLING AND SUSTAINING
INNOVATION
The data from Studies 2 and 3 suggest that in the case study organisation there is a
propensity and potential for innovation. Data collected in Study 2 demonstrate that
innovation in rural health settings does occur. These innovations have had wide reach
and the potential to strengthen patient care and outcomes (e.g. Advanced Emergency
Performance Training [ADEPT] and emergency protocols). Innovations originating in
the case study site have been adopted by agencies such as the NSW Ministry of Health,
Northern NSW Local Health District, the Clinical Excellence Commission and
Agency for Clinical Innovation (e.g. Emergency Protocols, ADEPT and Rural
Formulary). During the interviews, many examples of innovation that had been
initiated were captured. Fourteen innovations were described by informants and
Chapter 7: Analysis and Discussion 163
documented during the interview process and these are fully described in Appendix Q.
Eleven of these innovations (78%) had been sustained since implementation.
Informants described innovations that they had been involved in implementing
or originated themselves. The innovations identified were collated and classified by
the type of innovation as described in the literature (i.e. product or service, process,
organisational, marketing, administrative; Damanpour, 1996; Moreira et al., 2017).
Further, it was noted whether the innovation had been sustained and the impact of the
innovation.
A wide range of innovations to services, processes and the adoption of new
technologies were documented. Fourteen recent innovations that had been
implemented in the case study organisation were described by informants. Some of
these innovations, such as emergency protocols and ADEPT, had been adopted at the
Local Health District and proliferated at the NSW State Health level. The motivation
for the introduction of emergency protocols, A Flight Manual for the Crashing Patient
(Robertson, 2018), was explained by the informant as the critical patients who present
to the rural emergency department. The protocols, adapted and informed by practices
in the mining and aviation industry, can be found at
http://emergencyprotocols.org.au/downloads/. This clinician worked in a department
with a team of nurses but no other medical staff. Other innovations initiated at the
Ministry of Health had been uniquely tailored for the case study organisation and
implemented with high impact. The Hospital In The Home model developed by staff
in the case study site is a clear example of this. Despite push-back at the Local Health
District level, the clinical team for Hospital in the Home is configured as an acute
service that runs seven days a week and was designed as a quality improvement and
process initiative to reduce length of stay and increase bed capacity. Local
enhancements to the model involve direct interactions and interfacing with local
nursing homes, surgeons, physicians and general practice. The hospital-based service
is nurse led with a broad scope of practice and requires acute nursing skills and ability
to communicate widely across hospital and community-based teams. The model
developed uses a ‘pull’ strategy to identify suitable patients in acute care wards. The
nurse works closely with emergency department clinicians to divert admissions. A
simple model of referral and assessment of suitability is used by general practice and
for patients in residential aged care facilities. This contrasts with the model for
Hospital in the Home, based in the community, used in other settings in the Local
Chapter 7: Analysis and Discussion 164
Health District that is a ‘push’ model receiving referrals from the acute inpatient wards.
This community-based service tends to treat less acute patients and does not operate a
seven-day-a-week service.
A full list of innovations, the driver for adoption, type of innovation and impact
described by informants in Study 2 is shown in Appendix Q. Summary data is shown
in Table 7-2, which names the innovations identified and shows whether they were
organisational, process, product, service or technology innovations.
Table 7-2 Summary of innovations identified in the rural case study hospital
The pie chart in Figure 7-1 shows the numbers and types of innovations
identified in the case study site. Most innovations described (44%) were improvements
to processes and 22% to the way services were provided. Figure 7-1 shows innovation
type by number in the case study site with process orientations the largest number of
innovations. Process innovations comprised 44% (n = 8) of the innovations identified
by informants. Examples of process innovations included development of a rural
formulary and the development of emergency protocols. Crossan and Apaydin, (2010)
related that process or product innovation is often associated with incremental
innovations. Incremental innovations can have significant effects within organisations
(Johannessen, 2013; Salter & Alexy, 2013).
Chapter 7: Analysis and Discussion 165
Figure 7-1 Innovation types described by informants in the case study site
Innovation in the case study organisation occurred because clinicians and
managers want to provide better care and these innovations are implemented despite
many of the levers described in the theory being absent or inaccessible (e.g. leadership
for innovation, mission and vision for innovation, infrastructure for innovation).
7.4 HOW CAN WE UNLEASH FURTHER INNOVATION IN RURAL
HEALTH SETTINGS?
According to the literature, organisations will adopt innovations more readily if they
are large (in size), are functionally differentiated into small autonomous departments,
reflect maturity and have high-quality data systems, strong leadership with a clear
vision towards innovation, resources to channel into innovation and decentralised
decision-making processes (Greenhalgh et al., 2004; Greenhalgh et al., 2005).
Greenhalgh and colleagues (Greenhalgh et al., 2004; Greenhalgh et al., 2005)
produced a framework on the antecedents for innovation collated from the literature,
drawing on an extensive body of research. Some organisational and contextual factors
have a positive and significant impact upon innovation adoption and sustainability
including administrative overheads, functional differentiation, managerial attitudes to
change, professional knowledge of employees, ‘slack resources’ (resources beyond
minimal requirements to maintain operations), specialisation and technical capacity
Organisational
17%
Process
44%
Product
11%
Service
22%
Technology
6%
Chapter 7: Analysis and Discussion 166
(technical resources and potential) (Damanpour, 1991, as cited in Greenhalgh et al.,
2004; Greenhalgh et al., 2005).
Innovation in the rural health setting examined occurred without many of these
identified factors. The health care setting under study was small (not large) and this
could suggest that size is not a barrier to innovation. There is little specialised
differentiation or departmentalisation in the case study organisation. Nursing and
medical clinicians often have both clinical and managerial responsibilities. Clinicians
practice across a broad scope of practice and there were no super-specialties on site.
Despite low administrative intensity and no ‘slack’ in resourcing, innovation is
occurring in the case study site.
A significant body of work by Braithwaite and colleagues demonstrates the
strength of medical clinician cultures and their ability to manoeuvre and impact upon
the success or not of improvement initiatives such as those introduced by innovation
(Braithwaite et al., 2017; Braithwaite et al., 2016). This was noted in data collected
from medical informants in the case study site who knew who to speak with and how
to make approaches at the highest level of the organisation to pursue the innovative
ideas that they believed could make a difference to patients.
Ideas originating from clinical needs and champions in rural health settings are
crucial to drive change, innovation adoption and sustainability, and this concurs with
research in other health settings. The vision of leaders, strong managerial relations,
clear goals and priorities, high-quality knowledge systems, organisational culture and
context for change are important determinants of innovation (Damanpour & Aravind,
2012; Dobni, 2008; Dobni et al., 2015; Greenhalgh et al., 2005; Greenhalgh et al.,
2004).
In the case study site, it was clear that innovative ideas were valued, and to
further promote innovation, several factors from the literature that have been
determined to spread and sustain innovation could facilitate and unleash additional
innovation.
Innovation could be advanced in the case study site by strengthening within the
organisation signals that demonstrate an intention to be innovative. Examples of
proven factors include a mission and culture to support innovation and metrics to
measure innovation success. Small injections of money and time to support clinicians
with innovative ideas could be allocated. Time for thinking and reflection is important,
Chapter 7: Analysis and Discussion 167
and relief from demanding and relentless clinical roles could be rewarded by the
outcomes achieved through new innovations.
Several contextual factor impact upon the actions of those with innovative ideas.
Modification of systems or work practices beyond the team were identified by
informants as difficult and a barrier to innovation. Top-down bureaucratic structures
put in place for governance and safety can often be an impediment to innovation that
thrives in flatter organisational structures. Leaders can play an important role here in
helping clinicians to manoeuvre the necessary bureaucratic processes than hinder or
slow down innovation. This would reduce the frustrations reflected by informants in
Study 2 and ensure innovative ideas could be taken from conception through to
delivery.
The knowledge and orientation of employees to support innovation is an
important cultural and system antecedent for innovation (Dobni, 2008; Greenhalgh et
al., 2005). While the case study exhibited learning systems and some signs of a
‘learning organisation’ at play – for example, the WIS demonstrated that staff believe
that they can make mistakes and learn from them – there is no comprehensive strategy
towards equipping staff with the skills, knowledge and tools for innovation.
Knowledge management and communication systems were also regarded poorly by
Study 2 informants, who conveyed that identifying relevant policies and accessing
them in ways that supported them to conduct their work was challenging. Effective
knowledge management systems could enable further innovation and the more rapid
adoption of evidence-based medicine practices.
Clinical champions are important in the rural setting as innovations are occurring
on top of other activities, including busy clinical loads and routine work. Time out
from clinical activities is rare and usually requires the recruitment of a locum.
Clinicians in this study were often the initiators, implementers and funders of
innovations. Examples were provided of clinicians funding websites, graphic
designers, research evaluations of their innovations and printing of materials.
Development was often performed in their own time. Recognising, acknowledging and
rewarding innovative ideas and providing time and small amounts of resourcing could
expedite further innovation.
According to some authors, heterogenous or changing environments are more
likely to promote the adoption of innovations (Greenhalgh et al., 2005; Hewlett,
Marshall, & Sherbin, 2013). While this can be difficult in rural health settings where
Chapter 7: Analysis and Discussion 168
the workforce maybe relatively stable over time, increasing diversity could unlock
additional innovation. In Chapter 8 of this thesis, the enablers recognised in the case
study organisation and those identified in the literature as antecedents to innovation
uptake and adoption are presented to demonstrate leverage points for further
innovation.
7.5 CONCLUSION
So, how does innovation occur in rural health settings and how can high performance
be enabled in rural health settings? Findings from Study 1 demonstrate that the
measurement of performance is extremely difficult. To understand how high
performance might be enabled in rural health settings it is important to define what
performance constitutes and to work forward from that baseline. A comprehensive
scorecard to measure performance is suggested in Chapter 8 and it is acknowledged
that the initial research question posed was ambitious. Understanding performance
measurement could be the focus for future research studies.
The study did determine that rural health care organisation’s performance can be
assessed, and a picture of performance obtained from publicly reported data. However,
there is no ‘one stop’ shop for an overall representation of performance and no
scorecard of key measures. Interestingly, no agreed overall measures and definitions
for performance for rural settings was identified in the literature, but access, safety,
patient satisfaction, costs and so forth can give a proxy (Canaway et al., 2017a;
Canaway, Bismark, Dunt, & Kelaher, 2018). Ultimately, health care organisations are
seeking to achieve high reliability and the minimisation of errors that impact adversely
on patients, staff and families interacting with our health care systems – both rural and
metropolitan. Some of the innovations identified in the case study site were based upon
principles of high reliability as adapted from the airline industry, such as ADEPT and
Emergency Protocols. Performance data is reported retrospectively and the level of
granularity and timeliness is regarded as a limiting factor (Canaway et al., 2017a;
Canaway, Bismark, Dunt, & Kelaher, 2018). Visualisation tools can be used to present
performance data to synthesise large amounts of data and to show trends over time.
Innovation does occur in rural health settings, despite size (small), location, and
with no budget or time allocated for innovation. Clinicians, if they believe in an
initiative, will innovate for the benefit of patients and implement the innovations in
Chapter 7: Analysis and Discussion 169
their own time and at own cost. Fourteen innovations were identified in the case study
site, including process, service and technological innovations. When innovation does
occur, it needs a clear champion to drive through, break down bureaucratic barriers
and provide credibility for the change.
Study 3 measured innovation culture using the WIS, which measures
organisational, team, individual and innovation climate. The findings showed that in
the rural health organisation under study that staff can learn from mistakes, express
themselves frankly, work in teams to solve complex problems, are thinking of new
ideas to improve the workplace and that their work requires them to make innovative
decisions. The WIS demonstrated a culture receptive to innovation in the rural site
studied. Innovation may be occurring through necessity and the constraints of
workforce, resourcing and time. This is an interesting finding, as the limitations of
resourcing, workforce and infrastructure may enable and support a culture of
innovation in rural settings.
Chapter 8: Conclusions and Recommendations 170
Chapter 8: Conclusions and Recommendations
‘I can do that in my department and I can modify things quickly because
there’s just me and a couple of nurses. If we want to do things a different way, we
can crack on and do that when I’m there. To get it more broad than that is a
problem.’ Medical clinician and known innovator
8.1 INTRODUCTION
This study has identified the factors that facilitate the adoption of innovation in a rural
health setting. A case study methodology was used, and findings demonstrate that
unique factors enabled innovation to be adopted and sustained. The research reveals
that there is potential for further innovation in rural health settings. In this chapter,
future research directions will be discussed. The impact of the research is considered
with potential for results to be proliferated and shared with other rural health sites. An
online toolkit and self-assessment checklist will be developed based on study findings.
This resource will be free to access and designed to share the findings with other rural
health settings. The limitations of the study and its methods and a clear set of
recommendations from the findings are presented. Suggestions for extending and
repeating the study in other sites to validate findings are also presented. Practical
approaches for implementation are reported, as well as researcher reflections.
8.2 MEASUREMENT OF PERFORMANCE AND PERFORMANCE IN
RURAL HEALTH SETTINGS
This research set out to capture and analyse the performance of the rural health service
studied and to examine the management discourse on innovation and performance
through publicly available documents and data. In strategic documents such as
strategic plans, the usual and expected public statements about innovation and
performance were found; however, these were not able to be examined or synthesised
in any meaningful way.
Chapter 8: Conclusions and Recommendations 171
Despite this, the study has established that routinely available data can be used
to understand the performance in rural health settings. However, there is no ‘one-stop-
shop’ where this information can be accessed, and data collections utilise different
definitions for peer groups. Data must be sourced and combined, and visualisation
tools used to present the information so that it can be interpreted and used by managers
and clinicians. Understanding trends over time can be supported using visualisation
tools. Through these actions a representation of high performance, the attainment ‘of
excellence across multiple measures of performance and multiple departments’ can be
achieved (Taylor et al., 2015, p.1).
While there was no agreed definition of high performance Taylor et al.'s (2015)
definition has been applied in this study. The barriers to publicly reported performance
data and granularity of reporting and its use have been and continue to be robustly
argued in the literature (Aryankhesal et al., 2015; Canaway et al., 2017a, 2017b;
Canaway, Bismark, Dunt, & Kelaher, 2018; Canaway, Bismark, Dunt, Prang et al.,
2018b). The unintended consequences (misinterpretation) and perverse incentives
(gaming) that can result must be considered (Lynch, 2015; Mannion & Braithwaite,
2012). Effective use of data is to understand its role as indicative rather than definitive
measures and should be used in combination with more qualitative and descriptive
information from the local context (Mannion & Braithwaite, 2012; Mannion & Smith,
2017).
Consideration should be given to the granularity and methods for presentation
of performance data to increase its usefulness. Measures across multiple departments
and indicators is recommended in the literature to gain a complete picture of
organisational performance. Figure 8-1 shows suggested measures and scorecard items
for rural health care organisations. This scorecard includes six broad dimensions and
associated indicators of health system performance that could be made publicly
available across time.
Chapter 8: Conclusions and Recommendations 172
Figure 8-1 Suggested measures for rural health care organisations’ performance
scorecard
Note. Adapted from Veillard et al. (2005) and Veillard et al. (2013)
8.3 HOW INNOVATION OCCURS IN RURAL HEALTH SETTINGS
This research has determined that innovation occurred in the case study organisation
under unique contextual and organisational factors. The literature identified
antecedents and determinants of innovation that can almost never be present in rural
settings such as size, complexity, administrative intensity and ‘slack’ resources’
(Greenhalgh et al., 2005). Despite this, the culture for innovation in the case study site
shows that there is the organisational climate, individual attributes and team
behaviours to unleash further innovation. Innovation is occurring and is driven by
clinicians with ideas, energy, creativity and ways of working that enabled them to
implement change within the case study organisation. These innovations have had
wide reach, with some of the innovations proliferated from the case study site to other
rural settings.
The enablers recognised in the case study organisation and those identified in
the literature as antecedents to innovation uptake and adoption are presented in Figure
8-2. This diagram demonstrates leverage points for further innovation in the rural
health service studied. Strengthening knowledge management systems, introducing
metrics for innovation, a mission and vision directed to innovation, rewarding
innovation, and linking this to an overall strategy for improvement could advance
Chapter 8: Conclusions and Recommendations 173
further innovation. Providing small amounts of time for thinking and resources to
enable clinicians to innovate could encourage further innovation in the case study site.
This ‘slack’ would enable innovators time for a range of innovation-related activities,
such as research, planning and generating ideas. Health service leaders can play a vital
role in supporting clinicians to work through bureaucratic channels, freeing them to
focus on what is important to them delivering quality care.
Chapter 8: Conclusions and Recommendations 174
Figure 8-2 Leverage points for further innovation
Chapter 8: Conclusions and Recommendations 175
8.4 IMPACT
According to the National Health and Medical Research Council Australia, impact is
the verifiable outcomes that the research makes to knowledge, health, the economy
and or society. Impact is the effect of research after it has been adopted, adapted for
use, or used to inform further research (National Health and Medical Research
Council, 2017b). The Research Excellence Framework in the United Kingdom
similarly describes impact as ‘an effect on, change or benefit to the economy, society,
culture, public policy or services, health, the environment or quality of life, beyond
academia’ (REF2021, 2018).
8.4.1 Knowledge Impact
New knowledge has been generated through the conduct of this study relating to how
innovation occurs in a rural health setting and the unique factors that allow innovation
to be adopted and sustained. The comprehensive literature review revealed little to no
evidence of similar research on performance and there is a recognised and
acknowledged scarcity of research on the topic of innovation in rural settings. The
study identified new ways of analysing and interpreting publicly reported and available
performance information to attain a picture of performance in a rural health setting.
These findings can be applied in other settings.
The elements for enabling innovation in rural health have been determined.
Rural health settings do not have the factors that previous studies have determined
important such as size (large), dedicated resources and departmental differentiation
(Greenhalgh et al., 2004). The study established that the culture in the case study
organisation in a rural health setting is open to and has the propensity for innovation.
The learnings and new knowledge from this research will be translated into a
toolkit, including a self-assessment tool, for other rural health settings wanting to
position themselves and to leverage innovation to ensure the sustainability and the
ongoing viability of their services.
8.4.2 Health Impact
Measurement of performance can lead to improvements and greater transparency
(Canaway et al., 2017a). A comprehensive scorecard has been recommended by this
Chapter 8: Conclusions and Recommendations 176
study to support health services in identifying trends and areas of focus for safety and
quality improvement initiatives. Sustainability of health systems with an increasing
burden of disease and ageing population is critical for Australia’s health care system.
Determination of the enabling factors for innovation in rural settings will aid others to
advance innovative practice.
8.4.3 Social Impact
Rural health settings have difficulties in attracting and retaining their workforce. A
health workforce is critical to improving the recognised deficits in the health of rural
health communities (Australian Institute of Health and Welfare, 2017b). In some rural
locations, difficulty in attracting and retaining health professionals has resulted in the
removal or reduction of services. Understanding the performance of rural health
settings could be adopted as part of the approach to recruitment. Demonstration to
interested clinicians of the performance of a health care organisation through a
comprehensive scorecard could reduce concerns and provide reassurance. There are
anecdotal perceptions of rural health care organisations that practice may not be
contemporaneous, safe and not welcoming of innovative ideas. In the case study site
innovation was occurring and a culture for innovation identified.
Further study, testing and validation of a scorecard for rural health services and
its impact is needed. The scorecard could also be used by individual health settings to
measure, monitor and identify improvements in access, equity, efficiency and
sustainability, quality and safety over time. A contemporaneous scorecard could also
indicate early trends in improved or diminished performance.
8.4.4 Economic impact
Health service professionals form an integral part of and make social, socio-economic
and intellectual contributions to their communities. Health service professionals
contribute broadly in economic terms through the services they provide, and the
associated aspects involved in delivering services., For example, to practice effectively
a local orthopaedic surgeon will utilise a range of support services to provide
comprehensive care. One of the innovation examples cited in this study involved the
introduction of new approaches to reduce length of stay for knee surgery. This
innovation involved input from nurses, physiotherapists and a team approach to care.
Chapter 8: Conclusions and Recommendations 177
The innovation has been successful and involved pre-habilitation, changes to care
provided by the team during the acute and post-acute phases. The synergistic effect of
health services and health service professionals contributes to the economic well-being
of the population in rural centres.
Being rural adds a unique perspective, depth of understanding of expressed
experiences and perspectives, and allows rural researchers to achieve more informed
or advanced study (Farmer, Munoz, & Daly, 2012). This study collected an extensive
set of data drawn from informants who live and work in the rural context. Innovation
and the uptake of innovation in rural health settings can reap economic benefits to
health care organisations and rural health communities. Through the adoption of
technology, new processes and services, or the introduction of more efficient models
of care delivery, innovations can lead to more sustainable and viable health services.
An emphasis on performance, continual improvement and innovation can also
lead to increased productivity and a reduction in complications in turn, resulting in
lower costs and more efficient care delivery.
8.4.5 Impact for the case study organisation
The findings of this study can be used by the case study organisation in several ways.
First, the research demonstrated that innovation does occur in the organisation studied
and that individual clinicians are committed to innovation. The study identified that
individuals have original and creative thoughts and thinking of new ideas and ways to
improve patient outcomes and work processes. In the rural health setting studied,
individuals agreed that their work requires them to make innovative decisions. By
understanding how innovation occurs in the rural context and the levers identified in
the literature, this research can inform the case study to appreciate how further
innovation might be unleashed. Many of the organisational and contextual factors
responsible for innovation are in place, such as innovation culture. Adoption and focus
on specific ‘levers’ will support innovators to take forward new ideas to
implementation.
8.4.6 Reach
The findings from this research have wide reach nationally and internationally. In
Australia, 30% of the population live in rural and remote locations (Australian Institute
Chapter 8: Conclusions and Recommendations 178
of Health and Welfare, 2014) and, according to the United Nations, globally, 44% live
in rural and remote locations (United Nations, 2014a). There has been a trend to
urbanisation since the 1950s (United Nations, 2014b), and Australia is one of the most
urbanised populations in the world (Regional Australia Institute, 2015). However, it is
important for regional centres and rural towns to be developed and to flourish to reduce
population pressures on larger cities and to maximise the potential capacity and
potential of regional Australia (Regional Australia Institute, 2015, 2018). Well
performing health systems that can innovate are essential to the growth and long-term
sustainability of regional cities. The findings from this study can inform other rural
health settings so that they can address the organisational culture, infrastructure, team,
leadership, individual and learning factors that enable the adoption of innovation.
8.5 RESEARCHER REFLECTIONS
Through achievement of the PhD milestones and development of researcher skills, the
author now understands the complexity of case study research. A large amount of
qualitative data was collected in Study 2. The student has also gained important skills
in the ethical conduct of human research. Intellectual development and new
capabilities in research, as well as technical skills in NVIVO, SPSS and Tableau, have
been integral to the contribution and outcomes of this study.
The researcher has found the PhD a unique learning experience. From a personal
development perspective, key lessons have been learned over the three years. Research
design and methodology is critical to successful research outcomes. The researcher
used a case study methodology, collecting both qualitative and quantitative data.
Qualitative data is complex to analyse, and due to the ‘thickness’ of the data takes
considerable skill to analyse. On reflection, a simpler methodology would be more
suited to a novice researcher
While the researcher managed time well and kept to PhD timelines, estimation
of the time to analyse qualitative data was inadequate. Consequently, the planned tool
kit has not been completed and will be delivered in the second half of 2019.
Chapter 8: Conclusions and Recommendations 179
8.6 LIMITATIONS
Research and research methodologies can be limited by constraints or factors that may
influence the interpretation of the results. The researcher has managed the risks
associated with case study research using multiple sources and types of evidence.
Every effort was made to ensure that the research conducted was robustly designed
and that the analysis has been conducted with rigour and validity. Multiple methods of
research and sources of data have been used to inform the case study analysis.
However, with all research, particularly that completed by an emerging researcher
such as the PhD scholar, limitations will be encountered. The following section
recognises the potential constraints to interpretation and application of the study
findings.
A limitation of Study 1, an exploratory study of performance within the case
study organisation as compared to peers and using routinely reported information,
reflected the organisational performance at a point in time and was based on historical
data. Performance in future years may vary if systems and practices are changed and/or
if organisational culture changes or key clinicians leave the case study site. Publicly
reported health information is only as reliable as the underlying data and systems. The
indicators that have been analysed are the by-products from clinical and administrative
systems used in hospitals. This data may contain errors or reflect differences in data
collection between hospital sites, changes in data recording over time or patient mix
features such as socio-demographic or clinical features (Powell, Davies, & Thomson,
2003). In addition, peer groups as presented on My Hospitals and Bureau of Health
Information report with less granularity than that used by NSW Health (2016).
Publicly reported peer groupings use fewer groups than internally reported within the
department to hospitals and Local Health District managers. Peer group C, for
example, contains both hospitals with 4,000 or less weighted separations and those
with between 4,000 and 10,000 weighted separations – two very different types of
hospitals. This limits comparability and meaningfulness of the data that is reported in
the collections.
When commencing interviews with informants, the purpose and intent of the
study was explained. However, innovation was not explicitly defined. While on the
surface this could perhaps be seen as a methodological flaw, on analysing the interview
transcripts, it was apparent that innovation meant different things to informants. This
Chapter 8: Conclusions and Recommendations 180
however, did not limit the study as it demonstrated the diversity of understanding and
views among stakeholders as to what constitutes innovation. Historical and current
definitions take a wide view of what constitutes innovation.
A wide range of staff from across all clinical and administrative departments
were interviewed for Study 2 and used Dobni's (2008) four dimensions of innovation
culture as the underpinning theory and to inform semi-structured interview questions.
Findings, however, could be limited by personal opinions, experience, academic
backgrounds, personality and individual perceptions. Culture is very organisation
specific, and each organisation has their own culture (Braithwaite, Herkes, Ludlow,
Testa, & Lamprell, 2017; Braithwaite et al., 2018). While this study found that rural
health services can innovate and establish cultures of innovation, this may not be
generalisable to all rural health settings. Age and demographic factors of known
innovators interviewed may not be represented in other rural settings. The unique
contextual factors of the specific time and place when the study was conducted and the
individuals who contributed to the study could have influenced the results and
findings.
The results of Study 3, which measured innovation in the case study
organisation, was not based on a random sample. This limits generalisability of this
study; however, it was used to corroborate findings from other studies. In social
science research, social desirability bias like the ‘Hawthorn effect’ can be found.
Respondents may unintentionally bias responses by answering questions in a manner
that they think will be viewed favourably by others and this can translate in over-
reporting of favourable or positive responses to the statements posed in the WIS
(Dodou & De Winter, 2014; Kim & Kim, 2016).
Finally, while the evidence from all three studies was analysed and used to
inform the findings, case study analysis is difficult, with no simple ‘cookbook’
procedures (Yin, 2014). The researcher applied CAQDAS software to manage,
organise and code narrative data; however, the iterative processes of qualitative data
analysis are highly dependent upon the analytic and interpretive skills of the
researcher. A framework developed by Gale et al. (2013) was used to guide the
analysis. The qualitative researcher needs both the ability to query and retrieve
narrative data and to identify the patterns within but to also have a close understanding
of the overall picture and detailed familiarity with the narratives and the themes
described in the narrative (Bazeley & Jackson, 2013; Gibbs, 2013). The interviews
Chapter 8: Conclusions and Recommendations 181
conducted presented the sentiments about innovation culture according to the
perspectives of those studied and the research method selected to understand how
innovation in rural health settings occurs (Gibbs, 2013; Thomas, 2016; Yin, 2014).
Qualitative research methods have both strengths and limitations, and these are
acknowledged.
8.7 OPPORTUNITIES FOR FUTURE RESEARCH
This research has determined the factors that enable innovation and high performance
in rural health settings. To validate the findings, the research methodologies could be
refined, and the study repeated in other rural health sites.
Further understanding of performance, how it can be measured and scorecards
for reporting are required. The aim in providing treatments should be to work towards
zero harm and to adopt high reliability systems in health. A scorecard for rural health
performance should be explored and further research conducted. This might involve
understanding specific indicators for rural health settings, what the
scorecard/dashboard might look like, and how it might be presented and made
available.
More research is essential in rural settings to understand the unique factors at
play and to test whether the factors identified in this study are evident in other rural
health sites.
8.8 CONTRIBUTION TO PRACTICE
This study has made several contributions to practice. Health service research is an
emerging area with little or no rural health service management research conducted. A
case study methodology supported the in-depth analysis of a rural health setting and
an understanding how innovation is enabled. This thorough analysis has contributed
to the body of knowledge in rural health service management research.
This study has tested the WIS in a rural health setting. In the design stage of the
study many possible instruments were assessed for their suitability. The WIS
developed by (McMurray & Dorai, 2003) was used to measure innovation culture in
the case study organisation. The tool showed high internal reliability of measures
consistent with other studies conducted (McMurray, 2017). The scale has been used in
Chapter 8: Conclusions and Recommendations 182
six different countries and of the measurement tools assessed possessed a manageable
number of dimensions and questions and from a pragmatic perspective aided
completion by survey respondents.
The study of performance data contributes to the health information and health
informatics body of knowledge. Public reporting of performance is recognised as a
good thing but individual indicators across time are currently reported. Applying the
definition of high performance used in this study, that ‘high performing hospitals
consistently attain excellence across multiple measures of performance and multiple
departments’ (Taylor et al., 2015, p. 1), necessitates a bringing together of measures.
Bringing measures together and reporting performance trends over time in a scorecard
or dashboard as previously discussed enables a full understanding of performance to
be attained. Such a scorecard or dashboard could be used as a tool to assist in
recruitment to rural settings.
The outcomes from this research study will be used to produce a toolkit to enable
other rural health sites to make changes to support them to innovate and adopt the
cultural practices and systems required for innovation.
8.9 CONCLUSION
This research examined the factors that enable innovation in rural health settings. The
thesis documents the processes used by the researcher. The gap in the research was
identified through the synthesis and critical evaluation of the literature on innovation
and high performance in health. Research methodology and study design were
comprehensively explained in Chapter 3. Qualitative and quantitative approaches were
adopted and exposed the scholar to new software and the development of additional
skills in research design, analysis and reporting. The results from the three studies were
analysed individually and corroborated to gain a comprehensive and rich picture of
how innovation occurred in the rural health service under study.
The three studies conducted for the purposes of this PhD have provided an
extensive understanding of innovation culture in the case study organisation. These
findings could be examined for applicability to other settings in rural locations.
In the rural health setting under study, innovation often occurred through
necessity and a lack of human, financial and physical resources present in larger
settings. Clinicians stated that they were driven to find solutions to improve patient
Chapter 8: Conclusions and Recommendations 183
care or hospital processes. Innovators pursued their innovations without specific time
resource allocations and were relentless in driving ideas forward to achieve change
despite individuals who might resist the prosed changes. Innovation seemed to be
occurring in this rural health setting despite some of the known antecedents and
determinants, almost through necessity. What is promising is that by leveraging some
of these known factors innovation in rural settings could be further promoted.
The research has made practical and unique contributions to health service
research. This is expected to assist rural health settings by understanding the factors
that support innovation adoption and through addressing levers that could unleash
further innovation. The findings from this research project have provided a rich and
deep understanding of how innovation occurs and insights into measuring performance
in rural health settings.
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Appendices 209
Appendices
Appendix A Examples of high performing health organisations health organisations identified in the literature
Source Health care organisation identified Measures of performance
(Baker, 2011b)
(Scoville et al., 2016)
Jonkoping County Council Efficiency, timeliness, safety, patient
centredness, equity and effective
Intermountain Health care Reduction of mortality and readmission rates
of congestive heart failure and ischemic heart
disease
Veteran’s Administration New England Healthcare System Carey Award Winner
Birmingham East and North Primary Care Trust and Heart of
England Foundation Trust
Reduction in the over-prescription of
antibiotics.
NHS Innovation Award
Healthcare IT Effectiveness Award
Acute Care Trust of the Year
(Scoville et al., 2016) Saskatoon Health Region Canada Reputation for clinical excellence
Virginia Mason Health System Lean
(Institute for
Healthcare
Improvement, 2016)
Kaiser Permanente’s Improvement Reduced medication errors
Reducing sepsis rates
(Nelson et al., 2002) 20 sites identified including:
Mayo Clinic, Massachusetts General Hospital, Henry Ford Health
System, Scripps Clinic and Intermountain Health Care
Five factors used to identify:
Award winners and measured high
performance
Appendices 210
Source Health care organisation identified Measures of performance
Literature citations
Previous research and field experience
Expert opinion
Best within best
(Aboumatar et al.,
2015)
52 hospitals identified including:
Excela Health Latrobe Hospital; Faith Regional Health Services;
Fletcher Allen Health Care; Geisinger Medical Center; Genesis
Health System; Heart Hospital of Lafayette; Intermountain Medical
Center; Massachusetts General Hospital; Mayo Clinic Florida;
Mayo Clinic Rochester; Metro Health Hospital; Monongahela
Valley Hospital; Murphy Medical Center; The University of Kansas
Hospital; Thomas Jefferson University Hospital; Vanderbilt
University Medical Center.
The Hospital Consumer Assessment of
Healthcare Providers and Systems
(HCAHPS) survey.
This survey measures patients’ reports on
clinician behaviours that are deemed by
patients as key to a high-quality
hospitalisation experience
(Chatfield & Byrd,
2017)
20 top performing academic medical centres including:
Mayo Clinic Hospital, Duke University Hospital, Vanderbilt
University Medical Centre, Virginia Mason Medical Centre
Process of care measurements together with
Hospital Consumer Assessment of Healthcare
Provides and Systems and mortality scores.
Appendices 211
Appendix B Letter of Support from Chief Executive of Case Study Site
QUT Verified Signature
Appendices 212
Appendix C COREQ Checklist: Consolidated criteria for reporting qualitative studies (Tong et al., 2007)
No Item Guide Result
Domain 1: Research team and reflexivity
Personal Characteristics
1 Interviews Which author conducted interviews. PhD Scholar interviewed all informants in this study.
2 Credentials What were researcher credentials. MTM. PhD Scholar.
3 Occupation What was the interviewer
occupation at time of study?
Academic
4 Gender Was the researcher male or female? Female interviewer. Both genders interviewed.
5 Experience and training What experience did the researcher
have?
PhD scholar. Previous experience with applied research
using quantitative methods.
Relationship with participants
6 Relationship established Was as relationship established prior
to study commencement?
Interviews approached by phone/in person and/or email.
7 Participant knowledge of
interviewer
What did the participants know
about the researcher?
Participant information sheet provided to all informants
prior to interviews. This sheet fully outlined the
researcher, aims of researcher and what would happen
with data. Some interviewees had previously worked
with researcher but not on a day to day basis. One
informant had been in the researchers work team. See
Appendix J.
8 Interviewer characteristics What characteristics were reported
about the interviewer
Prior assumptions were that case study organisation was
not an environment that enabled innovation. Interest in
the research topic as at time research was initiated was
Appendices 213
No Item Guide Result
living in a rural setting and had worked in the case study
organisation.
Domain 2: Study Design
Theoretical framework
9 Methodological orientation and
theory
What methodological orientation
was stated to underpin the study
A pragmatic approach underpinned the design of this
study. Content and thematic analysis was applied to
analysis narrative data collected.
Participant selection
10 Sampling How were participants selected. Participants within the case study site were selected
using a purposive technique. Heads of department were
interviewed and then a snowballing technique applied
when an innovator was identified, or someone suggested
for interview based on study purpose.
11 Method of approach How were participants approached Phone, email and face to face.
12 Sample size How many participants in the study? 29. 4 interviews were poor quality and unable to be
transcribed and as such excluded. 25 final interviews
analysed and reported.
13 Non-participation How many people refused to
participate or dropped out? Reasons
One participant was not available to be interviewed
during times when the researcher was in the case study
organisation. No refusals.
14 Setting of data collection Where was the data collected Data collected in RA 2 rural health setting. Acute health
service in Northern NSW.
15 Presence of non-participants Was anyone else present besides
participants and researcher
No. Interviews conducted in office space. One interview
conducted in shared office space.
Appendices 214
No Item Guide Result
16 Description of sample What are the important
characteristics of the sample
All interviewees work in the case study organisation.
Interviews were conducted in 2018.
17 Interview guide Were questions, prompts, guides
provided by the authors? Was it
pilot tested?
Questions not piloted as adapted from a validated and
tested tool for measuring innovation culture by Dobni,
(2008). Interview questions included in the thesis
document.
18 Repeat interviews Were repeat interviews carried out? No repeat or follow-up interviews conducted.
19 Audio-visual recording Did the researcher use audio or
visual recording to collect the data?
Interviews with informants were audio recorded and
transcribed.
20 Field notes Were field notes made during or
after the interviews?
Notes made at time of interviews.
21 Duration What was the duration of the
interviews
Interviews were between 30 and 45 minutes.
22 Data saturation Was data saturation discussed? Data saturation was not applied. All targeted participants
were interviewed. This was used to support the content
analysis.
23 Transcripts returned Were transcripts returned to
participants for comment and/or
corrections.
No. Not possible with 29 interviews. All transcripts de-
identified to protect privacy.
24 Number of data codes How many data coders coded the
data?
Researcher completed all coding. Discussed with
principal supervisor.
25 Description of the coding tree Did the researcher provide a
description of the coding tree
Yes. See Appendix O.
Appendices 215
No Item Guide Result
26 Derivation of themes Were themes identified in advance
or derived from the data.
Some themes identified in advance based on questions
posed to informants. Additional themes identified
through analysis of narrative transcripts.
27 Software What software, if applicable, was
used to manage the data?
NVIVO utilised to organise, analyse and report on data.
28 Participant checking Did participants provide feedback
on the findings
Not each individual informant. Findings reported to
hospital executive staff and at Grand Rounds. Full thesis
to be provided to all interviewed when the study has
been finalised.
29 Quotations presented Were participant questions to
illustrate the themes/findings? Was
each quotation identified?
Yes
30 Data and findings consistent Was there consistency between the
data presented and the findings?
Yes
31 Clarity of the major themes Were major themes clearly
presented in the findings
Yes
32 Clarity of the minor themes Is there a description of diverse
cases or discussion of minor themes
Yes
Appendices 216
Appendix D Instruments identified to measure innovation in the literature
Instrument Measures Reference Validated Suitable for measurement of organisational
innovation
Innovation survey
Australian Public Service
Innovation activity (Torugsa &
Arundel, 2016)
Unable to
determine
No as validity of tool uncertain. Also measures
innovation activity and not culture
European Innovation
Scoreboard
Innovation activities
and enablers
(Filippetti et al.,
2017)
Unable to
determine
No as designed for measurement of innovation
across systems/sectors
Measuring Public Sector
Innovation in the Nordic
countries (MEPIN)
Innovation activities (Bloch & Bugge,
2013)
Unable to
determine
No as designed for measurement of innovation
across systems/sectors
Innovation framework Innovation
capabilities
(Saunila & Ukko,
2012)
Unable to
determine
No as validity of tool uncertain
Short Form Learning
Organisation Survey
Learning
organisation
(Singer et al., 2012) Yes No only measures one dimension.
27 items
Workplace Innovation
Scale (WIS)
Leadership,
Innovation Climate
and workplace
innovation
(McMurray et al.,
2013)
Yes Yes
24 items
Measurement Instrument
for the Determinants of
Innovation
Socio-political
context, user,
organisational and
(Fleuren et al.,
2014; M. Fleuren et
al., 2004)
Yes No as designed to be administered either before
or after the introduction of an innovation.
Intended for implementation consultants.
29 items
Appendices 217
Instrument Measures Reference Validated Suitable for measurement of organisational
innovation
innovation
characteristics
Innovation culture
construct
Culture of innovation (C. B. Dobni, 2008) Yes Seven factors
72 items
Not appropriate – too many items
Innovation Quotient
Survey (Rao and
Weintraub 2013)
Culture of innovation (Danks et al., 2017) Yes No
Lack of discriminate validity and reliability
across organisational groups (Danks et al., 2017)
Appendices 218
Appendix E Performance measures and indicators analysed, time periods and analysis conducted by researcher
Measure Indicators Source Year/s Analysis conducted
Access and Equity Median waiting time to surgery
by specialty
Percentage who waited more
than 365 days for intended
surgery by specialty
Time to first seen in the
Emergency Department
MyHospitals
2011–2017 Compared to peer average
organisation performance.
Visualisation of the
analysis.
Efficiency and Sustainability Average length of stay
Costs of acute admitted patient’s
data
MyHospitals 2011–2017 Compared to peer average
performance.
Visualisation of the
analysis.
Quality and safety/Patient
orientation
Accreditation status
Patient survey results on
experience and outcomes of care
SAB rates
Hand Hygiene results
Hospital Quality and
Safety Manager
Bureau of Health
Information NSW
MyHospitals
MyHospitals
2017
2011–2017
2011–2015
Compared to peer average
performance.
Visualisation of the
analysis.
Employee engagement Yoursay Cultural Survey 2017–2018 Compared to State and
District performance.
Visualisation of the
analysis.
Appendices 219
Appendix F Northern NSW Local Health District Ethics Approval
Appendices 220
QUT Verified Signature
Appendices 221
Appendix G Northern NSW Local Health District Ethics Site Specific
Assessment Approval
Appendices 222
QUT Verified Signature
Appendices 223
Appendix H Queensland University of Technology Ethics Approval
QUT Ethics – Email Confirmation 22/2/2018
Dear Dr Cynthia Cliff and Ms Sheree Lloyd Ethics category: Human – Administrative Review Lead HREC: As per Northern NSW Local Health District Ethics Committee Lead HREC approval number: LNR 176/17/NCC/127 & LNR SSA/17/NCC/129 QUT approval number: 1800000117 Approved until: 22/11/2020 Project title: Rural Health, Innovation and High Performance: A study of the organisational and contextual factors affecting adoption and sustainability Thank you for submitting the above research project for administrative review. We are pleased to advise that your application has been administratively approved. QUT's Office of Research Ethics and Integrity (OREI) is satisfied that your research project meets the following requirements for administrative approval: > Another HREC has granted ethics approval. > The approving HREC will remain the responsible Committee. > The approved application fully encompasses the QUT research component. > The QUT researchers are named on the approved application. Approval of this project from OREI is valid as per the dates above, subject to the following conditions being met: > Researchers must immediately notify OREI if there is a complaint regarding the conduct of a QUT researcher. Please be aware that in the event QUT is notified of any concerns regarding the conduct of a QUT researcher, it may be investigated according to QUT MoPP D2.7 Procedures for handling allegations of research misconduct. > All variations and adverse events must be submitted to the lead approving HREC for approval. Researchers are not required to submit post-approval documentation to QUT, except for TGA-regulated clinical trials. If your project is a TGA-regulated clinical trial you must also lodge all post approval documentation (including variations and adverse events) with OREI. > The Chief Investigator (CI) / Project Supervisor (PS) will report to the OREI annually in the specified format and notify the HREC when the project is completed at all sites (the CI/PS will receive an email on the anniversary of the approval). > The CI/PS will notify OREI of his or her inability to continue as CI/PS including the name of and contact information for a replacement. Please contact Office of Research (OR) or Office of Commercial Services (OCS), Division of Research and Commercialisation if your research project involves any of the following activities: > Exchange of confidential information (i.e. information that has not been made public).
Appendices 224
> Exchange of personal/private information. > Use of QUT's Intellectual Property or materials (e.g. methodology, reports, test results from other projects, samples). > Use of any third party intellectual property (e.g. commercial/open source software, mathematical models, evaluation tools, copyright materials). > Use of facilities during the course of the project. > Exchange of materials or resources including biological specimens, equipment or data. Should you have any queries about OREI'S consideration of your project please contact the Research Ethics Advisory Team on 07 3138 5123 or email humanethics@qut.edu.au. We wish you every success in your research. Janette Lamb and Debbie Smith Research Ethics Advisory Team, Office of Research Ethics & Integrity Level 4 | 88 Musk Avenue | Kelvin Grove +61 7 3138 5123 humanethics@qut.edu.au
Appendices 225
Appendix I Semi-structured interview questions posed to informants in the case
study site
Introduction
Explain the purpose and intent of the study.
1. Hand out participant information sheet and invite questions.
2. Consent form signing.
3. Explain the confidentiality of responses.
The study questions are built around Dobni’s 4 general dimensions of innovation
culture. Intention to be innovative, infrastructure to support innovation thrusts,
knowledge and orientation of employees to support thoughts and actions necessary for
innovation and an environment or context to support the implementation of innovation.
(Dobni, 2008)
I am here to collect information for a study I am conducting on the enablers and
barriers to high performance and innovation in rural health settings. I want to collect
information to understand the capacity of the organisation in terms of innovation and
what you believe are the barriers to innovation and high performance.
Appendices 226
Domain
Question Initials of
interviewee
for
anonymity
Position
Context to
support
innovation
Implementation
context
In this organisation I would like to know if you can modify systems
and processes quickly to improve services and processes and if so,
how do you go about this?
In this organisation do you know if there are metrics to measure the
effectiveness of innovation initiatives?
If you have a good idea would you say that in this organisation there
is a quick turnaround for ideas into useable services
When you have been involved in innovation can you describe the
experience and organisational factors that worked well and what
you believe would make a difference in future?
Intention to
be innovative
Organisational
constituency
In your role within this organisation are your contributions valued
by fellow employees
Secondly,
As an employee, do you feel as though you are able to generate
ideas and see these implemented?
If not, why not?
Intention to
be innovative
Innovation
propensity
Within the health care service, could you say that innovation is an
underlying culture and not just a word?
Would you say that innovation and innovative ideas are valued by
the organisation?
Intention to be
innovative
Innovation
readiness
Can you explain how innovation is reflected in the mission of the
hospital?
Appendices 227
Domain
Question Initials of
interviewee
for
anonymity
Position
Infrastructure
to support
innovation
thrusts
Leadership and
entrepreneurship
How do you make sure that sufficient time/money is allocated for
innovation projects
Knowledge
and
orientation of
employees to
support
innovation
Patient
orientation/value
We proactively engage with stakeholders in the value chain
There is consensus amongst employees about what is important to
patients and stakeholders
Knowledge
and
orientation of
employees to
support
innovation
Organisational
learning
There is an expectation to develop new skills, capabilities and
knowledge that is directed toward supporting innovation in this
organisation
The training I receive is directed at helping me deliver excellent
patient care
What are the challenges in getting people to be creative and to use
that creativity?
Can you explain how learning is supported within the hospital?
How is knowledge shared and maintained across the organisation
and filtered down to clinical areas?
Do you believe that this is effective?
Is learning and development connected to the overall strategy for
change, improvement and innovation?
Is learning and development rewarded and if so in what ways?
Appendices 228
Domain
Question Initials of
interviewee
for
anonymity
Position
Context to
support
innovation
Contextual
factors
Specifically, when you think of a time when an innovation was
introduced, can you identify the:
Enablers?
Barriers?
What could facilitate and support further innovation in this
organisation?
Other comments
Appendices 229
Appendix J Participant Information Sheet used in Studies 2 and 3
Research Team
Researcher Principal Supervisor Associate
Supervisor
Non QUT
Associate
Supervisor
Sheree Lloyd B
Bus, MTM, Dip
Gov, Dip Pjt Mgt,
Assoc Dip MRA,
CHIM, AFCHSM,
Dr Cynthia Cliff
BSc(Hons), PhD, ARACI,
Grad Dip Env Stud, Grad
Dip Outdoor Ed, Grad
Dip Bus Mgt, GAICD
Professor Gerry
FitzGerald MB BS,
BHA(NSW), MD
(QLD) FACEM
FRACMA
FCHSM
Dr Jean Collie
MB BS (UQ)
MHP (NSW)
FRACMA,
FAFPHM
PhD Student
QUT
Director (Knowledge
Transfer and Partnership
Development) Faculty of
Health QUT
Professor of Public
Health, QUT
Clinical Sub-dean
University Centre
for Rural Health
North Coast
By signing below, I confirm that I have read and understood the participant
information sheet and in particular have noted that:
• I understand that my involvement in this research will include a 30-minute
interview with the researcher where I will be asked questions about the enablers
and barriers to innovation in the health care setting where I am employed.
• I have had any questions answered to my satisfaction and if I have any
additional questions I can contact the research team;
• I understand the risks involved;
• I understand that the researcher will minimize any risks by ensuring that data
is maintained securely, responses deidentified and raw data destroyed in line
with University policy.
• I understand that there will be no direct benefit to me from my participation in
this research;
• Any information that’s is obtained in connection with this study is confidential
• I am free to withdraw my consent and to discontinue participation at any time
and this will not affect any relationship I may have in the future with the
XXXXX Valley Health Service
• I understand that my participation in this research is voluntary;
• I understand that I am free to withdraw at any time, without explanation or
penalty;
Appendices 230
• I understand that I can contact the North Coast NSW Ethics Committee on:
Executive Officer North Coast NSW Human Research Ethics Committee PO
Box 821 MURWILLUMBAH NSW 2484 Ph: 0266720269 Email:
EthicsNCNSW@ncahs.health.nsw.gov.au if I have any concerns about the
ethical conduct of the research;
• I can contact Sheree Lloyd, research student on 0420925099, at any time if I
have any questions to ask or comments to make;
• I will receive a summary report on the results of this survey, if I request same
and;
• I have read the information above and agree to participate in this study
Name and Signature
Date Final report requested (Y/N)
Appendices 231
Appendix K Workplace Innovation Scale (McMurray & Dorai, 2003)
Demographic data
Age group <20 20–29 30–39 40–49 50–59 60–69 ≥70
Gender
Clinical Department/Group
Manager (Y/N)
Main work location
Instructions
Please complete by circling or ticking the boxes that reflect your level of agreement
with the statement about innovation in the organization where you work.
Factors and
items
Strongly
disagree
Disagree Somewhat
disagree
Neither
agree or
disagree
Somewhat
agree
Agree Strongly
Agree
F1. Organisational Innovation (5 items) 1. Our
workplace has a
vision that is
made very clear
to the
employees.
2. The vision of
my workplace
often helps the
employees in
setting their
goals.
3. Innovation in
my workplace
is linked to its
business goals.
4. In our
workplace
opportunities to
learn are
created through
systems and
procedures.
5. Our
workplace
rewards
innovative
ideas regularly.
F2. Innovation Climate (6 items)
11. My boss is
our role model
Appendices 232
Factors and
items
Strongly
disagree
Disagree Somewhat
disagree
Neither
agree or
disagree
Somewhat
agree
Agree Strongly
Agree
in creative
thinking.
15. I discuss
with my boss
regularly, on
how to get
ahead.
16. I am always
given
opportunities to
try new ideas
and approaches
to problems.
17. My boss
gives me useful
feedback
regarding my
creative ideas.
18. My boss
gives me an
opportunity to
learn from my
mistakes.
24. My boss
and my
colleagues
perceive me to
be a creative
problem solver.
F3. Individual Innovation (8 items)
7. In my
workplace
performance
measurement of
an individual is
related to his or
her own
creativity.
10. At work I
sometimes
demonstrate
originality.
12. My work
requires me to
make
innovative
decisions.
13. I make time
to pursue my
own ideas or
projects.
14. I am
constantly
thinking of new
ideas to
improve my
workplace.
Appendices 233
Factors and
items
Strongly
disagree
Disagree Somewhat
disagree
Neither
agree or
disagree
Somewhat
agree
Agree Strongly
Agree
19. I express
myself frankly
in staff
meetings.
20. I work in
teams to solve
complex
problems.
6. In our
workplace
performance
measurement is
related to one’s
initiative to
solve problems.
F4. Team Innovation (5 items)
8. We work in
teams to solve
complex
problems.
9. In our
workplace
teams have
freedom to
make decisions
and act on them
without
needing to ask
for permission.
21. In my
company
people feel a
strong sense of
membership
and support.
22. My
colleagues
welcome
uncertainty and
unusual
circumstances
related to our
work.
23. Amongst
my colleagues I
am the first one
to try new ideas
and methods.
Notes
Workplace Innovation Scale Developed and first presented: McMurray, A.J. and
Dorai, R. (2003) ‘Workplace Innovation Scale: A New Method For Measuring
Innovation In The Workplace’. Refereed paper, Organizational Learning &
Appendices 234
Knowledge 5th International Conference, 30th May – 2nd June 2003 – Lancaster
University, UK.
Reference: McMurray, A.J., Islam, M., Pirola-Merlo, A., and Sarros, J. (2013)
Workplace Innovation in a Non-Profit Organization, Journal of Nonprofit
Management and Leadership, 23 (3), pp 367-388.
Appendices 235
Appendix L Participant Consent Form Study 2 – Interviews
Research Team
Principal Supervisor Associate Supervisor Non QUT Associate
Supervisor
Dr Cynthia Cliff BSc
(Hons), PhD, ARACI,
Grad Dip Env Stud, Grad
Dip Outdoor Ed, Grad Dip
Bus Mgt, GAICD
Professor Gerry
FitzGerald MB BS,
BHA(NSW), MD (QLD)
FACEM FRACMA
FCHSM
Dr Jean Collie
MB BS (UQ)
MHP (NSW)
FRACMA, FAFPHM
Director (Knowledge
Transfer and Partnership
Development) Faculty of
Health QUT
Professor of Public Health,
QUT
Clinical Sub-dean
University Centre for
Rural Health North Coast
By signing below, I confirm that I have read and understood the participant
information sheet and in particular have noted that:
• I understand that my involvement in this research will include a 30-minute
interview with the researcher where I will be asked questions about the enablers
and barriers to innovation in the health care setting where I am employed.
• I have had any questions answered to my satisfaction and if I have any
additional questions I can contact the research team;
• I understand the risks involved;
• I understand that the researcher will minimize any risks by ensuring that data
is maintained securely, responses deidentified and raw data destroyed in line
with University policy.
• I understand that there will be no direct benefit to me from my participation in
this research;
• Any information that’s is obtained in connection with this study is confidential
• I am free to withdraw my consent and to discontinue participation at any time
and this will not affect any relationship I may have in the future with the
XXXXX Valley Health Service
• I understand that my participation in this research is voluntary;
• I understand that I am free to withdraw at any time, without explanation or
penalty;
Appendices 236
• I understand that I can contact the North Coast NSW Ethics Committee on:
Executive Officer North Coast NSW Human Research Ethics Committee PO
Box 821 MURWILLUMBAH NSW 2484 Ph: 0266720269 Email:
EthicsNCNSW@ncahs.health.nsw.gov.au if I have any concerns about the
ethical conduct of the research;
• I can contact Sheree Lloyd, research student on 0420925099, at any time if I
have any questions to ask or comments to make;
• I will receive a summary report on the results of this survey, if I request same
and;
• I have read the information above and agree to participate in this study
Name
Signature
Date
Appendices 237
Appendix M Participant Consent Form Study 3 – Workplace Innovation Survey
Research Team
Principal Supervisor Associate Supervisor Non QUT Associate
Supervisor
Professor Gerry
FitzGerald MB BS,
BHA(NSW), MD (QLD)
FACEM FRACMA
FCHSM
Dr Cynthia Cliff BSc
(Hons), PhD, ARACI,
Grad Dip Env Stud, Grad
Dip Outdoor Ed, Grad Dip
Bus Mgt, GAICD
Dr Jean Collie
MB BS (UQ)
MHP (NSW)
FRACMA, FAFPHM
Professor of Public Health,
QUT
Director (Knowledge
Transfer and Partnership
Development) Faculty of
Health QUT
Clinical Sub-dean
University Centre for
Rural Health North Coast
By signing below, I confirm that I have read and understood the participant
information sheet and have noted that:
• I understand that my involvement in this research will include a 15-minute
survey that will be distributed by the researcher where I will be asked questions
relating to workplace innovation scale factors.
• I have had any questions answered to my satisfaction and if I have any
additional questions I can contact the research team;
• I understand the risks involved;
• I understand that there will be no direct benefit to me from my participation in
this research;
• Any information that’s is obtained in connection with this study is confidential
• I am free to withdraw my consent and to discontinue participation at any time
and this will not affect any relationship I may have in the future with the
XXXXX Valley Health Service
• I understand that my participation in this research is voluntary;
• I understand that I am free to withdraw at any time, without explanation or
penalty;
• I understand that I can contact the North Coast NSW Ethics Committee on:
Executive Officer North Coast NSW Human Research Ethics Committee PO
Box 821 MURWILLUMBAH NSW 2484 Ph: 0266720269 Email:
Appendices 238
EthicsNCNSW@ncahs.health.nsw.gov.au if I have any concerns about the
ethical conduct of the research;
• I can contact Sheree Lloyd, research student on 0420925099, at any time if I
have any questions to ask or comments to make;
• I will receive a summary report on the results of this survey, if I request same
and;
• I have read the information above and agree to participate in this study
Name
Signature
Date
Appendices 239
Appendix N Core values of the for the case study site
Appendices 240
Appendix O Study 2: Semi-structured interview codes developed for analysis
within NVIVO
PhD: Nodes & Codes
Name Files References
Context to support innovation
Implementation context Q1 Modify systems 25 61
Implementation context Q2 Metrics 25 34
Implementation context Q3 Useable services 23 37
Contextual factors enablers and barriers 25 138
Contextual factors other 13 27
Implementation context Q4
What worked well and what didn’t
20 61
Infrastructure to support innovation
Leadership and entrepreneurship Q1 Time and
resources for innovation
21 28
Intention to be innovative
Innovation propensity Q1 Underlying culture 23 28
Innovation propensity Q2 Ideas valued 18 21
Innovation readiness Q1 Mission 23 36
Organisational constituency Q2 Support for new
ideas
18 24
Organisational constituency Q1 Individuals
valued
22 26
Knowledge and orientation to innovation
Organisational learning directed at delivering
excellent patient care
1 1
Organisational learning Q1 Expectation to
develop skills directed towards innovation
23 38
Organisational learning Q2 Challenges in being
creative and using that creativity
21 40
Organisational learning Q3 Support for
Learning
13 24
Organisational learning Q4 Knowledge sharing 22 48
Organisational learning Q6 Learning connected
to an overall strategy for change, improvement
and innovation
20 26
Organisational learning Q7 Reward for learning 15 18
Patient orientation 24 51
Leadership approaches 10 19
Innovation comments 3 4
Example innovations discussed at interview 13 45
Appendices 241
Appendix P Mapping of study 2 and 3 data for corroboration purposes and to understand commonalities and variances
Innovation culture
dimension Study 2 Qualitative Interview
Question Study 3 WIS Question WIS Responses Informants stated
Pos Neu Neg
Context Would you say that innovation
and innovative ideas are valued
by the organisation?
5. Our workplace rewards innovative
ideas regularly.
42% 17% 41% Successful innovations are put up for
awards, no monetary rewards for
innovation.
12. My work requires me to make
innovative decisions.
74% 17% 9% Informants say in rural this can be
necessary but wary of risk in terms of
quality and safety. 13. I make time to pursue my own
ideas or projects.
58% 23% 20% Informants who had successfully
implemented innovations largely did
this in their own time as they believed
it would make a difference to
patients.
20. I work in teams to solve complex
problems.
86% 2% 12% Teams innovate and within team
innovations could be easier to achieve
that large innovations that required
approvals
Concurs 8. We work in teams to solve complex
problems.
78.80% 7.60% 13.60% See above
9. In our workplace teams have
freedom to make decisions and act on
them without needing to ask for
permission.
48.50% 13.60% 37.90% Interviews concur as informants
relate that system and bureaucracy a
barrier
Concurs
Appendices 242
Innovation culture
dimension Study 2 Qualitative Interview
Question Study 3 WIS Question WIS Responses Informants stated
Pos Neu Neg
22. My colleagues welcome
uncertainty and unusual circumstances
related to our work.
40.90% 12.10% 47.00% No not always
Infrastructure How do you make sure that
sufficient time/money is allocated
for innovation projects and Do
you know if there are any metrics
to measure innovation
3. Innovation in my workplace is
linked to its business goals.
48% 20% 32% Time and budget an issue – no formal
innovation metrics
Intention to be
innovative
14. I am constantly thinking of new
ideas to improve my workplace.
71% 14% 15% Some informants related that they
innovate
Can you explain how innovation
is reflected in the mission of the
hospital?
1. Our workplace has a vision that is
made very clear to the employees.
64% 14% 23% But not linked to innovation
Within the health care service,
could you say that innovation is
an underlying culture and not just
a word?
2. The vision of my workplace often
helps the employees in setting their
goals.
58% 9% 33% Focus on patient care within
organization but not explicitly
innovation
As an employee, do you feel as
though you are able to generate
ideas and see these implemented?
16. I am always given opportunities to
try new ideas and approaches to
problems.
62% 20% 18% Informants related that they can
however often difficulties were
encountered such as funding and
time. In your role within this
organisation are your
contributions valued by fellow
employees
21. In my company people feel a strong
sense of membership and support.
53.00% 18.20% 28.80% Individuals felt valued in their teams
but not by others in the wider
organisation
Appendices 243
Innovation culture
dimension Study 2 Qualitative Interview
Question Study 3 WIS Question WIS Responses Informants stated
Pos Neu Neg
Knowledge and
orientation of
employees to
support innovation
Is learning and development
rewarded and if so in what ways?
4. In our workplace opportunities to
learn are created through systems and
procedures.
70% 3% 27% Plenty of learning in the case study
site on offer but focused on
mandatory training not innovation.
Learning not linked to overall
improvement and strategy for
innovation 19. I express myself frankly in staff
meetings.
76% 8% 17% Informants conveyed that
communication was open and ideas
could be put forward.
11. My boss is our role model in
creative thinking.
58% 12% 30% Interviewees drive innovation and
creativity. Little time for creative
thinking
10. At work I sometimes demonstrate
originality.
74% 17% 9% Informants related 13 innovations in
the case study organisation
Appendices 244
Appendix Q Innovations identified by informants in the case study site
No Innovation Driver Description Type of innovation Sustained Impact Comments
1 Emergency protocols Safety and
quality
Developed and tested
by a team of
Australian doctors
and nurses in
Northern NSW. This
tool harnesses
expertise from the
aviation industry and
human factors
research.
Designed by Dr Dean
Robertson, it is
described as a flight
manual, for use ‘as a
cognitive aid in time-
critical emergencies.’
(Robertson, 2018)
Product and process Yes Distributed to 184
Emergency
Departments across
NSW.
Picked up by Clinical
Excellence
Commission for wider
distribution to
Emergency
Departments across
NSW
Prototyping, website,
graphic design self-
funded
2 ADEPT Safety and
quality
Advanced Emergency
Performance Training
(ADEPT) is a two-
day course teaching
non-technical skills to
critical care doctors
and nurses (Adept
Faculty, 2018)
Product and process Yes High impact as
exemplified by
feedback from
ADEPT training
“No-one has taught
me this in health
before’
‘More insight as to
how my
communication style
can affect others.’
‘I learned a lot about
myself and how I
communicate with
others’
Support from
University Centre for
Rural Health North
Coast
Appendices 245
No Innovation Driver Description Type of innovation Sustained Impact Comments
(Adept Faculty, 2019)
3 Osteoarthritis Chronic
Care program
Safety and
quality
Early identification
and treatment for
fractures
Service Yes Reduction in fractures
and presentations to
the emergency
department.
Initiative of Case Study
Health Service
4 Allied Health Student
Co-ordinator
Workforce Innovation to increase
student allied health
placements. Approach
to Universities to fund
a dedicated role to
supervise additional
students.
Organisational No Increased exposure of
students to rural
practice a known
predictor of future
willingness to work
rurally
Externally funded by
Universities
5 Prehabilitation for
knees/hips
Efficiency
Patient centred
care
Safety and
quality
Physiotherapy
program for patients
prior to orthopaedic
surgery
Service and process Yes Shorter length of stay
for procedure
Championed by
physiotherapists and
orthopaedic surgeons
6 Day Surgery Knee
Replacements
Safety and
quality
Patient centred
care
Efficiency
Reducing length of
stay for double knee
replacements.
(Martin, 2018)
Process Yes Shorter length of stay Championed by
orthopaedic surgeon
7 Hospital in the Home Access
Patient centred
care
Acute service, seven
days a week run by
hospital clinicians.
Designed to increase
bed capacity and
improve the patient
experience.
Service Yes Patient satisfaction.
Additional bed
capacity.
Funded by Local
Health District as
strategic priority.
Locally adopted with
vigour to provide
additional bed capacity.
Championed by
Director of Medical
Services, supported by
GPs and Emergency
Department NUM.
Appendices 246
No Innovation Driver Description Type of innovation Sustained Impact Comments
8 Imaging workflow
improvements
Access and
timeliness
Patient centred
care
Improved flow and
decreased waiting
time for ward and
emergency
department patients
requiring imaging
Organisational Yes Patient satisfaction and
reduced delays for
patients
Driven by managing
imaging
9 Safety Cross System Safety and
quality
Patient centred
care
A simple visual
representation of all
safety incidents
experienced on a
ward. Incident free
days are coded in
green. Discussed
regularly on the ward
by the multi-
disciplinary team and
introduced by a
physician. (Flynn,
2014)
Process No Championed by
physician.
10 Patient Empowered
Project
Safety and
quality
Patient centred
care
Provision of patient
information and
sharing of
information to inform
patients of their rights
and what to expect
during hospitalisation.
Process Unsure Unsure Championed by
Director Medical
Services
11 Rural Formulary Efficiency
List of medicines for
use in rural health
settings.
Process Yes Reduced waste. Championed by
Director Pharmacy
12 Fast Track Access
Safety and
quality
Patient centred
care
Evidenced based
service introduced to
improve waiting
times in the
Emergency
Service and process Yes Emergency
Department went from
worst performed in
peer group to meeting
Data driven solution.
Centre for Healthcare
Redesign methodology
applied.
Appendices 247
No Innovation Driver Description Type of innovation Sustained Impact Comments
Department.
Introduced to reduce
over-crowding and
excessive wait times.
emergency
performance targets.
13 Reshaping Mandatory
Education and
Orientation Days
Safety and
quality
Workforce
Education and training
delivered around case
scenarios using
simulation based
around delivery of
patient care.
Real situations with
documentation in the
EMR.
Organisational Yes Greater engagement
with staff in
orientation.
Introduction to
simulation as a
learning tool for new
employees.
Championed by Nurse
Educator
14 Electronic Medical
Record
implementation (EMR
2)
Quality and
safety
Continuity of
care
In 2006/2007 NSW
treasury funded an
investment in the
Electronic Medical
Record (eMR). EMR2
was initiated to
extend the original
eMR functionality.
Technology Yes
Electronic
discharge
summaries
provided to GPs
and uploaded to
MyHealth
Record
Increased
communication
Sponsored by NSW
Health and Treasury
Appendices 248
Appendix R Comparisons of key factors identified in the literature as linked to
successful innovation compared to study findings
Inner context Status Study findings
Size Small not
large
This research demonstrates that size is
not a barrier to innovation. The case
study site is a small rural health setting.
Functional differentiation –
divided into semi-
autonomous departments
and units
No Little differentiation or
departmentalisation in the case study
however this was not identified as a
barrier to innovation.
Clinicians have both clinical and
managerial responsibilities. Clinicians
practice across a broad scope. No super-
specialties on site.
Functional differentiation between
teams
Mature Unknown Not measured in this research study.
High quality data systems No EMR in place but poor knowledge
management systems.
Vision and mission directed
to innovation
No Orientation towards patients but no clear
mission and vision directed towards
innovation
Resources for innovation No No slack in case study organisation for
funding, physical and human resources.
No dedicated innovation resources in
the case study site.
Decentralised decision
making
No Some scope at unit or team level to
make local decisions. Bureaucratic
organisational structure identified as a
barrier to innovation.
top related