SUMMARY

Situated novelty

A study on healthcare innovation and its governance

 

Healthcare innovation and questions on governance

There are enormous expectations of what innovation could mean for care provision and the quality, accessibility and affordability of our healthcare systems. The results are already here. Novel technologies are improving our well-being, diagnostic technologies detect severe diseases in an early stage, treatments are available for diseases that were long thought incurable and several social innovations are improving health outcomes. Even though innovation has already brought much to healthcare, what is known as the 'innovation logic' - a collection of assumptions on innovation - currently limits our understanding of innovation processes. This innovation logic dominates current thinking about and understanding of healthcare innovation practices and policy. It has three main aspects: (1) it shows a strong preference and overrepresentation for technological innovation, (2) it claims that innovation is inherently good and uniformly positive, and (3) it reasons from a basic idea of linearity in processes of innovation.

 

These ideas on innovation have led to high hopes and enormous expectations of what innovation could bring in terms of solutions for many of the great challenges our societies and healthcare systems currently face. Linear thinking leads to clear distinctions between phases of development and a general idea of 'optimal implementation processes' with clear-cut guidelines. Practice-oriented research has, however, shown a different reality. It describes innovation as an inherently complex process. Though valuable for some innovation practices, these characteristic have negative effects as well. With its emphasis on radical - mostly technological - innovation, its smooth implementation and somewhat unproblematic nature, the innovation logic tends to leave unnoticed or unarticulated certain innovations, potential risks and downsides of innovation and the normativity of innovation.

 

The dominance of the innovation logic in public and scientific debates raises questions on how to manage innovation and organize it in practice. On the one hand there seems to be a strong desire to stimulate and enhance innovation practices by providing room for creativity, novelty and experimentation. On the other hand, however, there is a great desire to get a grip on or control over the same innovative developments. This dual desire raises questions on the governance of healthcare innovation, a topic of key importance in this study.

Governance, as discussed in relation to innovation in this study, refers to the collection of ways we use to stimulate innovation and to attempts to monitor, influence and intervene in the way innovations contribute to public values such as the quality, affordability and accessibility of care. This study sees the notions of 'governance' and 'innovation' as paradoxically related, in what is described as the 'governance struggle of healthcare innovation'. Paradoxically because it relates to the dual desire related to innovation in a sector such as healthcare. On the one hand there is the strong desire and collection of attempts by governments, healthcare insurers and managers etc. to organize, structure, steer and enhance innovation processes through programs, procedures and structures; and on the other hand there is the knowledge that innovation processes are often messy, unpredictable, uncertain, and chaotic. This study further explores this inherent paradoxical relation between innovation and governance. Based upon lessons learned in case studies of innovation practices, this study develops an alternative perspective to governance in answering the following research question:

 

How are healthcare innovations enacted in practice, and what can be learned from such an understanding about the governance of processes of innovation?

 

Instead of defining innovation beforehand, it is analyzed what the notion of innovation entails and means for practice. To learn lessons for the governance of innovation, this study makes the way innovations emerge, come about or are enacted in practice the specific subject of study. To gain an enhanced understanding of an innovation's normativity and engage with this topic directly, this study focuses on how value for an innovation comes into being, is created or enacted, negotiated and agreed upon in processes of innovation. This study's sources of data collection and analysis are five case studies and four theoretical paradigms.

 

Theoretical framework

Theoretically, this study builds strongly on innovation studies, a field nowadays recognized as a distinct scientific discipline. Positioned at the crossroads of sociological, technological, economic and policy studies, the literature in this field contains valuable insights into innovation and innovation processes. Besides defining innovation as novel technologies or artifacts, this literature also describes how innovation processes evolve. Descriptions vary from linear explanations that describe innovation as a rather straightforward process from invention to implementation and diffusion, to more systemic approaches that describe innovation as interactional and contextual processes. Lately the field has focused on social and interactive processes of change with respect to innovation. It has also been criticized for that it tends to underemphasize social, contextual, ethical, managerial and institutional elements of innovation processes. Partly because of this, this study builds on and adds insights to innovation studies by incorporating insights from three other theoretical fields.

 

Process theory is used to unravel what innovation is in practice. This field rests on a relational ontology and sees process as constitutive of the world. It does not deny the existence of concrete states, events, and entities, but insists on unpacking them so that the processes that contribute to their constitution are revealed. Considered from a process perspective, it implies that an innovation is never just a thing, technology or object, per se. Rather, it is conceptualized as something that embodies numerous processes and encounters between actors in ongoing processes. In this study, process theory is helpful in achieving a better understanding of processes of innovation.

 

The field of institutional theory is used to explain how innovations do not emerge out of nothing but are developed within highly institutionalized contexts. It helps in analyzing the role of actors as it contains descriptions of how actors can escape the so-called 'paradox of embedded agency': how actors, constrained by their institutional context, act to change that same context. In this study, agency-centered views on institutions are used to describe how institutions are both constitutive of the structure and context for innovation, just as they are the product of agents' interactive behavior. As such, institutional theory enables the analysis of actor's roles in innovation as it elucidates the interactions between an institutional context and the everyday practice and experiences of actors.

 

This study also builds on science & technology studies. This broad body of literature is used to describe that talking about 'the diffusion of innovations' is somewhat misleading as it neglects the role of work and materiality in innovation processes. As such, STS sheds a light on why innovations do not come naturally. It also offers a vocabulary and discourse to discuss the material, symbolic and social aspects of innovation processes.

 

Taken together these theoretical paradigms pave the way for the analysis of innovation processes in this study. The different streams of literature complement each other. A focus on analyzing innovations and identifying conditions for their development in innovation studies is supplemented with insights into how innovations are 'enacted' and 'come into being' in processes of work from the field of process studies. Whereas institutional theory emphasizes the role of individuals in achieving change in practice and takes the interactive context in which innovations emerge seriously, STS emphasizes that political, cultural and social-technical aspects of innovation matter as well - for example in showing the role of values, materiality and performativity in innovation processes.

 

Case studies and their results

Empirically, this study consists of five case studies into different healthcare innovation practices. The case studies and their main results are briefly described below.

 

In Chapter 2, the one-year innovation program in rehabilitation care forms the setting for the analysis of four innovation practices. Based on data collected in the form of observations and interviews with a variety of actors this chapter shows how people assign other meanings to innovation than 'novelty'; how innovation usually entails extensive work and how both innovation and its value are constructed in practice. Based upon these results, an alternative ontological conceptualization of innovation is introduced, as 'situated novelty'. This conceptualization extents current understandings of innovation and has major implications for the management of innovation in organizational practice.

 

In Chapter 3, innovation processes are analyzed by looking into entrepreneurial strategies. The focus on healthcare entrepreneurs finds its legitimation in the fact that entrepreneurs are often an important source of innovation as they are often the ones responsible for introducing them in practice. An analysis of the interaction between entrepreneurs and the context in which they operate delivers insights into the role of individuals in innovation processes that take place in institutionalized settings. Results of the conducted interviews show that entrepreneurs experience the interaction with the healthcare system context in various ways and act accordingly. Identifying this interaction in terms of influences and strategies led to a fourfold typology of healthcare entrepreneurs. The entrepreneurial types in this typology differ in terms of behavior and their beliefs as to if and how individuals can contribute to achieving structural change in healthcare.

 

Chapters 4 and 5 both analyze the development of a particular kind of healthcare innovation, i.e. new professional roles. These roles are worth studying as the reconfiguration of human resources for health is considered a promising innovative development with respect to threats to the sustainability of the healthcare system. Chapter 4 focuses on how the roles of professionals are constantly shaped and reshaped and how new professional roles get institutionalized in and beyond organizational environments. Results - coming from three studies in different clinical settings - show how new professional roles are institutionalized through the work of individuals in the organizational, professional and patient domain. This chapter shows the importance of daily work in institutional processes. Chapter 5 dives into the individual level, focusing on actors that constitute the innovation. Based on the theoretical notions of place and job crafting this chapter describes how new professionals actively create their own role in practice. Results from a study in two different practices point at the fluidity of the place for new professionals. Experience, routines, specializations and trust between new professionals and other staff members are important and enable professionals to gradually expand their role. It is concluded that new professionals add specific meanings to their role both individually and collectively and as such create a new work identity and place for themselves.

 

Chapter 6 explicitly discusses policy for innovation as it studies the design and functioning of two innovation programs in Dutch healthcare, one in long-term care and one in rehabilitation care. Results on how the programs work and what they do describe how programs are not merely a context for innovation. They appear to influence innovation practices directly through processes of facilitation, legitimation and prioritization. In conceptualizing them as performative accomplishments, it is argued that not their design but the way they are managed determines these programs' effects.

 

Main conclusions of this study

An elaborate cross-case analysis of the five case studies results in two main conclusions for this study: (1) a conceptualization of innovation as situated novelty and (2) an alternative perspective on the governance of innovation introduced and described as 'the situated novelty approach'.

 

Innovation as situated novelty

Insights into the nature of innovation from this study show that innovations are not always considered new. Novelty is a matter of perspective. What an innovation exactly is, is constructed in a social context. Instead of being defined as merely something new, innovation is described as processes of work, a strategic label, a symbol, an opportunity or a struggle. These meanings can vary over time and space. That is why innovation is best described as 'situated novelty'. Innovation processes are situated; they are local by definition. Innovations get enacted in specific practices; they are not fully determined by their design but are the result of practices in which many actors use and further develop an innovation, sometimes in unexpected ways. It is through these interactive processes that the value of an innovation is constructed - both for the actors involved and for healthcare in general. This implies that an innovation is not good in itself, but rather has a direct relation to a range of values. Additionally, it shows that the way innovation processes evolve can only be understood from within the context of those specific practices. The conclusion that innovations are situated makes them representative for unique sets of local actions, interactions and dynamics. Because an innovation is best described as a situated practice of ongoing work, it is conceptualized as situated novelty. This conceptualization directly impacts the other aim of this study, i.e. to learn lessons for the governance of healthcare innovation.

 

The situated novelty approach to the governance of healthcare innovation

The emphasis on situatedness in the understanding of innovation has a meaning beyond its mere conceptualization. This broader meaning is enshrined in an alternative approach to the governance of healthcare innovation that this study developed. Insights into innovation and innovation processes have provided the building blocks of the theoretically and empirically inspired situated novelty approach to the governance of healthcare innovation. This approach describes how innovation - as it emerges from contextualized, interactional and time-dependent processes - is open and reflexive and rhymes with the desire to influence, steer, and organize innovation processes in complex contexts. It describes how doing governance according to the situated novelty approach is about supporting, shaping, and modulating a field rather than trying to organize, steer or supervise and control it. This approach concludes that the governance of healthcare innovation is, in essence, about influencing and enhancing an emergent, temporary, fluid and mostly unforeseen process which requires reflection on the normative effects that are enacted over time. An overview of the situated novelty approach is presented below (Table S1).

 

Table S1: Overview of the situated novelty approach to the governance of healthcare innovation

#	Building Blocks	Description
1	Innovation	What an innovation exactly is, is situated and both contextually and socially constructed. An innovation is not just something novel; it represents a process. Innovations are ambidextrous - i.e. they are stable in terms of the basic idea or fundamental change they represent and flexible in terms of their exact appearance. What is seen as the innovation is created in continuous processes of work.
2	Innovation processes	Situated and ongoing processes of work determine and potentially change what an innovation is in practice. What happens, how it happens, why it happens, who is making it happen and to what results it leads depends on where and when it happens. Innovation is a situated practice. Innovations are enacted, produced, reproduced, reformulated or sometimes resisted under the influence of local behavior of actors in different, historical, cultural, social and economic contexts. As innovations represent ongoing processes, it is misleading to define a clear beginning and end to an innovation process or to see them as separately planned processes.
3	Normativity & value	Novelty is not decisive in determining an innovation's value. A healthcare innovation finds its legitimation in ideas on what good care is or ought to be. This normativity is important in the understanding of how innovation processes evolve, especially in sectors such as healthcare where the public interest is not always unequivocal. Also the performativity of innovations and innovation policy makes that value deserves renewed attention. Actions taken to organize or influence innovation processes have an importance in themselves, whatever the achieved outputs eventually are.
4	Doing governance	Governance is about influencing and enhancing an emergent, temporary, fluid and mostly unforeseen innovation process. It is about the modulation of ongoing processes rather than top-down steering and exercising control expecting to achieve predetermined goals. While acknowledging the paradoxical relation between governance and innovation, doing governance is about finding ways to support, shape, and modulate a field rather than trying to organize, steer or supervise and control it. In the concrete act of governance it is learned and enacted what constitutes 'good', therefore doing governance rests for a large part on the facilitation of good quality conversations in practice.

 

Implications for management, policy and research

The situated novelty approach to the governance of healthcare innovation has potentially major implications for innovation management, policy and research in healthcare and beyond.

 

The main implication of this study's findings for innovation management is that management can actively influence innovation processes and the involved dynamics, but only when it consists of processes of continuous coordination in emergent and situated processes of change. In this way, the management of innovation goes beyond setting conditions that merely cultivate novelty. Two topics are of particular importance: 'work' and 'normativity'. Management could focus its efforts on facilitating the work inherent to innovation as this would enhance the organization's innovative capacity. The normativity of innovation asks managers to organize reflexivity and reflection in practice in order to create legitimacy and value for their innovations. In sum, 'organized reflexivity' could help in discussions on innovations, their normativity and the work that is required.

 

The main implication of this study's findings for innovation policy is that governments play an active role in the governance of innovation. In fulfilling this role, governments should be aware of the normativity and performativity of innovations and the policy instruments they develop. This awareness has potentially huge implications for how innovation programs - often referred to as the pre-eminent instrument for innovation - are designed and implemented. The situated novelty approach shows how programs are not standardized instruments that lead to uniform innovative applications. Programs are performative accomplishments which require flexibility to be successful as a reflexive space.

 

The main implication for research is that the topic of healthcare innovation and its governance deserves further exploration in several ways as there is still much theoretical and empirical work to be done. For example, more research into the contextual processes of value creation could enhance understanding of the variety of 'goodness' that is associated with innovation. Although possibly counterintuitive, more research into the negative outcomes of innovation, into 'failed' innovations and into stability or situations in which no innovation is taking place, could also increase our understanding of innovation and processes of innovation. As innovation theory is still theory in the making, our understanding of innovation could profit from more multidisciplinary research that further modifies theories of innovation.

 

Taken together, these implications represent a change of register from an innovation logic that builds on great promises to a view based on lessons learned in innovative practices. The situated novelty approach this study developed offers an alternative perspective on the governance of healthcare innovation and should be read as an alternative way of thinking about, and looking at, healthcare innovation and its governance. It may offer partial solutions for the paradoxical relation between governance and innovation. I hope that situated novelty will prove to be the start of an approach that curbs our abilities to govern innovation just as it may enhance them.