The healthcare sector is currently undergoing tremendous

Innovation in Healthcare: A Systematic Review of Recent Research Hannakaisa Länsisalmi, PhD Researcher, Finnish Institute of Occupational Health, Hels...
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Innovation in Healthcare: A Systematic Review of Recent Research Hannakaisa Länsisalmi, PhD Researcher, Finnish Institute of Occupational Health, Helsinki, Finland

Mika Kivimäki, PhD Professor and Senior Researcher, University of Helsinki and Finnish Institute of Occupational Health, Helsinki, Finland

Pirjo Aalto, RN; PhD Chief Nursing Director, Pirkanmaa Hospital District, Tampere, Finland

Raija Ruoranen, RN; MNSc Human Resource Development Manager, Pirkanmaa Hospital District, Tampere, Finland Research on innovations in healthcare organizations published between 1994 and 2004 are here reviewed and summarized. The majority of the 31 identified studies dealt with the adoption of innovations and new practices and were cross-sectional designs applying quantitative methods, or multiple case studies applying qualitative methods. Five pathways for future research are recommended: (a) Multilevel approaches studying innovation simultaneously on individual, group, and organizational levels; (b) a combination of quantitative and qualitative data; (c) use of longitudinal designs (innovation both as the dependent and independent variable); (d) application of experimental designs in interventions; and (e) exploration of innovation generation and structural innovations.

The healthcare sector is currently undergoing tremendous changes throughout the Western world. The healthcare organizations are all facing the laborious task of staying up-todate in an environment in which medical information, technologies, and relationships with other healthcare systems are in constant flux (Cohen et al., 2004). At the same time, the demographic structure of the population is changing, the number of patients, in general, and those with multiple traumas and higher levels of acuity are increasing. Furthermore, the pressure on governments to reduce healthcare costs while improving quality continues unabated throughout the developed world (Howie & Ericson, 2002; McCue, 1997; Segesten, Lundgren & Lindström, 1998). To make matters worse, many nations are experiencing recruitment and retention crises in the nursing workforce, as the retirement rate of the current staff will increase dramatically within the next 10 years (Pirkanmaa Hospital District, 2004; Warne & McAndrew, 2002). As a result, in the coming few years, governments will face a shortage of skilled nursing staff. Authors’ Note: This review was supported by the Finnish Ministry of Labour (project 040843) and the Academy of Finland (project 105195). Nursing Science Quarterly, Vol. 19 No. 1, January 2006, 66-72 DOI: 10.1177/0894318405284129 © 2006 Sage Publications

Rather fundamental structural and regulative changes have already altered the entire industry in the United States (Lee & Alexander, 1999; McCue, 1997). In Europe, there is a lot of discussion about structural changes that would radically alter the healthcare system in many ways (Segesten et al., 1998; West & Anderson, 1996). On one hand, public and private players in the field are forming new kinds of cooperative networks with the aim of providing more efficient healthcare services of better quality for patients who now have increasing expectations (Berman, 2000; Lee & Alexander, 1999). On the other hand, rapid advances in medicine and technology offer attractive opportunities for radically new medical practices (Jadad & Delamothe, 2004). A large body of literature nevertheless shows that there is still a gap between scientific evidence and actual practice, underscoring the need for change in medical care (Kottke, Solberg, Brekke, Cabrera, & Marquez, 1997; McGinnis, Williams-Russo, & Knickman, 2002; McGlynn et al., 2003). Innovation has become a critical capability of all healthcare organizations. The purpose of this column is to systematically review recent published research on innovations in healthcare organizations. Particular attention is paid to what questions were Keywords: healthcare change, hospital service change, innovation, leadership, management, medical practice, organizational research

Global Perspectives asked and what research designs and methods were used. Research findings on innovations in the healthcare sector are summarized with recommendations for what services, processes, and structures would be best, considering the abovementioned trends and challenges. Gaps and shortcomings in the existing evidence are discussed with five recommendations for future research.

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sents another aspect that inhibits the adoption of other types of innovations. In sum, there exists a need for innovation in healthcare organizations, but the generation of innovations and their adoption is often complicated. In this review, the authors summarize the evidence regarding conditions and factors facilitating and inhibiting innovation in healthcare organizations, and propose some guidelines for future research in the field.

Innovations in Healthcare Innovation can be defined as “the intentional introduction and application within a role, group, or organisation, of ideas, processes, products or procedures, new to the relevant unit of adoption, designed to significantly benefit the individual, the group, or wider society” (West, 1990, p. 309). This definition is largely accepted among researchers in the field (Anderson, De Dreu, & Nijstad, 2004), as it captures the most important three characteristics of innovations: (a) novelty, (b) an application component and (c) an intended benefit. In line with the definition, innovations in healthcare organizations are typically new services, new ways of working and/or new technologies. From the patient’s point of view, the intended benefits are either better health or less suffering due to illness (Faulkner & Kent, 2001). From an organizational point of view, the desired benefits are often enhanced efficiency of internal operations and/or the quality of patient care. The attitudes toward innovations in the healthcare sector, as in other industries, are in general, positive. However, healthcare innovations seem to represent a unique and rather complex case. Several researchers have suggested that it is difficult to change the behaviors of clinicians (Greco & Eisenberg, 1993), current medical practices, and healthcare organizations (Shortell, Bennett, & Byck, 1998; Shortell et al., 2001). Innovations in patient care, treatment practices and hospital procedures may include significant health risks related to financial, social, and ethical issues (Collier, 1994; Faulkner & Kent, 2001). The adoption of healthcare innovations is often regulated by laws, making changes more laborious (Faulkner & Kent, 2001). Moreover, in healthcare organizations performance gaps, typical starting points of an innovation process, may lead to death, disability, or permanent discomfort. This, together with the clinicians’tendencies to protect their individual autonomy and reputation, can promote a culture of blame and secrecy that inhibits organizational learning and the generation of innovations (Huntington, Gilliam, & Rosen, 2000). Furthermore, in medicine new practices in patient care are traditionally examined thoroughly in their early development phases, so that potentially harmful innovations are not adopted (Faulkner & Kent, 2001). Clinicians are, thus, familiar with experimental research methods feasible for clinical research. Evaluation of organizational practice or structure innovations, in turn, requires research methods derived from social studies which, in turn, do not provide quantified answers to research questions and therefore may lack credibility in the eyes of many medical practitioners (Pope, 1995; Pope & Mays, 2000). This repre-

Methods Study Selection and Criteria Reports on innovation in healthcare organizations were located using computer searchers of electronic journals and reference databases. Of the 704 studies identified, only 31 were empirical studies, in peer-reviewed international journals (in English) on the topic of generation, adoption, or diffusion of innovations, or determinants of innovativeness in healthcare organizations. These studies were either field study designs applying qualitative and/or quantitative methods, case studies, intervention studies, or experiments. In other words, the authors excluded 673 review articles, editorials, review commentaries, theoretical model-building contributions without empirical data, and studies that focused on the evaluation of medical innovations. The data from the 31 studies were included in the multidimensional coding process. The first author classified all the studies within eight main areas. 1. Source of research question (questions derived from theory, questions derived from real-world problems, and questions derived from existing studies, so-called replication-extension studies) (Sackett & Larson, 1990). 2. Methodology (action research, case study, cross sectional, ethnography, experiment, grounded theory, intervention, prepost test, and longitudinal). 3. Method (analysis of documents, interviews, observations, questionnaires, analysis of register data, and multimethods). 4. Level of analysis of the innovation in question (individual, group, organization). 5. Innovation process in terms of whether studies had focused on the generation, adoption, or diffusion of innovations. 6. Type of innovation (climate, role, structure, organizational practice, service, technology). 7. Innovation conceptualization (studies applying mainly qualitative methods that focus on revealing content and modelling innovation processes, and studies applying mainly quantitative methods with innovation as either the dependent or independent variable). 8. Country of origin (Finland, Israel, Sweden, United Kingdom, United States).

Results The authors conducted a multidimensional content analysis and summarized the foci and methods used in the 31 research studies on innovations in healthcare organizations. Several interesting findings were identified. The research on

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innovations in healthcare organizations were primarily (62% of the studies) replication-extension in orientation, while 19% of the studies were derived from real-world problems, and 19% were based on theoretical frameworks. The methodologies used varied, ranging from action research to field experiments; multiple case study settings represented the most frequently used methodology (26% of the studies). Crosssectional design studies (23%) were more common than longitudinal designs (19%) in studies using quantitative methods. Of the case studies, 26% used multiple case studies, while 7% used single case studies. Questionnaires were used in 45% of the studies, while interview methods were the second largest group of methods (32%); within 16% of the studies it was the only method used, and it was combined with questionnaires, observations, register and/or document data in another 16% of the studies. In 13% of the studies, multimethod approaches using at least three different types of methods were used. The great majority of the studies reviewed focused on organizational (45% of the studies) or group level of innovations (42% of the studies). Only 13% of the studies focused on individual level innovations, and no studies were found applying a multilevel approach. Similarly, the vast majority of the studies (61%) were focused on the adoption of innovations, 32% focused on innovation generation, and 7% of the studies were diffusion studies. The most common type of innovation studied (36%) was new organizational practices (19% were service innovations and 19% were climate innovations). Surprisingly, only 10% of the studies focused on new organizational structures, and 13% on new technologies. One study (3%) focused on new roles. In the majority of the quantitative studies innovation was conceptualized as the dependent variable (45% of the studies). Only 13% of the studies treated innovation as the independent variable. The majority of the qualitative studies focused on revealing content (26%), that is, on describing factors and conditions enabling and/or inhibiting innovation, whereas only 16% modelled processes and mechanisms in innovation generation, adoption, and/or diffusion. Finally, the coding of the study origin resulted, unexpectedly, in a preponderance of studies from Europe (55%). Northern European countries represented 26% of the total number of studies, North American studies represented 42% of the studies, and one study had been done in Israel (3%). Summary of Findings External factors that were found to have a positive relationship with the adoption of practice and service innovations were involvement, motivation, and support (in the form of training consultants and technical support) provided by key stakeholders in the organizational context (Becker, Dumas, Houser, & Seay, 2000; Cohen et al., 2004; Evashwick & Ory, 2003). Furthermore, active contacts with external parties

were found to enhance the quantity of service innovations and the quantity of new technologies adopted by hospitals over time (Goes & Park, 1997). Findings on the role of competition were mixed. Punctuations in the organizational context that increased competition and lowered profit margins in healthcare services were related to reducing the variety of services provided by hospitals (Haveman, Russo, & Meyer, 2001). A highly competitive county, however, with wealthy residents combined with a high number of hospital beds, was positively related to the early adoption of service and technology innovations among healthcare service providers (Castle, 2001). Finally, a finding that underlines the political and problematic nature of structural innovations in the healthcare sector suggests that hospitals use defensive impression management techniques, such as excuses, justification, and concealment, when announcing organizational structure innovations publicly (Arndt & Bigelow, 2000). Regarding the internal factors facilitating or inhibiting innovation, the research results indicated that strong leadership, shared and clear objectives, task orientation, participative safety, reflective team practices, active internal marketing, correct timing, motivation and participation of personnel, lack of stress, and sufficient resources (financial, instrumental, and personal) all seem to be positively related to innovation in healthcare organizations (Becker et al., 2000; Castle, 2001; Cohen et al., 2004; Edmondson, Bohmer, & Pisano, 2001; Ericson, 2001; Evashwick & Ory, 2003; Felton, 2003; Länsisalmi & Kivimäki, 1999; West & Anderson, 1996). In studies of the structure and type of teams, no differences were found between single-disciplinary, multidisciplinary, management, and primary healthcare teams’ climate profiles, that is, support for innovation and task orientation (Williams & Laugani, 1999). An interesting finding was that primary healthcare teams scored lower on clarity of objectives, participation and support for innovation than did teams used in the oil industry, in National Health Service management, and in community mental health and social service teams (West & Poulton, 1997). Furthermore, the demographic characteristics of the top management team were related to the adoption of new technology. Tenure, level of education, and involvement in a professional society by the top management team was positively related to the adoption of new technology in nursing homes (Castle, 2001). Leadership and leader behavior seemed to be a complex issue in innovation research. Locock, Dopson, Chambers, and Gabbay (2001) found that in addition to an assigned project leader, different types of opinion leaders were influential in the different phases when adopting new clinical practices. A spectrum of involvement of different types of opinion leaders was observed, ranging from expert academic through expert clinician to peer clinical leaders (Locock et al., 2001). The closer the project progressed to the practical implementation phase, the more important the peer opinion leaders’ views became. Ambivalent and resistant opinion leaders also played a

Global Perspectives significant role in the adoption. Ericson (2001), in turn, found that the top management’s differing sense-making processes led to a lack of shared vision and resistance among the team members when implementing a new matrix structure in a hospital organization. Evidence about the effects of the interventions was inconsistent. Some of the interventions aiming at enhancing group interaction patterns, supervisor support, and innovation skills of the personnel had positive effects on innovation and creativity (Berg & Hallberg, 1999; Bunce & West, 1996; Kylén & Shani 2002; Lantz & Severinson, 2001; Newmann & Fitzgerald, 2001), whereas in other studies no effect was observed (Lökk & Arnetz, 2002) or the effects were mixed (Magnan, Solnberg, Glies, Kottle, & Wheeler, 1997). Furthermore, when comparing the different styles of intervention implementation in role innovation, internal customers perceived the bureaucratic style to enhance performance, whereas external customers perceived that person-job integration led to better role performance (Drach-Zahavy, Somech, Granot, & Spitzer, 2004). Telehealthcare was perceived to be successfully adopted through the following evaluative stages: ideation, mobilization, clinical specification, and specific application (May, Mort, Williams, Mair, & Gask, 2003). In a study by Edmondson and colleagues (2001), the adoption of new technology in cardiac surgery departments was successful when the adopters used enrollment to motivate team members, early trials to create psychological safety, and reflective practices to promote shared meaning. Finally, the structural change process where all practical nurses were replaced by registered nurses started with shared feelings of chaos and chaotic organization, proceeded to a stage of creativity, and was followed by feelings of weariness (lack of support and vulnerability). The studies that treated innovation as the independent variable found that in a creative climate nursing staff spent more time with residents with dementia in group dwellings when compared to times on less creative wards (Norbergh, Hellzén, Sandman, & Asplund, 2002). Finally, high levels of support for innovation predicted increased team effectiveness over time (Poulton & West, 1999). Discussion Only 31 studies published during the past 10 years in peerreviewed journals met the quality criteria set for the present review. This number is small considering the widely recognized need for innovations in healthcare practices and organizations in the Western world (Howie & Erickson, 2002; McCue, 1997; Segesten et al., 1998). Numerous structural and regulative changes are currently taking place and forcing healthcare organizations to renew their services, processes, and organizational structures (Cohen et al., 2004; Segesten et al., 1998). There are major limitations in the reviewed studies and the authors propose several guidelines and target areas for future innovation research in healthcare organizations.

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Limitations and Suggestions for Future Research The methodologies applied were surprisingly versatile, which is compatible with such a multifaceted and multilevel phenomenon as innovation in organizations. Several shortcomings in terms of methodology are observed, however. First, cross-sectional studies, which predominated in the reviewed articles focusing on the determinants of innovation, cannot determine the temporal order of relationships, and when both the independent and the dependent variables were measured with self-reports, concerns arose about commonmethod variance. Artificial inflation of relationships may result from confounding by social desirability, acquiescence, and negative affectivity. There is clearly room for more longitudinal studies, especially, for studying different types of innovation as both the dependent and independent variables. The authors encourage future longitudinal studies to employ relatively long-term frames in addition to shorter ones. This enables one to examine whether favorable or adverse consequences of the adopted innovations vary over time, or are temporary, long-standing, or specific to a particular time period (Lee & Alexander, 1999). In the vast majority of the qualitative studies the focus was on revealing content instead of modelling a process. As human conduct is perpetually a process, social reality is not a steady state and thus requires processural research designs in order to be explained thoroughly (Pettigrew, 1997). Furthermore, the single case studies (Ericson, 2001; Felton, 2003) and studies applying action research methodology (Kylén & Shani, 2002; Newmann & Fitzgerald, 2001) included in the present review represent examples of bad qualitative research in terms of design, because they lack descriptions of data collection and analysis. Future qualitative studies must pay more attention to documenting in detail the process of data collection and analysis, which makes the evaluation of qualitative research possible (Länsisalmi, Peiró, & Kivimäki, 2004; Pope & Mays, 2000). If the reader can see neither data nor its analysis, it is impossible to evaluate the validity of the conclusions. Finally, studies have largely ignored the fact that almost all large-scale innovations possess features which cross the levels of analysis among individuals, work groups, and organizations. There is a need for future multilevel research to chart these effects and processes (Anderson et al., 2004). However, all the studies reviewed here focused on only one level of analysis. Furthermore, only one study (Edmondson et al., 2001) linked the variation found in the innovation adoption process to objective outcome measures (successful or unsuccessful adoption). A multilevel approach combining innovation processes with quantitative performance data would be one avenue for generating new knowledge about innovation processes and outcomes in healthcare organizations, and for explaining why and how outcomes are differentially shaped by processes occurring on different levels (Pettigrew, 1997). Currently, in the behavioral sciences, in several types of equi-

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librium models in economics, and in biomedical sciences, the research focus is still predominantly on the outcome of the process and not on the process itself. By introducing more qualitative research methods in the field, one may access areas of social life which are not amenable to quantitative research, such as social construction of organizational reforms and changes in health service provision from the viewpoint of patients and health professionals (Pope & Mays, 2000). Areas in Need of Future Research Due to several methodological problems described above, recommendations for practitioners in the field, based on this literature review, are rather limited. If researchers want to make recommendations based on sound empirical evidence, they should base them on proven temporal and/or causal relationships between conditions, processes, and outcomes. Thus, intervention studies applying experimental or quasiexperimental designs would be feasible for that purpose. As these were rare among the reviewed studies, the authors took a slightly more tolerant approach and accepted also longitudinal studies and multimethod case or grounded theory studies that applied an acceptable level of methodological precision. The reviewed intervention studies suggested that the systematic clinical supervision provided for nurses enhances creativity in the organization through generating trust, liberating time for idea creation, and reducing conflicts in the group (Berg & Hallberg, 1999). Furthermore, an intervention that promoted innovative alternatives for stress management for health workers resulted not only in reduced stress but also in more frequent innovations implemented in the workplace (Bunce & West, 1996). These studies supported the idea that innovation capability may be systematically enhanced and encouraged with specific interventions aimed at improving supervisor support and personnel skills. However, Lökk and Arnetz (2002) found that external support provided for the staff of a geriatric hospital actually hampered the organizational change process compared to the control ward which received no support. A possible reason for this contradictory finding is that excessive intervention in group dynamics might actually lower the group’s self-esteem and its natural ability to cope with changes in the environment (Lökk & Arnetz, 2002). In summary, as the results from the intervention studies reviewed here were mixed, and the studies in general were few in number, more intervention studies with experimental or quasi-experimental designs need to be conducted to identify the best intervention practices for developing innovation capability in healthcare. The reviewed longitudinal studies on innovation-enhancing conditions suggested that healthcare organizations should actively seek contacts with research institutes and other organizations in the environment to become and remain innovative (Goes & Park, 1997). Such active interaction might not only bring new ideas into organizations (Allen, 1977; Goes & Park, 1997), and thus, generate better innovations, but also

ensure the support in terms of resources and motivation provided by key stakeholders in the environment. The role of competition and financial prosperity of the healthcare organizations and the community, in turn, remains somewhat unresolved. High competition combined with low profit margins seemed to be related to reducing services over time (Haveman et al., 2001), whereas competition in a wealthy community with a high number of hospital beds enhanced the adoption of new services and technologies (Castle, 2001). Previous research in the shipbuilding sector has shown that organizations seem to launch innovations in response to low performance (Greve, 2003). In conclusion, how much competition and how many resources are optimum for enhancing healthcare innovations remains unresolved in light of the present evidence and requires further research. In regard to the organizational and team processes, successful adoption of new practices seems to result when several types of opinion leaders are allowed to be involved in the different phases of the adoption process (Locock et al., 2001). Successful adoption of new health technology, in turn, seems to require that new technologies are evaluated on different levels of activity, ranging from initial ideation and mobilization to more detailed clinical specification and definition of applications (May et al., 2003). Edmondson and colleagues (2001) demonstrated how enrollment, early trials, and reflective practices created motivation, psychological safety, and shared meaning within a cardiac surgery team that adopted new technology. Shared goals, participation, task orientation, and support for innovations predicted innovation in top management teams (West & Anderson, 1996). In conclusion, by paying attention to group processes and practices in the adoption and implementation of innovations, one can enhance the innovative capabilities of healthcare organizations and, in the best case, turn the sometimes stressful and difficult collective learning process into a positive and motivating experience. The present review has revealed three largely understudied areas of research in the field. First, organizational change, as a form of innovation, remains a pervasive yet understudied phenomenon in the hospital sector. Even though a lot of reorganization is currently taking place in several healthcare organizations (Lee & Alexander, 1999), only three of the reviewed studies focused on organizational restructuring. Considering how widespread the effects of a hospital reorganization can be, it is surprising that new organizational structures are being adopted without research evidence on the best practices and alternative organizational models that have proven feasible in practice. Recent research seems to focus mainly on the adoption phase of innovation. In the current healthcare environment characterized by continuous changes and cost-efficiency pressures, the phases of idea generation, conceptualization, and legitimatization in the creation of new services and practices are critical. A structured and systematic front-end phase and critical evaluation of the suggested innovations before the adoption might diminish the risk of erroneous investments

Global Perspectives and prioritize the scanty development resources in the healthcare sector more efficiently. Furthermore, a multidisciplinary approach in innovation generation (before extensive investments are made) that carefully analyzes the proposed innovation from various perspectives would facilitate the often very difficult adoption phase (McDonough, 2000) and also enhance the realization of the intended benefits. The development of such practices would require, first, research that identifies efficient practices and processes in the generation phase of different types of innovations. Several researchers have pointed out that it is difficult to change healthcare practices and organizations, in general (Collier, 1994; Greco & Eisenberg, 1993; Shortell et al., 1998; Shortell et al., 2001). However, the so-called dark side of innovation remains largely understudied (Anderson et al., 2004). The innovators often assume a rather stressful role, questioning the existing organizational practices and rocking the boat, and consequently, meet with a lot of resistance (Anderson et al., 2004). If their support is inadequate, they may get stressed, give up, and/or leave the organization. Furthermore, the introduction of innovations in the healthcare sector seems to represent a process that is very political in nature both within the organization (May et al., 2003), and in the wider societal context (Arndt & Bigelow, 2000). This may result in emotionally distressing defensive behaviors, political disputes, and ethical debates. To further our understanding on innovation in the healthcare sector, the authors suggest that future research focuses not only on the bright side, but also on the potential negative aspects related to innovations in healthcare organizations. Conclusions Recent research into innovation in healthcare organizations is active, but not sufficient either in foci or in methodologies. This review has identified several methodological problems and areas requiring research in the field. The need for generating, adopting, and diffusing service, practice, and technology innovations in the healthcare sector remains urgent. The healthcare system is facing huge challenges with its retiring workforce, increasing number of elderly patients, and cost-efficiency demands, combined with expectations of high quality care that exploits all the latest advances in technology and related knowledge. Thus, thorough research that applies an array of methods and multilevel analysis in the field would offer a sound scientific knowledge base for the laborious work of keeping the healthcare sector relevant. References Allen, T. J. (1977). Managing the flow of technology. Cambridge, MA: MIT Press. Anderson, N., De Dreu, C., & Nijstad, B. A. (2004). The routinization of innovation research: A constructively critical review of the state-of-the-science. Journal of Organizational Behavior, 25, 147-173.

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