Creating Sustainable Change in Healthcare Delivery: Part 2 of 2

September 5, 2012

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

What is the role of ethnography in realizing the barriers to change, and how can it be used to reconcile these issues?

As discussed in the first part of this article, the culture of the staff as well as the organization as a whole plays a huge role in carrying through effective changes in practice. Ethnography as a stand-alone practice is particularly well-suited for gaining insight into the current behaviors and practices that are required to jumpstart a change initiative. Not only can ethnography help to uncover behavioral practices and routines, but it can help us, as researchers, understand strategies for realigning expectations across siloed teams as well as strategies for engaging participants with the changes.

A challenge when conducting ethnography in an organizational context is that the researcher must balance the need to deeply dive into particular areas in detail with the need to maintain awareness of the organizational culture and structure, and how those micro-level findings may impact the bigger picture (Swinglehurst et al., 2010). To understand the interplay between all these moving parts, the researcher must constantly be shifting between the micro and macro-level views.

But within the healthcare setting, ethnography alone isn’t always enough to carry the proposed changes through to implementation and adoption.

If ethnography alone isn’t enough to carry changes through to implementation, what are some additional approaches that can aid the process?

We have found the following approaches to be useful when paired with ethnographic research to achieve successful implementation and adoption of healthcare innovation initiatives:

  • Qualitative insights supported with quantitative data As discussed earlier, most healthcare professionals rely on evidence-based research, which tends to be quantitative in nature. We use quantitative data to help support our qualitative insights, which could mean using the IT department’s metrics database, or collecting metrics of our own. Many people require some sort of quantitative data to “validate” qualitative statements, especially when dealing with particularly contentious issues. It also allows us to track the changes being made – whether positive or negative, and this fosters foresight in creating future plans. We can compare metrics captured at different points during the change initiative. Occasionally challenges arise when relying on quantitative data, though. Based on flexibility and accuracy of the system, the healthcare institution that is using the data may be inaccurate, incomplete, or inaccessible. Thus, it is incredibly important to evaluate the quality of available data and understand the causes of inconsistencies. Another major problem is when the qualitative and quantitative conclusions conflict with one another; this makes it difficult to uncover the “true” story. A hard look at the quality of both types of data can help to reconcile this concern.
  • Co-creation with cross-functional teams Once insights have been gathered and corroborated with supporting quantitative data, how do we proceed? Many times with ethnographic approaches, the work ends at this point, and clients are left with a strategic hole to fill in terms of what to do with these insights. Co-creation, or having all relevant stakeholders included in the creation of a product or service, fits in where ethnography leaves off. Using the ethnographic insights as a basis, these stakeholders are able to participate in the creation of the future of their practice. Not only does this approach allow the stakeholders’ expertise to be gathered, but it has other benefits as well. It allows greater customization of the initiative according to the culture of the organization and professional domains – something that is particularly important if the initiatives will be spread within and across hospitals and healthcare systems. It also lessens the role of the researcher, and increases the stakeholders’ roles as the creators of their future.
  • Sustaining transformation through change management principles Many change management techniques are already incorporated into the ‘human-centered’ nature of ethnography. Even though they use phrases to encourage “focusing on the human side,” or “assessing the cultural landscape,” it takes much more to truly facilitate organizational innovation. Change can feel almost impossible with ineffective leadership or unwilling employees. We aim to give our clients hope that sustainable change can happen through proper training and mentoring to reach a level of effectiveness. Before progressing to co-creation with any new opportunity, the work team is required to go through the foundational work of defining roles, responsibilities, goals, expectations, and how they will be evaluated. This helps build leadership and team work within the context of a change initiative, preventing the burn-out and overwhelming feeling associated with trying to improve leadership and teamwork system wide.

Swinglehurst, D., Greenhalgh, T., Myall, M. & Russell, J. (2010) Ethnographic study of ICT-supported collaborative work routines in general practice. BMC Health Services Research; 10:348.