Creating Sustainable Change in Healthcare Delivery: Part 1 of 2

August 28, 2012

By Beth Werner, Senior Research & Product Strategist and Lindsey Messervy, Design Researcher and Strategist

Hospitals and healthcare organizations, especially in the United States, are beginning to see a major overhaul in terms of healthcare delivery. Healthcare innovation is being touted as a key strategy to refocusing and improving patient care and staff, but it has yet to be truly defined. Innovation does not have to be a full system transformation; it can be as simple as adjusting appropriate staffing levels, increasing communication between staff, patients, and management, or even bringing back the “care” in care giving.

The healthcare industry is a complex and confusing system. Providing care to one patient can require communication and collaboration between a primary care physician, a specialist, local labs, the pharmacy, hospitals, and rehab facilities. It is critical that every practitioner who is caring for a patient has access to all of the information available about that patient. But critical patient information often sits trapped inside archaic systems, or worse - written on scraps of paper far away from those who need it.

In recent times, hospitals and healthcare organizations have become more accepting of using human-centered approaches, such as ethnography, to lend insight on how to prevent risk, increase efficiency, improve staff experience and advance delivery of care.

While we present an approach to methodology, it is meant to provide inspiration for advancement in the field rather than a prescriptive solution. Additionally, focusing on renewal and change in the hospital environment can contribute relevant insight to many other industries experiencing resistance in variations in current practices. With this paper, our aim is to reflect on the barriers that make change and innovation so difficult in this field, and ultimately provide a qualitative-based approach to enabling and enacting change in a healthcare organization through the use of ethnography and alternative approaches.

What specifically are you referring to when you describe ‘barriers to change’ in the healthcare setting?

Complexity is an understatement when it comes to healthcare. On a recent project, it was found that one patient undergoing surgery will interact with 29 different roles in 8 different physical locations. In order for that patient to progress through the system, over 500 pieces of information are entered digitally and as many as 40 different paper documents can be used.

At a systems level, healthcare is a public service, which means that change may be coming from conflicting directions. Demands for cost-cutting push hospitals to adopt more efficient solutions, while regulatory entities insist that safety is paramount, narrowing our ability to enact innovative, human-centered solutions (Bessant & Maher, 2009). As ethnographers, our role is to act as guides through the gauntlet of competing goals.

At an organizational level, communication of critical information between departments and units tend to be fragmented. Yet patient care requires a seamless flow of information within and across these entities, which is rarely achieved, whether it is a consequence of the information technology employed (such as EMR/EHRs) or inconsistent communication between staff members (Cebul et al., 2008).These barriers can create negative perceptions and infighting within and between departments, which can lead to an unsuccessful change initiative.

At a cultural/social level, practitioners and hospital administration tend to rely on evidence-based research to make decisions. While this approach is thought to reduce variations in practice, it can undervalue tacit knowledge that practitioners have honed over years of experience (Gabbay & le May, 2004). On the other hand, some institutions rely solely on the tacit knowledge of the caregiver, which can create a huge challenge when it comes to succession planning and training. A lack of standardized practices can create risk for everyone involved.

At an attitudinal, cognitive, or motivational level, practitioners and staff members have differing (and sometimes conflicting) priorities. These differing priorities may be due to a lack of awareness or knowledge, or may be a lack of motivation to change their routines (National Institute of Clinical Studies, 2006). Either way, the siloing of departments can escalate this issue of differing priorities – thus it is essential to understand what is important to and motivates each group. Otherwise, consensus on important insights and the “realities” of what goes on will be nearly impossible to achieve.


Bessant, J. & Maher, L. (2009) Developing Radical Service Innovations In Healthcare — The Role Of Design Methods. International Journal of Innovation Management; 13(4), 555-568. [Online:]
Cebul, R. D, Rebitzer, J. B., Taylor, L. J. & Votruba, M. (2008) Organizational Fragmentation and Care Quality in the U.S. Health Care System. Journal of Economic Perspectives; 22, 93-113.
Gabbay, J. & le May, A. (2004) Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care. BMJ; 329(7473): 1013.

National Institute of Clinical Studies. (2006) Identifying barriers to evidence uptake. Available from:

Stay tuned for Part 2 of this article next Tuesday, when you’ll learn how ethnographic research can give insight into organizational problems, as well as what can be done when ethnography alone isn’t enough…