Insights Gained From a Re-analysis of Five Improvement Cases in Healthcare Integrating System Dynamics Into Action Research

Document Type : Original Article

Authors

1 Department of Clinical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden

2 Regional Cancer Centre West, Gothenburg, Sweden

3 Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden

4 Department of Geography, University of Bergen, Bergen, Norway

5 LEFO – Institute for Studies of the Medical Profession, Oslo, Norway

6 Institute of Stress Medicine, Gothenburg, Sweden

7 Sahlgrenska University Hospital, Gothenburg, Sweden

8 Institute of Health and Care Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden

Abstract

Background 
Healthcare is complex with multi-professional staff and a variety of patient care pathways. Time pressure and minimal margins for errors, as well as tension between hierarchical power and the power of the professions, make it challenging to implement new policies or procedures. This paper explores five improvement cases in healthcare integrating system dynamics (SD) into action research (AR), aiming to identify methodological aspects of how this integration supported multi-professional groups to discover workable solutions to work-related challenges.

Methods 
This re-analysis was conducted by a multi-disciplinary research group using an iterative abductive approach applying qualitative analysis to structure and understand the empirical material. Frameworks for consultancy assignments/client projects were used to identify case project stages (workflow steps) and socio-analytical questions were used to bridge between the AR and SD perspectives.

Results 
All studied cases began with an extensive AR-inspired inventory of problems/objectives and ended with an SDfacilitated experimental phase where mutually agreed solutions were tested in silico. Time was primarily divided between facilitated group discussions during meetings and modelling work between meetings. Work principles ensured that the voice of each participant was heard, inspired engagement, interaction, and exploratory mutual learning activities. There was an overall pattern of two major divergent and convergent phases, as each group moved towards a mutually developed point of reference for their problem/objective and solution, a case-specific multi-professional knowledge repository.

Conclusion 
By integrating SD into AR, more favourable outcomes for the client organization may be achieved than when applying either approach in isolation. We found that SD provided a platform that facilitated experiential learning in the AR process. The identified results were calibrated to local needs and circumstances, and compared to traditional top-down implementation for change processes, improved the likelihood of sustained actualisation.

Highlights

 

Commentaries Published on this Paper

 

  • Closing the Implementation Gap; Comment on “Insights Gained From a Re-analysis of Five Improvement Cases in Healthcare Integrating System Dynamics Into Action Research”

        Abstract | PDF

 

  •  A Pragmatic and Systemic Approach to Advance Research in Health Policy and Management; Comment on “Insights Gained From a Re-analysis of Five Improvement Cases in Healthcare Integrating System Dynamics Into Action Research”

        Abstract | PDF

 

Keywords


  • epublished Author Accepted Version: February 9, 2022
  • epublished Final Version: February 26, 2022
  1. Brownson RC, Allen P, Jacob RR, et al. Understanding mis-implementation in public health practice. Am J Prev Med. 2015;48(5):543-551. doi:1016/j.amepre.2014.11.015
  2. Davidoff F. On the undiffusion of established practices. JAMA Intern Med. 2015;175(5):809-811. doi:1001/jamainternmed.2015.0167
  3. Greenhalgh T, Wherton J, Papoutsi C, et al. Beyond adoption: a new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies. J Med Internet Res. 2017;19(11):e367. doi:2196/jmir.8775
  4. May CR, Johnson M, Finch T. Implementation, context and complexity. Implement Sci. 2016;11(1):141. doi:1186/s13012-016-0506-3
  5. Øvretveit J, Andreen-Sachs M, Carlsson J, et al. Implementing organisation and management innovations in Swedish healthcare: lessons from a comparison of 12 cases. J Health Organ Manag. 2012;26(2):237-257. doi:1108/14777261211230790
  6. Bååthe F, Norbäck LE. Engaging physicians in organisational improvement work. J Health Organ Manag. 2013;27(4):479-497. doi:1108/jhom-02-2012-0043
  7. Mintzberg H. Structure in Fives: Designing Effective Organizations. Prentice Hall; 1992.
  8. Lindgren Å, Bååthe F, Dellve L. Why risk professional fulfilment: a grounded theory of physician engagement in healthcare development. Int J Health Plann Manage. 2013;28(2):e138-157. doi:1002/hpm.2142
  9. Sterman J. System Dynamics: Systems Thinking and Modeling for a Complex World. Boston: Irwin/McGraw-Hill; 2000.
  10. Rouwette EA. Group Model Building as Mutual Persuasion [thesis]. Nijmegen: Wolf Legal Publishers; 2003.
  11. Ackermann F, Andersen DF, Eden C, Richardson GP. Using a group decision support system to add value to group model building. Syst Dyn Rev. 2010;26(4):335-346. doi:1002/sdr.444
  12. Voinov A, Jenni K, Gray S, et al. Tools and methods in participatory modeling: selecting the right tool for the job. Environ Model Softw. 2018;109:232-255. doi:1016/j.envsoft.2018.08.028
  13. Holmström P, Elf M. Scoping Group Interventions for Suitability in Participatory Modeling. Operations Research Society Conference OR52; September 2009; Warwick.
  14. Andersen DF, Richardson GP. Scripts for group model building. Syst Dyn Rev. 1997;13(2):107-129. doi:1002/(sici)1099-1727(199722)13:2<107::aid-sdr120>3.0.co;2-7
  15. Ackermann F, Andersen DF, Eden C, Richardson GP. ScriptsMap: a tool for designing multi-method policy-making workshops. Omega. 2011;39(4):427-434. doi:1016/j.omega.2010.09.008
  16. Hovmand PS, Andersen DF, Rouwette E, Richardson GP, Rux K, Calhoun A. Group model-building ‘scripts’ as a collaborative planning tool. Syst Res Behav Sci. 2012;29(2):179-193. doi:1002/sres.2105
  17. Scott RJ. Group Model Building: Using Systems Dynamics to Achieve Enduring Agreement. Singapore: Springer; 2018.
  18. Reason P, Bradbury H. The Sage Handbook of Action Research: Participative Inquiry and Practice. 2nd ed. London: SAGE Publications; 2008.
  19. Deming WE. The New Economics for Industry, Government, Education. 2nd ed. Cambridge, MA: Massachusetts Institute of Technology, Center for Advanced Engineering Study; 1994.
  20. Mingers J, Gill A. Multimethodology: The Theory and Practice of Combining Management Science Methodologies. Chichester: John Wiley & Sons; 1997.
  21. Hesse-Biber SN. Navigating a turbulent research landscape: working the boundaries, tensions, diversity, and contradictions of multimethod and mixed methods inquiry. In: Hesse-Biber SN, Johnson RB, eds. The Oxford Handbook of Multimethod and Mixed Methods Research Inquiry. 1st ed. Oxford: Oxford University Press; 2015.
  22. Zolfagharian M, Romme AGL, Walrave B. Why, when, and how to combine system dynamics with other methods: towards an evidence-based framework. J Simul. 2018;12(2):98-114. doi:1080/17477778.2017.1418639
  23. Howick S, Ackermann F. Mixing OR methods in practice: past, present and future directions. Eur J Oper Res. 2011;215(3):503-511. doi:1016/j.ejor.2011.03.013
  24. Brailsford SC, Harper PR, Patel B, Pitt M. An analysis of the academic literature on simulation and modelling in health care. J Simul. 2009;3(3):130-140. doi:1057/jos.2009.10
  25. Fone D, Hollinghurst S, Temple M, et al. Systematic review of the use and value of computer simulation modelling in population health and health care delivery. J Public Health Med. 2003;25(4):325-335. doi:1093/pubmed/fdg075
  26. Scholl HJJ. Action research and system dynamics: can they benefit from each other? Paper presented at: 37th Annual Hawaii International Conference on System Sciences; 5-8 January 2004; Big Island, HI. doi:1109/hicss.2004.1265243
  27. Walker B, Haslett T. System dynamics and action research in aged care. Aust Health Rev. 2001;24(1):183-191. doi:1071/ah010183
  28. Holmström P, Hallberg S, Björk-Eriksson T, et al. Insights gained from a systematic reanalysis of a successful model-facilitated change process in health care. Syst Res Behav Sci. 2021;38(2):204-214. doi:1002/sres.2724
  29. Rosmulder RW, Krabbendam JJ, Kerkhoff AHM, Houser CM, Luitse JSK. Computer simulation within action research: a promising combination for improving healthcare delivery? Syst Pract Action Res. 2011;24(5):397-412. doi:1007/s11213-011-9191-y
  30. Miles MB, Huberman AM, Saldaña J. Qualitative Data Analysis: A Methods Sourcebook. 4th ed. Los Angeles: SAGE Publications; 2020.
  31. Eisenhardt KM. Building theories from case study research. Acad Manage Rev. 1989;14(4):532-550. doi:2307/258557
  32. Peirce CS. Collected Papers of Charles Sanders Peirce. Cambridge: Harvard University Press; 1931.
  33. Kubr M. Management Consulting: A Guide to the Profession. 2nd ed. Geneva: International Labour Organization (ILO); 1986.
  34. James M, Cotter S, Fairley A, Payne A. Hot to Use and Choose a Management Consultant. London: The Economist; 1989.
  35. Rowbottom RW. Social Analysis: A Collaborative Method of Gaining Usable Scientific Knowledge of Social Institutions. London: Heinemann Educational; 1977.
  36. Sjölund A. Gruppsykologi. Vol 2. Stockholm: Rabén & Sjögren; 1979.
  37. Adizes I. Mastering Change: The Power of Mutual Trust and Respect in Personal Life, Family Life, Business, and Society. Santa Monica, CA: Adizes Institute; 1992.
  38. Guilford JP. Personality. New York: McGraw-Hill; 1959.
  39. asadur M, Pringle P, Speranzini G, Bacot M. Collaborative problem solving through creativity in problem definition: expanding the pie. Creat Innov Manag. 2000;9(1):54-76. doi:1111/1467-8691.00157
  40. Parnes SJ. Guide to Creative Action. New York: Scribner; 1977.
  41. Kolb DA. Experiential Learning: Experience as the Source of Learning and Development. 2nd ed. Upper Saddle River, New Jersey: Pearson Education, Inc; 2015.
  42. Kennedy MR. Shapeholders: Business Success in the Age of Activism. New York: Columbia University Press; 2017.
  43. Kemmis S, McTaggart R, Nixon R. The Action Research Planner: Doing Critical Participatory Action Research. Singapore: Springer; 2014. doi:1007/978-981-4560-67-2
  44. Rahmandad H, Sterman JD. Reporting guidelines for simulation-based research in social sciences. Syst Dyn Rev. 2012;28(4):396-411. doi:1002/sdr.1481
  45. Oyo B, Williams D, Barendsen E. Integrating action research and system dynamics: towards a generic process design for participative modelling. In: 2009 42nd Hawaii International Conference on System Sciences. Waikoloa, HI: IEEE; 2009:1-11. doi:1109/hicss.2009.266
  46. Vennix JAM. Group Model Building: Facilitating Team Learning Using System Dynamics. Chichester: John Wiley & Sons; 1996.
  47. Straus DA. Managing meetings to build consensus. In: Susskind LE, McKearnen S, Thomas-Lamar J, eds. The Consensus Building Handbook: A Comprehensive Guide to Reaching Agreement. Thousand Oaks, CA: Sage Publications; 1999:.
  48. Prins S. The psychodynamic perspective in organizational research: making sense of the dynamics of direction setting in emergent collaborative processes. J Occup Organ Psychol. 2006;79(3):335-355. doi:1348/096317906x105724
  49. Von Foerster H. Cybernetics of Cybernetics: The Control of Control and the Communication of Communication. 2nd ed. Minneapolis: Future Systems; 1995.
Volume 11, Issue 11
November 2022
Pages 2707-2718
  • Receive Date: 13 November 2020
  • Revise Date: 01 February 2022
  • Accept Date: 06 February 2022
  • First Publish Date: 09 February 2022