Elsevier

Social Science & Medicine

Volume 67, Issue 10, November 2008, Pages 1530-1540
Social Science & Medicine

Behind the scenes in health care improvement: The complex structures and emergent strategies of Implementation Science

https://doi.org/10.1016/j.socscimed.2008.06.001Get rights and content

Abstract

Implementation Science (IS) is a new branch of health services research (HSR) that strives to increase the efficiency and effectiveness of health care quality improvement (QI) efforts. Despite the fact that IS takes a systems approach, building contextual factors into its research designs, the complex systems context of IS itself—and the impact this context has on IS practice—has never been scrutinized. Using individual interviews and participant observation, the research described here characterizes key contextual factors affecting how implementation scientists in one large health care organization approach and conduct their research. Some of the organizational and professional system forces structuring their attitudes and actions were grant-related timelines, administrative burdens, and team turnover. The need for publications also figured highly. While such pressures (and related responses to them) may be rife in most grant-funded health care research settings, IS's particularly marginal position drove these implementation scientists to strategically highlight particular aspects of their work depending on which audience or part of the system they required favor from. Their narratives illuminate the contradictions and contests entailed within and engendered by organizational and professional structures, and the strategies used to negotiate these. They also reveal a great deal about the struggles underwriting disciplinary identity claims in a complex systems context.

Section snippets

Complex adaptive systems

Until recently, organizational theorists conceived of organizations as machines. Like clocks or heating systems, organizations were thought to consist of moving parts that worked together in an orderly fashion. Organizational machines might be complicated and dynamic, but they were also predictable. This was because mechanical parts have no agency; nothing novel can take place.

As Plsek notes, however, in regard to health care quality improvement (Plsek, 2001; see also Plsek, 2003), according to

Methods

Data were collected using a focused ethnographic approach that included key informant interviews and immersion within the host IS unit. This approach can be likened to ‘institutional ethnography’ (Campbell & Gregor, 2004), which focuses on explicating social relations as they are realized in people's activities, including relations that are trans-local, extend across time, entail authority and subordination (however implicit), and are mediated by organizational texts (e.g., policy statements

Findings

Relevant themes highlighted by the respondents in regard to IS, and their associated meanings and implications, are described and discussed below. The themes are identified in section subheads. Participants quoted2 are identified with a systematically scrambled interviewee number (e.g., ‘[103]’); general job titles are provided only where needed for clarity.

Discussion and implications

The IS unit that formed the central focus of this study is one of nine such units in a large, integrated health care system. The centers are physically located at specific facilities throughout the USA, but core staff (including IS Coordinators) report to the organization's central office. Work is carried out by core center staff, whose work is funded by program grants, and center-affiliated researchers, whose work is funded by project researchers.

Acknowledgements

The project described here was supported by a Veterans Healthcare Administration (VHA) Academic Expert Collaboration Supplement grant (#IMA 04-4117). Institutional Review Board approval was granted by the VHA, University of California San Diego, and San Diego State University.

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