situated change

Change From Within

Anticipated crisis in health care

The solution?

External innovations such as new drugs, nanotechnology etc.

The solution? Evidence-Based Medicine

Successful implementation of innovations, bridging the gap between research & practice

Innovations = Things Awaiting Implementation

?

Innovation = The Ongoing Act of ’Making do’

?

Situated change

• Local acts of improvisation

• Departing from resources ’at hand’ rather than a predetermined goal

• May have unintended consequences

What mechanisms were involved?

The emergence of new orders – ways of doing things

Fluctuations

Recombination dynamics

Stabilizing dynamics

Amplifying dynamics

The transformation of practice

Cross-sectorial and multi-level health care innovation

37 000602010

’Seeing’ patients in a new way13 000432004

Making results transparent & comparable

14071995

Emerging orderPatients in the registry

Clinics using the registry

Year

1990s: New medical evidenceA collective decision to standardize evaluation

11

Amplification & Recombination

Amplification dynamics: Self-organized loops: peer-to-peer

meetings; Registry board was elected: creating

attractors & facilitatorsRecombination: new modules for side-

effects, reusing locally invented modules

1st order:Making results transparent

Disrupted the previous orderFrom private – explicit, transparent

2003:Registry is used at 32 clinicsIncludes >10 000 patients

2004: Technological developments (Internet),

research, economic pressure

Patients were employed

Pain estimation via VAS entered by patient

Patient’s self-assessment of

swollen and tender joints

Amplification & Recombination

Amplification dynamics:self-organized loops: peer-to-peer meetings, emploing a patient in the registry board

Recombination: copying the US idea, repurposing resources, ’creating resources’, reusing locally invented modules, re-interpretaing regulations

2nd order: Seeing patients in a new way

Using the measures to re-distribute tasksPatients are receivers – patients are co-

producers of care

In 2007: Registry is used at 49 clinics24 000 patients included

Amplification & Recombination

Amplification dynamics:self-organized loops: peer-to-peer meetings, courses

Recombination: reusing locally invented modules

2009: Swedish crisis, performance measurement movement

Amplification & Recombination

Amplification dynamics:self-organized loops: peer-to-peer meetings,

coursesTop-level users interested (open

comparisons, local managers promoting use)

Recombination: repurposing the registry

3rd order: cross-sectorial and multi-level health care innovation

A new norm for health care innovation, using new types of evidence in real time

Critical mass of data make new users interested (government and managers)

Generic model for health care innvoation

Stabilizing mechanisms

• Common reference points

• Improving patients’ health via research– finding the cure

• Professional freedom and change initiative

• Collective decisions

• ’Human’ nature of health care

- Expanding borders- Delimiting borders- Creating attractors- Providing ground service

Influencing emergence?Non-managerial management?A manifestation of stabilizing mechanisms?

Previous studies on situated, non-linear change

Unintended consequences as organizational members enact and use new tools in expected but also unexpected ways

The case studied

The environment (external actors and medical, economical, policy, research developments

Health care managers

Front-line employees (health care personnel)

What does this suggest?

• Supports the situated change pespective• Change is not the result of ’break-down’

but ongoing• How can we understand the ’management

of such processes’?• How can we separate ’deliberate’ from

non-deliberate’ activities?