Typology of organizational innovation components: building blocks to improve access to primary healthcare for vulnerable populations

We developed a typology of components of organizational innovations. A typology is a description and categorization of complex organizational forms [21] developed using qualitative (or quantitative) analysis [22]. The goal of a typology is to divide a whole phenomenon – in our case, organizational innovations to improve access to primary healthcare for vulnerable populations – into distinct but related categories [22, 23]. Typologies have been used in primary healthcare with the intent of guiding organizational change and can provide a “menu” of items to inform the design of interventions [24‐29]. In a “typology” – as opposed to a “taxonomy” – items are not ordered hierarchically and are not entirely mutually exclusive.

A qualitative typology is generally structured around a conceptual framework that helps classify emerging categories [22, 23]. In the IMPACT research program, access to primary healthcare for vulnerable populations was conceptualized primarily based on the Patient-Centred Accessibility Framework [18]. This framework posits that access to healthcare results from the interaction, at different stages, between organizational dimensions of healthcare and patients’ abilities (Fig. 1). We focused on the dimensions of accessibility on the organizational side of the framework (i.e., Approachability, Acceptability, Availability & Accommodation, Affordability, and Appropriateness).

Inspired by Greenhalgh et al. [30], we defined organizational innovations as: “a novel set of organizational behaviours, routines, and ways of working that are directed at [a common objective] and that are implemented by planned and coordinated actions.” Organizational innovations to improve access to primary healthcare for vulnerable populations were identified from two complementary sources of data: a) a scoping review of the peer-reviewed literature [17] and b) an environmental scan [16]. Both are described briefly below and have been described in detail elsewhere [16, 17]. The scoping review and scan were conducted as part of the IMPACT research program [19].

A scoping review was conducted to explore the breadth of available evidence on organizational innovations in primary healthcare [17]. The search focused on academic, peer-reviewed literature and was conducted in three of the largest and most relevant databases for studies related to primary healthcare (Medline, Embase, and CINAHL). The search was performed by a specialized librarian (see an example of the search strategy in Additional file 1). In addition to the database searches, four primary care experts from the IMPACT team (including JH) were asked to share their personal primary care reference files, from which citation tracking was performed to identify additional relevant studies. The search was limited to articles published between January 2000 and March 2014, a period corresponding to an international commitment to strengthening primary healthcare, up to the beginning of the IMPACT program. One researcher (VK) scanned 8694 titles and abstracts for relevance, then assessed 1760 potentially relevant studies for eligibility. For the typology, we selected any quantitative, qualitative, or mixed methods studies carried out in Organization for Economic Cooperation and Development (OECD) countries and published in English or French that met all four of the following eligibility criteria:

The 129 eligible full texts were read by three team members (MAS, JH, SD) to select 90 articles where innovations were described in detail.

The environmental scan was conducted after the review. It was designed to capture organizational innovations that had not been published in the academic literature [16]. Briefly, a 5-min online survey was disseminated using a social network approach over 6 weeks between July 10 and August 21, 2014. Primary healthcare informants known to the research team were sent a link to the online survey by email and, in turn, were asked to share the survey link within their social networks. The survey was also promoted on social media through 248 posts on Twitter linked to findings of interest and emerging findings from the survey. Participants were invited to identify a program, service, approach, or model of care that they considered innovative in helping vulnerable populations access primary healthcare. They were encouraged to provide links to any available description, such as websites or documents. The definition of an organizational innovation was left to the discretion of the respondents to ease the response burden. We received 744 survey responses. After screening innovations for eligibility and redundancy, 240 unique innovations were retained for the typology.

We conducted a typological analysis [22, 23]: first, a) of the selected peer-reviewed articles (n = 90) and, subsequently, b) of the selected survey responses (n = 240). Each article (n = 90) was carefully read independently by two individuals (MAS, SD), who focused on the ‘types’ of organizational innovations that addressed accessibility and highlighting all passages describing the innovation. The highlighted passages were used to draft a detailed description of each innovation in an Excel document. For each article, we also extracted information about the setting, target population, and vulnerabilities addressed (e.g., frail elderly, homeless, Aboriginal, low income). Reading the detailed description of each innovation, we used a predominantly inductive approach, grouping similar components recurring across organizational innovations. The unit of analysis was a distinct component that could either be a stand-alone intervention (navigation & information), or a combination of components consistently occurring together (e.g., case management, advanced access). We applied standard labels to components where possible (e.g., community health worker) and descriptive labels to others (e.g., proactive identification of need, cultural adaptation).

Our initial analysis yielded 48 unique innovation components. Most of the innovations reported in the studies were complex interventions that involved 1–14 components, with an average of six components each. Almost all components were established in the first 40 published studies; analysis of additional published studies and the environmental scan led to refinements. The scoping review and scan data coding were reviewed based on this initial typology and adjusted for consistency and to ensure all relevant components had been captured. We then reviewed the innovations coded to each component of the typology to write a short general description of the component and to select illustrative examples of the component.

Two individuals (MAS, JH) then reviewed the initial typology components, descriptions, and examples and mapped them to the organizational dimensions of the Patient-Centred Accessibility Framework [18]. The classifications were based on principal and secondary dimensions of accessibility addressed by the component. Discrepancies in classification were resolved through discussion and checked by the rest of the team.

The 90 selected peer-reviewed studies were set in: the USA (n = 60) [31‐90], Canada (n = 9) [91‐99], Australia (n = 8) [100‐107], UK (n = 6) [108‐113], New Zealand (n = 2) [114, 115], Israel (n = 2) [116, 117], Italy (n = 1) [118], Mexico (n = 1) [119], and Germany (n = 1) [120]. For the environmental scan survey, 45.0% of responses originated from Canada, 40.8% from Australia, 9.4% from others countries (e.g., Ireland, UK, USA, Netherlands, Italy, Israel, Switzerland, Cameroon, India, Indonesia, Sudan) and 4.8% were missing country information [16].

The organizational innovations identified in our data targeted a wide variety of vulnerable populations. Targeted populations typically combined various vulnerabilities, most commonly: low-income, chronic illnesses, Indigenous populations, homeless, migrant or refugee status, ethnic minorities, uninsured or underinsured, marginalized groups (drug users, recently incarcerated), persons with mental illness, the frail elderly, at risk youth, and frequent users of emergency departments.

The final typology was comprised of 18 components of organizational innovations, presented with examples [42‐44, 54‐61, 78‐83, 94‐96, 105, 110, 113, 119‐136] in Table 1. The innovation components are organized by the principal accessibility dimension they address. The 18 components principally addressed the dimensions of Availability & Accommodation (7/18), Approachability (6/18), and Acceptability (3/18). Only one component addressed each of Affordability and Appropriateness as principal dimensions, although these were addressed as secondary dimensions as part of other innovation components.

This typology is intended to provide “building blocks” that can be combined into complex innovations or added to existing organizational processes to address specific access needs of vulnerable populations. The analysis done by Khanassov et al. [17] emphasizes that interventions are most effective in reducing unmet needs, emergency department visits, and hospitalizations when the intervention components are formally coordinated or integrated with other parts of the health system. Integration and coordination are critical considerations in implementing any of these interventions.

The Patient-Centered Accessibility Framework [18] is helpful in both identifying the access needs of the population and the components that are most appropriate to address those needs. For example, a population that frequently visits the emergency department may require an innovation that targets Approachability or Acceptability (e.g., navigation & information, proactive identification of need, culturally adapted services). Conversely, if the target population is seeking services but is disengaged from ongoing care, then Appropriateness-related components such as proactive appointment-making, case management, or one-stop shops may be better suited.

It is not surprising that most of the innovation components pertain to Approachability and Availability & Accommodation. Several studies have highlighted that vulnerable populations often face difficulties perceiving health needs, navigating the health system to find services, finding time to obtain services, making an appointment, and finding transportation to reach services [18, 137‐139]. This typology emphasizes the importance of addressing barriers early in the care-seeking trajectory and provides a range of potential solutions to mitigate these barriers.

Although other components addressed Affordability as a secondary dimension, it is surprising that only one component in the typology (defraying costs to patients) related principally to Affordability, especially given the importance of direct and indirect cost as a barrier to care for vulnerable populations [140‐143]. This result is partly due to our focus on identifying organizational innovations that can be implemented by a single organization or sub-system. Macro-level ‘innovations,’ such as universal health insurance and the Affordable Care Act, were excluded from our analysis because they are country-level legislative policies rather than organizational innovations.

As mentioned, the typology was field-tested for relevance and usability in our local partnerships between 2014 and 2018 as they designed and piloted innovations to address local access priorities for vulnerable populations. In the local partnership in Quebec (Canada), a preliminary version of the typology was used to inform discussions about the design of an innovation for patients from disadvantaged neighbourhoods who face barriers connecting with a regular primary care provider. The innovation was a combination of several components: trained volunteer community members (inspired by community health workers) reached out to patients from disadvantaged neighbourhoods who were on the provincial centralized waiting list to find a primary care provider (existing primary healthcare brokerage) to screen for potential access barriers (proactive identification of need). These volunteers provided support by telephone before and after their first visit with their new primary care provider, including discussing the importance of attending the first visit, offering information about the clinic, giving visit preparation materials, and providing general information about the health system (navigation & information). Stakeholders in the local partnership perceived the typology as a useful tool to expand the menu of innovations and to reflect on how components could be added to existing organizational processes. Furthermore, we used the typology and the Patient-Centred Access Framework [18] to describe each local partnership’s innovations. This tool allowed the IMPACT research team, which spanned six sites in Canada and Australia with different contexts, languages, and terminology, to clarify their aims, improve mutual understanding across sites, and compare their innovations.

The selection of components as part of a complex innovation also depends on the resources and implementation control available to innovation designers. The decision to implement components such as group visits, drop-in services, facilitated appointment making, expanded hours, culturally adapted services, case management, or advanced access are generally within the control of a single primary healthcare organization and can be resourced through the reorganization of existing resources. In contrast, components such as outreach of primary healthcare services, transportation, and navigation & information services require investment of new resources that may be possible for a single organization with a strong commitment and sufficient resources. Other components, such as role expansion and virtual health services, may require changes at a higher level since they involve changes beyond the reach of a single organization. For instance, role expansion – such as nurses working at the top of their scope of practice or empowering front office staff to refer patients to social workers – may require collaboration with professional associations to modify regulations governing professional practice. Similarly, implementing a community health worker may require collaboration with other organizations to set up certified training programs or to secure funding to cover salaries. Similarly, one-stop shops or inter-organizational pathways are based on collaborations between various organizations outside of primary healthcare and require substantial support and political will from local or regional health authorities for implementation.

Because we achieved saturation with the peer-reviewed articles from the scoping review and descriptions of innovations from the environmental scan, we are reasonably confident that this typology reflects the most common innovation components to improve access for vulnerable populations. We recognize that we have excluded innovations outside the study period. Yet, as 2000 to 2014 represents a period of renewal and reform for primary healthcare marked by an effervescence of innovations, we believe that we have captured the most common components to improve access to primary care. Since 2014, we have continued to test the comprehensiveness of our typology by informally comparing it to innovations described in more recent peer-reviewed studies (although we did not use the systematic approach applied to the literature of the study period). In subsequent presentations to international audiences at conferences, we heard of additional examples of innovations, such as organizational arrangements between hospitals and farmers’ markets, but were able to locate them within typology components. We have not found any new components emerging from more recent literature or examples of innovations to add to our typology. An additional strength of this study is that from 2014 to 2018, the typology was field-tested for usability and relevance with local partners to design pro-vulnerable innovations. We are therefore reasonably confident that, although a new scan or scoping review would add detail and examples to the typology, it would not fundamentally change the components.

We also recognize that our scoping review data, from which we developed our initial typology components, described innovations in only nine OECD countries (Canada, USA, UK, Australia, Germany, New Zealand, Italy, Israel, and Mexico). We minimized the effect of publication bias by doing an environmental scan to identify unpublished innovations, but this method is susceptible to selection bias. Most responses came from Australia and Canada, and running the survey during the Northern Hemisphere’s summer may have limited responses from Europe and the USA. We also have no way of assessing the response rate or comprehensiveness of responses gathered using the social media approach. Although we did have a small number of respondents from low-income countries in our environmental scan, our approach may have excluded some innovative initiatives in low- and middle-income countries (e.g., community-based insurance plans [144], identification of accredited clinics [145], and subsidized payments for primary healthcare services [146]. Another example is the well-known hub-and-spoke models in India [147], which combine role expansion with inter-organizational pathways to provide low-cost, high-quality services to underserved populations [148].