Disseminating healthcare innovations to secondary
healthcare institutions: a qualitative problem-solving study
By
Stijn Analbers
S2972336
s.a.analbers@student.rug.nl
Thesis supervisor: Dr. M.A.G. van Offenbeek
Co-assessor: Dr. I. Maris-de Bresser
Date: 18-7-2019
MSc BA Change Management
Faculty of Economics and Business
University of Groningen
Number of words: 13136
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ABSTRACT
Clinical science in the mental healthcare progresses fast, yet many innovations in the mental healthcare remain unused. The problem of dissemination of innovation not only lies in the new scientific innovation, but also in the required changes in numerous processes that arises with the innovation. This study focuses on why dissemination of new innovations rarely happens and what factors influence the dissemination process. 19 interviews have been conducted at multiple healthcare organisations and semi-government institutions. Two process models are presented about the development and dissemination phase of mental healthcare innovations, accompanied with 14 bottlenecks. In addition, 7 improvements for tertiary healthcare organisations are given on how to improve their dissemination process.
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TABLE OF CONTENT
Introduction- Introduction into tertiary healthcare innovations - Introducing UMCG-UCP
- Explaining problem at UMCG-UCP
- Introducing the research question: How can UMCG-UCP successfully disseminate their new
treatments to secondary healthcare institutions?
Theory
- Explaining classical theory of dissemination of innovation - Explanations of the definitions
- Discuss use of dissemination theory in healthcare
- Discuss stakeholder theory, and stakeholder theory in the healthcare industry, presentation of the system model of the external context
- Integration and conclusions, presentation of the system model of the research Methods
- Research design
- Discuss data collection, including amount of interviews and interview sites. - Examples of interview questions and approach of contacting interviewees - Discuss data analysis by using inductive coding and use of fragmented approach - Discuss expected results
Results
- Development phase (process model) - Dissemination phase (process model) - A successful dissemination trajectory - An unsuccessful dissemination trajectory - Integration of the process model and subcases Discussion
- Development and dissemination process in mental healthcare - Link with literature
- Successful and unsuccessful disseminations - Bottlenecks and comparison with literature - Implications for UMCG-UCP
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INTRODUCTION
Healthcare is among the best endowed of all industries in the richness of its scientific base. Even though many questions still exist, clinical science progresses fast, providing better drugs, surgeries, diagnostic methods and new treatments. Yet, a lot of innovations remain unused (Ellis, Mulligan, Rowe and Sackett, 1995). Also, when innovations are implemented in one location, they often disseminate slowly (Greenhalgh, Robert, Bate, Kyriakidou, Macfarlane and Peacock, 2004). The problem of dissemination of innovation not only lies in the new scientific innovation, but also in the required changes in numerous processes that arise with the innovation (Berwick, 2003). Invention of a more effective drug, treatment or surgery is hard, but dissemination seems even harder.
Many of these innovations are being developed in tertiary healthcare organisations. Tertiary healthcare organisations are healthcare facilities for advanced medical care. Besides delivering specialty care, they conduct research to improve their treatments. Once a more successful or improved treatment has been found, the healthcare organisation needs to diffuse this innovation to secondary and primary care. Organisations in the tertiary healthcare sectors are experiencing a necessity for change: instead of being a ‘production machine’, they would rather focus more on developing and disseminating effective innovations (Abbass, Kisely, Rasic, Town and Johansson, 2015). The change vision is that in this way they could better treat patients and enable secondary and primary care to benefit from healthcare innovations (Cawsey, Deszca and Ingols, 2016).
This academic problem solving research entails a problem-solving study and will focus on one specific tertiary healthcare organisation: the University Centre Psychiatry of the University Medical Centre Groningen (UCP). Following a change in the Dutch health care law in 2006, the UMCG-UCP lost its incentive to proactively innovate and develop new treatments. However, more recently the UMCG-UCP revised its position: being a tertiary healthcare institution. They decided that they not only want to focus on treating complex patients, but also aim to develop new treatments (Haarman, Kamphuis, Homan-Stokker, Boerhout, Siero, de Boer, Verschure, 2018). In the past few years they have developed a few successful treatments to treat anxiety and mood disorders. For instance, the UMCG-UCP has developed ketamine and light therapy treatment to treat depression (Haarman et al., 2018). These new treatments seem more successful than current treatments for depression. Nevertheless, UMCG-UCP has not been successful in disseminating their treatments to secondary healthcare institutions. In aiming for improved healthcare, it is crucial for UMCG-UCP to know how they can effectively disseminate their new innovations so patients and secondary healthcare organisations can benefit from it.
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involve other relevant stakeholders. In the dissemination of new treatments direct and indirect stakeholders are involved. In this case, following the criteria of Achterkamp and Vos (2006), direct stakeholders are the innovators at UMCG-UCP; patients; the board of (the UCP department of) UMCG; healthcare insurers; secondary healthcare institutions; ministry of Health, Welfare and Sports; and depression unions. Indirect stakeholders are, Zorginstituut Nederland, Inspectie Gezondheidszorg en Jeugd or the Dutch Federation of University Medical Centres (NFU). For instance, healthcare institutions are unwilling to large-scale implement a new treatment if they are unsure whether it will work for their patients. Likewise, insurance companies do not want to finance a treatment on which not enough research is conducted. Therefore, the research question is the following: How can
UMCG-UCP successfully disseminate their new treatments to secondary healthcare institutions?
This paper entails a case study conducted in 2019. In the theory section, I review the extant research on dissemination of innovations and stakeholder theory and highlight what is already known and what is problematic in this context, including the relationship between the two. The theory section clarifies the conceptual focus and defines the scope of this paper. Thereafter, in the method section the research design and methods are described. Afterwards, the results are presented where a process model of the development and dissemination phase is examined. In the discussion section, the process model is discussed and reflected on by making use of the relevant literature. Lastly, the research question is answered and recommendations are given.
THEORY
The relevant theory can be split into two subsections: the ‘what’ and the ‘how’. The ‘what’ will focus on the relevant factors in the dissemination process and will be handled under the first subsection about the diffusion of innovation theory. In the second subsection, the ‘how’ will focus on how the relevant stakeholders influence each other and how these relationships determine the dissemination process. In the last subsection, the ‘what’ and the ‘how’ will be integrated, hence the scope of this study will be made clear.
Diffusion of innovation theory
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performance gap. The definition of Rogers (1995) in Table 1 shows that adoption is a process where people or organisations rationally choose to adopt an innovation because of an actual or perceived advantage (Greenhalgh et al., 2004). Adoption of an innovation can, therefore, be seen as an individual process as well as an organisational process (Kostova and Roth, 2002). This study focuses on the organisational process, as decisions to adopt new innovations within the healthcare sector are mostly taken on the organisational level. The main assumption of the diffusion of innovation theory is that the adoption rate is predictable: it follows an S-shaped curve, where there is a slow initial adoption, then a fast acceleration period, followed by a deceleration phase. The main logic behind this theory is comparable to the nature of growth (Greenhalgh et al., 2004; Rogers, 1995). At UMCG-UCP, the S-curve seems to stop at the beginning, when an evidence-based innovation is found in the literature. This innovation needs to be developed and implemented within UMCG-UCP. Yet, full-scale implementation and the dissemination towards other stakeholders seems difficult. This study will focus on what the reason is for the stagnation in the S-curve. Hence, this study will focus on crossing the chasm of the mental healthcare innovations (Moore, 1991).
Table 1: Definitions of the concepts
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innovation within an individual or organisation, while diffusion and dissemination focus more on the spread of the innovation (Kostova and Roth, 2002). This research will focus exclusively on the dissemination process instead of the diffusion process. For the reason that the spread of healthcare innovations are mainly planned changes where the targets are clearly defined. The definition of innovation by Greenhalgh et al. (2004) has been adopted since it is widely used in many healthcare related articles (Table 1).
One of the frequently used models is the diffusion of innovation model of Rogers (1995). Out of his theory about diffusion of innovation, Rogers developed a model that shows and categorizes the distribution of new adopters over time. There are five groups categorized according to a normal distribution: the innovators, early adopters, early majority, late majority and laggards. Many practitioners want to increase the speed of adoption by influencing the early adopters as soon as possible (Berwick, 2003). In trying to explain how to increase the speed of adoption, authors mainly focus on three areas: (1) perceptions of the innovation by adopters, (2) characteristics of the people who adopt the innovation, (3) contextual factors like leadership, communication and management (Collins, Hawks, and Davis, 2000; Thakur et al., 2012; Atun, Kyratsis, Jelic, Rados-Malicbegovic and Gurol-Urganci, 2007). The scope of this research entails a management or organisational level focus, therefore only relevant principles related to the organisational or management level will be discussed, hence being perceptions of the innovation and contextual factors.
Perception of the innovation by the adopters predict between 49% and 87% of the variance in the spread (Rogers, 1995; Yi, Jackson, Park and Probst, 2006). In this study we will focus on whole organisations as adopters. The most powerful perception is the perceived benefit of change (Yi et al., 2006). Individuals are more likely to adopt an innovation if they believe it is beneficial for them. The second perception is that the innovation must be compatible with the values and beliefs of the individuals. For example a very controversial treatment will be less likely to be accepted than a less controversial treatment. The third perception is the complexity of the innovation. The more complex the innovation is, the less likely the innovation will be accepted. Lastly, trialability and observability are important factors. Trialability refers to whether the adopter can try the innovation on a small scale instead of fully implementing it. Observability refers to whether the adopter can watch others try the innovation first. For adopters, in this study the relevant stakeholders, these factors can influence their decision to adopt. According to earlier research, a diffusing tertiary healthcare organisation needs to address these abovementioned five issues to ensure a successful dissemination process.
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innovation influences the dissemination of innovations. Johnston and Linton (2000) studied the influence of networks in healthcare organisations. They concluded that networks are significantly associated with implementation of the innovation. Therefore, the innovation has a higher chance of being adopted by a healthcare organisation which has an extensive network compared to a healthcare organisation which lacks an extensive network.
Adoption and change are interlinked. In order to adapt to a new innovation, people and organisations have to change. Van Schaik et al. (2002), and more specifically for healthcare settings: May and Finch (2009), reveal that adopting innovations requires changes in work practices and supporting technologies. Unsurprisingly, resistance to change is often involved when adopting an innovation. That is why many models of the adoption process link back to the change management literature (Fjeldsoe, Marshall and Miller, 2009). Useful implications can be drawn from the management literature related to dissemination and adoption. For instance, an example is the process of adoption as consisting of five stages (Ryan and Gross, 1950). The five stages suggests that besides the perceptions of the innovations and contextual factors, creating awareness and creating resistance are an important part of the dissemination process as well. However, Ryan and Gross see adoption as a black and white view, you either use the innovation or not. Later researchers dove deeper into the implementation process (Cooper and Zmud, 1990). They mention that the implementation process consists of six phases at the organisational level: initiation, adoption, adaptation, acceptance, routinization, infusion. This shows a more thorough framework of adopting innovations, where routinization and infusion are particularly important in the healthcare sector.
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should also not be too complex, unambiguous and not too risk full. Sanson-Fisher (2004) researched how the dissemination of innovation models can be applied in healthcare. In his research, he proposes five clear steps how to successfully disseminate an innovation: (1) researchers should acquire knowledge about the proposed clinician change, (2) the individual clinician is persuaded about the advantages of the innovation, (3) the clinician engages in activities that will lead to a choice about adopting or rejecting the innovation (reading about the innovation, attending demonstrations, workshops), (4) the innovation should be incorporated in daily activities of the clinician and (5) the clinician seeks reinforcement about the innovation. In this study, these steps will be used to analyse the current situation and subsequently be compared to the approach of similar organisations.
Furthermore, a study in the primary care showed a full range of factors that should be taken in account when convincing other parties about your innovation. They argue that there should be clear, scientific evidence; the innovation should be applicable to many patients; the innovation should not be too complex; and higher satisfaction levels as a result of cost savings or benefits from the innovation should be generated (Fitzgerald, Ferlie and Hawkins, 2003). In this study, these four factors will be used to test whether the disseminating firm uses the right approach to disseminate their innovations.
To conclude, multiple factors influence the dissemination of innovations within healthcare. These factors are split under four categories: perception of the adopters, contextual factors, attributes of the innovation and the process of dissemination. The categories and factors are summarized in Appendix 1. Although these factors focus on the diffusing tertiary healthcare organisation and adopter, other stakeholders are involved as well.
Stakeholder theory
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Factor / Role DefinitionPower “A relationship in which between one social actor, A, can get another social actor, B, to do
something that B would not have otherwise done” (Dahl, 1957)
Legitimacy “A generalized perception or assumption that the actions of an entity are desirable, proper or appropriate within some socially constructed system of norms, values or beliefs” (Suchman, 1995)
Urgency “The degree to which stakeholder claims call for immediate attention”
Client “A client is the party whose purposes are being served through the innovation”
Decision maker
“A decision maker sets requirements regarding the innovation and evaluates whether the innovation meets these requirements”
Designer “A designer contributes expertise to the innovation process and is responsible for the (interim) deliverables”
Table 2: Factors and roles to define stakeholders
Mitchell, Agle and Wood (1997) elaborated the stakeholder theory by defining the stakeholder attributes. They argue that stakeholders can possess three attributes: power, legitimacy and urgency (see Table 2). In addition to Freeman’s book, Mitchell et al. (1997) elaborated the stakeholder theory in their qualitative classes of stakeholders. They state that stakeholder salience will be low when stakeholders only possess one stakeholder attribute (power, legitimacy or urgency). These stakeholders are called latent stakeholders. Additionally, stakeholder salience will be medium when stakeholders hold two stakeholder attributes, these are called expectant stakeholders. Finally, stakeholders who possess all stakeholder attributes are called definitive stakeholders which will result into high stakeholder salience.
Focusing specifically on the innovation context, Vos and Achterkamp (2006) take a role perspective when it comes to stakeholder analysis in innovation context. They mention that stakeholders can either be actively involved or passively involved. When a stakeholder is actively involved, they can take the role of a client, decision maker or designer (see Table 2). Being passively involved entails that the stakeholder is affected by the outcomes without influencing the outcomes.
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decide whether to adopt the innovation and and adapt it to their daily processes. In terms of Mitchell et al. (1997), they hold the legitimacy and power attribute, but not the urgency. Secondary healthcare institutions take the role of client. Their purposes are being served when a new treatment is adopted. Healthcare purchasers (e.g. insurers) are also clients, they want to spread the successful innovations, so the costs of healthcare will decrease. Their purposes are being served when many successful innovations are spread. They hold power and legitimacy, as they decide which innovation to fund and which not. Additionally, the ministry of Health, Welfare and Sports has a stake in the dissemination of new therapies, hence they promote innovations in the healthcare business. They hold mostly legitimacy, but also have power to intervene. They can either take up the role as a client or designer. The ministry wants the best healthcare for their citizens. Their goals are being met when the better innovations are rapidly disseminated. Additionally, they can deliver expertise for the development and dissemination of the innovation. The designer role is also applicable on the semi-government institutions, who deliver expertise and / or financing. They receive money from the central government if they execute certain goals of the government. Additionally, there are also semi-government institutions which take up a decision-making role. These institutions support the central government and give advice whether to financing or not finance a new treatments whenever the negotiations between the healthcare institutions and insurers stagnate. Both semi-government organisations hold legitimacy and power.
The system model of the most important stakeholders within a tertiary dissemination process is represented in Figure 1. The tertiary healthcare organisation disseminates its treatments to the secondary healthcare organisation. The purposes of the secondary healthcare organisation and insurers are met whenever a successful innovation is adopted. Government and semi-government organisations take up a designer role or decision-maker role in the dissemination process.
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Integration dissemination and stakeholder theory
To apply the dissemination and stakeholder theory in an integrated way, a combination has been made of ‘what’ to study and ‘how’. For the ‘what’ this study follows a framework for dissemination of health services intervention to analyse the current dissemination process at UMCG and the search for new opportunities (Mendel, Meredith, Schoenbaum, Sherbourne and Wells, 2008). This framework has been amended to fit the situation and scope of this study (see Figure 2). This much-cited framework has been chosen because it bridges the research-practice gap by providing a theoretically-grounded understanding of the nature of healthcare contexts and the mechanisms by which new practices and programs disseminate within these settings. Additionally, it distinguishes key components and facilitates the identification of new strategies for adapting, disseminating and implementing healthcare innovations.
Figure 2: Amended framework of dissemination in healthcare
The framework consists of the context of dissemination and the process of dissemination, where the former influences the latter. The context entails the perception of adopters, contextual factors and attributes of the innovation. The process of dissemination includes five steps that need to be taken in order to spread innovations. These five factors resemble the three stages of Meyer and Goes (1988). These factors have been discussed in the first subsection and are further elaborated in Appendix 1.
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expertise centre) and Zorginstituut Nederland (as financer and decision maker) and the central government (Ministry of HWS) will be analysed.
Figure 3: System model of the research
METHODS
The research question focuses on a tertiary healthcare organisation and it’s dissemination process to secondary healthcare organisations. To generate deeper insights in the relevant stakeholders, this paper reports the results of a qualitative study that was carried out in 2019 at the University Medical Centre in Groningen (UMCG), the Netherlands. The study focuses on one specific section of the UCMG, called the University Centre Psychiatry (UCP). In order to find out how UMCG-UCP can disseminate their innovations to secondary healthcare institutions, this study follows the regulative cycle in order to make recommendations to solve the current issues at the UMCG-UCP (Van Strien, 1986). In this research a diagnosis of the current situation is conducted by making use of the narrative approach (Howard, 1991). The narrative approach focuses on collecting stories of individuals. Hence, the stories of individuals within UMCG-UCP and other relevant stakeholders are collected to provide a rich insight in dissemination of healthcare innovations. Based on this diagnosis, difficulties in the process are elucidated and points for improvement for UMCG-UCP are identified.
Data collection
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a data collection method in comparison to other methods is the ability to capture verbal and non-verbal ques, steering the conversation and getting a deeper understanding of the issue. 19 interview were held with different organisations (see Appendix 2). In Appendix 3, the codes for every interview can be found. Thirteen interviews were held with various people at the UMCG-UCP, including psychologists, psychiatrists, nurses and managers. These interviews provided more insight in how the current dissemination process of UMCG-UCP looks like. Three interviews were held at a secondary healthcare institutions. These secondary healthcare institutions were all close partners from UMCG-UCP in the northern region of the Netherlands. The purpose of these interviews was to find out how they see the dissemination process and how they interact with UMCG-UCP and other relevant parties. Two interviews were held with semi-government organisations (Zorginstituut Nederland and ZonMw). They specify the role of the government in the financing of studies and treatments. Lastly, one interview has been conducted at a network institution which UMCG-UCP is part of. This gave a deeper insight in the functioning of a network in the north of the Netherlands.
The interview protocol includes open-ended questions that allowed interviewees to pick up spontaneously on those factors that were perceived as most important for their innovations and then they were prompted to discuss the issues in more depth (Barnett, Vasileiou, Djemil, Brooks and Young, 2011). The interview protocol can be found in Appendix 4. Interviewees at the UMCG were approached in person and by email. During the design of this research, I was in contact with people from the UMCG-UCP department. Via these contacts other interviewees at the UMCG-UMCG-UCP were approached. Additionally, the website of various organisations and LinkedIn was used to contact potential interviewees. In total 46 people have been approached by the researcher, 19 people were willing to participate in the study. The reason that potential interviewees declined was because they didn’t respond to the email of message (16), thought they were not the right person (5), had no time to do the interview (3), needed to discuss with supervisor / communication department and didn’t follow up on it (3). The interviews were 43:58 minutes on average with a word density of 5357 words. With permission of the interviewees, I recorded the interviews, which allowed further examination of the conversations and information missed when taking notes. None of the interviewees declined the request to record the interviews. None of the interviewees were previously known by the researcher and confidentiality was guaranteed. Besides semi-structured interviews, archival data were collected. UMCG-UCP recently drafted a dissemination plan. These records were collected and analysed. Additionally, UMCG-UCP drafted a plan to create a new national network.
Data analysis
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using open codes. The open codes label the phenomena that emerged from the data. Secondly, axial coding was used to put the data back together to make connections between categories. Whereas open coding fractures the data into categories, axial coding puts the data back together by making connections between the categories and subcategories. Axial coding focuses on the conditions that give rise to a category, the context in which it is embedded, the action/interactional strategies by which the processes are carried out, and the consequences of the strategies (Kendall, 1999). Finally, selective coding integrated the categories that have formed an emergent framework (Strauss and Corbin, 1990). The interviews were coded one by one on multiple consecutive days. The codes that were used in one interview were noted on paper and then used for the next interview, so redundant codes were minimalised. In total, 255 inductive open codes were used with 557 quotations (see Appendix 5). The 255 inductive codes were merged in 53 second-order codes and these second-order codes were merged into 13 categories. The 13 categories were arranged into 4 selective themes. The codebook of the second-order codes can be found in Appendix 6.
I noticed, when reading the interview transcripts and coding the interviews, that the healthcare is very fragmented. I used the same fragmented approach to make a process model of the development and dissemination phases. I gave a specific colour to every interview and every code. The different colours made it possible to make a visual display of a timeline about which part of the dissemination process the interviewee talked about. This timeline formed the basis of the process model that was made in the result section. For the initial process model, the most dominant voices were used1. The model was refined and upgraded multiple times using the inferior voices to make it as rich as possible. During the refinement, not only the codes were used, but also the original interview transcripts. There were little to none contradictions between the interviewees. The interviewees complemented each other or strengthened the story of the other interviewees. The voices of the interviewees can be seen in the quotes in the result section and Appendix 6.
The result of this research is, as above mentioned, a process model of the development and dissemination process of UMCG-UCP. Multiple bottlenecks in this process model are mentioned and extensively described. Additionally, points for improvement on how UMCG-UCP can improve its development and dissemination process are given. The development and dissemination process model of UMCG-UCP could be transferred to and used for other tertiary medical hospitals.
1 Dominant voices refers to (1) the frequency that something was said and (2) the relative weight of that
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RESULTSMultiple pathways of disseminating innovations in healthcare institutions were described by the interviewees. Two process models were created based on the interviews. First of all, the development phase will be described by the interviewees with the experienced bottlenecks in Figure 4. Thereafter, the dissemination phase will be described by the interviewees with the accompanied bottlenecks in Figure 5. Subsequently, one successful dissemination subcase at UMCG-UCP is examined, which shows the integration between Figure 4 and Figure 5. Finally, an unsuccessful dissemination subcase at UMCG-UCP is examined, which shows the relative importance of the bottlenecks.
Development phase
Figure 4: Development phase at UCMG-UCP
When asked, every interviewee mentioned that the development phase starts with an evidence-based new treatment seemingly derived from the literature (see Figure 4). An example of an evidence-based treatment that UMCG-UCP adopted in 2017 was ketamine treatment for depression (Haarman et al., 2018). Multiple interviewees mention that the adoption of a new treatment and the decision of the clinician to execute a pilot study is largely an organic process. The clinician needs to be interested in the treatment otherwise the idea and motivation dies within the healthcare organisation. Additionally, the continuity in people is important for continuity of the study and regular offering of treatments:
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had no interest in biological rhythms. Within no-time the lecturers were also gone. You could say that it [the research on biological rhythms] was almost dismantled. In that time, we shifted our focus towards animal biology.” – TERCLIN8
“When the nurse who gave the training was transferred to a different department, the training stopped being given. An other thing we talked about was monitoring potential patients. On a certain moment that collapsed because people where not motivated or found it too much trouble to do so.” – NETCLIN1
Continued motivation and continuity in people are the first two bottlenecks in the process of developing and disseminating healthcare innovations (B1 & B22). The process of developing a treatment stops once motivation drops or crucial people leave the organisation. Moving on to the third bottleneck, multiple processes are described by the interviewees that are necessary for a pilot study to happen. Many interviewees mention the role of the management in the development phase. The management of an institution needs to be informed about the studies and they need to approve the study, as follows from the quotes:
“I can imagine that the board says “this doesn’t fit our scope or plans”, and that you need more conversations [with the management] to get it going.” – TERMAN1
“So you first try with your own department, mood and anxiety, with the clinical manager. Mostly the clinical managers are positive about new plans. Then the clinical managers bring it a step further, to the board. They [the board] are going to look at the price tags and decide if they can get it done with their limited amount of resources. If that doesn’t work, they [the board] can try to get some money from central [UMCG].” – TERCLIN8
“They have a big influence on major things. They broadly determine what is going to happen and where UCP is going.” – TERCLIN13
The interviewees show that management support is needed before a pilot study can start. Once the pilot study or new treatment doesn’t fit the scope of the organisation, it will not be routinized within the organisation. Hence, it will be the third bottleneck (B3). In addition to management support, the interviewees mention a combination of a few facilities that are necessary to execute the pilot, the so
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called supporting facilities (B4). This includes (a) time for research, (b) possible participants, (c) available rooms for the study (d) supporting staff, (e) use of test subjects or patients. Lastly, almost any interviewee, solicited or unsolicited, talked about the financing of the treatment or study. They mention the clear need for external financing to fund the treatment:
“I work here [at UCP] with temporary employment contract. I apply for a subsidy or join an application of someone else. Sometimes I apply for a subsidy to supervise an other researcher. Such subsidy can be provided by ZonMw. This tool we are developing right now is from a subsidy of Zorginstituut Nederland….. You also got MWO. That is affiliated with ZonMw. And here in the north you got Stichting tot Steun, an old-school subsidy provider. Stichting De Friesland also provides funds for research. If the insurer [De Friesland] made a profit, they put this money in the foundation that funds innovations and research projects.” –SECRES1
Obtaining funds plays a key issue in conducting the research (B5). Mostly, the research is financed via subsidies. The interviewees mention that interorganisational networks can play a positive role in requesting the subsidy. For instance, subsidies can be requested together with many organisations and being part of an interorganisational network gives you a higher chance of receiving a subsidy. Additionally, many tertiary institutions also offer clinicians to spend 10-20% of their time on research. When this is not the case, researchers need to find a subsidy that supports their research. The interviewees mention that in order to get the subsidy, an extended proposal needs to be submitted where the purpose and explanation of the research is given. Additionally, they mention that many organisations apply for the same subsidy. This competition decreases the chances that you get the subsidy.
“I work full time as a researcher. But about one third of my time is spend on requesting subsidies….. My experience from my own projects is if you want to do it good, it costs a lot of time. Because the reader should be convinced that this research is needed in this specific field. At one subsidy provider you need to hand in a 12.000 word document with your plans…… But it is part of the job. So you are busy quite a lot of time, while the chances are sometimes less than 10% that you get it.” – SECRES1
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Therefore, finance remains an important issue when the study is in progress. When management support, support facilities and the financing of the study are available, the researcher or clinician can start the pilot. The pilot outcomes are an event which is largely independent of the efforts of the clinician. Once the pilot has been completed, it marks the end of the development phase and start of the dissemination phase.
Dissemination phase
Figure 5: Dissemination phase at UMCG-UCP
The dissemination phase starts when the researcher or clinician publicizes the pilot results. A few interviewees mention the need to archive and communicate information within the organisation. Otherwise, duplication of studies and inefficiency occurs:
“In the whole healthcare sector it is not strange if two different departments within the organisation, or even three or four [departments], are working on the same innovation without each other’s knowledge.” – SECMAN2
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– SECMAN2
“We are really good in trying things out, that is UMCG wide. But not good in archiving information. Mostly something else pops up….. You are being caught up by the issues of the day. I wonder if we have fully finished and closed up a project. I think mostly the answer is ‘No’ and I am part of that. I think it is really good to look at what we have actually done. How do we look back at the process? Not only content wise, but also the evaluation of the process. That is really important. And we don’t do that, me neither. But we should do it.” – TERMAN1
The managers show that in a fast evolving healthcare sector, the archiving of information proposes a bottleneck in the development and dissemination of new treatments (B7). The information needs to be stored and spread in the organisations, hence that everyone is aware of the studies that have been conducted and duplication is minimalised. Additionally, the study needs to be evaluated, before the decision can be made if they want to disseminate the innovation. The quick shift in focus from one study to another results in not giving the full attention that the study outcomes need.
Furthermore, it is related to the first bottleneck: the continuance of motivation. When the study is completed the clinician decides if they want to implement further and disseminate the innovation. Multiple clinicians mention that they drop the innovation when the results are slightly significant, but not extremely significant (B8):
“Another bottleneck is that, in general, implementing is the most difficult. So, letting professionals show different behaviours is way more difficult than changing the patterns of behaviours of patients. It means that you need to use all different kinds of networks, inspire people, have conversations at the right places, have the guidelines committee on your side. You need to ‘grab’ the professionals.” – TERMAN6
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Most interviewees mention that the choice whether to disseminate or not disseminate an innovation is up to the clinician. They mention that dissemination happens both internally as well as externally: without a full internal adoption, external dissemination is unlikely. Internal adoption is necessary to collect more data, write protocols and get more experience with the new treatment, to convince other healthcare institutions of the new innovation. Internal implementation without external dissemination is possible. For instance, when a study is finished, insurers can still finance the treatment for patients specifically at that healthcare organisation.
The internal adoption faces multiple bottlenecks. Still, the interviewees mention that the same bottlenecks that happen in the development phase, being management support, supporting facilities and financing also reappear in the internal implementation phase (B9, B10 and B11). For a further discussion about internal implementation issues, see Venema (2019). This paper focusses on external dissemination and the accompanied bottlenecks.
The interviewees mention that the dissemination towards external organisations happen through multiple channels. The most used channel is conference presentations. Many conferences are organised via interorganisational networks. Every clinician is part of many interorganisational networks. These networks are partly related to their discipline, but there are also multidisciplinary networks. Multiple clinicians mention that the network plays a role at multiple stages of the development and dissemination of new treatments. Networks play a role in doing research together, sharing patients for the research, requesting subsidies and sharing problems and study results.
“Here in the north [of the Netherlands] we have the Noord-Nederlands netwerk voor stemming en angststoornissen. That is a partnership between all the northern institutions. Also we have yearly a conference where we all come together. But also a meeting with the coordinators of the different institutions.” – TERCLIN12
In total there are many interorganisational networks in which psychiatrist, psychologist, nurses, insurers and management are all connected. In general, the interviewees don’t mention an explicit strategy for spreading information through networks or on individual basis.
“If I want to disseminate the innovation in the region well, if the region asks for it, we are glad to have some conversations. I think we do a lot, but it is not systematic.” – TERMAN5
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Managers at multiple levels mention that an explicit dissemination strategy is missing in the mental healthcare institutions. They mention that their approach is really organic. However, none of the managers reflects on whether their approach is really organic or more a messy approach for disseminating healthcare innovations. Without an explicit strategy, the clinicians don’t exactly know how to effectively disseminate their treatments, formulating the twelfth bottleneck (B12). Even though the network effects seem positive in many aspects, downsides are also mentioned:
“I think the amount of information is a bottleneck. Kind of less is more. Keep it concise and see how with relevant key words you can reach someone. Or make sure someone reads further. I also think that the context or range in which you spread information is determining on how you bring it up.” – TERCLIN13
“We have the first meeting and then another meeting, then you are mostly from one o’clock busy with meetings. Then you are actually saturated.” – TERCLIN9
The clinician in the first quote proposes a clear improvement for UCP and the whole healthcare sector. The clinicians get too much information and can’t separate the relevant information from the irrelevant information. This becomes an issue when the clinicians in different organisations are not well informed about the potential therapies they can adopt in their organisation (B13).
Besides the information distribution, obtaining financing is also a key issue during the dissemination phase of mental healthcare innovations. A few clinicians and a manager at Zorginstituut Nederland describe the dissemination pathway. They mention that once the pilot study has been conducted, the healthcare institution negotiates with the insurers whether to fully fund the new treatment as a regular treatment. When the insurers and institution cannot come to agreement, e.g. the insurer does not want to finance the treatment of the institution, Zorginstituut Nederland mediates between the organisations. Zorginstituut Nederland gives a (binding) advice to the ministry of HWS to finance the treatment or not. When the treatment is financed, the dissemination process will rapidly expand. However, once the treatment is not financed, dissemination is much harder to accomplish (B14).
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“We have found a few insurers who wanted to finance it [rTMS]. But that was only for the patients here [within UMCG-UCP]. To look if it…. Well… start and see how it goes. But when it became apparent that on national level there was insufficient support for rTMS, the insurers also stopped financing it for our patients [within UMCG-UCP].” – TERMAN4
A senior clinician and a manager say that financing is a key issue to make sure other institutions adopt a new treatment as well. When the funding of a treatment stops, the organisation or patient need to pay it for themselves. However, for patients in mental healthcare, this is a huge burden.
“If the insurer doesn’t pay, the patients need to pay it [the treatment] for themselves. People with long-term depression have a low earning capacity. So 300 euro’s for the ketamine is a large amount for them.” – TERMAN6
Not only the patients cannot pay for the treatment, also the organisations cannot finance the offering of the treatment on the longer term:
“I got the impression that at least in our region many institutions are sitting on separate islands. Also because of the fear and competition and there is, well not really at our place, but a lot of institutions have had budget cuts. They have trouble with closing their budgets, they got it done by firing people. The other employees were less satisfied. So there is not always space to work together.” – TERMAN7
When asked, almost any clinician responded that the financial pressure in the healthcare is a serious issue. Not only when it comes to dissemination, but also working together on a daily basis (e.g. daily work, doing research, consulting with clients and co-workers). Because of the high workload, the focus of the employees is more at keeping their institutions running than working on new projects. The eventual decision to adopt the new treatment is made by the clinician of the other organisation.
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A successful dissemination trajectoryFigure 6: The development and dissemination phase of light therapy
UMCG-UCP have one very successful dissemination: light therapy for winter depression patients. Since it was developed in the 1970’s and 1980’s not many of the leading clinicians still work at UMCG-UCP. Yet, one of the leading clinicians, TERCLIN8, extensively discussed the light therapy subcase. Every other clinician referred to this person as ‘the’ professional when they were asked about light therapy. Hence, the larger amount of the quotes belong to this person.
In 1970’s research has been conducted into biological rhythms. By accident, in the United States during the 1980’s light therapy showed successful in treating gloom at patients in the winter. A Dutch professor at the UMCG-UCP took this idea and brought it into his organisation (see Figure 6). The clinician mentions little about the lack of motivation, crucial staff changes or the lack of management support (B1, B2, B3). Therefore, I tentatively conclude that this bottleneck did not occur at the time. The financial support is described by the clinician as follows:
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The clinician mentions that in the development phase they got a subsidy for the study (B5). With this study, they got the opportunity to provide information that helped in the negotiations with the insurance companies to finance the treatment on a regular basis (B14). A bottleneck that the clinician mentioned were the issues with the supporting facilities, especially with the finding test-subjects (B4).
“Especially in the beginning, we looked if the therapy worked. There was a lot of scepticism. We wanted participants that want to participate in this study. We send a mail to all the general practitioners in the four northern provinces. But we got 0,0 response.” – TERCLIN8
Because of the scepticism, participants were hard to find. The clinician mentions that they found a way to solve this bottleneck by contacting the local radio station.
“Thanks to Radio Noord, we could have a talk on the radio station about the therapy to find participants. The participants who cooperated, luckily responded good on the therapy. And success spreads itself. Primarily a magazine like Libelle works well. The subscriber reads it, then the magazine is handed over to its mother, its daughter, is displayed at the hairdresser, dentist and so on. So you profit a lot from it.” – TERCLIN8
The clinician mentions that the national publicity already started during the development phase. When they were working on the study, IKEA was already making an advertisement about the new treatment. The public was more receptive than the regular medicine sector. The clinician mentions that success spreads itself by word-of-mouth and via the media. Later on, the scepticism disappeared and the therapy “attracts people”.
“It appeals to people. A lot of people feel down in the winter than in the summer. Of course you have gradations, some people don’t have any problems at all. Others need more sleep and are slower, this is called winter blues. Men talk about mood disorders if men becomes really depressive. That is with around 3% of the Dutch population.” – TERCLIN8
The clinician mentions that the effectiveness of light therapy also played a role in the development and dissemination process:
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The advantage of light therapy is that it works quite quickly. Well, at least it does for depression. It is relatively harm free and has little side effects. The downside is that it takes time. An antidepressant is one swallow and gone. For light therapy you need to be sitting in front of a lamp for 45 minutes. But at least you are relieved from you complaints. This is not always the case with medication.” – TERCLIN8
The clinician comments that the high success rate results in a clear incentive to pursue the light therapy as a regular treatment within UCP (B8). Additionally, the clinician mentions that the success from light therapy also led to a successful implementation internally.
“From 1987 this department is working on light therapy here [at UCP]. Initially very small research. This became somewhat larger, as every successful treatment. Success always creates a craving for more success. So we established an outpatient clinic, where we treated a few hundred people a year with light therapy.” – TERCLIN8
The quote shows that the internal implementation grew as it became more clear that it was a very successful treatment. The dissemination process towards external parties goes hand in hand with the development process of light therapy. As mentioned before, the finance issue is settled, because it made its way into the basic package insurance. Additionally, the national publicity helped to create awareness at secondary healthcare institutions. The result of the national publicity is noticeable by the attention the clinician got from the public and other institutions.
“You got invited to give a presentation [about light therapy]. There was a time that I was giving presentations at other institutions in the whole country. But also at peoples’ home, at the countryside. There were all kinds of people who were interested [in light therapy]. You give the talks, because then you get more test subjects. It was a win-win situation.” – TERCLIN8
The clinician gave presentations to whomever was interested in light therapy. He mentions that the interorganisational network helped in spreading the information to other clinicians. They shared treatment protocols, plans and know-how. In the end, the clinician mentions the following about the success of the development and dissemination of light therapy.
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“There are multiple centres that work on research with light therapy. For example in Amsterdam, research is being conducted on light therapy with Parkinson patients. In Rotterdam research is being conducted for upcoming mothers who are depressive.” – TERCLIN8
The clinician mentions that the success in light therapy is seen in the amount of institutions that offer the treatment and the research that is still being conducted in this field. Till this day, light therapy is a relevant and successful treatment against depression.
In sum, light therapy does not follow the exact process as in Figures 4 and 5. Instead, it simultaneously goes through the development and dissemination phase. The unsuccessful dissemination subcase provides deeper insight in which bottlenecks are pivotal in the development and dissemination process.
An unsuccessful dissemination trajectory
Unlike the success stories, several interviewees mention that unsuccessful stories are less remembered. Only a few clinicians and managers could name where the development and dissemination of new treatments failed.
In the case of the psilocybin, this clinician mentions that he was excluded from the psilocybin study because of the lack of facilitating conditions and lack of time (B4).
“We have the psilocybin study, which could be a new treatment. Nurses were asked to be part of this study. We [the nurses] were quite busy with the study. The management eventually pulled the plug for us, because the study put too much pressure on occupation of the nurses. We [the nurses] were eventually not needed in the study and it was not implemented at the department…. It was quite an ad hoc decision, but they [the management] had their reasons to do it.“ – TERCLIN9
Because the nurses were too busy with their daily work, they were not included in the study. The lack of time of the nurses resulted in the study being executed on a far smaller scale. A different study that was mentioned multiple times is the rTMS. The financing of this study seemed an issue.
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“We have found a few insurers who wanted to finance it [rTMS]. But that was only for the patients here [within UMCG-UCP]. To look if it…. Well… start and see how it goes. But when it became apparent that on national level there was insufficient support for rTMS, the insurers also stopped financing it for our patients [within UMCG-UCP].” – TERMAN4
As described by the manager, the study was initially financed. rTMS made it through the development phase and even got money to be internally implemented (B10). However, the lack of national support for rTMS resulted in the ceased finance for this treatment. The exact reason of the lack of national support was not mentioned by the interviewees. Because secondary institutions receive no money, interest in rTMS quickly declined. Additionally, the money issue also returned in different studies at different organisations, for example a lifestyle study and a study with psychosis.
“At GGZ Friesland, we conducted a few studies in lifestyle. The results show that it was effective, and I wanted to pursue the study. But there was no money. The study was based on lifestyle coaches that stimulated patients to change their lifestyle. That was more effective than if they [the staff] do it themselves. But yeah, there was no money for the coaches.” – SECRES1 “We have an early detection study for psychosis. The goal is to prevent that the patient develops a big psychosis…. But this is not financed by the insurer, because there is no diagnosis involved. We only get money for patients who have a diagnosis. Not for prevention, that is the municipality issue.” – NETCLIN1
Most clinicians and managers point the financing of the study or finance for the treatment on regular basis as prominent bottleneck in the development and dissemination process. Additionally, multiple clinicians found it hard to really influence the clinicians in other institutions. They mention that time constraint at the secondary healthcare institution is the main factor that makes is hard to disseminate.
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“But what you notice is a lack of time and high work pressure, so that’s why people are busy in their own small world. Everything that adds to their work, like a new treatment, costs time. Even if they win time in the long term. In the short term it is… difficult. So yes, that is why there is too little exchange of information, openness and interest in each other’s ideas.” – TERCLIN10
The clinicians show that time is a crucial aspect in getting a foothold at the other institutions. This was also noticed by the researcher during the study. Many interviewees had limited time to do an interview, sometimes the interview was aborted due to time issues. This was especially the case when it involved a clinician and was less an issue with the managers. As one clinician says, first their daily work needs to be done, before they have time to innovate.
Integration of the process model and subcases
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DISCUSSIONThe central question of this research is “How can UMCG-UCP successfully disseminate their new
treatments to secondary healthcare institutions?”. In order to answer this question, a literature review
has been conducted of the dissemination and stakeholder theory in healthcare. Thereafter, interviews have been conducted at secondary and tertiary healthcare institutions, government institutions and a network institution. The results are discussed below, following the structure of the selective themes out of Appendix 5. First, the development and dissemination process of new treatments is discussed. Thereafter, the successful and failed disseminations and then the bottlenecks are discussed and compared with the literature. Afterwards, the implications for UMCG-UCP, the limitations of this research and avenues for further research are addressed.
Development and dissemination process in mental healthcare
The development process starts with an evidence-based treatment that is brought under the attention of a clinician (Figure 4). This clinician starts a pilot study of the treatment within his organisation. Before the pilot study can start, the clinician needs management support, supporting facilities (patients, time, available treatment rooms) and funds to execute the pilot. Various stakeholders can fund the pilot study. When these three conditions are met, the clinician decides to pursue and execute the pilot study. The pilot study outcomes marks the end of the development phase.
The process of dissemination starts when the pilot study is finished and the clinician starts publishing the results (Figure 5). Afterwards, the results need to be archived and communicated within the organisation. In the meantime, the clinician implements the new treatment internally and disseminates the new treatment externally. These decisions whether to implement and disseminate are based on the effectiveness of the new treatment; the effort from the clinician to change the behaviour management, staff and other clinicians; the ability to change routines and protocols; and available time to adopt a new treatment. The internal adoption is dependent on the management support, supporting facilities and the finance of the treatment. The external dissemination can happen via conference presentations, individual contact or national interest in the new treatment. These dissemination channels help to create interest of the clinicians at the secondary healthcare institution. Once the insurers finance the treatment, the secondary healthcare institutions can adopt the new treatment. When many institutions adopt the treatment, the dissemination of the treatment is successful.
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treatments and think of ways to test it in their healthcare organisation. The management of a healthcare organisation resembles the early and late majority. They have to weigh the potential of a new treatment against the available resources. When they realize the treatment has the needed potential to start a pilot study, they give the approval and help the study further. Lastly, laggards also exist in the healthcare. Scepticism of a new treatment is a common issue, even when a treatment is adopted.
Additionally, in alignment with the literature, government regulations and safety compliance influence the development of innovations (Atun et al., 2007). They provide the framework in which developments can take place. For example, a new treatment with a new medicine can’t be developed if the medicine does not fulfil the safety standards set by the central government. However, it does not influence the dissemination of innovations. When an innovation has been developed, it already fulfils the government and safety regulations. Therefore, it is not a key issue in the dissemination phase. Additionally, as Johnston and Linton (2000) showed in their research about networks, networks can be beneficial in the dissemination process. This is reflected in the process model where the allocation of a subsidy to a healthcare institution is more likely when the healthcare organisation is part of particular networks. Likewise, the networks can function as a basis where new information can be spread. Furthermore, they can help to get the national financing for the new treatment.
However, in the dissemination of innovations literature, perceived benefit of change is the most powerful perception (Rogers, 1995; Yi, Jackson, Park and Probst, 2006). This perception determines whether individuals or organisations adopt a new innovation. Yet, in the mental healthcare, the decision whether adopt or not adopt a new treatment is largely based on scientific evidence. Following strict rules, the scientific evidence largely determines the perceived benefit of change. Hence, the perceived benefit of change is still important, however, can’t be influenced by the clinicians.
Successful and unsuccessful disseminations
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innovation literature with the attributes of the innovation (Appendix 1). Light therapy was well-defined, clear evidence, limited side effects and were applicable to many patients.
A clear pathway for failed disseminations has not been found. Yet, many disseminations fail when either there is no finance in the development phase or in the dissemination phase. Without a subsidy, the clinician can’t pursue the pilot study. Without structural financing of a new treatment in the dissemination phase, the clinicians at secondary healthcare institutions are not interested to adopt the treatment. Another factor that plays a role in failed disseminations is the lack of time. In order for secondary institutions to adopt a new treatment, they need to have the time to invest in the new treatments and convince their own management. But due to the high work pressure, many clinicians don’t have the time to adopt a new treatment. Even if it would result in more time in the future. The lack of time could be categorised as passive resistance (Ryan and Gross, 1950). Hence, the clinicians do not make time available do adopt new innovations. Furthermore, the healthcare environment is not supportive in the spread of new healthcare innovations (Meyer and Goes, 1988). Clinicians, managers and the central government need to make changes in the healthcare environment so healthcare innovations can be easier spread and adopted.
Bottlenecks in the mental healthcare development and dissemination phase
In total, 14 bottlenecks have been identified in the development and dissemination phase. Six of these bottlenecks are in the development phase and eight in the dissemination phase. These bottlenecks are inductively identified and then compared to the healthcare innovation literature. The bottlenecks with a short description and the related literature are presented in Table 3.
Bottle-neck
Short explanation Resembling in innovation literature
1 Continuity in motivation of the study 2 Continuity in people during the study
3 Management supporting the study Leadership and styles of the managers (Rogers, 1995; Meyer and Goes, 1988)
4 Supporting facilities for the study Support in changing work practices and technology (Van Schaik et al., 2002)
5 Obtaining finance for study 6 Time constraint subsidy request
7 Archiving and communicating information of study
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8 Not extremely significant results, too much effortchanging routines
Clear and unambiguous evidence (Fitzgerald et al., 2003); Limited risks (Denis et al., 2002); Support in changing work practices and technology (Van Schaik et al., 2002)
9 Management support internal adoption of new treatment
Leadership and styles of the managers (Rogers, 1995; Meyer and Goes, 1988)
10 Finance the new treatment within own healthcare organisation
11 Supporting facilities for new treatment Support in changing work practices and technology (Van Schaik et al., 2002)
12 Lack of an explicit dissemination strategy Process of dissemination (Sanson-Fisher, 2004) 13 Information overload of clinician Healthcare environment (Atun et al., 2007) 14 Obtaining finance for new treatment for all
healthcare organisations
Table 3: Experienced bottlenecks in the development and dissemination process.
Some bottlenecks are previously described in the healthcare innovation literature. As mentioned before, management support is needed for a successful study and adoption. Rogers (1995) and Meyer and Goes (1988) support this assumption as shown in their research that leadership and styles of the managers influence the mental healthcare innovation. Furthermore, Van Schaik et al. (2002) argue that support in changing work practices and technology is necessary in mental healthcare innovations. This corresponds to the supporting facilities for the study and adoption, archiving and communicating of study results and changing work routines. Likewise, the changing work practices is also reflected in the eighth bottleneck: too much effort to change organisational routines or not extremely significant results. Fitzgerald et al. (2003) also state that clear evidence is necessary, as well as Denis et al. (2002) state that high risks disturbs the dissemination process. Additionally, the lack of an explicit dissemination strategy (B12) corresponds to the process of dissemination, as described by Sanson-Fisher (2004). Since the process of dissemination is missing, many interviewees experienced this as a bottleneck. In the book of Schrijvers (2014: p.235), the lack of good examples of dissemination is described as an issue that the mental healthcare organisations have been struggling with for several years. Over 750 innovations have been counted in the mental healthcare that were developed without any good examples (Schrijvers, 2014: p.235).
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studies and financing of new treatments are serious bottlenecks in the dissemination process. However, little is said about the necessary financing in the innovations literature. The occurrence of financial pressure is not only perceived by the clinicians, it is also seen in the higher costs of the mental healthcare. In 1998, the costs of mental healthcare in the Netherlands were 2,3 billion euros. In 2011, the costs of mental healthcare in the Netherlands were 5,2 billion euros (Schrijvers, 2014: p. 231). Additionally, the time constraint for applying for a subsidy is barely mentioned in the (international) literature. An explanation for this is that it could be just a problem in The Netherlands, which the international literature is not tackling. The continuity of people and motivation during the study are the last issues that were not displayed in the literature. The continuity of people and motivation are necessary to make sure studies proceed and are finished. In the healthcare management literature, little to none studies have been conducted about the continuity of people and motivation.
In sum, the healthcare management literature is well reflected in the development and dissemination process, as well as in the bottlenecks. Yet, there are still gaps in the literature that need to be further explored. The major gap is the lack of research being conducted in the influence of finance on the dissemination process. This study proved the relevance of the finance in the dissemination process.
Implications for UMCG-UCP
In order to answer the research questions, seven improvements for UMCG-UCP have been identified. These opportunities are mentioned by the interviewees, described in the literature or seen by the researcher as potential improvements. The improvements are further elaborated using the five W’s model (‘Where’ has been replaced by ‘How’, considering it is more relevant in this case):
What & Who When Why How
1: Avoid the bottlenecks Who: Clinicians & managers During the development and dissemination phase.
The bottlenecks result in failed dissemination. Avoiding of or dealing with the bottleneck results in a higher success rate of the dissemination of a new treatment.
Archive and communicate all the bottlenecks within the organisation. Make sure they are clearly understood. Discuss the bottlenecks with the employees who are involved during meetings (GWO / team meeting). Read the available literature on the bottlenecks (Table 3). 2: Find the right people During the development and dissemination phase.
Without the right people, the organisation cannot pursue the vision and goals. When people
