The implementation of evidence based innovative treatments at UMCG-UCP: A problem-solving study
Master Thesis, MSc Change Management,
Faculty of Economics and Business, University of Groningen
September 13, 2019
Bernou Venema Student number: s2693712 j.a.b.venema@student.rug.nl
Soephuisstraatje 7b 9712BZ, Groningen
Thesis supervisor Dr. M.A.G. van Offenbeek
Second Assessor Dr. I. Maris-de Bresser
Word Count: 14.097 (excluding figures, tables and appendices)
Abstract
Since more people are affected by mental healthcare problems, it is important to successfully implement evidence based innovative treatments. The department of mood and anxiety disorders of a mental healthcare institution (UCP-UMCG) recognizes this important topic. As a result, this academic problem-solving study with an action oriented approach was set up to help UMCG-UCP increase their performance regarding the implementation of evidence based innovative treatments. By means of two research cycles, a combined framework using Cooper and Zmud (1990) and Pettigrew (1987) was developed to detect the implementation problems and provide recommendations and/or solutions that fit the organizational context. For each stage recommendations and/or solutions are proposed for the department of mood and anxiety disorders at UMCG.
Keywords: implementation, evidence based innovative treatments, change, academic problem-solving
Table of content
1. Introduction 5
2. Theoretical background 8
2.1 Evidence-‐‑based innovations 8
2.2 The model of Cooper and Zmud and the implementation process 9
2.3 Content, context and process 11
3. Methods 14
3.1 Action-‐‑oriented research design 14
3.2 Research cycle one: Orienting phase 16
3.2.1 Analysis 16
3.2.2 Diagnosis 16
3.2.3 Evaluation 16
3.3 Research cycle two: Assessing implementation factors 16
3.3.1 Analysis 17
3.3.2 Diagnosis 17
3.3.3 Evaluation 18
4. Results 19
4.1 Research results: cycle one 19
4.1.1 Defining the implementation 19
4.1.2 Implementation phase 20
4.3 Research results: Cycle two 20
4.3.1 Initiation of content, context and process 23 4.3.2 Adoption content, context and process 25 4.3.3 Adaptation content, context and process 29 4.3.4 Acceptance content, context and process 31 4.3.5 Routinization content, context and process 32
5. Discussion 35
5.1 Answer to the research question 35
5.2 Practical recommendations 38
5.3 Practical recommendations for each stage 39
5.4 Future research and limitations 48
6. Conclusion 49
Acknowledgements 49
References 50 Appendix A: Interviewees Codes, Additional Documents and Distribution 55
Appendix B: Interview Protocol 57
Appendix C: Interview Protocol nurses 65
Appendix D: Codebook Overview 70
Appendix E: Attributes Greenhalgh additional document 73 Appendix F: Driving and constraining forces per stage Cooper and Zmud 76
1. Introduction
The attention on mental health disorders has risen as a result of increasing concerns about the number of people affected by mental and neurological disorders (World Health Organization, 2018). Approximately 450 million people suffer from mental health disorders, making them a global issue. Moreover, around 300 million people of all ages are affected by depression.
With these numbers in mind, it is important for hospitals to keep innovating and to develop new treatments, not only for mental healthcare but also for regular healthcare. Healthcare can be defined as complex, turbulent, fragmented, and it has the characteristic of difficult to evaluate (Meroño-Cerdan & López-Nicolas, 2013). In light of such a complex environment, success is dependent on the innovativeness of a healthcare organization in creating a
competitive advantage, which in turn balances the costs and increases quality (Lansisalmi et al., 2006).
Additionally, nearly all the countries of the world are facing problems concerning increasingly unaffordable healthcare costs caused by the increasing population as well as by related aging problems (Negash et al., 2018). Healthcare institutions face economic and political pressure to perform better and faster, combined with a reduction in financial and personal resources (Meroño-Cerdan & López-Nicolas, 2013). Furthermore, as globalization accelerates, the competition in healthcare increases; thus, innovation has become an important way to achieve a competitive advantage (Lin & Su, 2017). Therefore, it is becoming
increasingly important to implement and adopt innovation and to translate that knowledge in order to efficiently adapt and sustain innovative breakthroughs across the health sector.
The Dutch health care system has a number of Academic Health Science Centres (AHSCs). These centres strive to minimize gaps in knowledge translation by focusing on the tri-sector collaboration between the academic, industrial and healthcare sectors (Ii et al., 2018). In this regard, AHSCs link academic institutions, such as universities, to healthcare providers to stimulate research, teaching and education. Such collaborations in turn stimulate the adoption of innovations. In the context of such collaborations, AHSCs translate research innovations into product development and subsequently disseminate and implement these innovations into clinical practice (Ii et al., 2018).
In addition to the challenge AHSCs face in implementing evidence-based therapies, mental healthcare institutions also have problems in implementing evidence-based innovative treatments. This study was conducted in a mental healthcare institution (UCP), which is linked to the Academic Health Science Centre in Groningen (UMCG). In view of the
importance of innovations in the healthcare sector and in light of the current issues institutions
are facing, there is also a need for UMCG-UCP to continue innovating. Currently, UMCG- UCP is doing well at developing innovative treatments. For example, the UMCG-UCP is one of the first in the Netherlands to study the rediscovered ketamine treatment, at its department of mood and anxiety disorders (Vrieze, 2018). That department in particular strives for an effective implementation; thus, an implementation strategy has been established for the implementation of innovative treatments. However, the current situation also reveals the need for better performance. In fact, the acknowledgement of the need for better performance by the head of the department of mood and anxiety disorders led to this problem-solving study.
UMCG-UCP is not the only organization facing these problems. For example, Lin et al. (2017) state that only one third of organizational innovation strategies are successful, therefore arguing for the urgent improvement. The article of Chung and Choi (2018)
recognizes the implementation process as key to explaining the high failure rate, because that process represents the stage between an organization’s initiation or adoption of an innovation and the routinized behaviour of that organization (Greenhalgh et al., 2004). With these arguments in mind, it is important for this study to consider the implementation of evidence- based innovative treatments within UMCG-UCP at the department of mood and anxiety disorders. Based on this, the following research question was created:
“Given its organisational context, how can the department implement innovative evidence- based therapies to ensure their routinised and sustained use?”
This academic problem-solving study was requested and performed at UMCG-UCP.
UMCG-UCP is the mental healthcare department of the Academic Hospital in Groningen and consists of seven departments, with a total of 419 employees. UMCG-UCP maintains a leading position in patient-centred healthcare, research, education and training. UMCG-UCP offers patients innovative treatments which are not provided at regular institutions. They have a close tri-sector collaboration with the university as well as other healthcare institutions and organizations. Their scope is not only limited to the northern part of the Netherlands but comprises national and international relations as well.
The head of the department of mood and anxiety disorders asked the faculty of economics and business to help them increase their performance with regard to the diffusion and dissemination of innovative treatments both internally and externally. The department of mood and anxiety disorders has two managers and 70 employees, including psychiatrists, psychologists, therapists, nurses and administrative staff. The interviews conducted for this
research revealed that all interviewees have already used innovative treatments for over a year.
The goal of this study was to investigate the managerial question of the mental healthcare centre of the AHSC in Groningen (UMCG-UCP), focusing on the department of mood and anxiety disorders. This study contributes to a deeper understanding of the gap between the realized state of the implementation of evidence-based innovative treatments and the desired state of implementation that UCP wants to achieve. The factors driving and constraining implementation are defined. These factors can be used for future strategies to implement evidence-based innovative treatments. Managers need to make decisions in complex and unpredictable situations, so the effective implementation of innovative treatments is important for making managerial practices easier (Meroño-Cerdan & López- Nicolas, 2013). This question reveals the challenges facing management: “How good are management at adopting their own strategy of implementing innovations, and what can they improve?” This is an academic problem-solving study with an action-oriented research approach. The study focuses on the implementation of evidence-based innovative treatments, resulting in the routinized use. The aim of action research is to enrich views, increase
knowledge and strengthen organizational theories by means of a common learning process used in a heuristic way – that is, current theories help identify adequate questions and answers.
2. Theoretical background
In this section, a theoretical framework is developed to answer the research question. Firstly, the literature on innovative evidence-based interventions and the implementation process is examined. This is followed by an elaboration of the most important stages in the process, using the model of Cooper and Zmud (1990). After this, I consider the implementation factors of adopting and sustaining to achieve routinized use. We look at the organizational level as well as the individual level to understand the processes of implementation, adoption and sustainability. Furthermore, important definitions are provided as well as the most significant aspects in healthcare.
2.1 Evidence-based innovations
As mentioned above, innovation has become an important factor with regard to competitive advantage in organizations. Thus, organizations need to keep innovating in order to survive (Lin et al., 2017). More importantly, organizations must consider different operation models, management concepts and organizational structures to realize this success. The
implementation of innovations is important to achieve a beneficial outcome of dedicated and consistent use (Choi & Chang, 2009; Klein, Conn, & Sorra, 2001). The concept of planned change relates to changes which are purposely shaped internally by organizational members (Levy, 1986). Birkinshaw et al. (2008) argue that an innovation is not static when
implemented and adopted; rather, the context is critical and can be viewed from an
evolutionary perspective (Hellstrom et al., 2015). In that same line of argument, Prendergast et al. (2017) point to the considerable influence of an organization’s environment on the implementation of planned change. Organizational theorists taking the contingency perspective stress the importance of both concentrating on the attributes of innovation and considering the perspectives of its understanding with the organization or environment into which it was initiated (Becker, 1970; Greenhalgh et al., 2004; Kaluzny, 1974; Mohr, 1969).
Additionally, the implementation of evidence-based innovative treatments can be understood as a socially constructed process established by interaction with others. This suggests that innovation is an ongoing process constructed by social dynamics between employees; thus, innovation can have consequences on the outcome of an implementation (Chung and Choi, 2018). The theoretical framework of Choi and Chang (2009) incorporates the collective processes of both institutions and employees, which together influence the implementation outcome. In addition to social construction, Marcus and Weber (1989) found that managers
should not just implement prescribed changes but also be aware of the consequences of blind adoption, which could lead to unintended outcomes.
It is important to consider different perspectives on previous research on innovation in healthcare to illustrate the underlying basis. The definition of innovation can be used in an individual context; however, the organizational context is required as well in order to conceptualize the complementary aspects of innovation implementation. In addition, organizational aspects can influence employees’ behaviour and attitudes, which in turn influence the success of an organization’s implementation (Choi & Chang, 2009; Greenhalgh et al., 2004). The following differentiation should be made to understand which definition of innovation is applied in this study: Innovations can be related to management processes and activities and are defined as administrative/process innovations. This study concerns
innovations in diagnosis and treatments, which can be understood as product/service innovations (Dewar & Dutton, 1986). However, according to Meroño-Cerdan and López- Nicolas (2013), different types of innovations are needed in different types of organizations, and most organizations combine multiple approaches.
In light of these findings, organizations situated in a fast-changing and unpredictable environment position innovations as a priority to their survival (Kim & Chung, 2017).
Applied to this organization UMCG-UCP, innovative treatments are a driving factor, as the overall aim of UCP is to generate new knowledge for improving the lives of patients and to utilize this knowledge to develop interventions and to improve existing treatments (UMCG, 2019). Therefore, the concept of planned change takes a dominant construct in this study, whereas the management of the department of mood and anxiety disorders consciously designed a new strategy for implementing innovative treatments, with the desired result of routinized behaviour (Lin et al., 2017; McCabe, 2002). The level of analysis is at the
individual level as well as at the organizational level at UMCG-UCP in order to consider all aspects which influence a successful and effective process. Moreover, this study focuses on the organizational process of implementing evidence-based innovative treatments by the department of mood and anxiety disorders.
2.2 The model of Cooper and Zmud and the implementation process
Two types of innovation process models are prominent in innovation research. Firstly, source- based models emphasize products or services that start with the production of an idea and that end with the diffusion of the product or service. Secondly, user-based models focus on a technology or practice employed for the first time in an organization (Chung and Choi, 2018).
The analysis of user-based models is focused on two prominent stages: the decision of an organization to use a new innovation (i.e. adoption) and the establishment of the innovation (i.e. implementation). Additionally, Choi and Chang (2009) focus on two implementation outcomes: implementation effectiveness, which refers to a unit’s level of absorption in the work processes and innovation effectiveness, the extent of the benefits of an innovation for a unit. This study focuses, as mentioned above, on the implementation of evidence-based innovative treatments and the strategy used for such implementation. Therefore, the implementation process model of Cooper and Zmud (1990) is discussed.
The model of Cooper and Zmud (1990) is used to define the implementation process and its stages. Cooper and Zmud (1990) designed an IT implementation model which includes six stages: initiation, adoption, adaptation, acceptance, routinization and infusion. The model is based on the change model of Lewin (1952), which is based on three stages: unfreezing, change, refreezing. The model of Cooper and Zmud (1990) also includes post-adoption behaviour; therefore, a number of connections can be made: initiation with Lewin’s unfreezing stage; adoption and adaptation with the change stage; and acceptance,
routinization and infusion with the refreezing stage. The refreezing stage incorporates post- adoption behaviours with the goal of the infusion stage, which seeks to optimize
organizational effectiveness by using innovation (Cooper and Zmud, 1990).
The stages in the model provide a framework for this study and thus make it possible to determine the different processes in an implementation process. Additionally, successful implementation depends not only on aspects of the innovation or on individual adoption characteristics but also no organizational factors, such as managerial and technical support (Yetton et al., 1999; Zmud, 1984; Attewell, 1992). Taken together, this study focuses on implementation and its effectiveness at UMCG-UCP because the adoption of (and therefore the decision to use) innovative treatments has already occurred at UMCG-UCP. Furthermore, infusion is the performance-dependent variable, which is the goal of the implementation strategy. In order to determine the stage of the implementation from the point of view of different healthcare professionals, the focus in this study is on all stages of the model as well as on the effectiveness of the process together with the factors that affect the process.
Figure 1. Lewin change model (1952) and IT implementation model Cooper and Zmud (1990)
2.3 Content, context and process
To understand the whole context surrounding organizational change, Pettigrew (1987) argues that the first questions pertain to the content, context and process as well as the inter-
connections between them. He clarifies that the content of organizational change and its organizational strategy involves coping with the context and process. The definition of the organizational context entails the whole environment of the organization and/or the
environment of the organizational strategy. A distinction is made between the inner and outer context. The inner context is defined as the structure, culture and political background within the organization. The outer context refers to the environment around the organization (e.g.
political, social, economic, technical). The content is defined as the ‘what’ of change. Lastly, the process of change refers to the ‘how’ and incorporates all people involved, including their reactions, actions and interactions. The perspective that Pettigrew (1987) takes is multilevel and continuous, and it fits in a contextualist view. This includes the choice of different process methods. In line with Pettigrew is the “open-systems perspective”, which highlights the complex interactions within an organization’s environment and which is based on five assumptions: (1) systems are not isolated; (2) systems are not simple linear causes, but rather complex and highly interrelated products; (3) systems seek equilibrium and can only be changed if they are shifted by activity; (4) individuals have different views; (5) components are interconnected and complex and cannot be viewed as isolated (Cawsey et al., 2016).
The framework of Pettigrew (1987) and the open-systems perspective conceptualizes the research question and divides the focus of this research into three categories. It is too limited to see organizational change as a rational process that moves in a linear way (Pettigrew, 1987). Additionally, it is necessary to take into account the contextual view presented by Pettigrew (1987) and the importance of the interaction between different factors in explaining and analysing the research question (Cooper and Zmud, 1990). Supplementary articles are added to improve the understanding of the categories and to define and identify
specific characteristics in the implementation process of the organizational change initiative of UMCG-UCP.
Figure 2. Pettigrew’s (1987) Framework
Content Content is defined as the ‘what’ of organizational change and can be split up into the strategies, structure and systems of an organization (Kuipers et al., 2014). In the literature review of Kuipers et al. (2014), a distinction is made between first-order changes (sub-system level), second-order changes (organizational level) and third-order changes (sector level), where eventually the study zooms in on specific levels. First-order level is defined, because the level of analysis in this study is at departmental level. First-order change is a sub-system change that takes place within a specific part of an organization or sub-
system.
This study considers the content on a departmental level (i.e. first-order change). The structure, strategies and systems can be diverse at different levels of an organization. In the specific case of UMCG-UCP, the broader level is the academic hospital. In this regard, UCP has a connection to the academic hospital and is consequently shaped by the policy of UMCG. The importance of a multilevel perspective, as stated by Pettigrew (1987), is important, so this study takes multiple levels into account. However, the content is implemented in the department of mood and anxiety disorders.
Context Elaborating on management innovation, Birkinshaw et al. (2008) argues that innovation is not static when implemented and adopted; rather, the context is critical when implementing (Hellstrom et al., 2015). In line with that argument, Prendergast et al. (2017) point to the considerable influence of an organization’s environment on the implementation of planned change. Drawing on the model of Cooper and Zmud (1990), they argue that five major contextual factors are present: characteristics of the user community, characteristics of
the organization, characteristics of the technology (in this study the implementation of innovative treatments) and the characteristics of the organizational environment (Kwon and Zmud, 1987). However, different perspectives can be drawn on when looking at the influence of context on the implementation. Firstly, the positivist view identifies the context as a reality and argues that this reality can be observed and measured. Contingency theorists analyse context with this perspective and examine the interaction of characteristics of the environment of influence. In contrast, the phenomenological view states that context is complex and not easily observed or measured. For example, it could be suggested that context is socially constructed and can only be explained by understanding the power relationships that construct the characteristics of the environment and by understanding the influence of those
relationships on the organization.
Pettigrew’s (1987) perspective when analysing the context of a social process considers vertical and horizontal levels of analysis and the interconnection between them.
Vertical levels can be defined as interdependencies between higher and lower levels of analysis – for example, the impact of a macrolevel phenomenon on the microlevel. The horizontal level indicates the interconnectedness between the past, present and future. This perspective is useful for considering all aspects of change.
Process The process of change refers to the ‘how’ and incorporates all people involved, including their reactions, actions and interactions (Pettigrew, 1987). To expand on
implementation effectiveness, Kim and Chung (2017) argue in their systematic review to focus more on the individual level, such as motivating individuals to engage in
implementation behaviours that assist in an innovation. As mentioned above, although collective influence should be taken into account, there is yet an unbalanced emphasis on distal factors, such as management support. Consequently, more research needs to emphasize individual characteristics, like motivation, to understand the implementation process and eventually to ensure highly committed use by employees, combined with routinization (Kim and Chung, 2017). Innovations are not passively adopted by people; rather, there is an active process of evaluating, experimenting, challenging, complaining, modifying and improving, or redesigning. To show that adopters interact by choice, seven key factors have been researched with regard to the adoption process. General psychological antecedents, such as personality traits and intellectual ability, and context-specific psychological antecedents, such as
motivation and skills, are aspects which increase the likelihood of adoption (Furnham, 1997).
Moreover, the personal meaning of the innovation for the adopter has a strong influence on the decision to adopt (Timmons, 2001).
It is interesting to note that the awareness of the need for change and the readiness for implementing innovations are related to organizational factors and on previous change experiences (Cawsey et al., 2016; Greenhalgh et al., 2004). To elaborate on the influence of organizational factors, Marcus and Weber (1989) illustrate that managers should not just implement prescribed changes but rather be aware of the consequences of blind adoption, which may lead to unintended outcomes. Moreover, the theoretical framework of Choi and Chang (2009) incorporate the collective processes of both institutions and employees, both of which influence the implementation outcome. Such processes include implementation
effectiveness, which is determined by the management by measuring the level of absorption of an innovation into a unit’s work processes, thus supporting and influencing employees’
collective acceptance of the innovation. The inner context of an organization includes a number of features and contexts that influence in the successful adoption process of an innovation. The first such factors are structural, such as innovativeness, organizational size, specialization and available resources (Damanpour, 1991). The second such factors include the absorptive capacity of an organization for new knowledge and the open attitude of the organization to change (Bate et al., 2002). In addition to these three features is the readiness of the system for implementation, which consists of the tension for change, the system-fit of the innovation, the appraisal of implications, support, available time and resources, and the ability to evaluate the innovation (Greenhalgh et al., 2004).
3. Methods
This chapter describes the research design and actions taken in answering the research question. This is a problem-solving study based on action-oriented research; it specifically considers a managerial problem at the mental healthcare department of the UMCG-UCP – namely, the departmental implementation and routinized use of evidence-based innovative treatments. Firstly, this chapter clarifies the action-oriented research design. This is followed by an explanation of the two research cycles.
3.1 Action-oriented research design
This study uses action research, which is based on Ramondt (1996). Action research is a combination of theory-driven research and action research. The position of theory in action research is used in a heuristic way: The theory helps to identify the appropriate questions and
answers. This approach was chosen because it aims at a frequent interaction between the people involved in an organization and because it allows researchers to implement a cyclical research method. This approach fits well with academic problem solving, as evaluations are provided after every cycle and can redefine the question in order to contribute to solving the organizational problem (Ramondt, 1996). The research steps are short and are completed in a fixed way: First, a cyclical approach of integrating local knowledge and scientific knowledge is provided to the organization, after which the results are evaluated in a reflective cycle and with subsequent feedback. The reflective cycle was used to analyse the initial findings of this study, to diagnose and evaluate the findings, and to conclude. A frequent feedback loop is necessary to integrate the knowledge at the organizational level and empirical level and eventually answer the problem-focused research question.
The first research cycle was helpful in understanding UMCG-UCP as an organization and in providing a clarifying view of the organization’s structure, systems and culture. It also helped to conceptualize a theoretical framework, which in turn guided the second cycle. A foundation was created for the second research cycle, and the research question was refined in order to fit the needs of UMCG-UCP. The second research cycle contributed to answering the research question and provided a base for conceptualizing an evaluation and recommendation report for managerial interest.
Figure 3. Research design based on Ramondt (1996).
3.2 Research cycle one: Orienting phase 3.2.1 Analysis
An introduction meeting was arranged to align the interests of both parties. Subsequently, an introduction speech was initiated at one of the quarterly consultations to introduce the study and to determine the first impression of UMCG-UCP, together with that of the employees working in the department of mood and anxiety disorders. In addition, documents were provided by one of the managers, such as an annual report and the implementation strategy for new innovative treatments. Lastly, three interviews were conducted with the initiators of the study from UMCG-UCP in order to understand the organization and the department.
3.2.2 Diagnosis
Research cycle one used different types of sources and methods of analysis. These documents were analysed using Greenhalgh et al. (2004) and his 12 attributes of successful innovation adoption (Appendix E). The attributes were used to review the features of the written strategy and to eventually compare them with the findings of interviews with regard to the realized implementation. Additional codes were added in an inductive way. Thereafter, I compared the espoused strategy and the realized strategy to review if it was implemented in the described way. Additionally, the theoretical background was constructed, which provided guidance for refining the interview questions.
3.2.3 Evaluation
Research cycle one provided a holistic overview of first impressions and helped to refine the initial research question as follows:
“Given its organisational context, how can the department implement innovative evidence- based therapies to ensure their routinised and sustained use?”
3.3 Research cycle two: Assessing implementation factors
The second research cycle investigated the implementation stage of the evidence-based innovative treatments. In addition, the second cycle contributed to creating a better
understanding of the driving and constraining forces in every stage of the implementation. In this cycle, 12 more interviews were conducted in order to understand the dynamics between employees from all user groups.
3.3.1 Analysis
In order to ensure the most fitting type of research, a combination of inductive and deductive qualitative content analysis was employed, using primary data in form of semi-structured interviews to answer the research question and to gain information about the current situation at UMCG-UCP. Additionally, this type of interviewing enabled a deeper understanding of the full story and made it possible to gather data about personal experiences, beliefs and values.
The structure of the interviews was based on defining the information needed for the
theoretical framework and consequently on defining the conceptual variables, as explained by Emans (2004). Secondly, indicators were required to translate the conceptual variables into clarifying representations. In this regard, it was important to be aware of biases, such as focusing on a single detail and concurrently losing the context; as a result, the indicators were differentiated into sub-variables, together with the use of multiple indicators for a conceptual variable. Appendix B + C conceptualizes the basis for the interviews. Nevertheless, in order to conform to the cyclical approach of this study, more than merely a deductive way of structuring the interviews was appropriate. In this regard, it was important for inductive questions to be able emerge during the interview, and the basic interview framework was primarily used to open the cyclical approach from the empirical knowledge to the
organizational problem. Furthermore, completely structured interviews would not investigate the ‘why’ of certain topics (Eisenhardt, 1989).
In order to provide a clear overview, 15 different stakeholders involved with the implementation strategy were interviewed, including heads of department, psychiatrists, psychologists, therapists, nurses and administrative staff. The interview protocol can be found in Appendix B + C and includes the semi-structured interview. Semi-structured interviews were used to ensure that the most important subjects were covered. Interviewees were contacted by email, phone or in person. The interviews took approximately 30–60 minutes, and the interviewees were ensured of their anonymity and consented to the interview being recorded (Appendix A, B, C).
3.3.2 Diagnosis
The data analysis was divided into several parts to make a frequent feedback loop, as explained in the first heading. Expressscribe was used for recording and transcribing the interviews. After conducting the interviews, an analysis was conducted to examine each interview. In order to do this, Eisenhardt’s (1989) method of data analysis was used to read the transcripts, code and interpret the interviews. An inductive coding process and a deductive
coding process were both conducted to analyse the interviews. ATLAS.ti was used for the qualitative analysis of the interviews and to code the large bodies of textual data. After the analysis of the interview codes, the findings were compared to the literature. Thereafter, a specific evaluation and recommendation were developed, as presented in the final chapter.
After the first analysis, the results showed that it was necessary to adjust the approach to the framework as well as to adjust the codes from the framework of Pettigrew (1987). The reason behind this was that the axes of the triangle between the elements gave a deeper understanding of the driving and constraining elements of the implementation – in contrast to just the single elements at every corner of the triangle.
3.3.3 Evaluation
The outcomes of the analysis are categorized and added as components into the combined framework of Pettigrew (1987) and Cooper and Zmud (1990). The figure below shows the combination of the model with the framework. This framework can be used for the
managerial level of the department of mood and anxiety disorders to detect their success factors as well as their constraining factors and point of improvement. The driving and constraining forces can be identified for every stage of the implementation, also general implementation problems are detected and can be used for managerial recommendations. An advice is presented for all employees working on the department in a form of an oral
presentation of the findings.
Figure 5. The combination of Pettigrew’s (1987) framework with the model of Cooper and Zmud (1990)
4. Results
Following a consideration of the research question that directed this research, this results section is divided into the two research cycles. In the first research cycle, I define how
innovative treatments are being implemented at the department of mood and anxiety disorders in order to have a better understanding of the context. I will look at the model of Cooper and Zmud (1990) to identify the stage of the implementation of those innovative treatments.
Additionally, In the second research cycle I will structure the outcomes of the interviews according to the elements of the model of Pettigrew (1987). Twelve sub-headings were made to give direction to answering the main research question. For a deeper understanding, and in addition for examination of the concepts at every corner of the triangle, I also evaluate the axes between the corners.
4.1 Research results: cycle one 4.1.1 Defining the implementation
Because it is important to have a better understanding of the innovative treatments and their implementation at the department of mood and anxiety disorders, it is necessary to explain and define those treatments. The department of mood and anxiety disorders has five
innovative treatments/studies, which were started because of the evidence mentioned above:
“If you can offer innovative treatments which are evidence-based, that gives people hope”
[AS3]. A newly designed care path was created for these evidence-based innovative treatments (‘path C’), next to the offering of regular treatments (‘paths A + B’). This innovative path was linked to the other paths of closed and open depression admission. An implementation plan was formed containing the strategy and design for this new path of innovative treatments. The innovative treatments at the department of mood and anxiety disorders are described in the plan to secure the purpose of UCP: “With this implementation plan, we give a specific direction to the department of mood and anxiety disorders to develop and sustain academic tertiary mental healthcare and innovative treatments” [Implementation document]. Two out of five innovative treatments (rTMS and ketamine) were being newly offered and have a more comprehensive explanation than the other three (combined
chronotherapy, light therapy for winter depression and ECT). In addition to an explanation of those treatments, other resources were also available: a description of the three programs (A, B and C), policy considerations, a timetable and protocols for the innovative treatments.
4.1.2 Implementation phase
If we look at the model of Cooper and Zmud (1990), we can determine the stage of the implementation of evidence-based innovative treatments. The innovative treatments were taken together when looking at the stage of implementation. The stages of initiation, adoption and adaptation had already passed because the organizational need to change was serving as an intrinsic pull factor (i.e. initiation) and because the decision to implement innovative treatments and to invest in necessary resources was salient (i.e. adoption). Employees
working on this specific path were trained and protocols were set up for new procedures (i.e.
adaptation): “Gradually, it changed by trainings to administer certain questionnaires . . . and we also had a workshop for the calculation of ketamine” [PP1]. Acceptance was reached according to the definition of Cooper and Zmud (1990) and according to some interviewees.
For example, the comment “The IT application is employed in organizational work” fits with the comment of the director nurse in charge of the innovative path, who explained which procedures were available: “There are three paths: closed is A, open is B and the innovative path” [PP1]. Innovative treatments are a normal activity in daily work practices, and all nurses acknowledged their activities on the innovative path when asked about their daily practices: “I am currently working on the open depression admission, so I have that
department and one or two times a week on the innovative path as well” [PP4]. Hence, if we look at the implementation process of the innovative treatments, the process is moving from acceptance to routinization.
Figure 4. Current stage of the implementation of innovative treatments
4.3 Research results: Cycle two
In this cycle, the framework of Pettigrew (1987) was combined with the model of Cooper and Zmud (1990). In every stage of the implementation process model, according to Cooper and Zmud (1990,) a triangle can be placed to provide a better understanding of the driving and constraining elements in that specific stage. As acknowledged above and based on the results of this study, the concepts at the corners of the triangle cannot be taken into account
independently. Therefore, the axes of two concepts were instead examined as the focus points.
An overview of the categories, subcategories and codes is given below to provide an overall picture of the discovered findings.
Cooper and Zmud (1990) [Deductive]
Category Subcategories Definition Codes
Initiation Process-content, content-context, context-process
“Active or passive scanning of organizational problems/opportunities
and solutions undertaken. Pressure to
change evolves form either organizational need (pull), technical innovation, or both.”
Emerging process [Inductive], Preparatory research [Inductive], Need for change [Deductive],
Competence [Inductive], Vision
[Inductive], Motivational factors [Deductive], System dynamics [Deductive]
Adoption Process-content, content-context, context-process
“Rational and political negotiations ensue to get
organizational backing for implementation of the
EB innovative treatment.”
Informing [Inductive], Evaluation [Inductive], Attributes of strategy
[Deductive], Understanding need
[Inductive], Strong storytelling [Inductive], Management involvement [Inductive]
Adaptation Process-content, content-context, context-process
“The innovative treatment is developed,
installed, and maintained.
Organizational procedures are revised
and developed.
Organizational members are trained both in the
new procedures.”
Cooperation [Inductive], Feedback loop
[Inductive], Lacking information
[Inductive], Unfamiliar with implementation strategy [Inductive], Management support
[Inductive], Coordinating role
[Inductive], Clear task division [Inductive], Resistance
[Inductive], Culture paraprofessionals [Inductive], Variety
[Inductive]
Acceptance Process-content “Organizational members are induced to commit to EB innovative
treatment usage.”
Support [Inductive], Shifts consistency
[Inductive], Training consistency
[Inductive]
Routinization Process-content, context-process
“Usage of the EB innovative treatment is encouraged as a normal
activity.”
Task division [Inductive], Work
load [Inductive], Information overload [Inductive], Financial problems [Inductive]
Infusion - “Increased
organizational effectiveness is obtained
by using the EB innovative treatment in a more comprehensive and
integrated manner to support higher level aspects of organizational
work.”
-
Table 1. Codebook overview
Pettigrew (1987) [Deductive]
Category Subcategories Definition Codes
Content Ipad attitude
[Inductive], Ipad needs [Inductive]
“The what of change, so particular areas of transformation under
examination.”
Positive [Inductive], Insecure [Inductive], Evaluation [Inductive],
Training [Inductive]
Context Inner-context
[Deductive], Outer- context [Deductive]
“The whole environment around
the organization and/or the environment
of the organizational strategy. A distinction is made between inner and outer. Inner is defined in structure,
culture, political background within an
organization. Outer refers to the environment around
the organization.”
Top-management [Inductive], Middle-
management [Inductive], Dependence person in
charge [Inductive], Academic Health
Science Centre (UMCG) [Inductive],
Finance [Inductive].
Government policy [Inductive], Laws [Inductive]. Research
[Inductive]
Process Communication [Inductive], Improvements communication [Inductive], Communication channels [Inductive], Gap departments [Inductive]
“The process refers to the how and incorporates all people
involved and the reactions, actions and
interactions between them.”
Coordinating role [Inductive], Slow [Inductive], Lacking
information [Inductive], Coordinating role [Inductive], Less is more [Inductive], No
clear solution [Inductive], GWO [Inductive], E-mail [Inductive], Face-to- face [Inductive], Size
organization
[Inductive], Level of innovativeness
[Inductive], Comprehensive department [Inductive],
Meeting point [Inductive], Coordinating role
[Inductive]
Table 2. Codebook overview
4.3.1 Initiation of content, context and process
Initiation content-context The implementation plan showed the strategy and design for the new path. In advance, preparatory research had been done to close the gap between highly specialized care and experimental research, as one initiator argued: “It expresses in the implementation strategy that we have written . . . it is more focused on the boundary between high specialist care and on the other side experimental research, but this a slow process . . . We make plans by looking at the gaps in treatments offers” [AS3]. This preparatory research was focused on the organization itself and on its environment.
Both initiators stated the need for change, with one initiator stating about the other, “I think it was X [name] his goal to bring cohesion in research activities and innovative
activities” [AS2]. The need for change was also mentioned in the strategy created by the head departments. The motivation behind the strategy was as follows: “This implementation plan will give a specific direction regarding the goal of UCP to develop tertiary psychiatric care and to analyse academic care and innovative treatments, specifically at the department of mood and anxiety disorders” [AD2]. To assess the need for change, the initiators collected their personal concerns and perspectives as well as making sense of internal data in a limited way. Nonetheless, their making sense of external data was not informed. Furthermore, it was ambiguous if the initiators accurately assessed the perspectives of internal and external stakeholders: such an assessment was only mentioned once by one of the initiators and was not acknowledged by any of the recipients. Hence, it seems that the internal and external context affects the content of the implementation strategy.
The initiators consciously thought about the direction they desired to achieve, as stated above. However, they perceived a lack of competence in implementing innovative treatments, as mentioned multiple times by the initiators. For instance, one manager argued, “I think we can do better. . . . That is why we reached out to you. . . . I think we are doing it sloppy [In
Dutch: amateuristisch] in a way that we have to some extent an idea” [AS3]. The initiators did some preparatory research, but they doubted the sufficiency of that research. For example, one initiator argued about the internal and external need: “It is possible that nobody is waiting for it. I do not know. We did not do any research. We did not measure it” [AS3].
It became clear from the interviews that all heads of department shared the same vision. Thus, there was consistency in the goals of middle-management. Another motivation behind the implementation strategy was to suit the vision of UMCG-UCP: “We will give a specific direction to the purpose of UCP [AD2].
Initiation context-process Five contextual factors influenced the set-up of this innovative path, including three outside factors: 1) research evidence from publications of other
universities or hospitals, 2) patients requesting innovative treatments and 3) government policies. As one initiator expressed about the influence of evidence from research:
“Especially when something new demonstrated that it worked, then it is very promising”
[AS2]. Moreover, a psychiatrist added, “Well, the researchers found something successful. Of course, this will be highly investigated, publications, but it is also familiar for the
department” [DC1]. Consequently, patients are informed, for example, by the media. In this regard, a psychiatrist explained the advantages of a magazine and its word-of-mouth
publicity: “In particular, a magazine like Libelle works really well. The magazine is read, and then it goes to the mother, daughter, hairdresser and dentist” [DC1]. The influence of government policies on innovative treatments was explained by a head of department:
“Eventually that is the biggest incentive. The ministry declares that the ‘academic hospitals need to be more innovative regarding care and complex treatments’, and subsequently insurers will question the providers . . . and so it will be translated to us” [AS3].
Besides outer contextual factors, inner contextual factors also played a role as a force in initiating the establishment of an innovative path. Inner contextual forces were mentioned by all initiators as necessitating a change in the usual way of working. The first such factor is the need of UCP to fulfil their purpose as a research institution linked to an academic hospital.
This is an intrinsic motivational factor. Furthermore, another important intrinsic motivational factor mentioned by all initiators is the commitment to patients – namely, helping patients who cannot be helped anymore by regular treatments, as one initiator argued: “Taking the perspective of the patient care . . . you see people struggling to get out of it [depression]”
[AS3]. These organizational pull factors initiated the implementation.
The inner and outer drivers were not alone in initiating the implementation; however, they did influence each other and the process of implementation. In this regard, a psychiatrist
explained how some patients’ desperation influences his choice of an innovative path:
“Taking the view of the care for patients, you will see people struggling to get better . . . and you will feel yourself helpless. . . . It helps to have a wide range of different treatments. . . . It helps from the powerlessness I feel to do things for people” [DC5].
Initiation of process-content Results show that the process surrounding the
implementation of innovation has elements of an emerging process rather than a completely planned change. A conscious choice was made to merge innovative treatments into an additional path next to regular treatments. A strategy was also written in an additional document to give direction to the implementation, as mentioned by one of the initiators:
“There was a need to have a clear trajectory” [AS2]. Nonetheless, the emerging process appeared in the statements of eight interviewees and in all user groups. As one manager stated about the set-up of the innovative path, “In essence, they investigated it themselves, so it would fit the other activities” [AS1]. Another nurse from the innovative path added, “It is an ongoing process; it is not finished at one point, and it is working perfectly now” [PP2]. In addition, a psychiatrist explained the establishment of the innovative TMS treatment: “We created it a little bit ad hoc. . . . A little bit exploring the needs of nurses regarding schooling, and they will come eventually to you. Together with my colleague, we looked at the needs and requirements, and if we can provide sufficient. Well it is an interaction and tuning” [DC2].
4.3.2 Adoption content, context and process
Adoption content-context As mentioned above, an implementation strategy was written to inform employees of the department of mood and anxiety disorders. The
implementation strategy was incorporated into the annual strategy, and one of the initiators made this point about the plan they had written: “It needs to consist of two things. You need to convince the Executive Committee that it [the implementation plan] does the right thing so it fits the vision of UCP, and internally it needs to provide enough guidance to work with it”
[AS2]. In light of the 12 attributes of successful adoption of innovation by Greenhalgh et al.
(2004), certain aspects of the strategy become apparent (Appendix E). First of all, eight out of 12 attributes are mentioned and explained in the strategy. The attributes are not directly related to innovation, though, as some are related to the innovative treatments. Furthermore, several moments of evaluation were mentioned in the implementation process. These
evaluations are necessary, according to one of the managers: “And then monitoring . . . and if I have had an evaluation, subsequently letting know, ‘Where are we? How do we do?’”
[AS1]. However, the evaluation moments that are added in the implementation strategy are not initiated by the heads of departments or requested by recipients and therefore are not carried out. Both heads of departments and paraprofessionals argued that they would like to have these evaluation moments. As one head of department stated, “I think I am guilty, but we have added the evaluations maybe too enthusiastically and maybe not implemented it well enough, and I think we should . . . at least every six months evaluate” [AS3]. A nurse also acknowledged the need for a consultation or evaluation with everyone working on the innovative path: “. . . or a consultation for everyone. We did not have it yet. I think it is important” [PP4].
Adoption context-process With regard to the context-process element of adoption, all interviewees acknowledged that they understand the need for the implementation of innovative treatments. They had intrinsic and extrinsic motives to be aware of this need, as mentioned before with regard to the drivers of the initiators. For all user groups, the intrinsic motivation to help patients was salient. This is connected to the understanding of employees regarding the vision of UCP, which all interviewees were aware of. All three groups were informed about the innovative path and its innovative treatments. They all knew of its existence. It became clear that social interaction is a way for employees to make sense of information. In this regard, five interviewees mentioned strong storytelling. For example, the nurse director stated about realizing new ideas: “You need a strong story, and sometimes I have difficulties” [PP1].
Strong storytelling would also help create awareness for innovative treatments at other departments. Some interviewees felt that other departments were not well enough informed about a number of factors: 1) the purpose of the innovative path: “I think a lot of studies are done . . . but I was not acquainted” [DC4]; 2) the content of the innovative path with regard to treatments: “It appears that not everyone completely knows what is happening relating innovative treatments” [DC3]; 3) and the process for referring patients for intakes: “Well people are not aware that a study is running and that they can sign up and pass on
patients. . . . But it still feels like two separate worlds” [DC3]. Solutions for the gap between the department of mood and anxiety disorders and other departments were acknowledged, and the interviewees pointed to the need for more interaction between the different departments.
This desire will be taken into account in the new building, as a member of the Executive
Committee stated: “We have of course a clinical organization and thought about how we can do better qualitative, but also more efficient. We have a lot of small departments and a lot of nurses because you are not sitting on the hallway, so we thought about the departments and more exchange [nurses] so the easier it becomes to swap . . . and therefore another cohesion will arise and we have considered this in the new building. We have a large central place where patients can come . . . and employees” [AS6].
Hence, the environmental context affects the implementation of innovative treatments, including both external and internal factors. Firstly, the internal force of the Executive
Committee influences the choices that are made to fit the vision of UCP. Interviewees
mentioned the importance of receiving approval from the Executive Committee if things need to be done. For instance, a psychologist stated, “Well, if there is no formal support from the Executive Committee . . . then you can discuss whatever you want, but you will not achieve it”
[DC4]. Things can be arranged via middle management too, after they bring it to the Executive Committee, as explained by a psychiatrist: “So, first you will try it on your own department . . . and they bring it a step further to the Executive Committee. They will look at the costs and the resources they have. If this is not possible, they will bring it to UMCG”
[DC1]. This can be identified as a second inner contextual factor influencing the
implementation. It is interesting to note that one recently appointed psychologist described the process of approval as follows: “Well, I think the communication, it is really slow [in Dutch:
stroperig]; to get something done, you need to move heaven and earth” [DC3]. The last inner contextual factor is the dependence of the person in charge on the choices that are made. For example, one nurse argued, “Sometimes I think in UMCG and UCP change is just about which person [in Dutch: poppetje] is in which position and who will bring about change”
[PP1].
The outer contextual factor influencing the adoption stage is the involvement of UMCG. Even though UCP is relatively independent and responsible for their own results, they still perceive the influence of the policy of UMCG: “Well if you look at the smoke policy (and of course a lot of general things) they want to tackle, and that will be done here as well, but there is a big difference in being a hospital and a psychiatric clinic” [PP4]. The direct involvement of UMCG in the implementation was not mentioned by any of the initiators, so it is not a constraining factor for this research. Nevertheless, consideration of the influence of UMCG is necessary for further implementation of innovative treatments and perhaps for other future changes.
Adoption process-content In order to get organizational support for the implementation of innovative paths and treatments, interventions should ensure
accommodation for the implementation. A communication channel, which is often used to inform about innovative treatments, is a large work consultation [in Dutch: groot werk overleg, GWO]: “Indeed I would do it at a GWO. You give people something interactive, and of course I would use email” [AD1]. Conversely, three interviewees acknowledged the passive nature of communication on the channel. For example, one manager stated, “We talked about it lately. It is sometimes a lot of listening and just receiving. . . . Something more interactive would be better . . . to make it more attractive, maybe more interactive, yes”
[PP4]. There were some differences in opinion between employees about GWOs.
Disadvantages were acknowledged regarding a number of elements. Firstly, some believed GWOs are characterized by information overload: “However, a GWO is experienced as a barrage of information, and after 30 minutes, everyone is a little bit like, we shall see. It is surely an indolent [in Dutch: gezapig] of a lot of information” [PP1]. Secondly, some criticized the duration: “Because we have most of the time another consultation before and then the GWO . . . starts around three p.m. and then you are already satiated” [PP1]. Thirdly, regarding overall effectiveness, one psychiatrist stated: “How I observed it is that indeed two people address everyone, and I am wondering if it is efficient and effective” [DC2]. It is interesting to note that the manager providing the GWOs noticed the need for interaction:
“We have every term a GWO where all employees from the department are invited for, and it is repeatedly announced, but I have the feeling that they heard, but on the other side they did not. Not sure if this is the case . . . but I feel that there is more need for contact” [AS3].
Moreover, an observation of a GWO revealed that many employees from many departments were absent. This was further confirmed by the head manager of the department, who stated,
“A GWO is really to inform, because you do not affect everyone, so it is more like who will be responsible and giving people time to perhaps respond” [AS1]. With regard to possible solutions, all user groups argued for more interactive consultations. They considered GWOs as useful for reaching most employees at once and informing them: “I think it is the best way to bring everyone together and discuss important things, so it is necessary” [PP4]. The advantage of a GWO includes the appreciation of the connecting purpose, as a nurse stated:
“But I feel like it is the best way of getting people together and discussing the most important stuff, so it is necessary” [PP4].
4.3.3 Adaptation content, context and process
Adaptation content-context All user groups acknowledged the active role of management in the implementation of innovative treatments. The organizational context influences the content of the implementation of innovative treatments, as managers determine the decisions that are made. One manager explained the coordinating role: “I think there should be an active role . . . because otherwise I am afraid that one pilot after the other shows up, and many other things will be running, and that it will be at the expense of patient care”
[AS1]. In addition, a psychiatrist argued, “The researchers and the practitioners want to help patients. . . . They will come with ideas, and it is for the management to contrive it” [DC1]. A director nurse indicated the importance of an active and honest manager concerning decision making: “Well, we already said to X [the new manager] . . . just communicate and be honest, and if something is implemented, we want to know the reason behind it, because most of the times we don’t know. We don’t know the additional information. It is lacking most times”
[PP1]. However, the director nurse was explicit with regard to business operations: “Before, there were some director nurses who interfered with the business operations, so there was a gap at the department, and some tasks are infiltrated and we have to deal with it today”
[PP1].
Adaptation context-process A closer look at the context and process reveals that employees manage and handle change differently. As a psychologist stated, “I absolutely perceive the differences in employees and the extent to which they explore and their needs [of working together]” [DC4]. In addition, a psychiatrist stated a positive general perception about change: “I observe that people in general are open for these kind of treatments [innovative treatments]. I perceive a lot of enthusiasm in the adoption of these treatments”
[DC2]. However, a manager acknowledged some resistance: “Well, a little bit of grumbling:
‘There is already happening so much, and then this too?’ and ‘We think we are doing okay.’
Well sometimes there are interesting points. You need that [resistance] as well” [AS2]. This confirms the above-mentioned statement of the head of department about his feeling
regarding the existence of some resistance.
The culture of nurses and their vision on change is a driving force. The
paraprofessionals’ approach to work was also mentioned as being characterized by loyalty and helpfulness. As the director nurse acknowledged, “People [nurses] will adopt because they feel loyal, and that is of course also a little bit the nature of nurses. I worked in three
