The unpredictable journeys of spreading, sustaining and scaling healthcare innovations: a scoping review

Everett Rogers’ seminal research on the diffusion of innovations model (DIM) moved the field from technological determinism (i.e. improvements will inevitably be adopted) to a focus on social dynamics (i.e. social factors determine whether and how an improvement will be adopted) [16, 20‐22, 55]. The innovation journey according to Rogers is a process of social exchange and construction in which meanings and values attributed to the innovation take form [56]. His work illustrates that it is not just the properties (relative advantage, compatibility, complexity, trialability and observability) of innovations that determine their diffusion [36, 56], but rather an aggregate set of factors associated with social relations and communication across networks [57, 58]. These include government regulations, social values promoted by various actors and human interactions around a given innovation [22, 59]. Indeed, the properties of an innovation will not have the same meaning and value for all actors within a given context, and communication among various individuals and groups within and across contexts influence the acceptability and dissemination of the innovation [59].

The DIM helps to understand the dynamics that take place in centralised diffusion systems as well as decentralised systems that recognise the agency of users in shaping an innovation [58]. However, the DIM does not focus on the mechanisms and enabling conditions for moving innovations from local to large-scale uptake within complex and highly institutionalised sectors such as healthcare. This paper aims to address this gap, in part by looking at the 3S of healthcare innovations within Rogers’ DIM perspective on the innovation journey.

A scoping review of the literature was undertaken between October 2016 and April 2017, commissioned by the Canadian Foundation for Healthcare Improvement (CFHI). The central research question was: How to facilitate the 3S processes of healthcare innovations? Booth’s five-stage process for scoping reviews [60] was employed, involving (1) an exploratory scoping search of existing reviews to get a sense of the volume and scope of available literature on the research topic in order to identify relevant databases and key search terms for the search strategy, (2) a search for relevant peer-reviewed articles and grey literature papers in these databases, using key search terms (both free-text and thesaurus terms), (3) a search for additional relevant articles by screening the bibliographies (reference lists) of all papers, (4) revision and modification of the initial search strategy to ensure that we included all articles potentially relevant to the research question, and (5) extraction, analysis and recording of data from all articles in the form of summary tables.

We started by exploring 48 prior studies to develop our search strategy. We then used three search engines (EBSCOhost, ERIC, Google Scholar) and seven electronic databases (CINHAL, Academic Search Complete, Business Complete Source, PsycINFO, SocINDEX, MEDLINE, EconLit) to comprehensively search for articles, using the following key search terms: How to Spread OR How to Sustain* OR How to Scale AND Innov* AND health OR healthcare OR health organization* OR health system*. We identified 641 potentially relevant papers from grey and peer-review literature for the review. A two-stage screening process was used. The first stage consisted in reviewing articles by title and abstract, which resulted in 112 articles meriting further review. Papers were retained for inclusion if (1) abstracts included the word(s) spread* AND/OR sustain* AND/OR scale*, (2) papers were specific to the healthcare domain, (3) papers provided conceptual and/or empirical guidance on how to facilitate the 3S processes of healthcare innovation, and (4) papers represented OECD countries. A total of 18 papers met these criteria and were retained. Screening the bibliographies of these papers and hand searching and verification identified 26 additional papers that went on to full-text review, of which 7 met the above criteria and were retained, bringing us to a total of 25 articles for analysis. Finally, the documentation stage involved extracting, analyzing and summarising the following data from the 24 papers included in the review:

We used a two-phase analytical approach to extract and synthesise data from retained papers. First, a descriptive analysis was undertaken to categorise papers according to (1) grey literature or peer-reviewed publication status, (2) the 3S process(es) addressed and (3) their jurisdiction of publication. Second, we conducted a thematic analysis of the data. Three analytical themes were selected by the CFHI based on their organisational needs and priorities, as follows: (1) 3S definitions, (2) 3S mechanisms and (3) conditions that enable or limit the potential for 3S (Table 1). We should emphasise that, while the definition of ‘mechanisms’ used in this study is supported by Normalisation Process Theory (NPT), NPT was not used as a theoretical lens to extract, analyse and record data specific to the 3S mechanisms. NPT is a sociological approach developed to understand the dynamics of integrating new technologies and innovations, particularly in healthcare contexts; in the present paper, we use NPT to add conceptual traction to our efforts to uncover the mechanisms involved in the 3S of healthcare innovations.

Both the descriptive and thematic analyses were performed by a single investigator and were validated through peer-review by stakeholders at CFHI. Following each of three review cycles (submitted December 16th, 2016, February 28th, 2017, and July 19th, 2017), the research team revised and refined the outcomes of the scoping review according to feedback provided by CFHI stakeholders. While it was not among the initial study objectives, recurrent insights emerging from analysis of the data allowed us to inductively identify five key learnings on 3S from which a framework of actionable guidance was developed and submitted to CFHI in the form of a research report (October 12th, 2017). CFHI then created a task force, including the research team and CFHI senior directors, improvement leads and faculty leads, to provide feedback on the framework, which saw multiple iterations before consensus was reached on its final form.

Scoping reviews are useful to answer broad research questions, drawing on a comprehensive literature review to explore the breath of available data produced over a specified time period on a given topic [60]. We performed a scoping review to explore what is known about how to spread, sustain and scale innovations in healthcare. The search and selection process illustrated in Fig. 1 resulted in the inclusion of 24 papers. Of the 24, 15 were peer-reviewed articles and 9 were grey literature publications. The study designs of the peer-reviewed papers included systematic reviews (n = 3), case studies (n = 3), scoping reviews (n = 2), narrative review (n = 1), qualitative grounded theory (n = 1), longitudinal ethnography (n = 1), Delphi technique (n = 1) and others (n = 3). Most of the scientific and grey literature was informed by sociological, organisational and health sciences disciplines. Overall, the literature mainly focussed on the scale of healthcare innovations (n = 7), their sustainability (n = 4), spread (n = 4), or spread and scale (n = 4), or spread and sustainability (n = 4), with only one paper addressing all 3S components. In terms of jurisdiction, most studies were conducted in the United Kingdom (n = 10), followed by Australia (n = 4), Canada (n = 4), the United States (n = 3), New Zealand (n = 1), the Netherlands (n = 1) and Kenya (n = 1).

Descriptive analysis aimed to categorise peer-reviewed articles (n = 15) and grey-literature publications (n = 9) included in the final selection. Tables 2 and 3 present the data extracted from peer-reviewed articles and grey-literature publications, respectively.

An innovation is not an invention, and what is new to some organisations or practitioners may already be very familiar to others. An innovation will have different meanings for different people, which is something that should be valued. Meanings and values that emerge through 3S may challenge usual practices or reveal that an innovation is ill-suited to a given context and consequently result in its rejection. However, the evidence suggests that, if a sufficient number of individuals or organisations have adopted an innovation, it may successfully spread across a system [57]. Given the complexity, dynamism and plurality of healthcare institutions, it appears utopian to expect that the meaning of an innovation remains static over time [112]. Rather than try to propagate a standardised vision of an innovation within a given organisational setting or system, energies should focus on ensuring that everyone involved in or affected by the 3S process can answer why they commit to the innovation; answers will not be the same for everyone [75]. Lags in momentum and interruptions are to be expected along the 3S journey, but it is crucial that stakeholders consider that the innovation adds value to their work and to the quality of care and services they provide to patients [25]. As found by the NHS Scotland Quality Improvement Hub, “focussing on the why” ([94], p. 4) involves efforts such as sharing evidence on the relative advantage of the innovation, highlighting promising experiences from other jurisdictions, and monitoring and measuring performance to see improvement.

Innovation is always, to some degree, disruptive [113]. Innovation demands changes in the usual ways of doing things in an organisation or system [114, 115]. We call the efforts to spread, sustain and scale-up innovations ‘innovation work’ to reflect the emotional and behavioural adjustments potential users must make to put an innovation into practice. Further, adjustments reach beyond the level of individual adopters. The implementation of a new model of care requires changes in the roles of professional groups, in the relationships between providers from various sectors, in the financing of care, in regulations and labour contracts, and in the politics that shape care delivery [116]. Any significant innovation is a source of destabilisation and change for practice settings, and requires commitment from influential leaders and the development of policies to promote alignment between attributes of the innovation and existing regulations, thereby mitigating the negative effects of change [34]. Innovation work can be facilitated by support from influential leaders and by policies that promote alignment between the characteristics of the innovation and system functioning and regulations [104, 116]. Given the effort and energy required, the focus of 3S must be on the perceived value and feasibility of innovations for health system actors. Efforts deliberately engaged by organisational actors, especially in disruptive contexts, are significantly motivated by the value they intend to create. The value pursued by health system actors may refer to the ‘quadruple aim’ of improvements in patient experience, population health and the well-being of healthcare teams, along with reductions in cost. However, as discussed earlier in this paper, value can be decontextualised by individuals into what they intrinsically aim to create or maximise for users, families, citizens, colleagues, etc. In highly pluralistic environments such as healthcare organisations, the feasibility of the efforts innovations require appears as a powerful condition to generate and maintain common values among actors. The belief in people that they are equipped and able to contribute to 3S is crucial to maintaining motivation over time [64, 117‐120]. Supporting and guiding collective action towards common goals throughout the innovation journeys requires the agility to create complementarities among stakeholders, even as each seeks to bring value to their own work and reinforce each other’s competencies to achieve value.

Politicians and policy-makers are often impatient to see change and improvement in health systems [104]. They design and adopt policy reforms that often, from the point of view of healthcare providers, involve a wide range of innovations. Providers often must learn to work and collaborate differently to make innovation a reality in their practice setting. They need support to learn new ways of organising work and delivering care. Innovations are not adopted by reorganising people and rules to support, sustain and eventually spread and scale them up. Rather, innovation will become routine practice if providers have time to incorporate new practices into their local context, learning as they do so, and designing an approach that fits well with local needs and capacities [65]. This is one of the more delicate balances to manage in healthcare innovation – the need to leave space for local adaptation and the risk of diluting the strengths of the innovation [1, 121, 122]. It is not realistic to expect managers and policy-makers to support an open agenda for 3S, nor for providers to maintain motivation and commitment without incentives, especially when the innovation’s benefits in improving patients’ health status and care experience is unclear. However, forcing innovation work within a short-term agenda might hinder its potential sustainability [1]. The focus must therefore be on what people do, rather than what they should be doing. One strategy is to adopt management tools that continuously monitor and provide feedback on the ongoing work accomplished by stakeholders, rather than management tools that aim to increase control and coercion over expected work [123]. The more an innovation circulates across a variety of settings and contexts, the more it – and the stakeholders involved – will change [124]. Focussing on what people do, rather than on what they should do, helps to identify the sources of value and issues of feasibility in innovation work. Moreover, this allows us to situate the value and feasibility of innovation in a mechanism to assess and monitor the innovation process, which creates and protects room for adaptation in the innovation, in people and in the system.

There is growing recognition of the importance of context in shaping the destiny of innovation. Context is a multi-faceted concept. It can refer to broader policy and political context, and to more micro organisational or clinical contexts. The more diverse the contexts (political, organisational, clinical) an innovation touches, the more it will demand exchanges among a variety of actors [125]. An innovation will navigate these interlinked contexts along its journey from delivery to policy, or from policy to delivery [97]. For example, propagation of a new model of primary care may be influenced by negotiations between medical associations and government. To accommodate the multiplicity of contexts and forms of knowledge in the innovation journey, delivery and policy actors will establish a dialogue to arrive at common views of challenges and opportunities. Facilitating an innovation journey requires more than discussions across groups or organisations. This part of innovation work is essentially relational – the aim is for stakeholders to negotiate a way to move an innovation forward that will take their values and interests into account. Strategies to integrate the values and interests of a wide array of stakeholders may include forums and seminars that enable dialogue and problem solving, as well as informal opportunities for communication and deliberation between actors from all levels, from delivery to policy, who may have different views and interests. Champions of an innovation are often seen as facilitators to bridge the various groups affected by the propagation of an innovation, but let’s think outside the box. Evidence points to benefits from distributed and unconventional (e.g. medical secretaries, support staff, patients and citizens) forms of leadership around the 3S of innovation in healthcare [71]. While there are challenges associated with distributed leadership, such as shared decision-making and governance capacities, the presence of genuine experimenters is crucial to accelerate the impact of the 3S of innovation [106, 126]. Dialogue between delivery and policy bodies during innovation journeys (3S) is a significant condition for increasing value, bringing coherence and creating complementarities among parts of healthcare systems that may challenge the penetration of new ways of thinking and doing.

Health systems are driven by the views, values and interests of multiple professional groups and organisations. In such an environment, it is difficult to promote an innovation by decree [127]. The risk of inertia is high and the propagation of innovations that challenge the status quo is slow. Innovations that are minimally or potentially disruptive will be adopted in health systems if they can challenge this inertia. There is a political economy inherent to health systems, and innovations that affect the allocation and circulation of resources or challenge the position of powerful groups will require explicit discussion and strategies to move forward [112]. The focus must therefore be on fostering distributed governance capacities. The involvement of new actors, such as citizens in health policy and patients in the design of care, may provide a strategy for moving forward. However, this may be insufficient on its own – multiple levers for large-scale transformation and improvement are needed. Countervailing powers, such as evidence of the pay-off of innovations, comparison between current practice and the proposed innovation, monitoring and measurement of performance gaps in the system, and dissemination of promising experience in other health systems, may help to challenge the status quo.