what sparks innovation in rural health settings a case … lloyd thesis_redacted.pdf · what...

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


Figure 6-8 Workplace Innovation Scale team innovation level of agreement,


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,


Table 6-5 Individual innovation descriptive statistics .............................................. 146

Table 6-6 Workplace Innovation Scale individual innovation level of


Table 6-7 Team innovation descriptive statistics for the Workplace Innovation

Scale ........................................................................................................... 148

Table 6-8 Workplace Innovation Scale team innovation level of agreement,


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,


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).


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


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


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


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.


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


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.


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


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).


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.


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.


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.


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


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


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


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


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,


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).


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


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


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


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.


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).


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


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,


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.


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


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.


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,


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


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).


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.


(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


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


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


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.


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).


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


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


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


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


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 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.


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


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


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


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.


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).


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


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.


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).


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.


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


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


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


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.


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.


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


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,


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.


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.


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,


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.


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


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


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


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


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


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


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


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


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


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).


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.


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.


Figure 4-5 Number of significant positive and negative responses to patient survey peer comparisons


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.


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.


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


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


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.


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.


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.


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.


• 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


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.


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.


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


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.


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


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.



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.


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


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.


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


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.


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.


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.


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


(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.


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.


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.


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.


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.’


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.


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.


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.


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


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.’


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.


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.


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.


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].


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.


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.


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.


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’.


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


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.


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



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.


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.


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.


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.


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.


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


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.


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.


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


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.


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.


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


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.


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


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.


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.


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


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.


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.


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.


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


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.


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.


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.


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


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.


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.


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.


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.


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.


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 –


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.


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.


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.


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.


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.’


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


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.


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.


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.


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.


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


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.


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.


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


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.


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.


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.


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.


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.


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.


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.


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.


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


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


the problem. No one knows how to actually take these things down, because there’s no

process.


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.


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)


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


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.


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.


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.


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.


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.


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


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


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


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


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


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


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.


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


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.


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.


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


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



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


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%


neutral responses and level of disagreement using the traffic light colours.




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



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.


Table 6-6 Workplace Innovation Scale individual innovation level of agreement,


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


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%


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,


Statistics

Team innov

Mean 4.2697



50 4.5000

75 5.2000



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,


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,


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


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%


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


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


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


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


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


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


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.


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


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.


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.


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


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

http://emergencyprotocols.org.au/downloads/


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).


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%


(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,


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


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


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.


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.


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


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.


Figure 8-2 Leverage points for further innovation


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


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.


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


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.


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


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


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


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


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


References 184

References

Aboumatar, H., Chang, B., Danaf, A., Shaear, M., Namuyinga, R., S, E., …

Pronovost, P. J. (2015). Promising practices for achieving patient-centered

hospital care: A national study of high-performing US hospitals. Medical Care,

53(9), 758–767. https://doi.org/10.1097/MLR.0000000000000396

Accreditation Canada. (2015). The Value and Impact of Health Care Accreditation :

A Literature Review. Accreditation Canada.

Accreditation Canada. (2017). Accreditation of Hospitals. Retrieved January 16,

2017, from https://accreditation.ca/hospitals-and-health-systems

ACHS. (2018). Australian Council On Healthcare Standards. Retrieved November

30, 2018, from https://www.achs.org.au/about-us

Adept Faculty. (2018). ADEPT : Advanced Emergency Performance Training.

Retrieved November 29, 2018, from http://emergencyprotocols.org.au/adept/

Adept Faculty. (2019). ADEPT COURSE DESCRIPTION.

Agency for Clinical Innovation. (2019a). About ACI. Retrieved from

https://www.aci.health.nsw.gov.au/about-aci/collaboration-innovation-better-

healthcare

Agency for Clinical Innovation. (2019b). About ACI.

Ahluwalia, S. C., Damberg, C. L., Silverman, M., Motala, A., & Shekelle, P. G.

(2017). What Defines a High-Performing Health Care Delivery System: A

Systematic Review. Joint Commission Journal on Quality and Patient Safety,

43(9), 450–459. https://doi.org/10.1016/j.jcjq.2017.03.010

Akenroye, T. O. (2012). Factors Influencing Innovation in Healthcare : A conceptual

synthesis. The Innovation Journal, 17(2).

Allen, J. D., Jr, S. D. T., Maxwell, A. E., Dimartino, L., Leyva, B., Bowen, D. J., …

Weiner, B. J. (2017). Meausures of organizational characteristics associated

with adoption and / or implementation of innovations : A systematic review, 1–

11. https://doi.org/10.1186/s12913-017-2459-x

References 185

Arnaboldi, M., Lapsley, I., & Steccolini, I. (2015). Performance management in the

public sector: The ultimate challenge. International Journal of Public Sector

Management, 31(1), 1–22. https://doi.org/10.1111/faam.12049

Arundel, A., & Huber, D. (2013). From too little to too much innovation? Issues in

measuring innovation in the public sector. Structural Change and Economic

Dynamics, 27, 146–159. https://doi.org/10.1016/j.strueco.2013.06.009

Aryankhesal, A., Sheldon, T. A., Mannion, R., & Mahdipour, S. (2015). The

dysfunctional consequences of a performance measurement system: The case of

the Iranian national hospital grading programme. Journal of Health Services

Research and Policy, 20(3), 138–145.

https://doi.org/10.1177/1355819615576252

Australian Commission on Quality and Safety in Healthcare. (2018). National Safety

and Quality in Healthcare Standards. Retrieved January 21, 2017, from

http://www.achs.org.au/achs-nsqhs-standards

Australian Commission on Safety and Quality in Healthcare. (2014). Core Hospital-

based Outcome Indicators. Retrieved October 18, 2016, from

https://www.safetyandquality.gov.au/our-work/information-

strategy/indicators/core-hospital-based-outcome-indicators/

Australian Government Department of Health. (2016a). DoctorConnect. Retrieved

March 29, 2016, from

http://www.doctorconnect.gov.au/internet/otd/publishing.nsf/Content/home

Australian Government Department of Health. (2016b). Health Workforce Data.

Retrieved November 1, 2018, from

http://hwd.health.gov.au/summary.html#part-3

Australian Government Productivity Commission. (2015). Efficiency in Health:

Productivity Commission Research Paper. Retrieved from www.pc.gov.au

Australian Government Productivity Commission. (2017). Shifting the Dial Five

Year Productivity Review. Canberra.

Australian Healthcare and Hospitals Association. (2017). Healthy people , healthy

systems : Strategies for outcomes-focused and value-based healthcare: A

blueprint for a post-2020 National Health Agreement.

References 186

Australian Institute of Health and Welfare. (2014). Australia’s Health 2014.

https://doi.org/Cat. no. AUS 178

Australian Institute of Health and Welfare. (2015). Australian hospital peer groups.

Health Services Series (Vol. 66). https://doi.org/10.1016/j.tripleo.2004.07.023

Australian Institute of Health and Welfare. (2017a). MyHospitals. Retrieved January

21, 2017, from http://www.myhospitals.gov.au/

Australian Institute of Health and Welfare. (2017b). Rural and Remote Health.

Retrieved from https://www.aihw.gov.au/reports/rural-health/rural-remote-

health/contents/rural-health

Australian Institute of Health and Welfare. (2018). MyHospital : Grafton Base

Hospital. Retrieved November 6, 2017, from

https://www.myhospitals.gov.au/hospital/1155H2100/grafton-base-

hospital/healthcare-associated-infections

Australian Institute of Health Innovation University of NSW. (2013). Final Report:

Performance indicators used internationally to report publicly on healthcare

organisations and local health systems.

Australian Research Council. (2018). Research impact. Retrieved February 7, 2019,

from https://www.arc.gov.au/policies-strategies/strategy/research-impact-

principles-framework

Baker, G. R. (2011a). The contribution of case study research to knowledge of how

to improve quality of care. BMJ Quality & Safety, 20(Suppl 1), i30-35.

https://doi.org/10.1136/bmjqs.2010.046490

Baker, G. R. (2011b). The roles of leaders in high-performing health care systems.

Commission on Leadership and Management in the NHS. The Kings Fund.

Retrieved from http://www.kingsfund.org.uk/publications/articles/roles-leaders-

high-performing-health-care-systems

Bazeley, P., & Jackson, K. (2013). Qualitative Data Analysis with NVIVO (2nd ed.).

SAGE Publications Ltd.

Bloch, C., & Bugge, M. M. (2013). Public sector innovation-From theory to

measurement. Structural Change and Economic Dynamics, 27, 133–145.

https://doi.org/10.1016/j.strueco.2013.06.008

References 187

Board, N., & Watson, D. (2010). Using what we gather — harnessing information

for improved care, 193(8), 93–94.

Bourke, L., Humphreys, J. S., Wakerman, J., & Taylor, J. (2010a). From ‘problem-

describing’ to ‘problem-solving’: Challenging the ‘deficit’ view of remote and

rural health. Australian Journal of Rural Health, 18(5), 205–209.

https://doi.org/10.1111/j.1440-1584.2010.01155.x

Bourke, L., Humphreys, J. S., Wakerman, J., & Taylor, J. (2010b). From “problem-

describing” to “problem-solving”: Challenging the “deficit” view of remote and

rural health. Australian Journal of Rural Health, 18(5), 205–209.

https://doi.org/10.1111/j.1440-1584.2010.01155.x

Bourke, L., Humphreys, J. S., Wakerman, J., & Taylor, J. (2012). Understanding

rural and remote health: A framework for analysis in Australia. Health and

Place, 18(3), 496–503. https://doi.org/10.1016/j.healthplace.2012.02.009

Bourke, L., Waite, C., & Wright, J. (2014). Mentoring as a retention strategy to

sustain the rural and remote health workforce. Australian Journal of Rural

Health, 22(1), 2–7. https://doi.org/10.1111/ajr.12078

Braithwaite, J., Westbrook, J., Coiera, E., Runciman, W. B., Day, R., Hillman, K., &

Herkes, J. (2017). A systems science perspective on the capacity for change in

public hospitals. Israel Journal of Health Policy Research, 6(1), 1–5.

https://doi.org/10.1186/s13584-017-0143-6

Braithwaite, Jeffrey, Clay-williams, R., Vecellio, E., Marks, D., Hooper, T.,

Westbrook, M., … Blakely, B. (2016). The basis of clinical tribalism , hierarchy

and stereotyping : a laboratory- controlled teamwork experiment.

https://doi.org/10.1136/bmjopen-2016-012467

Braithwaite, Jeffrey, Ellis, L. A., Churruca, K., & Long, J. C. (2018). The goldilocks

effect: The rhythms and pace of hospital life. BMC Health Services Research,

18(1), 1–5. https://doi.org/10.1186/s12913-018-3350-0

Braithwaite, Jeffrey, Greenfield, D., Westbrook, J., Pawsey, M., Westbrook, M.,

Gibberd, R., … Lancaster, J. (2010). Health service accreditation as a predictor

of clinical and organisational performance: a blinded, random, stratified study.

Quality & Safety in Health Care, 19, 14–21.

References 188

https://doi.org/10.1136/qshc.2009.033928

Braithwaite, Jeffrey, Herkes, J., Ludlow, K., Testa, L., & Lamprell, G. (2017).

Association between organisational and workplace cultures, and patient

outcomes: Systematic review. BMJ Open, 7(11), 1–11.

https://doi.org/10.1136/bmjopen-2017-017708

Brigham, T. J. (2016). Feast for the Eyes: An Introduction to Data Visualization.

Medical Reference Services Quarterly, 35(2), 215–223.

https://doi.org/10.1080/02763869.2016.1152146

Bureau of Health Information. (2017). Admitted Adult Patient Survey 2017 Results.

Retrieved from http://www.bhi.nsw.gov.au/BHI_reports/snapshot_reports/adult-

admitted-patient-survey-2017

Bureau of Health Information. (2018a). Retrieved November 1, 2018, from

http://www.bhi.nsw.gov.au/

Bureau of Health Information. (2018b). Development of patient experience key

performance indicators for local health districts in NSW.

Bureau of Health Information. (2018c). Healthcare Observer. Retrieved October 1,

2018, from http://www.bhi.nsw.gov.au/Healthcare_Observer

Canaway, R., Bismark, M., Dunt, D., & Kelaher, M. (2017a). Perceived barriers to

effective implementation of public reporting of hospital performance data in

Australia: a qualitative study. BMC Health Services Research, 17(1), 391.

https://doi.org/10.1186/s12913-017-2336-7

Canaway, R., Bismark, M., Dunt, D., & Kelaher, M. (2018). Public reporting of

hospital performance data: Views of senior medical directors in Victoria,

Australia. Australian Health Review, 42(5), 591–599.

https://doi.org/10.1071/AH17120

Canaway, R., Bismark, M., Dunt, D., Prang, K. H., & Kelaher, M. (2018a). “What is

meant by public?”: Stakeholder views on strengthening impacts of public

reporting of hospital performance data. Social Science and Medicine,

202(February), 143–150. https://doi.org/10.1016/j.socscimed.2018.02.019

Canaway, R., Bismark, M., Dunt, D., Prang, K. H., & Kelaher, M. (2018b). “What is

meant by public?”: Stakeholder views on strengthening impacts of public

References 189

reporting of hospital performance data. Social Science and Medicine,

202(February), 143–150. https://doi.org/10.1016/j.socscimed.2018.02.019

Canaway, R., Bismark, M. M., Dunt, D., & Kelaher, M. A. (2017b). Public reporting

of clinician-level data. Medical Journal of Australia, 207(6), 231-232.e1.

https://doi.org/10.5694/mja16.01402

Chalmers, L. M., Ashton, T., & Tenbensel, T. (2017). Measuring and managing

health system performance: An update from New Zealand. Health Policy,

121(8), 831–835. https://doi.org/10.1016/j.healthpol.2017.05.012

Chatfield, J. S., & Byrd, H. F. (2017). Ten CEO Imperatives for Healthcare

Transformation : Lessons From Top-Performing Academic Medical Centers,

371–384. https://doi.org/10.1097/JHM-D-16-00003

Chaudoir, S. R., Dugan, A. G., & Barr, C. H. I. (2013). Measuring factors affecting

implementation of health innovations: a systematic review of structural,

organizational, provider, patient, and innovation level measures. Implementation

Science : IS, 8(22), 22. https://doi.org/10.1186/1748-5908-8-22

Chorpita, B. F., Bernstein, A., & Daleiden, E. L. (2008). Driving with roadmaps and

dashboards: Using information resources to structure the decision models in

service organizations. Administration and Policy in Mental Health and Mental

Health Services Research, 35(1–2), 114–123. https://doi.org/10.1007/s10488-

007-0151-x

Clarence Valley Council. (2015). Our Community Plan 2015:2024.

Clinical Excellence Commission. (2016). Clinical Excellence Commission Letter

Provided to Executive Officer, Grafton Base Hospital.

Coghlan, D., & Brydon-Miller, M. (2014). The SAGE Encyclopedia of Action

Research. London. https://doi.org/10.4135/9781446294406 NV - 2

Commonwealth of Australia. (2009). Innovation in the public sector : Best Practice

Guide. Strategy Unit Cabinet Office, October. Retrieved from

http://michaellittle.org/documents/Mulgan on Innovation.pdf

Commonwealth of Australia. (2012). National Strategic Framework for Rural and

Remote Health.

References 190

Commonwealth of Australia. (2015). National Innovation & Science Agenda.

Retrieved from https://www.innovation.gov.au/system/files/case-study/National

Innovation and Science Agenda - Report.pdf

Commonwealth of Australia. (2017a). Australia’s First National Rural Health

Commissioner Media release 8 Assistant Minister for Health.

Commonwealth of Australia. (2017b). Department of Health Corporate Plan 2017-

2018.

Commonwealth of Australia. (2017c). Shifting the Dial : 5 Year Productivity Review.

Cresswell, J. W. (2009). Research Design Qualitative, Quantitative, and Mixed

Methods Approahces (3rd ed.). SAGE Publications Ltd.

Crossan, M. M., & Apaydin, M. (2010). A multi-dimensional framework of

organizational innovation: A systematic review of the literature. Journal of

Management Studies, 47(6), 1154–1191. https://doi.org/10.1111/j.1467-

6486.2009.00880.x

Crowe, S., Cresswell, K., Robertson, A., Huby, G., Avery, A., & Sheikh, A. (2011).

The case study approach. BMC Medical Research Methodology, 11, 100.

Retrieved from

http://go.galegroup.com.ezp01.library.qut.edu.au/ps/i.do?id=GALE%7CA26208

1253&sid=summon&v=2.1&u=qut&it=r&p=HRCA&sw=w&asid=ff5c07af176

043ee4c5a0b6f85d16eba

Curry, L. A., Thompson, J. W., Bradley, E. H., Krumholz, H. M., Cherlin, E., Spatz,

E., … Berg, D. (2013). What Distinguishes Top-Performing Hospitals in Acute

Myocardial Infarction Mortality Rates? Annals of Internal Medicine, 154(6),

384. https://doi.org/10.7326/0003-4819-154-6-201103150-00003

Damanpour, F. (1991). Organisational innovation: A meta-analysis of effects of

determinants and moderators. Academy of Management Journal, 34(3), 555–

590. https://doi.org/10.2307/256406

Damanpour, F. (1996). Organizational Complexity and Innovation: Developing and

Testing Multiple Contingency Models. Management Science, 42(5), 693–716.

https://doi.org/10.1287/mnsc.42.5.693

Damanpour, F., & Aravind, D. (2012). Managerial Innovation: Conceptions,

References 191

Processes, and Antecedents. Management and Organization Review, 8(2), 423–

454. https://doi.org/10.1111/j.1740-8784.2011.00233.x

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., &

Lowery, J. C. (2009). Fostering implementation of health services research

findings into practice: A consolidated framework for advancing implementation

science. Implementation Science, 4(1), 1–15. https://doi.org/10.1186/1748-

5908-4-50

Danks, S., Rao, J., & Allen, J. M. (2017). Measuring Culture of Innovation : ( Part

One ). Performance Improvement Quarterly, 9, 427–454.

https://doi.org/10.1002/piq.21236

Darke, P., Shanks, G., & Broadbent, M. (1998). Successfully completing case study

research : combining rigour , relevance and pragmatism. Information Systems

Journal, 8(4), 273–289. https://doi.org/10.1046/j.1365-2575.1998.00040.x

Dias, C., & Escoval, A. (2013). Improvement of hospital performance through

innovation: toward the value of hospital care. The Health Care Manager, 32(2),

129–140. https://doi.org/10.1097/HCM.0b013e31828ef60a

DiCicco-Bloom, B., & Crabtree, B. F. (2006). The qualitative research interview.

Medical Education, 40(4), 314–321. https://doi.org/10.1111/j.1365-

2929.2006.02418.x

Dobni, B., Klassen, M., & Nelson, T. (2015). Innovation strategy in the US: Top

executives offer their views. Journal of Business Strategy, 36(1), 3–13.

https://doi.org/10.1108/JBS-12-2013-0115

Dobni, C. B. (2008). Measuring innovation culture in organizations: The

development of a generalized innovation culture construct using exploratory

factor analysis. European Journal of Innovation Management, 11(4), 539–559.

https://doi.org/10.1108/14601060810911156

Dobni, C. B., Klassen, M., & Nelson, W. T. (2015). Innovation strategy in the US:

Top executives offer their views. Journal of Business Strategy, 36(1), 3–13.

https://doi.org/10.1108/JBS-12-2013-0115

Dobrzykowski, D. D., Callaway, S. K., & Vonderembse, M. A. (2015). Examining

Pathways from Innovation Orientation to Patient Satisfaction: A Relational

References 192

View of Healthcare Delivery. Decision Sciences, 46(5), 863–899.

https://doi.org/10.1111/deci.12161

Dodgson, M., Gann, D. M., Phillips, N., & Phillips, N. (2013). Organizing

Innovation. In Oxford Handbook of Innovation. Oxford University Press.

Retrieved from

//www.oxfordhandbooks.com/10.1093/oxfordhb/9780199694945.001.0001/oxf

ordhb-9780199694945-e-028

Dodou, D., & De Winter, J. C. F. (2014). Social desirability is the same in offline,

online, and paper surveys: A meta-analysis. Computers in Human Behavior, 36,

487–495. https://doi.org/10.1016/j.chb.2014.04.005

Duckett, S., Breadon, P., Jorm, C., Scott, T., Street, A., & Willcox, S. (2014).

Controlling costly care : a billion - dollar hospital opportunity. Report for

Grattan Institute. Melbourne.

Duckett, S. J., Jorm, C., Danks, L., & Moran, G. (2018). All complications should

count: using our data to make hospitals safer. https://doi.org/10.1088/1742-

6596/1025/1/012046

Duckett, S., & Willcox, S. (2015). The Australian Health Care System. The

Australian Healthcare System (5th ed.). Melbourne: Oxford University Press.

Edmondson, A. C. (2004). Learning from failure in health care: frequent

opportunities, pervasive barriers. Quality & Safety in Health Care, 13 Suppl

2(suppl 2), ii3–ii9. https://doi.org/10.1136/qshc.2003.009597

Eisenhardt, K. M., Graebner, M. E., Eisenhardt, K. M., & Graebner, M. E. (2007).

Theory building from cases : opportunities and challenges. The Academy of

Management Journal, 50(1), 25–32.

Eriksson, T., Elwyn, G., Edwards, A., Kuch, C., Braspenning, J., & Tapp, L. (2015).

Developing Organisational Maturity: Considering the Role of Culture

Typologies for Primary Care Practices. Education for Primary Care, 19(1), 1–

12. https://doi.org/10.1080/14739879.2008.11493644

Ertug, G., Gruber, M., Nyberg, A., & Steensma, H. K. (2018). From the Editors—A

Brief Primer on Data Visualization Opportunities in Management Research.

Academy of Management Journal, 61(5), 1613–1625.

References 193

https://doi.org/10.5465/amj.2018.4005

Farmer, J. (2012a). Healthcare in rural areas: the answer is not more of the same in

the Conversation. Retrieved from https://theconversation.com/health-care-in-

rural-areas-the-answer-is-not-more-of-the-same-9252

Farmer, J. (2012b). Healthcare in rural areas: the answer is not more of the same in

the Conversation.

Farmer, J., Munoz, S.-A., & Daly, C. (2012). Being rural in rural health research.

Health & Place, 18(5), 1206–1208.

https://doi.org/10.1016/j.healthplace.2012.05.002

Farmer, J., Munoz, S.-A., & Threlkeld, G. (2012). Theory in rural health. Australian

Journal of Rural Health, 20(4), 185–189. https://doi.org/10.1111/j.1440-

1584.2012.01286.x

Filippetti, A., Frenz, M., Ietto-gillies, G., Filippetti, A., Frenz, M., & Ietto-gillies, G.

(2017). Are Innovation and Internationalization Related ? An Analysis of

European Countries Are Innovation and Internationalization Related ? An

Analysis of European Countries, 2716(January).

https://doi.org/10.1080/13662716.2011.583461

Fitzgerald, A. (2019). Personal conversation on transparency of qualitative research -

checklists.

Fleuren, M. A. H., Paulussen, T. G. W. M., Dommelen, P., & Buuren, S. V. (2014).

Towards a measurement instrument for determinants of innovations.

International Journal for Quality in Health Care, 26(5), 501–510.

https://doi.org/10.1093/intqhc/mzu060

Fleuren, M., Paulussen, T. G. W. M., Dommelen, P., & Buuren, S. Van. (2014).

Measurement Instrument for Determinants of Innovation (MIDI). Innovation for

Life. https://doi.org/10.1093/intqhc/mzu060

Fleuren, M., Wiefferink, K., & Paulussen, T. (2004). Determinants of innovation

within health care organizations. Literature review and Delphi study.

International Journal for Quality in Health Care.

https://doi.org/10.1093/intqhc/mzh030

Flynn, M. (2014). The Safety Cross System : Simple and Effective. Quality and

References 194

Safety Directive (HSE).

Flyvbjerg, B. (2006). Five Misunderstandings About Case-Study Research.

Qualitative Inquiry, 12(2), 219–245.

https://doi.org/10.1177/1077800405284363

Foster, T. C., Johnson, J. K., Nelson, E. C., & Batalden, P. B. (2007). Using a

Malcolm Baldrige framework to understand high- performing clinical

microsystems. Qual Saf Health Care, 16, 334–341.

https://doi.org/10.1136/qshc.2006.020685

Fox, A., Gardner, G., & Osborne, S. (2014). Theoretical frameworks to support

research of health service innovation. Australian Health Review, 39(1), 70–75.

https://doi.org/10.1071/ah14031

Freeman, T. (2002). Using performance indicators to improve health care quality in

the public sector: a review of the literature, (May).

Gale, N. K., Heath, G., Cameron, E., Rashid, S., & Redwood, S. (2013). Using the

framework method for the analysis of qualitative data in multi-disciplinary

health research. BMC Medical Research Methodology, 13, 117.

https://doi.org/10.1186/1471-2288-13-117

Garman, A. N., McAlearney, A. S., Song, P. H., & McHugh, M. (2011). High-

performance work systems in health care management, part 2: qualitative

evidence from five case studies. Health Care Management Review,

36(September), 214–226. https://doi.org/10.1097/HMR.0b013e318201d1bf

George, D., & Mallery, P. (2007). SPSS for windows step by step: a simple guide

and reference, 14.0 update . Boston : Pearson A and B . Retrieved from

http://griffith.summon.serialssolutions.com/2.0.0/link/0/eLvHCXMwY2AwNtIz

0EUrE5KSk4xNjU2SkyxMTEA7oJJNU4GJISnFKBHYAjBOs6B4JAOY8IzN

LZiBDSQzC0QXzMgA2CAATXxBj9qB89G300CqEzdBBhbQFgMhBqbUPG

EGLlB7D3JcsgiDbHBAcLACsCGpUA7sLOeXFysAY6FAIakSTIsyKLq5hjh7

6MJMjYe6OR7mNE

Ghazisaeidi, M., Safdari, R., Torabi, M., Mirzaee, M., Farzi, J., & Goodini, A.

(2015). Development of performance dashboards in healthcare sector: Key

practical issues. Acta Informatica Medica, 23(5), 317–321.

References 195

https://doi.org/10.5455/aim.2015.23.317-321

Gibbs, G. R. (2013). Qualitative Data Analysis Explorations with NVivo. Open

University Press.

Gillham, B. (2010). Case Study Research Methods. London, GB: Continuum.

Retrieved from http://site.ebrary.com/lib/qut/docDetail.action?docID=10404926

Glesne, C. (2016). Becoming qualitative researchers: An introduction, 4th edition.

Becoming Qualitative Researchers: An Introduction (5th ed.). Pearson.

Grandy, G. (2010). Intrinsic Case Study. In Encyclopedia of Case Study Research

(pp. 500–502). SAGE Publications Inc.

https://doi.org/http://dx.doi.org.prox.lib.ncsu.edu/10.4135/9781412957397.n183

Gray, D. E. (2014). Doing Research in the Real World (2nd ed.). London: SAGE

Publications Ltd.

Greenfield, D., & Braithwaite, J. (2008). Health sector accreditation research: a

systematic review. International Journal for Quality in Health Care, 20(3),

172–183. https://doi.org/10.1093/intqhc/mzn005

Greenhalgh, T, Wherton, J., Papoutsi, C., Lynch, J., Hughes, G., A’Court, C., …

Shaw, S. (2017). Beyond adoption: A new framework for theorizing and

evaluating nonadoption, abandonment, and challenges to the scale-up, spread,

and sustainability of health and care technologies. Journal of Medical Internet

Research. https://doi.org/10.2196/jmir.8775

Greenhalgh, Trisha., Robert, G., Bate, P., Macfarlane, F., & Kriakryidou, O. (2005).

Diffusion of innovations in health service organisations: a systematic literature

review. Malden, Mass: Blackwell Publishing Ltd.

Greenhalgh, Trisha, Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004).

Diffusion of Innovations in Service Organizations: Systematic Review and

Recommendations. Milbank Quarterly, 82(4), 581–629.

https://doi.org/10.1111/j.0887-378X.2004.00325.x

Hage, E., Roo, J. P., van Offenbeek, M. A. G., & Boonstra, A. (2013).

Implementation factors and their effect on e-Health service adoption in rural

communities: a systematic literature review. BMC Health Services Research,

13, 19. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23311452

References 196

Hanson, R. M. (2011). Good health information--an asset not a burden! Australian

Health Review : A Publication of the Australian Hospital Association, 35(1), 9–

13. https://doi.org/10.1071/AH09865

Harrison, M. I., Paez, K., Carman, K. L., Stephens, J., Smeeding, L., Devers, K. J., &

Garfinkel, S. (2014). Effects of organizational context on Lean implementation

in five hospital systems. Health Care Management Review, 00(0), 1.

https://doi.org/10.1097/HMR.0000000000000049

Hewlett, A., Marshall, M., & Sherbin, L. (2013). How Diversity Can Drive

Innovation. Harvard Business Review, (December).

Hibbert, P., Johnston, B., Wiles, L., & Braithwaite, J. (2015). Sax Institute : Evidence

Check Healthcare performance reporting bodies.

Hoelscher, J., & Mortimer, A. (2018). Using Tableau to visualize data and drive

decision-making. Journal of Accounting Education, 44(October 2017), 49–59.

https://doi.org/10.1016/j.jaccedu.2018.05.002

Holosko, M. J., & Thyer, B. A. (2011). Pocket Glossary for Commonly Used

Research Terms. SAGE Publications Ltd.

Humphreys, J., & Gregory, G. (2012). Celebrating another decade of progress in

rural health: What is the current state of play? Australian Journal of Rural

Health, 20(3), 156–163. https://doi.org/10.1111/j.1440-1584.2012.01276.x

Humphreys, J., & Wakerman, J. (n.d.). Primary health care in rural and remote

Australia: achieving equity of access and outcomes through national reform A

discussion paper, 1–28.

Humphreys, J., & Wakerman, J. (2018). Learning from history: How research

evidence can inform policies to improve rural and remote medical workforce

distribution. Australian Journal of Rural Health, 26(5), 329–334.

https://doi.org/10.1111/ajr.12473

Independent Hospital Pricing Authority. (2018). National Benchmarking Portal :

User FactSheet.

Institute for Healthcare Improvement. (2016). Lessons in Leadership for

Improvement:Kaiser Permanente’s Improvement Journey Over 10 Years.

References 197

Johannessen, J. a. (2013). Innovation: a systemic perspective - developing a systemic

innovation theory. Kybernetes, 42(8), 1195–1217. https://doi.org/10.1108/K-04-

2013-0069

Joint Commission. (2017). The Joint Commission : Accreditation Body United

States. Retrieved January 15, 2017, from https://www.jointcommission.org/

Kapoor, K. K., Dwivedi, Y. K., & Williams, M. D. (2014). Innovation adoption

attributes: A review and synthesis of research findings. European Journal of

Innovation Management, 17(3), 327–348. https://doi.org/10.1108/EJIM-08-

2012-0083

Ketokivi, M., & Choi, T. (2014). Renaissance of case research as a scientific method.

Journal of Operations Management, 32(5), 232–240.

https://doi.org/10.1016/j.jom.2014.03.004

Kim, S. H., & Kim, S. (2016). Social Desirability Bias in Measuring Public Service

Motivation. International Public Management Journal, 19(3), 293–319.

https://doi.org/10.1080/10967494.2015.1021497

Kimberly, J. R., & Evanisko, M. J. (1981). Organizational innovation: The influence

of individual, organisational and contextual factors on hospital adoption of

technological and administrative innovations. Academy of Management Journal

Dec, 24(4), 689–713.

Kirk, A. (2012). Data visualization: a successful design process. Birmingham: Packt

Publishing.

Körner, M., Wirtz, M. A., Bengel, J., & Göritz, A. S. (2015). Relationship of

organizational culture, teamwork and job satisfaction in interprofessional teams.

BMC Health Services Research, 15(1), 243. https://doi.org/10.1186/s12913-

015-0888-y

Kringos, D. S., Sunol, R., Wagner, C., Mannion, R., Michel, P., Klazinga, N. S., &

Groene, O. (2015). The influence of context on the effectiveness of hospital

quality improvement strategies: a review of systematic reviews. BMC Health

Services Research, 15(1), 277. https://doi.org/10.1186/s12913-015-0906-0

Larisch, L., Isis, A.-W., & Hidefjall, P. (2013). Understanding healthcare innovation

systems: the Stockholm region case. Journal of Health Organization and

References 198

Management, 30(8). https://doi.org/http://dx.doi.org/10.1108/MRR-09-2015-

0216

Leathley, C. M., Gilbert, R., Kennedy, P. J., & Hughes, C. F. (2010). Measuring

hospital performance — 2008 forum summary. Medical Journal of Australia,

Supplement, 193(8), 95–96.

Lee, D. (2015). The effect of operational innovation and QM practices on

organizational performance in the healthcare sector. International Journal of

Quality Innovation, 1(8), 1–14. https://doi.org/10.1186/s40887-015-0008-4

Leeb, K. (2018). Does health system performance reporting stimulate change?

Healthcare Management Forum, 31(6), 235–238.

https://doi.org/10.1177/0840470418782515

Lerro, A. (2012). Knowledge-based perspectives of innovation and performance

improvement in health care. Measuring Business Excellence, 16(4), 3–13.

https://doi.org/10.1108/13683041211276401

Liamputtong, P. (2013). Research methods in health: foundations for evidence-based

practice (2nd ed.). South Melbourne, Vic: Oxford University Press.

Loeb, J. M. (2004). The current state of performance measurement in health care.

International Journal for Quality in Health Care : Journal of the International

Society for Quality in Health Care / ISQua, 16 Suppl 1, i5–i9.

https://doi.org/10.1093/intqhc/mzh007

Lynch, T. (2015). A Critique of Health System Performance Measurement.

International Journal of Health Services : Planning, Administration,

Evaluation, 45(4), 743–761. https://doi.org/10.1177/0020731415585987

Macquarie Dictionary. (2017). Macquarie Dictionary online. Retrieved from

https://www-macquariedictionary-com-au.libraryproxy.griffith.edu.au/

Mafini, C. (2015). Performance Through Innovation , Quality And Inter-

Organisational Systems : A Public Sector Perspective, 31(3), 939–952.

Mannion, R., & Braithwaite, J. (2012). Unintended consequences of performance

measurement in healthcare: 20 salutary lessons from the English National

Health Service. Internal Medicine Journal, 42(5), 569–574.

https://doi.org/10.1111/j.1445-5994.2012.02766.x

References 199

Mannion, R., Davies, H., & Marshall, M. (2005). Cultural characteristics of “high”

and “low” performing hospitals. Journal of Health Organization and

Management, 19(6).

Mannion, Russell, & Smith, J. (2017). Hospital culture and clinical performance:

where next? BMJ Quality & Safety, (1), bmjqs-2017-007668.

https://doi.org/10.1136/bmjqs-2017-007668

Marchildon, G. P., Ludlow, K., Boyling, C., Braithwaite, J., & Philippon, D. J.

(2018). The comparative performance of the Canadian and Australian health

systems. Healthcare Management Forum, 31(6), 239–244.

https://doi.org/10.1177/0840470418788378

Mariano, S., & Casey, A. (2015). Is organizational innovation always a good thing?

Management Learning, 46(5), 530–545.

https://doi.org/10.1177/1350507615569429

Martin, S. (2018). Making Less Fuss of Knee Replacement Surgery in Australia and

the Inexorable Trend Towards Day Stay : Conference Paper.

McAlearney, A. S., Robbins, J., Garman, A. N., & Song, P. H. (2013). Implementing

high-performance work practices in healthcare organizations: qualitative and

conceptual evidence. Journal of Healthcare Management / American College of

Healthcare Executives, 58(6), 446–462; discussion 463-4. Retrieved from

http://www.ncbi.nlm.nih.gov/pubmed/24400459

McMurray, A. J. (2017). Email correspondence regarding validity and reliability of

workplace innovation scale and permission to use.

McMurray, Adela, Islam, M. M., Sarros, J. C., & Pirola-Merlo, A. (2013).

Workplace Innovation in a Nonprofit Organization. Nonprofit Management and

Leadership, 23(3), 367–388. https://doi.org/10.1002/nml.21066

McMurray, AJ, & Dorai, R. (2003). Workplace innovation scale: A new method for

measuring innovation in the workplace. … Paper, Organizational Learning &

Knowledge 5th …, 1–19. Retrieved from

http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.412.144&rep=rep1&t

ype=pdf

Mewburn, I., Firth, K., & Lehmann, S. (2018). How to Fix Your Academic Writing

References 200

Trouble: A Practical Guide. Open University Press.

Moreira, M. R. A., Gherman, M., & Sousa, P. S. A. (2017). Does innovation

influence the performance of healthcare organizations? Innovation:

Management, Policy and Practice, 19(3), 335–352.

https://doi.org/10.1080/14479338.2017.1293489

Moussa, M., McMurray, A., & Muenjohn, N. (2018). A Conceptual Framework of

the Factors Influencing Innovation in Public Sector Organizations. The Journal

of Developing Areas, 52(3), 231–240. https://doi.org/10.1353/jda.2018.0048

Murphy, K. M., Hughes, L. S., & Conway, P. (2018). A path to sustain rural

hospitals. JAMA - Journal of the American Medical Association, 319(12), 1193–

1194. https://doi.org/10.1001/jama.2018.2967

National Health and Medical Research Council. (2017a). NHMRC Centres of

Research Excellence. Retrieved March 2, 2019, from

https://www.nhmrc.gov.au/funding/find-funding/centres-research-excellence

National Health and Medical Research Council. (2017b). Research Translation and

Impact. Retrieved January 1, 2019, from https://nhmrc.gov.au/research-

policy/research-translation-and-impact

National Health Performance Authority. (2016). MyHospitals. Retrieved March 31,

2016, from http://www.myhospitals.gov.au/about-myhospitals

National Health System. (2018). NHS Innovation Accelerator : Understanding how

and why the NHS adopts innovation.

National Institute of Standards and Technology. (2016). Baldrige Performance

Excellence Program Are we Making Progress Self Assessment Tool. Retrieved

November 1, 2017, from https://www.nist.gov/baldrige/self-

assessing/improvement-tools/are-we-making-progress

Nelson, A., Earle, A., Howard-Grenville, J., Haack, J., & Young, D. (2014). Do

innovation measures actually measure innovation? Obliteration, symbolic

adoption, and other finicky challenges in tracking innovation diffusion.

Research Policy, 43(6), 927–940. https://doi.org/10.1016/j.respol.2014.01.010

Nelson, E., Batalden, P., Huber, T., Mohr, J., Godfrey, M., Headerick, L., & Wasson,

J. (2002). Microsystems in Health Care: Part 1. Learning from high performing

References 201

front-line clinical units. Microsystems in Health Care, 472–493.

New South Wales Government. (2015). Role of Local Health District Boards.

Retrieved from https://www.health.nsw.gov.au/lhd/boards/Pages/role-of-

lhdboards.aspx

North Coast Primary Health Network. (2017). Clarence Valley Local Government

Area Health Check, (June).

Northern NSW Local Health District. (2013). Health Care Services Plan 2013-2018

(Vol. 1).

Northern NSW Local Health District. (2017). Expense budget general expenses.

Retrieved from https://nnswlhd.health.nsw.gov.au/wp-content/uploads/1.0-

2018-19-NNSW-LHD-Expense-budget-by-Facility.pdf

Northern NSW Local Health District. (2018). Northern NSW Local Health District :

About Us. Retrieved November 1, 2018, from

https://nnswlhd.health.nsw.gov.au/about/northern-nsw-local-health-district/

Northern NSW Local Health District Board. (2018a). Minutes August 2018.

Northern NSW Local Health District Board. (2018b). Minutes July 2018.

Northern NSW Local Health District Board. (2018c). Minutes September 2019.

NSW Health. (2016). IB2016_013 Information Bulletin Hospital Peer Groupings.

NSW Health Education and Training Unit. (2018). Our CORE values. Retrieved

from http://www.heti.nsw.gov.au/About/Mission-and-functions/our-core-values/

NSW Ministry of Health. (2014). New South Wales Rural Health Plan : Towards

2021.

NSW Ministry of Health. (2018). Health Education Training Institute : About HETI.

Retrieved December 8, 2018, from https://www.heti.nsw.gov.au/about-heti

NSW Public Service Commission. (2018). People Matter 2018 NSW Public Sector

Employee Survey : Northern NSW Local Health District.

OECD/Eurostat. (2005). Guidelines for Collecting and Interpreting Innovation Data.

https://doi.org/10.1787/9789264013100-en

OECD. (2018). OECD Data Length of Hospital Stay. Retrieved November 1, 2018,

References 202

from https://data.oecd.org/healthcare/length-of-hospital-stay.htm

Ovretveit, J. (2011). Widespread focused improvement: Lessons from international

health for spreading specific improvements to health services in high-income

countries. International Journal for Quality in Health Care, 23(3), 239–246.

https://doi.org/10.1093/intqhc/mzr018

Ovretveit, J. C., Shekelle, P. G., Dy, S. M., McDonald, K. M., Hempel, S.,

Pronovost, P., … Wachter, R. M. (2011). How does context affect interventions

to improve patient safety? An assessment of evidence from studies of five

patient safety practices and proposals for research. BMJ Quality & Safety, 20,

604–610. https://doi.org/10.1136/bmjqs.2010.047035

Pashaeypoor, S., Ashktorab, T., Rassouli, M., & Alavi-Majd, H. (2016). Predicting

the adoption of evidence-based practice using “Rogers diffusion of innovation

model.” Contemporary Nurse, 52(1), 85–94.

https://doi.org/10.1080/10376178.2016.1188019

Powell, A. E., Davies, H. T. O., & Thomson, R. G. (2003). Using routine

comparative data to assess the quality of health care: understanding and

avoiding common pitfalls. Quality and Safety in Health Care, 12(2), 122–128.

https://doi.org/10.1136/qhc.12.2.122

Pronovost, P. J. (2017). High-Performing Health Care Delivery Systems: High

Performance Toward What Purpose? Joint Commission Journal on Quality and

Patient Safety, 43(9), 448–449. https://doi.org/10.1016/j.jcjq.2017.06.001

Queensland Health. (2013). Queensland rural and remote health service framework

Final draft, (June), 1–27.

Queensland Health. (2015). Strategic plan 2014 – 2018 ( 2015 update ), 2018, 2014–

2015.

Rao, J., & Weintraub, J. (2009). What’s Your Company’s Innovation Quotient.

Strategy, (1), 1–9.

Rao, J., & Weintraub, J. (2013). How Innovative Is Your Company ’ s Culture? MIT

Sloan Management Review, 54(54315), 29–37.

Rapport, F., & Braithwaite, J. (2018). Are we on the cusp of a fourth research

paradigm? Predicting the future for a new approach to methods-use in medical

References 203

and health services research. BMC Medical Research Methodology, 18(1), 131.

https://doi.org/10.1186/s12874-018-0597-4

Rapport, F., Clay-Williams, R., Churruca, K., Shih, P., Hogden, A., & Braithwaite, J.

(2018). The struggle of translating science into action: Foundational concepts of

implementation science. Journal of Evaluation in Clinical Practice, 24(1), 117–

126. https://doi.org/10.1111/jep.12741

Reeve, C., Humphreys, J., & Wakerman, J. (2015). A comprehensive health service

evaluation and monitoring framework. Evaluation and Program Planning, 53,

91–98. https://doi.org/10.1016/j.evalprogplan.2015.08.006

REF2021. (2018). Research Excellence Framework : UK System for Quality of

Research in Higher Education Institutions. Retrieved September 20, 2001, from

https://www.ref.ac.uk/

Regional Australia Institute. (2015). Australia’s Hidden Metropolis.

Regional Australia Institute. (2018). Submission to the Senate Standing Committees

on Economics into the indicators of, and impact of, regional inequality in

Australia.

Research England. (2019). No Title. Retrieved October 3, 2019, from

https://re.ukri.org/about-us/

Rizan, C., Phee, J., Boardman, C., & Khera, G. (2017). General surgeon’s antibiotic

stewardship: Climbing the Rogers Diffusion of Innovation Curve-Prospective

Cohort Study. International Journal of Surgery, 40(2017), 78–82.

https://doi.org/10.1016/j.ijsu.2017.02.040

Robertson, D. (2018). Emergency Protocols A Flight Manual for the Crashing

Patient. Retrieved November 29, 2018, from

http://emergencyprotocols.org.au/about/

Rogers, E. (1983). Diffusion of innovations. Journal of Continuing Education in the

Health Professions (3rd Editio, Vol. 17). The Free Press.

https://doi.org/10.1002/chp.4750170109

Rowe, R. J., & Cadzow, R. (2014). Core values are the bedrock of a culture of

compliance in health care agencies. Home Health Care Management &

Practice, 26(3), 163–166. https://doi.org/10.1177/1084822313518557

References 204

Runciman, W. B., Coiera, E. W., Day, R. O., Hannaford, N. A., Hibbert, P. D., Hunt,

T. D., … Braithwaite, J. (2012). Towards the delivery of appropriate health care

in Australia. Medical Journal of Australia, 197(2), 78–81.

https://doi.org/10.5694/mja12.10799

Salter, A., & Alexy, O. (2013). The Nature of Innovation. The Oxford Handbook of

Innovation Management, (February), 26–49.

https://doi.org/10.1093/oxfordhb/9780199694945.013.034

Sarto, F., & Veronesi, G. (2016). Clinical leadership and hospital performance:

assessing the evidence base. BMC Health Services Research, 16(S2), 169.

https://doi.org/10.1186/s12913-016-1395-5

Saunila, M., & Ukko, J. (2012). A conceptual framework for the measurement of

innovation capability and its effects. Baltic Journal of Management, 7(4), 355–

375. https://doi.org/10.1108/17465261211272139

Schoo, A., Lawn, S., & Carson, D. (2016). Towards equity and sustainability of rural

and remote health services access: supporting social capital and integrated

organisational and professional development. BMC Health Services Research,

16(1), 111. https://doi.org/10.1186/s12913-016-1359-9

Scott, I. (2014). Ten clinician-driven strategies for maximising value of Australian

health care. Australian Health Review. Retrieved from

http://dx.doi.org/10.1071/AH13248

Scoville, R., Little, K., Rakover, J., Kuter, K., & Mate, K. (2016). Sustaining

improvement. Sustaining Improvement. IHI White Paper, 93–106.

Shahian, D. M., Normand, S.-L. T., Friedberg, M. W., Hutter, M. M., & Pronovost,

P. J. (2016). Rating the Raters. Annals of Surgery, 264(1), 36–38.

https://doi.org/10.1097/SLA.0000000000001631

Shaw, C. D. (2000). External quality mechanisms for health care: summary of the

ExPeRT project on visitae, accreditation, EFQM and ISO assessment in

European Union countries. International Journal for Quality in Health Care,

12(3), 169–175.

Shelllner, P. (2007). Book Review: Relationship-Based Care : A Model for

Transforming Practice.

References 205

Shields, J. A., & Jennings, J. L. (2013). Using the Malcolm Baldrige “Are We

Making Progress” Survey for Organizational Self-Assessment and Performance

Improvement. Journal for Healthcare Quality, 35(4), 5–15.

https://doi.org/10.1111/j.1945-1474.2011.00191.x

Shwartz, M., Cohen, A. B., Restuccia, J. D., Ren, Z. J., Labonte, A., Theokary, C.,

… Horwitt, J. (2011). How Well Can We Identify the High-Performing

Hospital? Medical Care Research and Review, 68(3), 290–310.

https://doi.org/10.1177/1077558710386115

Silverman, D. (2011). Interpreting Qualitative Data : A Guide to the Principles of

Qualitative Research (4th ed.). London: SAGE Publications Ltd.

Silverman, D. (2017). Doing Qualitative Research (5th ed.). London: SAGE

Publications Ltd.

Singer, S. J., Moore, S. C., Meterko, M., & Williams, S. (2012). Development of a

short-form Learning Organization Survey: the LOS-27. Medical Care Research

and Review : MCRR, 69(4), 432–459.

https://doi.org/10.1177/1077558712448135

Snowden, A., & Cohen, J. (2012). Strengthening Health Systems Through

Innovation: Lessons Learned. International Centre for Health Innovation.

Ontario.

Srinvasan, U., Ramachandran, D., Quilty, C., Rao, S., M., N., & Jonas, D. (2018).

Flying Blind : Australian Researchers and Digital Health Australian Health

Data Series, Digital Health Cooperative Research Centre. Harvard Business

Review (Vol. 2). https://doi.org/10.1016/S0262-4079(14)62108-4

Sword, H. (2012). Stylish Academic Writing. Stylish Academic Writing. Harvard

University Press. https://doi.org/10.4159/harvard.9780674065093.c3

Tableau Software Inc. (2018). What is Tableau? Retrieved from

https://www.quora.com/What-is-Tableau

Taylor, N., Clay-Williams, R., Hogden, E., Braithwaite, J., & Groene, O. (2015).

High performing hospitals: a qualitative systematic review of associated factors

and practical strategies for improvement. BMC Health Services Research, 15(1),

1–22. Retrieved from 10.1186/s12913-015-0879-z

References 206

The Independent Hospital Pricing Authority. (2018). Consultation Paper Pricing

Framework for Australian Public Hospital Services 2019-2020. Retrieved from

http://www.ihpa.gov.au/internet/ihpa/publishing.nsf/Content/CA257944001224

52CA257B8A000178EA/$File/Draft-PricingFramework14-15.pdf

Thomas, G. (2016). How to do your case study (2nd ed.). London: SAGE

Publications Ltd.

Tomson, C. R. V. (2009). What would it take to improve the quality of healthcare:

More money, or more data? Clinical Medicine, Journal of the Royal College of

Physicians of London, 9(2), 140–144.

Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting

qualitative research ( COREQ ): a 32-item checklist for interviews and focus

groups, 19(6), 349–357.

Torugsa, N. A., & Arundel, A. (2016). The Nature and Incidence of Workgroup

Innovation in the Australian Public Sector: Evidence from the Australian 2011

State of the Service Survey. Australian Journal of Public Administration, 75(2),

202–221. https://doi.org/10.1111/1467-8500.12095

United Nations. (2014a). World’s population increasingly urban with more than half

living in urban areas. Retrieved September 20, 2001, from

http://www.un.org/en/development/desa/news/population/world-urbanization-

prospects-2014.html

United Nations. (2014b). World’s population increasingly urban with more than half

living in urban areas.

United States Department of Health and Human Services. (2018). Esource

Behavioural and Social Science Research. Retrieved from

http://www.esourceresearch.org/eSourceBook/QualitativeMethods/11Glossary/t

abid/277/Default.aspx

Van Der Wiele, T., Millen, R., Whelan, D., & Section, B. (2000). Improvement in

Organizational Performance and Self-Assessment Practices by Selected

American Firms, 7(4).

van Oorschot, J. A. W. H., Hofman, E., & Halman, J. I. M. (2018). A bibliometric

review of the innovation adoption literature. Technological Forecasting and

References 207

Social Change, 134(March 2017), 1–21.

https://doi.org/10.1016/j.techfore.2018.04.032

Vandeusen Lukas, C., Engle, R. L., Holmes, S. K., Parker, V. A., Petzel, R. A.,

Nealon Seibert, M., … Sullivan, J. L. (2010). Strengthening organizations to

implement evidence-based clinical practices. Health Care Management Review,

35(3), 235–245. https://doi.org/10.1097/HMR.0b013e3181dde6a5

Veillard, J, Champagne, F., Klazinga, N., Kazandjian, V., Arah, O., & Guisset, A.

(2005). A performance assessment framework for hospitals : the WHO regional

office for, 17(6), 487–496.

Veillard, Jeremy, Huynh, T., Ardal, S., Kadandale, S., Klazinga, N., & Brown, A.

(2013). Making Health System Performance Measurement Useful to Policy

Makers: Aligning Strategies, Measurement and Local Health System

Accountability in Ontario. Healthcare Policy | Politiques de Santé, 5(3), 49–65.

https://doi.org/10.12927/hcpol.2013.21639

Wakerman, J. (2009). Innovative rural and remote primary health care models: What

do we know and what are the research priorities? Australian Journal of Rural

Health, 17(1), 21–26. https://doi.org/10.1111/j.1440-1584.2008.01032.x

West, M. A., & Lyubovnikova, J. (2013). Illusions of team working in health care.

Journal of Health Organization and Management, 27(1), 134–142.

https://doi.org/http://dx.doi.org/10.1108/14777261311311843

West, M. A., Lyubovnikova, J., Eckert, R., & Denis, J.-L. (2014). Collective

leadership for cultures of high quality health care. Journal of Organizational

Effectiveness: People and Performance, 1(3), 240–260.

https://doi.org/10.1108/JOEPP-07-2014-0039

Wilson-Evered, E., Härtel, C. E. J., & Neale, M. (2001). A longitudinal study of

work group innovation: The importance of transformational leadership and

morale. In Advances in Health Care Management (Vol. 2, pp. 315–340).

Emerald Group Publishing Limited. https://doi.org/doi:10.1016/S1474-

8231(01)02032-8

Witell, L., Synder, H., Gustaffson, A., Fombelle, P., & Kristensson, P. (2016).

Defining service innovation: A review and synthesis. Journal of Business

References 208

Research, 69(8), 2863–2872. https://doi.org/10.1016/j.jbusres.2015.12.055

Workplace Gender Equality Agency. (2018). Gender segregation in Australia ’ s

workforce, (February), 1–9.

Wutzke, S., Benton, M., & Verma, R. (2016). Towards the implementation of large

scale innovations in complex health care systems: views of managers and

frontline personnel. BMC Research Notes, 9(1), 327.

https://doi.org/10.1186/s13104-016-2133-0

Yin, R. K. (2014). Case study research: design and methods (5th ed.). SAGE

Publications Inc.

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


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


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


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


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.


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.


analysis.

Employee engagement Yoursay Cultural Survey 2017–2018 Compared to State and

District performance.


analysis.

Appendices 219

Appendix F Northern NSW Local Health District Ethics Approval

Appendices 220


Appendices 221

Appendix G Northern NSW Local Health District Ethics Site Specific

Assessment Approval

Appendices 222


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).

tel:1800000117

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 [email protected]. 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 [email protected]

mailto:[email protected]

tel:%2B61%207%203138%205123


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


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


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:

[email protected] 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,


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



Health QUT

Professor of Public Health,

QUT

Clinical Sub-dean

University Centre for

Rural Health North Coast


information sheet and in particular have noted that:


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 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.


this research;







penalty;

Appendices 236









and;


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,


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



Health QUT

Clinical Sub-dean


Rural Health North Coast


information sheet and have noted that:


survey that will be distributed by the researcher where I will be asked questions

relating to workplace innovation scale factors.





this research;







penalty;




Appendices 238






and;


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



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



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


Rural Health North

Coast

Appendices 245


(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


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


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.