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Table 2 Case studies

From: A time-responsive tool for informing policy making: rapid realist review

Project title: Knowledge And Action For System Transformation (KAST): A Systematic Realist Review and Evidence Synthesis of the Role of Government Policy in Directing Large System Transformation Interorganizational Partnerships
Partner: Saskatchewan Ministry of Health National Institutes of Health - Office of Behavioral and Social Science Research and the Canadian Health Services Research Foundation
Funder: Canadian Institutes of Health Research Same as partner
Length of time: Six months Two months
Published article: Best A, Greenhalgh T, Lewis S, Saul J, Carroll S, Bitz J 2012. Large system transformation in health care: A realist systematic review and evaluation of its usefulness in a policy context. The Milbank Quarterly, 90(3): 421–456. Riley BL, Best A. (in press). Stakeholders, organizational partnerships, and coalitions. In S. Kahan, A. Gielen, P. Fagan, & L.W. Green (eds). Health Behavior Change in Populations: The State of the Evidence and Roles for Key Stakeholders. Baltimore, MD: Johns Hopkins University Press.
Purpose: The Saskatchewan Ministry of Health has a mandate to support a significant transformation of the provincial health system. Large system transformation refers to systematic initiatives to create coordinated change across organizations working toward shared priorities within specified boundaries. The Ministry recognizes that success hinges on a cultural change based on collaboration, a comprehensive innovation strategy for system redesign, and systems integration. Therefore, they seek guidance -- on such considerations as successful models and strategies, partnership principles (including with patients), monitoring and evaluation -- from a systematic review of knowledge on large system transformation. With all of these considerations, there is an emphasis on the role of government. To provide a RRR of evidence-based principles for effective interorganizational collaboration and partnership, as the principles relate to two contexts: the collaborations in which health research funders engage; and the forms and processes of linkage within universities and their community partners to promote interdisciplinary health research and effective knowledge exchange. The review also summarized the existing evidence to identify aspects of interorganizational partnerships (a) where sufficient evidence exists to conduct a full systematic review, and (b) where insufficient evidence exists to articulate the further primary research that is necessary.
Questions asked in the review: 1. What are the key mechanisms or social processes that influence or drive successful large systems transformation in the health care sector? 1. What are the evidence, experiential and theory-based critical success factors for increased interorganizational collaboration?
  2. What are the contextual factors that have the most impact (positive or negative) on large systems transformation efforts in the healthcare sector? 2. What is the nature of the evidence, and what is known about external validity and generalizability?
  3. Are there identifiable ‘transition’ points in large systems transformation efforts? If so, how do the key mechanisms and contexts interact to produce these changes? 3. What are the best indicators to monitor collaboration and outcomes a) within the research funder context, b) within the university/institutional (researcher performer) context, and c) within the context of the users of research knowledge (research user)?
  4. What is the role of government or government-like entities (these need definition or at least examples) in large system transformation efforts? 4. What are the strategies most likely to generate buy-in of key influentials in each context for strategic plans and new initiatives?
   5. What does the literature say about the challenges or constraints most likely to affect success in each context?
   6. What does the literature say about stages of the development of collaborations and the most effective tactics at each stage?
Resulting evidence statements (In the full report, each has an associated list of contextual factors and related mechanisms): From a synthesis of literature on the subject, the review identified a number of key factors critical to realizing the full promise of ‘the collaborative advantage.’
  1. Large system transformation in healthcare systems requires both top-down leadership that is passionately committed to change, as well as distributed leadership and engagement of personnel at all levels of the system. 1. Clear common aims. It often takes time and cycling through the various stages of direction setting, action, and trust building, to develop the overarching partnership-level goal, common language, and aims necessary to enable and sustain a productive partnership.
  2. Measurement and reporting on progress toward short- and long-term goals is critical for achieving effective and sustainable large system transformation. 2. Trust. An essential foundation for any partnership, trust builds on itself over time, often starting with modest, low-risk initiatives.
  3. Consideration and acknowledgement of historical context will help avoid unnecessary pitfalls, and increase buy-in and support from system stakeholders. 3. Leadership. Effective interorganizational collaboration requires sustained and engaged leadership, and a shift in leadership/management style from ‘command and control’ to facilitating and empowering, and from delegation to participation.
  4. Large system transformation in healthcare systems relies on significant physician engagement in the change process. 4. Sensitivity to power issues. Each partner in a collaborative brings different resources and strengths. Effective collaboration requires acknowledging these differences and taking care in negotiating expectations and the ground rules for decision-making.
  5. Large system transformation that aims to increase patient-centeredness requires significant engagement of patients and families in the change process. 5. Membership structures. Shared understandings about what the collaboration involves, and formalized rules, roles and structures enable participation. Both governance and task structures are important. The evidence shows the need for effective coordination infrastructure with agreed-action strategies, and sufficient resources, capacity, and role clarity to support good communication and management functions. Because membership is often dynamic and changing, continuing work is essential to sustain the shared understanding and common focus. Effective coordination structures also help speed the uptake of innovations.
   6. Action learning. Effective collaborations continuously improve through feedback loops and reflective shared learning.
Strengths of the review: Much of the success of this review was due to the timely topic, which inspired commitment from the reference group and expert panellists. Key to this was the direct involvement of key decision makers in the Saskatchewan government, which ensured relevancy of the final product and maximized the potential for uptake of the findings. The project was designed for and succeeded in blending practice knowledge with research knowledge. Within the design, this review was unique in the use of a consensus network to validate the findings. This network was made up of national and international experts in the area; using an online survey, they were asked to comment on the five evidence statements and reflect on how well these statements compared with their understanding and experience. Out of 100 people invited, 50 % took part. Considering the voluntary nature and the length of the survey (it took people on average 30 minutes), we deemed this a very good response rate. The consensus network was particularly useful given the literature base was relatively sparse. Also contributing to the success of the project was the opportunity to link the final workshop with another major CIHR initiative, providing an additional opportunity for shared learning and partnering. This review was positioned to inform a strategic planning initiative for OBSSR; as such it was an important support to future work for them and was applied in practice almost immediately. This review began with a key set of articles that were provided by the research team and expert panellists, thus expediting the process. Articles were added as we came across them through citation searching or from the panellists over the duration of the project. As is the case in all successful RRRs, the expert panel was engaged and committed to the topic.
Challenges for the review: As is often a reason for choosing a realist review methodology, the amount of published and grey literature on the topic was scarce. Remedies to this challenge were in-depth and on-going consultation with a reference group and an expert panel, further enhanced by the use of the consensus network. An additional challenge was the fact that the findings were intuitive, and did not appear to provide ‘novel’ solutions or courses of action to the decision makers in the Saskatchewan Ministry of Health. However, they were pleased to have formal confirmation of what they already knew. Considering tacit knowledge often runs ahead of research knowledge, this can be a typical of many reviews, rapid and otherwise. The review had to be done within a two-month timeframe with limited resources. This meant no time or money to include a key word literature search. However, due to the research team’s prior work and the expertise from the panel, the project was initiated with a solid set of articles for review, and completed within the timeframe allocated for the project.