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Managing boundaries in primary care service improvement: a developmental approach to communities of practice.

ABSTRACT: Effective implementation of change in healthcare organisations involves multiple professional and organisational groups and is often impeded by professional and organisational boundaries that present relatively impermeable barriers to sharing knowledge and spreading work practices. Informed by the theory of communities of practice (CoPs), this study explored the effects of intra-organisational and inter-organisational boundaries on the implementation of service improvement within and across primary healthcare settings and on the development of multiprofessional and multi-organisational CoPs during this process.The study was conducted within the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester-a collaborative partnership between the University of Manchester and local National Health Service organisations aiming to undertake applied health research and enhance its implementation in clinical practice. It deployed a qualitative embedded case study design, encompassing semistructured interviews, direct observation and documentary analysis, conducted in 2010-2011. The sample included practice doctors, nurses, managers and members of the CLAHRC implementation team.The study showed that in spite of epistemic and status differences, professional boundaries between general practitioners, practice nurses and practice managers co-located in the same practice over a relatively long period of time could be successfully bridged, leading to the formation of multiprofessional CoPs. While knowledge circulated relatively easily within these CoPs, barriers to knowledge sharing emerged at the boundary separating them from other groups existing in the same primary care setting. The strongest boundaries, however, lay between individual general practices, with inter-organisational knowledge sharing and collaboration between them remaining unequally developed across different areas due to historical factors, competition and strong organisational identification. Manipulated emergence of multi-organisational CoPs in the context of primary care may thus be problematic.In cases when manipulated emergence of new CoPs is problematic, boundary issues could be addressed by adopting a developmental perspective on CoPs, which provides an alternative to the analytical and instrumental perspectives previously described in the CoP literature. This perspective implies a pragmatic, situational approach to mapping existing CoPs and their characteristics and potentially modifying them in the process of service improvement through the combination of internal and external facilitation.

SUBMITTER: Kislov R

PROVIDER: S-EPMC3514317 | biostudies-literature | 2012 Oct

REPOSITORIES: biostudies-literature

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Managing boundaries in primary care service improvement: a developmental approach to communities of practice.

Kislov Roman R Walshe Kieran K Harvey Gill G

Implementation science : IS 20121015

<h4>Background</h4>Effective implementation of change in healthcare organisations involves multiple professional and organisational groups and is often impeded by professional and organisational boundaries that present relatively impermeable barriers to sharing knowledge and spreading work practices. Informed by the theory of communities of practice (CoPs), this study explored the effects of intra-organisational and inter-organisational boundaries on the implementation of service improvement wit ...[more]

PMID: 23068016

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Project description:BackgroundHealthcare systems and their primary care practices are redesigning to achieve goals identified in Patient-Centered Medical Home (PCMH) models such as Veterans Affairs (VA)'s Patient Aligned Care Teams (PACT). Implementation of these models, however, requires major transformation. Evidence-Based Quality Improvement (EBQI) is a multi-level approach for supporting organizational change and innovation spread.ObjectiveTo describe EBQI as an approach for promoting VA's PACT and to assess initial implementation of planned EBQI elements.DesignDescriptive.ParticipantsRegional and local interdisciplinary clinical leaders, patient representatives, Quality Council Coordinators, practicing primary care clinicians and staff, and researchers from six demonstration site practices in three local healthcare systems in one VA region.InterventionEBQI promotes bottom-up local innovation and spread within top-down organizational priorities. EBQI innovations are supported by a research-clinical partnership, use continuous quality improvement methods, and are developed in regional demonstration sites.ApproachWe developed a logic model for EBQI for PACT (EBQI-PACT) with inputs, outputs, and expected outcomes. We describe implementation of logic model outputs over 18 months, using qualitative data from 84 key stakeholders (104 interviews from two waves) and review of study documents.ResultsNearly all implementation elements of the EBQI-PACT logic model were fully or partially implemented. Elements not fully achieved included patient engagement in Quality Councils (4/6) and consistent local primary care practice interdisciplinary leadership (4/6). Fourteen of 15 regionally approved innovation projects have been completed, three have undergone initial spread, five are prepared to spread, and two have completed toolkits that have been pretested in two to three sites and are now ready for external spread.DiscussionEBQI-PACT has been feasible to implement in three participating healthcare systems in one VA region. Further development of methods for engaging patients in care design and for promoting interdisciplinary leadership is needed.

Dataset Information

Managing boundaries in primary care service improvement: a developmental approach to communities of practice.

Publications

Managing boundaries in primary care service improvement: a developmental approach to communities of practice.

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