Altering Frontiers E-Book
139,99 €
Mehr erfahren.
- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
How can healthcare systems be transformed by reimagining their multiple silos to favor processes and practices that are more responsive to local, horizontal initiatives? Altering Frontiers analyzes numerous experiences, using a multidisciplinary approach, paying attention to certain actors, collectives and organizational arrangements. Through this work, levers are identified that promote lasting transformation: recognizing the legitimacy of the practices of many who are often "invisible"; trusting those who know their intervention territory; investing in methodological support; taking advantage of tools and procedures such as instruments for strategic and managerial discussion; and developing the capacity to absorb innovative ideas and experiences that circulate within the environment.
Sie lesen das E-Book in den Legimi-Apps auf:
Seitenzahl: 419
Veröffentlichungsjahr: 2021
Ähnliche
Table of Contents
Cover
Title Page
Copyright
Foreword by Jean-Louis Denis Adaptation, Trust and Methodology
Foreword by Norbert Nabet The Challenges of Altering Frontiers: For Other More Collaborative Approaches
Introduction The Challenges of “Altering Frontiers”: The Multiple Facets of Boundaries to Cross and Articulate
I.1. Altering frontiers: a boundary concept
I.2. Conclusion
I.3. References
PART 1: Innovations as Seen by Stakeholders
Introduction to Part 1
1 Recognition of Patients’ Experiential Knowledge and Co-production of Care Knowledge with Patients and Citizens in the 21st Century
1.1. Introduction
1.2. From “empowerment” to the “patient revolution”, an international trend
1.3. From paternalism to different forms of participation and partnership with patients
1.4. Innovative practices
1.5. Conclusion
1.6. References
2 Innovative Organizations and Professional Strategies: The Nursing Professional Space
2.1. Introduction: experimenting experimentation
2.2. Participatory evidence-based policy: a new conceptual framework?
2.3. Article 51: a full-scale test
2.4. The nursing space: a controlled extension
2.5. Conclusion: new ways of doing things
2.6. Appendix: examples of emancipatory innovations in the 1990s
2.7. References
3 Managed Communities of Practice in the Gerontology Sector: Case of a CoP of Gerontology Volunteers in Sweden
3.1. Introduction
3.2. Context and questions
3.3. Conceptual framework
3.4. Illustrations
3.5. Conclusion
3.6. References
PART 2: Innovations on the Collective Side
Introduction to Part 2
4 Moving from Partitioning to Transversality in Operating Rooms using Robot-assisted Surgery
4.1. Introduction
4.2. The context of operating rooms mobilizing the surgical robot
4.3. The issue of technical and non-technical skills in the context of robotic surgery
4.4. The effects of new technologies in terms of individual and collective skills
4.5. Viewing at the heart of robot-assisted surgery in urology
4.6. Discussion
4.7. References
5 Clinical Poles of Activity, an Opportunity for New Cooperation Between the Actors? The Case of a Hospital
5.1. Key elements and objectives of polar reform
5.2. Improving cooperation and better articulating the logics present in the hospital: challenges and theoretical identification
5.3. Context and methodology of the study
5.4. Modalities of cooperation permitted by the establishment of the clinical poles
5.5. Conditions for the use of articulations
5.6. Cooperation in a polar structure, some research avenues
5.7. References
6 Learning from Reforms Aiming to Disseminate Innovative Organizational Models: The Case of Family Medicine Groups in Quebec
6.1. Introduction
6.2. Conceptual framework
6.3. Illustration of the analytical framework: the reflexive processes related to the implantation of family medicine groups in Quebec
6.4. Discussion
6.5. Conclusion
6.6. References
7 Variety and Performance of Innovative Organizational Structures: The Emergence of Territorial Support Platforms
1
7.1. Introduction
7.2. Context of the study
7.3. Conceptual framework
7.4. Empirical analysis
7.5. Conclusion
7.6. Acknowledgments
7.7. References
PART 3: Reflective Insights on Organizational Innovations in Healthcare
Introduction to Part 3
8 Proposals for New Approaches to Contributory Evaluation of Healthcare Pathways from Interface Organizations
8.1. Introduction
8.2. Context and research questions
8.3. Framework for analyzing the processes of diffusion of organizational innovations: definition and principles (conceptual framework)
8.4. Empirical illustrations of the innovation diffusion processes supported by coordination platforms
8.5. Conclusion
8.6. Acknowledgments
8.7. References
9 Innovation and Absorptive Capacity of Organizations in the Healthcare Field
9.1. Introduction: absorbing to innovate
9.2. Context and questions: the challenge of openness
9.3. Theoretical framework: the notion of organizational absorption capacity
9.4. Responses to the three OAC pitfalls: illustrations
9.5. Conclusion
9.6. References
10 Quality Management in Hospitals: The Two Faces of Rationalization Through Indicators
10.1. Introduction: are quality indicators a managerial innovation?
10.2. Context and issues
10.3. Management tools and organizational rationalization dynamics
10.4. A dynamic of professional rationalization?
10.5. A dynamic of managerial rationalization?
10.6. Conclusion: rationalizing through indicators to rationalize “softly”
10.7. References
List of Authors
Index
Other titles from iSTE in Innovation, Entrepreneurship and Management
End User License Agreement
List of Tables
Chapter 4
Table 4.1. Categorization of main types of communication (Blavier & Nyssen 2010)
Table 4.2. Typical configuration of the operating room using the surgical robot
Table 4.3. Spatial and temporal partitioning within and outside the operating ro...
Chapter 7
Table 7.1. Data collection protocol
Table 7.2. Characteristics of the seven structural configurations according to M...
Table 7.3. Analysis of internal contingency factors
Table 7.4. Analysis of external contingency factors
List of Illustrations
Chapter 1
Figure 1.1. Continuum of patient engagement modalities
Figure 1.2. The continuum of care practices. For a color version of this figure,...
Figure 1.3. Different approaches to care. For a color version of this figure, se...
Figure 1.4. Patients’ skills in frame of reference. For a color version of this ...
Figure 1.5. The competence framework for collaborative practice and patient part...
Figure 1.6. Distinctive record of the nature of patient-professional relationshi...
Figure 1.7. Systemic transformation practice. For a color version of this figure...
Chapter 4
Figure 4.1. Configuration of the team and operating room during the filmed proce...
Chapter 6
Figure 6.1. Illustration of the theory of intervention described in the MSSS pol...
Chapter 7
Figure 7.1. Contingency factors, organizational congruence and performance. For ...
Figure 7.2. Expected organizational form of PTAs after situational analysis. For...
Guide
Cover
Table of Contents
Title Page
Copyright
Foreword by Jean-Louis Denis
Foreword by Norbert Nabet
Introduction
Begin Reading
List of Authors
Index
Other titles from iSTE in Innovation, Entrepreneurship and Management
End User License Agreement
Pages
v
iii
iv
xi
xii
xiii
xiv
xv
xvii
xviii
xix
xxi
xxii
xxiii
xxiv
xxv
xxvi
xxvii
xviii
xxix
1
3
4
5
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
141
143
144
145
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
239
210
211
212
213
214
215
216
217
218
219
220
221
222
223
225
Health and Innovation Set
coordinated byCorinne Grenier
Volume 1
Altering Frontiers
Organizational Innovations in Healthcare
Edited by
Corinne Grenier
Ewan Oiry
First published 2021 in Great Britain and the United States by ISTE Ltd and John Wiley & Sons, Inc.
Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms and licenses issued by the CLA. Enquiries concerning reproduction outside these terms should be sent to the publishers at the undermentioned address:
ISTE Ltd
27-37 St George’s Road
London SW19 4EU
UK
www.iste.co.uk
John Wiley & Sons, Inc.
111 River Street
Hoboken, NJ 07030
USA
www.wiley.com
© ISTE Ltd 2021
The rights of Corinne Grenier and Ewan Oiry to be identified as the authors of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act 1988.
Library of Congress Control Number: 2021934597
British Library Cataloguing-in-Publication Data
A CIP record for this book is available from the British Library
ISBN 978-1-78630-707-1
Foreword by Jean-Louis DenisAdaptation, Trust and Methodology
The issue of organizational innovation in health is not new, but it is nonetheless topical. All health systems in high-income countries face significant challenges when adapting their health systems to changing demands, knowledge and preferences, economic circumstances or technologies (Denis et al. 2018). The current COVID-19 pandemic highlights the need for organizational innovation to better respond to the unexpected and ensure an adequate and accountable response. These organizational innovations are multifaceted and refer to a reconfiguration of the professional, clinical, managerial and civic logics, to name but a few, that structure the functioning of a healthcare system (Thornton & Ocasio 2008). The healthcare system has long been characterized by a significant gap between technical innovation and organizational or institutional innovation. While such a gap is not unique to the healthcare sector, it is surprisingly acute in this sector. Technical innovation in the broadest sense of the term is a powerful driver of change in the healthcare sector. New drugs and diagnostic and therapeutic technologies are penetrating the healthcare system and organizations at a speed that makes them difficult to master. What is looming in terms of cell therapies is described as a tsunami that could sweep away the healthcare system, or at least revive it without being able to escape the difficult question of costs and what should or should not be offered by our social welfare systems. Digital innovation and artificial intelligence will also bring about organizational and institutional transformations (Hinings et al. 2018).
Organizational innovation, which can be more broadly described as immaterial innovation, is difficult to bring about, or at least to such a degree that it would allow better control of so-called technical innovations. One need only think of the experience of healthcare systems in the face of the deinstitutionalization of care made possible (in principle) by the arrival of laparoscopic technologies in the 1990s. The development of ambulatory care has been slower than otherwise, and clinical or organizational environments have had difficulty capitalizing on this opportunity.
This is certainly a reflection of reasonable caution, since innovation must make it possible to produce quality care in complete safety. There is also the imprint left by professional, organizational or political rigidities that make this capitalization uncertain or late.
Healthcare is not alone in this fight for innovation. Other sectors of activity, including that of economically oriented companies, have long stressed the difficulty of renewing social relations of production in favor of greater adaptation to a constantly changing environment (Osty et al. 2007). In the healthcare sector, organizational innovations, which I would call “basic”, are also slow to materialize. Take, for example, the difficulty in linking the designation of responsibility for care, the establishment of incentives to take on this responsibility and the optimization of the use of clinical resources. The interest in France and elsewhere in the implementation of new organizational forms such as Accountable Care Organizations (ACOs) is a major challenge in terms of innovation (Lemaire 2019). More broadly, we could also highlight the difficulty for several healthcare systems to also refocus their mission toward emerging priorities (mental health, frailty, etc.). Obviously, this is not only a question of organizational innovation, but also of innovations in terms of mentalities and social relations between stakeholders. So what does this book offer us? Without claiming to do it justice in a few lines, it serves to better understand the strategies likely to promote and capitalize on organizational innovation. The interest of such a book lies not in its diagnostic scope – the problem is fairly well known – but in the avenues of response it proposes to the tricky issue of the cumbersomeness or inadequacy of organizational innovation in health. I will limit myself to some remarks on the three main theses that make up the three parts of the book. These three themes are partly overlapping and I will come back to them in conclusion.
The first theme of this book, dealt with in Part 1 entitled “Innovations as Seen by Stakeholders”, raises the question of the agility of health innovation processes. In this case, innovation means developing a greater scope for the thought and action of stakeholders on the usual channels of power, whether they are professionals or patients. Organizational innovation here involves the ability to generate counter-powers in order to increase the legitimacy of new knowledge, modes of intervention and representations. These counter-powers (Light 2010) are the source of innovation insofar as they are and will be powerful enough to move away from the reproduction of the logics that dictate the current functioning of organizations and the health system. Behind this staging of new stakeholders is a real political project in the sense that organizational innovation consists of fundamentally renewing the social relationships between stakeholders in the healthcare sector (Hallett & Ventresca 2006). Under this topic, a greater or at least more explicit place could be given to stakeholders who live on the limits of the health system but who call for its renewal. I am referring here to people in social situations described as marginal and militant organizations for whom the social and healthcare issues overlap and are confused.
The second topic, dealt with in Part 2 entitled “Innovations on the Collective Side”, explores innovation as the product of new agencies. These spaces or collectives of all kinds, communities of practice and innovation laboratories among others, are themselves innovations from the point of view of organizations and the health system. Their establishment questions current practices and expresses a form of productive resistance in organizations and the healthcare system (Courpasson et al. 2012). The hypothesis here sees innovation as the product of a protective zone that allows stakeholders to freely engage in exploration and experimentation. The vitality of such spaces depends on the fact that the organization accepts the temporary suspension of environmental discipline to allow innovation to emerge (Zietsma & Lawrence 2010). These spaces testify to the importance of creativity and detachment in rethinking ways of doing things. They also enable the bringing together of stakeholders who usually operate in parallel or separate universes. They will bring innovation insofar as what they produce is taken up and accepted by stakeholders who can influence the decisions made within the organization.
This is the challenge of sustainability and scaling up of healthcare innovations where, too often, successful local experiences fail to be brought to light and institutionalized. Here, the authors do not deal only with innovative spaces but also with innovations in the design of organizations (structuring into clusters, for example) or in public policies (territorialization of policies, for example). It can be hypothesized that innovative design and new spaces of innovation complement each other, perhaps offering the prospect of an institutionalization of innovation. Innovations in organizational design in a sense absorb the logic of the living laboratory by formalizing new frameworks for interaction. They must be accompanied by change and boldness of ideas and mindsets in order for organizational innovations and new practices to emerge. Finally, technologies are called upon to play an increasingly important role in bringing together and creating tension between various stakeholders in search of innovation. Each of the chapters presented in this section could consider the potential of new technologies to create collective spaces that accelerate organizational innovation (Ansell & Gash 2018).
The third topic, dealt with in Part 3 entitled “Reflective Insights on Organizational Innovations in Healthcare”, gives way for the systematic analysis of experiences to contemplate change and innovation, whether through research or through evaluation in context. This part highlights, through the various contributions that compose it, the importance of the knowledge-power nexus in understanding and shaping innovations (Ferlie & McGivern 2014). Organizational innovation emerges from a rather deliberate process and does not easily reveal all its subtlety. Systematic processes must be put in place in order to learn from experience and produce knowledge that can accompany and propel innovations. The idea is to produce, by means of a reflexive analysis, knowledge about the conditions for transforming an organization or a health system. The analysis of public healthcare policy offers an opportunity to learn in real time from initiatives aimed at bringing about large-scale transformations and generalizing organizational innovations.
The next challenge is to make this knowledge effective, i.e. to create the conditions for stakeholders to take an interest in it in order to act in favor of innovation. Management tools and policy instruments play a key role here, since they put into circulation representations of activities, behaviors and changes they can induce that were previously less or little known. Ideally, they make it possible to open up new objects to governance, whether it be the state of health of a population, quality of life or healthy living with illness (Jarzabkowski & Kaplan 2015). In all innovation processes, it is important to pay attention to the resource allocation channels that weigh in favor of or against organizational innovation. It is not enough to want to renew primary care or encourage the so-called grassroots innovation; an organization must be able to dedicate the resources that will enable these stakeholders to materialize their projects. These resources are not necessarily new, underlining the importance of being able to reallocate resources to emerging priorities or representations in the healthcare system.
The three parts that structure this book on organizational innovation in healthcare complement one another. Fostering innovation requires stakeholders with the capacity to influence, spaces to create and experiment, and knowledge about processes that can support and accelerate the challenging of the status quo and the implementation of new organizational modes or practices. One of the essential conditions for the governance of innovation in healthcare systems is the question of alignment and coherence between public policies and the dynamics and needs found in organizations and clinical settings. This book provides us with the pieces to tackle the puzzle of organizational innovation with seriousness and relevance. It will benefit from being complemented by a reflection on the political and social conditions that enable health systems to adapt better than others to the major contemporary challenges of health and thus to capitalize on innovation on a large scale, whether organizational or not.
Jean-Louis DENIS
CR-CHUM
Université de Montréal
March 2021
References
Ansell, C. and Gash, A. (2018). Collaborative platforms as a governance strategy. Journal of Public Administration Research and Theory, 28(1), 16–32.
Courpasson, D., Dany, F., Clegg, S. (2012). Resisters at work: Generating productive resistance in the workplace. Organization Science, 23(3), 801–819.
Denis, J.L., Usher, S., Preval, J., Côté-Boileau, É. (2018). Health system reforms in mature welfare states: Tales from the North. Revista Brasileira em Promoção da Saúde, 31(4), 1–15.
Ferlie, E. and McGivern, G. (2014). Bringing Anglo-governmentality into public management scholarship: The case of evidence-based medicine in UK health care. Journal of Public Administration Research and Theory, 24(1), 59–83.
Hallett, T. and Ventresca, M.J. (2006). Inhabited institutions: Social interactions and organizational forms in Gouldner’s Patterns of Industrial Bureaucracy. Theory and Society, 35(2), 213–236.
Hinings, B., Gegenhuber, T., Greenwood, R. (2018). Digital innovation and transformation: An institutional perspective. Information and Organization, 28(1), 52–61.
Jarzabkowski, P. and Kaplan, S. (2015). Strategy toolsation: An institutional perspective “technologies of rationality” in practice. Strategic Management Journal, 36(4), 537–558.
Lemaire, N. (2019). Accountable Care Organizations (ACO) : quelle pertinence pour le système de santé français ? Les Tribunes de la santé, 1, 99–107.
Light, D.W. (2010). Health-care professions, markets and countervailing powers. Handbook of Medical Sociology, 6, 270–289.
Osty, F., Sainsaulieu, I., Uhalde, M. (2007). Les mondes sociaux de l’entreprise : penser le développement des organisations. La Découverte, Paris.
Thornton, P.H. and Ocasio, W. (2008). Institutional logics. In The SAGE Handbook of Organizational Institutionalism, Greenwood, R., Oliver, C., Suddaby, R., Sahlin, K. (eds). SAGE Publications, Thousand Oaks.
Zietsma, C. and Lawrence, T.B. (2010). Institutional work in the transformation of an organizational field: The interplay of boundary work and practice work. Administrative Science Quarterly, 55(2), 189–221.
Foreword by Norbert Nabet The Challenges of Altering Frontiers: For Other More Collaborative Approaches
Healthcare systems are complex, the result of historical evolutions that are sometimes contradictory, rich in their diversity but finally well enough organized to resist change, especially institutional change. In France, however, it is the institution that drives change: a hyper-regulated and over-administered system, the fruit of our poorly tamed health history, rich in specificities, achievements and compromises, and therefore of compartments and sectors with their own governance, representations, rates, authorities, hindered or finally protected by their own partitions.
In France, the law and the administration, in the name of quality, safety and equal access to healthcare, use their traditional tools to organize the system, its robustness and universality, as well as its performance and evolution.
On the one hand, spectacular health crises impose strong and visible, and therefore legislative, reactions. Accustomed to dealing with problems at this level of power, governments have become accustomed to the legislative ritual, turning each presidential term into an opportunity to reform, improve and transform the entire healthcare system, which everyone now, certainly for the sake of simplicity, agrees to refer to it as a healthcare “system”.
Moreover, since the beginning of the 2000s, two symbolic and operational guardianships have been more or less in competition with each other, each issuing its own rules, recommendations and therefore partitions to redundant central and territorial administrations.
Finally, over the last 10 years or so, as arithmetic control of spending has gone from being an exclusive solution to being a problem, the organization of the system – its governance (ARS1), its operation (path) and its evolution (innovation) – has become the embodiment of everyone’s attention, hopes and ambitions.
Unfortunately, if the objective changes, the means resist and the law still prescribes these evolutions, which are for many a decompartmentalization. The homeric struggles of lobbies and corporations condemning, most of the time, the mountain to give birth to a mouse. The system devised by the government is thus often cut off from its essence because it was necessary to find a point of balance in the parliamentary debate and negotiations, be they deliberate or political.
The other legislative framework is the annual Social Security Financing Act, which sets the French national health insurance spending target (objectif national des dépenses d’assurance maladie, ONDAM2). This financial regulation tool has a terrible influence on operational organizations in cities, hospitals and medical-social institutions and services, without any health professional or manager understanding its rationale or the means and methods available to influence it.
With this barely caricatural observation, what can we do? Perhaps, first of all, question our system in order to understand what would make it a readable, controllable and therefore decompartmentalizable organization. Understand in order to act. Choose a reading grid to define a master plan and finally a strategy of actions and innovations that does not erect new partitions and does not increase the cacophony.
Thus, for example, it is not only possible to consider our system, but also our innovation projects, as value propositions addressed to one or more segments of the population or patients, through specific channels and according to specific relationship patterns, relying on resources and activities that mobilize partners. Each of these elements naturally has a cost that must be considered and optimized. It is certainly the methodical, pragmatic and uncompromising analysis of these processes or stages that will enable us to understand and build health organizations that are readable, manageable and therefore decompartmentalizing.
Then, on this basis, the innovation of practices and organizations is first and foremost conceivable at constant law. It is also necessary to point out the legislator’s will to leave a little more room for operators (and not only their representatives) and patients to develop their professional organizations locally and concretely by providing them with contractual and financial tools to help them (art. 51 of the
HPST3 law on cooperation and the LFSS 2018 on organizational innovations, CPTS, GHT4, etc.). In all cases, it is necessary to get to know each other, listen to each other, talk to each other, share a common implicit, acquire tools and methods, experiment, observe related experiences and be able to rely, when necessary, on a benevolent and helpful administration.
It is in this context that the innovations reported in this book were conceived. They are most often the work of pioneers whose leadership and charisma have made it possible to create a space of freedom. In this respect, they show us the way and demonstrate the usefulness of decompartmentalization not only in operating theaters, centers or territories, but also in the production of knowledge and professional practices among professionals themselves and with patients.
The question of the transformation of the system rests on our collective capacity to disseminate these innovations: either by rapidly transferring to them the status of common law rules – this is the spirit of article 51 of the LFSS5 2018; or by authorizing “at the same time” each person to imagine his or her own organization, according to his or her ecosystem and capacities, and by drawing inspiration from a similar, neighboring achievement and relying on flexible and spontaneously evolving regulations.
In all cases, the methods of benchmarking and exchanging practices are central to the dissemination of innovative practices. Operators are too often totally immersed in their work, looking for solutions that, most of the time, exist just a few kilometers away. Facilitating exchanges, the use of social networks, and the publication and distribution of specialized journals or books – such as the one you are about to read, which demonstrates the will, enthusiasm and competence of all the players in our healthcare system – is undoubtedly the best way to progress.
Norbert NABET
Director
Institutional and partnership relations
NEHS Group
March 2021
1
ARS:
Agence Régionale de Santé
; i.e. Regional Healthcare Agency.
2
ONDAM: national health insurance expenditure target.
3
HPST:
Hôpital, Patient, Santé et Territoire
; Hospital, Patient, Health and Territory.
4
CPTS:
Communauté Professionnelle Territoriale de Santé
; Professional Territorial Community for Health; GHT:
Groupement Hospitalier de Territoire
; Territorial Hospital Grouping.
5
LFSS:
Loi de Financement de la Sécurité Sociale
; Law for the Financing of Social Insurance.
IntroductionThe Challenges of “Altering Frontiers”: The Multiple Facets of Boundaries to Cross and Articulate
In most developed countries, health systems and organizations at first glance seem a kind of mystery to anyone wishing to understand their mechanisms and dynamics. Their challenges are well known, and meeting them is a challenge (aging population, rise in chronic diseases, technological upheavals made possible by the arrival of Big Data and artificial intelligence, financial equilibrium, increasing inequalities in access to healthcare and healthcare services, the desire for greater patient autonomy and the legitimacy of their voice and experiences, etc.). Conditions are identified as being reinforced by a system that is too procedural, losing its ability to respond in a personalized and individualized manner to the needs of its users and patients. It appears to be “ungovernable” through the usual channels when it comes to dealing with crises with sudden manifestations that are part of a complex network of causes (such as the COVID-19 pandemic or climate change).
Once this diagnosis has been made, the avenues for transformation have also been identified around the central priority of altering frontiers in a system that is too strongly compartmentalized: inventing new forms of governance and cooperation to counter the impossibility of doing things “collectively” in a pluralist system, and giving back room for maneuver and spaces for inventiveness and transformation to local stakeholders in the face of a system that is heavily top-down and has little trust and legitimacy in a number of stakeholders; and yet, health systems remain difficult to transform when there is an extraordinary number of experiments, creative approaches, local dynamics, organizational reorganizations, etc.
In order to go beyond this apparent paradox, it is necessary to adopt relevant viewpoints that broaden analytical perspectives that are conducive to transformation.
This is why the angle of this book is that of “altering frontiers”, at the micro (stakeholders), meso (various collectives, organized groups) and now macro (organizations) levels. Indeed, the expression “altering frontiers” offers different viewpoints, enabling the researcher and professional and institutional stakeholders to rethink what constitutes a boundary and to act on them in order to organize or coordinate activities differently. This book therefore proposes a new way of analyzing organizational innovations that aim to transform the healthcare system from a vertical and compartmentalized approach to a more horizontal and decompartmentalized one. This approach provides a multifaceted view of the drivers, favorable conditions and methodological principles that can support sustainable transformations in order to “rebuild institutions”.
I.1. Altering frontiers: a boundary concept
Thinking of innovation from a perspective of “altering frontiers” invites us, on the contrary, to invest in that which forms a boundary. Indeed, a boundary makes it possible to name, identify, make tangible or visible what is distinctive between what is inside or outside a “space” (Lamont & Molnar 2002). There are thus multiple dimensions (Zietsma & Lawrence 2010; Bucher & Langley 2016): social, relational, cognitive, symbolic, geographical, temporal, material, institutional, etc. (Zietsma & Lawrence 2010; Bucher & Langley 2016). From this perspective, innovation becomes opportune when crossing boundaries, and makes it possible.
Let us consider, for example, the new methods of intervention with the elderly that are currently emerging in France or in other countries and that are described by the still imprecise expression: EHPAD hors les murs (EHPAD1 outside the walls). For such an establishment, it is a question of intervening in the homes of these people by relocating expertise there. The depth of the innovation is measured in terms of the different boundaries crossed: institutional boundaries between the establishment and the home or professional boundaries between the professions of the EHPAD and the home, for example. Some of the contributions in this book shed light on these crossed boundaries that are necessary to support innovation in the field of healthcare: with the emergence of a new “profession”, that of advanced practice nurses which, according to Philippe Mossé (Chapter 2), attempts to create a new, autonomous professional space between the nurse and the general practitioner; with entry into the domain of the common stakeholders of care or support, of volunteers who, according to Bertrand Pauget (Chapter 3), seek to make the most of their expertise, which is neither professional nor completely lay.
Another way of rethinking boundaries is to design new spaces conducive to innovation (Grenier & Denis 2017), taking the form of original structural reorganizations, which may be internal and/or external, and bringing together stakeholders from different services or structures. This is the case, for example, of teams reshaping their relationships and knowledge when, according to Delphine Wannenmacher (Chapter 4), they use a new technology (surgical robot) to deliver care differently. In this chapter, the author shows in particular how much, with respect to this robot, visual communication (and associated skills) is reduced and the usual partitions (with regard to time and division of work) are no longer effective. In the same way, the creation of service clusters within hospitals constitutes, for Christelle Havard (Chapter 5), a potential for transformation provided that the stakeholders can carry out cooperative work, at three levels: structural (at the level of the hospital as a whole, to divide and coordinate work), operational (at the level of a department, to organize care tasks around the patient) and trajectorial (around the patient to design and implement a care plan). Finally, we can cite the example of the PTA (plateforme territoriale d’appui, territorial support platform), which organizes in an original way the coordination between so-called “front-line” professionals to provide a coordinated response to patients in complex situations. For Matthieu Sibé, Sandrine Cueille and Tamara Roberts (Chapter 7), this organizational innovation will reach its full capacity to provide individualized solutions in the monitoring of trajectories if the stakeholders reinvent their relationships and governance according to the adhocracy model (Mintzberg 1993). This form reflects flexible organizations, combining multidisciplinary and crossdisciplinary skills, capable of adapting to the needs and constraints of the tasks to be accomplished. In this way, another lesson from the various contributions in this book is that the managerial and organizational innovation that accompanies the adoption of new intervention models, new tools or processes only produces its effects if the paradigms relating to modes of governance and decision-making are also transformed (Moore & Hartley 2008).
This calls for a look at a second point to think about innovation, enabled by the boundary concept: creating new networks of knowledge, insights and experience. One way is to introduce new stakeholders who will renew the cognitive reserve of those typically present. With reference to charitable workers working with older people in Sweden, Bertrand Pauget (Chapter 3) examines the interest in encouraging the creation of communities of practice, henceforth called “managed communities” (Bootz 2015), to enable these stakeholders to exchange their experiences in order to improve or even transform them. Focusing on patients, Luigi Flora (Chapter 1) relates the original experience of the “UniverCité” of patients, based in the south of France (Nice). The latter is inspired by similar Quebec models, and brings together health professionals, patients, caregivers, users and civil society to develop experiential knowledge about care, particularly about chronic diseases. It is a double innovation that is thus introduced: the recognition of patients’ knowledge and the recognition of experiential knowledge.
Following the example of this type of university, a community of practice forms spaces conducive to building new knowledge, beyond the diversity of stakeholders, and could generate misunderstandings if it is not accompanied in this way. This misunderstanding is of three kinds (Carlile 2004): syntactic, when the misunderstanding concerns words or acronyms; semantic, when it stems from different representations or values; and pragmatic, when it calls into question the re-articulation of interests and areas of power.
These spaces are favorable to the co-construction of knowledge and discursive elements when they have certain characteristics. Thus, Delphine Wannenmacher (Chapter 4) draws our attention to the importance of establishing interactive and reflexive spaces of dialog, in which the stakeholders will define their language and acquire new skills together. Similarly, Boiteau and Baret (2017), studying a working group on new HR practices in a public hospital, show the conditions under which this group was able to support this innovation: by being a “translation center” within which problematization and enlistment made it possible to “tackle subjects considered until then as taboos” by transforming misunderstandings or disinterest around certain questions into controversies that allow stakeholders to express themselves and develop acceptable proposals. It is here that the quality of the controversy enables innovation (Grenier & Denis 2017).
More broadly, we can understand the significance of new stakeholders in the health field, known by the generic term “intermediary organizations”, “boundary partners” (Chesbrough & Haas 2016) or “brokers” (Hargadon 1997), whose role (political, cognitive and symbolic) is to bring together professionals who are not accustomed to working together or interacting, in order to build new cognitive and discursive resources together. However, following the example of what is generally observed in third places such as FabLabs, do specific methodological resources (such as those provided by Design Thinking; Grenier et al. 2020) still need to be developed to allow stakeholders to cross the boundaries of their institutional embeddedness?
If innovation takes place “at the boundaries”, by putting stakeholders in a position to collaborate despite their different cultural or professional spheres, they must also be able to absorb this “novelty” that is made available. Corinne Grenier and
Christine Dutrieux (Chapter 9) question the extent to which organizations can absorb, and thus bring within their boundaries, ideas, models and practices “from elsewhere”. Absorptive capacity is understood as a set of organizational routines and processes by which the organization acquires and mobilizes external knowledge to produce dynamic organizational capacity (Todorova & Durisin 2007; Imbert & Chauvet 2012). This capacity is based on four processes (or four stages):
1) acquisition, referring to the organization’s ability to recognize, value and acquire external knowledge and ideas;
2) assimilation, referring to the organization’s ability to understand, analyze and interpret this knowledge and ideas;
3) transformation, consisting of the organization’s ability to develop new routines to facilitate the combination of the old and the new;
4) exploitation, aimed at deploying this renewed stock of knowledge and ideas into new projects, activities and processes.
Entering this process means that some distance is necessary in the exploration of new ideas and knowledge from the acquired stock (to avoid absorbing only those with which individuals and organizations are already familiar). This distance is created a priori in the specific places we mentioned above (third places), which host both established operators and start-ups, professionals or entrepreneurs, and very often from various sectors. It is up to Hugo Bertillot (Chapter 10) to offer us an original view on this ability to distance ourselves from habits. He focuses on the comparative management indicators developed since the end of the 2000s, integrated into the certification procedure for public hospitals in France and made public at the national level. They are instruments for regulation, decision support for contractualization and internal drivers for improvement. However, the power of indicators to transform hospitals is far from self-evident. Everything will depend on the ability of the stakeholders to “open the black box” of these indicators, to detect, or even build in, room for maneuver in relation to their habits of doing and thinking.
Finally, this book questions the boundary from a temporal and spatial view by questioning the diffusion of innovation. Many currents are mobilized by the literature investigating the field of health, such as: the adoption of what is new (de Vaujany 2005); a network of stakeholders to advance innovation, by operations of problematization, translation and irreversibility mechanism (Callon 1986), or more recently, by networks of practices (Agterberg et al. 2010, 2011) consisting of organizing the circulation of practices and ideas from one place to another. Healthcare innovation has a high degree of contextualization, stemming from in particular the territorialization of the stakeholders’ intervention; the question is then approached in terms not of adoption but of adaptation (Sahlin & Wedlin 2008).
This adaptation process requires specific methodologies to capture what has been experimented with in order to disseminate it, and in particular everything that is “invisible”, tacit or informal and too often cannot be reduced to “experience capitalization guides”. Thus, for Jessica Gheller, Christian Bourret and Gérard Mick (Chapter 8), dissemination appears to be a “journey” reinforced by an exciting, meaningful communication, making it possible to identify the experiences acquired during an expedition, then continuing with the deployment of a living “memory” that will be enriched as innovations are disseminated in other places. This living memory forms a knowledge base that can be subject to questioning and reflexivity for professionals wishing to adopt experiences already developed in other spaces. It promotes learning, an essential element identified by Frédéric Gilbert (Chapter 6) in his study on the dissemination of the family doctor group model in Quebec. In this experience, it is then, a contrario, the downside of an evaluative approach that prevents this learning and limits the journey from place to place of this original front-line organizational form.
I.2. Conclusion
The creation of a book is always the fruit of a long process. The present project began in 2019 when, in the vast majority of countries, the transformation of the health system was thought to be a long-term process, with uncertain results, and marked by a fiercely negotiated balance between “high” and “low”, between center and periphery, between institutional entrepreneurs and those more inclined to preserve so-called “assets”.
However, its manufacture concludes with a context that is completely new for many: the (global) health crisis of COVID-19 and the ways to combat it. Daily reports (TV, newspapers) recount the major difficulties faced by organizations and health professionals in informing, caring for and accompanying patients, users and caregivers: lack of personnel – and those who remain are exhausted – lack of masks and other protection, insufficient intensive care beds, etc. These are all the aspects of the healthcare system that are affected: hospitals, EHPAD, medical and social institutions providing support or accommodation for disabled children and adults, SAAD and SSIAD2, social services, “front-line” professionals, etc. This crisis will have been a powerful indicator of dysfunctions that have already been in place for a long time.
At the same time, many testimonies have revealed daily the determination of all professionals and other stakeholders (charitable workers and citizens) to continue to practice their “profession for the other”. In many countries, everyone seemed to be rallying for the “common good”, based on a principle of solidarity in capitalist societies (Tirole 2016). What a lot of tinkering! In the sense that, in a do-it-yourself approach, the stakeholder knows the aims of his or her actions, but at the same time, he or she must identify or locate the resources to achieve them (Levis-Strauss 1962; Garud & Karnoe 2003).
These do-it-yourself projects, as varied as they are ingenious and surprising, are all based on the different facets of action that we have just mentioned, all of which are based on the identification of boundaries and the conditions under which they are crossed. However, they reveal, with renewed acuity, three ingredients for a sustainable transformation of the health system: the autonomy of the stakeholders, enabling them to invent solutions; the benevolence of the supervisory authorities, with a view to mobilize methodological and support resources to assist these professionals and organizations; and the need for a sense of control and evaluation to ensure the sustainability of this inventiveness.
Finally, it emerges from most of the chapters of the book that this crisis is also a call to put an end to a culture of “the fairest”. The crisis has revealed what can be called a slack of solidarity, when individuals, companies, merchants, etc., spontaneously offer their help and service. The term slack refers to the surplus (time, resources) which we do not know a priori what it can be used for, except when it has to be used! Schulman (1993) identifies two types of slack: that of resources (surplus not strictly engaged in current activities) and that of control relative to the degree of freedom in organizational activities (i.e. a set of actions that are not framed by formal modes of power, and supervision). It is thanks to these that the crisis is overcome as quickly as possible. May this lesson be kept in mind, not only because some people predict the multiplication and complexity of future crises, but more generally because it is an important condition for any innovative organization, when individuals have time, outside of protocolized and routine activities, to imagine how to renew themselves in a different way.
I.3. References
Agterberg, M., Van den Hooff, B., Huysman, M., Soekijad, M. (2010). Keeping the wheels turning: The dynamics of managing networks of practice. Journal of Management Studies, 47(1), 85–108.
Agterberg, M., Van den Hooff, B., Huysman, M. (2011). Cracking the core: How core members of electronic networks of practice contribute to organizational learning. Annual Meeting of the Academy of Management, San Antonio, Texas, 1–19.
Boiteau, K. and Baret, C. (2017). La conduite du changement en hôpital psychiatrique : le rôle des centres de traduction dans la valorisation des innovations lors d’un projet de promotion du bien-être au travail. Politiques et management public, 34(3–4), 231–246.
Bootz, J. (2015). Comment concilier auto-organisation et contrôle au sein des communautés de pratique pilotées ? Une scoping review. Management international, 19(3), 15–30.
Callon, M. (1986). Éléments pour une sociologie de la traduction : la domestication des coquilles Saint-Jacques et des marins-pêcheurs dans la baie de Saint-Brieuc. L’Année sociologique, 36(3), 169–208.
Carlile, P. (2004). Transferring, translating and transforming: An integrative framework for managing knowledge across boundaries. Organization Science, 15(5), 555–568.
Chesbrough, H. and Haas, W.A. (2006). Open innovation: A new paradigm for understanding industrial innovation. In Open Innovation: Researching a New Paradigm, Chesbrough, H., Vanhaverbeke, W., West, J. (eds). Oxford University Press, Oxford.
De Vaujany, F.X. (ed.) (2005). De la conception à l’usage : vers un management de l’appropriation des outils de gestion. EMS, Caen.
Garud, R. and Karnøe, P. (2003). Bricolage versus breakthrough: Distributed and embedded agency in technology entrepreneurship. Research Policy, 32(2), 277–300.
Grenier, C. and Denis, J.L. (2017). S’organiser pour innover : espaces d’innovation et transformation des organisations et du champ de l’intervention publique. Politiques et management public, 34(3–4), 191–206.
Grenier, C., Ibrahim, R., Duprat, L. (2020). Comment organiser un tiers-lieu éphémère pour favoriser l’émergence d’innovations institutionnelles ? Le cas d’un pôle d’opérateurs de services à domicile. Innovations, 66(1), 89–115.
Hargadon, A. (1997). Technology brokering and innovation in a product development firm. Administrative Science Quarterly, 42(4), 716–749.
Imbert, G. and Chauvet, V. (2012). De la capacité d’absorption à la capacité d’insémination. Revue française de gestion, 221, 111–127.
Lamont, M. and Molnár, V. (2002). The study of boundaries in the social sciences. Annual Review of Sociology, 28(1), 167–195.
Levi-Strauss, C. (1962). La pensée sauvage. Plon, Paris.
Mintzberg, H. (1993). Structure in Fives: Designing Effective Organizations. Prentice-Hall, Upper Saddle River.
Moore, M. and Hartley, J. (2008). Innovations in governance. Public Management Review, 10, 3–20.
Sahlin, K. and Wedlin, L. (2008). Circulating ideas: Imitation, translation and editing. In The SAGE Handbook of Organizational Institutionalism, Greenwood, R., Oliver, C., Suddaby, R., Sahlin, K. (eds). SAGE Publications, Thousand Oaks.
Schulman, P.R. (1993). The negotiated order of organizational reliability. Administration & Society, 25(3), 353–372.
Tirole, J. (2016). Économie du bien commun. PUF, Paris.
Todorova, G. and Durisin, B. (2007). Absorptive capacity: Valuing a reconceptualization. Academy of Management Review, 32(3), 774–786.
Wenger, E., McDermott, R., Snyder, W.M. (2002). Cultivating Communities of Practice. Harvard Business Publishing, Brighton.
Zietsma, C. and Lawrence, T.B. (2010). Institutional work in the transformation of an organizational field: The interplay of boundary work and practice work. Administrative Science Quarterly, 55(2), 189–221.
1
EHPAD:
Etablissement d’Hébergement pour Personnes Agées Dépendantes
; retirement home.
2
SAAD:
service d’aide et d’accompagnement au domicile
(social homecare service); SSIAD:
service de soins infirmiers à domicile
(home nursing service).
Introduction written by Corinne GRENIER and Ewan OIRY.
PART 1Innovations as Seen by Stakeholders
Introduction to Part 1
Taking up the challenge of “altering frontiers” through organizational innovations raises the double question of the place of different individuals in this profound transformation.
Individuals are first and foremost at the heart of this transformation because they are the driving force behind it. They are singular individuals – the innovators – who develop new interdisciplinary practices, implement decompartmentalization and transform usual routines (Gherardi 2008). They transform their practices by experimenting in “innovative spaces” typically outside the organization, sometimes protected from the rules that usually govern it (Bucher & Langley 2016). They are sometimes tired of the multiple social norms to which they cross in order to innovate (Alter 2011). However, they are clearly, for many, the heart and driving force of the organizational innovation process that enables decompartmentalization.
As for the rest of the professionals, even if they are not exactly innovators, are they not also the target of organizational innovations that aim to decompartmentalize? In this way, they discover and experience on a daily basis the transformations that have been designed for them and that they must appropriate and implement. These innovations transform their ways of working, shake up their skills and sometimes their professional identities (Robelet et al. 2005). This can also make them more efficient and even satisfy them by giving more meaning to their work, emphasizing that a decompartmentalized organization ensures better and more effective patient care or support.
“Altering frontiers” through organizational innovations is therefore bringing about interplay of identity dimensions as well as questions of competence or performance.
