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Advancing the application of systems thinking in health: realist evaluation of the Leadership Development Programme for district manager decision-making in Ghana.

ABSTRACT: Although there is widespread agreement that strong district manager decision-making improves health systems, understanding about how the design and implementation of capacity-strengthening interventions work is limited. The Ghana Health Service has adopted the Leadership Development Programme (LDP) as one intervention to support the development of management and leadership within district teams. This paper seeks to address how and why the LDP 'works' when it is introduced into a district health system in Ghana, and whether or not it supports systems thinking in district teams.We undertook a realist evaluation to investigate the outcomes, contexts, and mechanisms of the intervention. Building on two working hypotheses developed from our earlier work, we developed an explanatory case study of one rural district in the Greater Accra Region of Ghana. Data collection included participant observation, document review, and semi-structured interviews with district managers prior to, during, and after the intervention. Working backwards from an in-depth analysis of the context and observed short- and medium-term outcomes, we drew a causal loop diagram to explain interactions between contexts, outcomes, and mechanisms.The LDP was a valuable experience for district managers and teams were able to attain short-term outcomes because the novel approach supported teamwork, initiative-building, and improved prioritisation. However, the LDP was not institutionalised in district teams and did not lead to increased systems thinking. This was related to the context of high uncertainty within the district, and hierarchical authority of the system, which triggered the LDP's underlying goal of organisational control.Consideration of organisational context is important when trying to sustain complex interventions, as it seems to influence the gap between short- and medium-term outcomes. More explicit focus on systems thinking principles that enable district managers to better cope with their contexts may strengthen the institutionalisation of the LDP in the future.

SUBMITTER: Kwamie A

PROVIDER: S-EPMC4073809 | biostudies-other | 2014 Jun

REPOSITORIES: biostudies-other

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Advancing the application of systems thinking in health: realist evaluation of the Leadership Development Programme for district manager decision-making in Ghana.

Kwamie Aku A van Dijk Han H Agyepong Irene Akua IA

Health research policy and systems 20140616

<h4>Background</h4>Although there is widespread agreement that strong district manager decision-making improves health systems, understanding about how the design and implementation of capacity-strengthening interventions work is limited. The Ghana Health Service has adopted the Leadership Development Programme (LDP) as one intervention to support the development of management and leadership within district teams. This paper seeks to address how and why the LDP 'works' when it is introduced into ...[more]

PMID: 24935521

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Project description:BackgroundHealth systems interventions, such as capacity-building of health workers, are implemented across districts in order to improve performance of healthcare organisations. However, such interventions often work in some settings and not in others. Local health systems could be visualised as complex adaptive systems that respond variously to inputs of capacity building interventions, depending on their local conditions and several individual, institutional, and environmental factors. We aim at demonstrating how the realist evaluation approach advances complex systems thinking in healthcare evaluation by applying the approach to understand organisational change within local health systems in the Tumkur district of southern India.MethodsWe collected data on several input, process, and outcome measures of performance of the talukas (administrative sub-units of the district) and explore the interplay between the individual, institutional, and contextual factors in contributing to the outcomes using qualitative data (interview transcripts and observation notes) and quantitative measures of commitment, self-efficacy, and supervision style.ResultsThe talukas of Tumkur district responded differently to the intervention. Their responses can be explained by the interactions between several individual, institutional, and environmental factors. In a taluka with committed staff and a positive intention to make changes, the intervention worked through aligning with existing opportunities from the decentralisation process to improve performance. However, commitment towards the organisation was neither crucial nor sufficient. Committed staff in two other talukas were unable to actualise their intentions to improve organisational performance. In yet another taluka, the leadership was able to compensate for the lack of commitment.ConclusionsCapacity building of local health systems could work through aligning or countering existing relationships between internal (individual and organisational) and external (policy and socio-political environment) attributes of the organisation. At the design and implementation stage, intervention planners need to identify opportunities for such triggering alignments. Local health systems may differ in their internal configuration and hence capacity building programmes need to accommodate possibilities for change through different pathways. By a process of formulating and testing hypotheses, making critical comparisons, discovering empirical patterns, and monitoring their scope and extent, a realist evaluation enables a comprehensive assessment of system-wide change in health systems.

Project description:BACKGROUND:There is accumulating evidence for the value of collective and shared approaches to leadership. However, relatively little research has explored collective leadership in healthcare and thus, there is a lack understanding of the mechanisms that promote or inhibit the practice of collective leadership in healthcare teams. This study describes the development of an initial programme theory (IPT) to provide insight into the mechanisms underpinning the enactment of collective leadership. METHODS:This IPT was informed by a multiple-method data collection process. The first stage involved a realist synthesis of the literature on collective leadership interventions in healthcare settings (n?=?21 studies). Next, we presented initial findings to receive feedback from a realist research peer support group. Interviews with members of teams identified as working collectively (n?=?23) were then conducted and finally, we consulted with an expert panel (n?=?5). Context-mechanism-outcome configurations (CMOCs) were extrapolated to build and iteratively refine the programme theory and finalise it for testing. RESULTS:Twelve CMOCs were extrapolated from these data to form the initial programme theory and seven were prioritised by the expert panel for focused testing. Contextual conditions that emerged included team training on-site, use of collaborative/co-design strategies, dedicated time for team reflection on performance, organisational and senior management support, inclusive communication and decision-making processes and strong supportive interpersonal relationships within teams. Mechanisms reported include motivation, empowerment, role clarity, feeling supported and valued and psychological safety which led to outcomes including improvements in quality and safety, staff and patient satisfaction, enhanced team working, and greater willingness to share and adopt leadership roles and responsibilities. CONCLUSIONS:This study has identified preliminary support for the contexts, mechanisms and outcomes underpinning the practice of collective leadership. However, it must be noted that while they may appear linear in presentation, in reality they are independent and interlinked and generative of additional configurations. This paper contributes to the nascent literature through addressing an identified gap in knowledge by penetrating below the surface level inputs and outputs of an intervention to understand why it works or doesn't work, and for whom it may work.

Project description:BACKGROUND:Shared Decision-making (SDM), a medical decision-making model, was popularized in the late 1980s in reaction to then predominate paternalistic decision-making, aiming to better meet the needs of patients. Extensive research has been conducted internationally examining the benefits of SDM implementation; however, existing theory on how SDM works, for whom, in which circumstances, and why is limited. While literature has shown positive patient, health care provider, and system benefits (SDM outputs), further research is required to understand the nuances of this type of decision-making. As such, we set out to address: "In which situations, how, why, and for whom does SDM between patients and health care providers contribute to improved engagement in the Shared Decision-making process?" METHODS:To achieve our study goals we conducted a seven-step realist synthesis process, which included: (1) preliminary program theory development, (2) search strategy development, (3) selection and appraisal of literature in accordance with realist methodology, (4) data extraction, (5) identification of relevant formal theories, (6) data analysis and synthesis, and (7) formation of a revised program theory with the input of stakeholders. This process was done in accordance with RAMESES guidelines and publication standards for a realist synthesis. Expert consultations were also held to ensure consistency within the SDM literature. RESULTS:Through our realist synthesis, we developed a program theory of SDM which includes three contexts (pre-existing relationship, difficulty of decision, and system support), eight mechanism sets (anxiety, trust, perception of other party capacity, perception of time, self-efficacy, world view, perception of capacity to external support, and recognition of decision), and one outcome (engagement in SDM). CONCLUSIONS:As far as the authors of this paper are aware, this paper is the first to begin unpacking how SDM works, for whom, in which circumstances, and why. By examining key mechanism sets and exploring how they facilitate or inhibit SDM, we have produced a program theory that may assist health care professionals, policy makers, and patients. While further research is suggested to further unpack the concepts identified within this paper, this provides an initial understanding into the theory behind SDM. REGISTRATION:PROSPERO: CRD42017062609.

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Advancing the application of systems thinking in health: realist evaluation of the Leadership Development Programme for district manager decision-making in Ghana.

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Advancing the application of systems thinking in health: realist evaluation of the Leadership Development Programme for district manager decision-making in Ghana.

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