Situated change
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Transcript of Situated change
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Change From Within
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Anticipated crisis in health care
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The solution?
External innovations such as new drugs, nanotechnology etc.
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The solution? Evidence-Based Medicine
Successful implementation of innovations, bridging the gap between research & practice
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Innovations = Things Awaiting Implementation
?
Innovation = The Ongoing Act of ’Making do’
?
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Situated change
• Local acts of improvisation
• Departing from resources ’at hand’ rather than a predetermined goal
• May have unintended consequences
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What mechanisms were involved?
The emergence of new orders – ways of doing things
Fluctuations
Recombination dynamics
Stabilizing dynamics
Amplifying dynamics
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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
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1990s: New medical evidenceA collective decision to standardize evaluation
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11
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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
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1st order:Making results transparent
Disrupted the previous orderFrom private – explicit, transparent
2003:Registry is used at 32 clinicsIncludes >10 000 patients
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2004: Technological developments (Internet),
research, economic pressure
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Patients were employed
Pain estimation via VAS entered by patient
Patient’s self-assessment of
swollen and tender joints
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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
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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
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Amplification & Recombination
Amplification dynamics:self-organized loops: peer-to-peer meetings, courses
Recombination: reusing locally invented modules
2009: Swedish crisis, performance measurement movement
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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
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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
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Stabilizing mechanisms
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• Common reference points
• Improving patients’ health via research– finding the cure
• Professional freedom and change initiative
• Collective decisions
• ’Human’ nature of health care
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- Expanding borders- Delimiting borders- Creating attractors- Providing ground service
Influencing emergence?Non-managerial management?A manifestation of stabilizing mechanisms?
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Previous studies on situated, non-linear change
Unintended consequences as organizational members enact and use new tools in expected but also unexpected ways
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The case studied
The environment (external actors and medical, economical, policy, research developments
Health care managers
Front-line employees (health care personnel)
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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?