Addressing complex healthcare problems in diverse settings: insights from activity theory.

In the U.K., approaches to policy implementation, service improvement and quality assurance treat policy, management and clinical care as separate, hierarchical domains. They are often based on the central knowledge transfer (KT) theory idea that best practice solutions to complex problems can be identified and 'rolled out' across organisations. When the designated 'best practice' is not implemented, this is interpreted as local--particularly management--failure. Remedial actions include reiterating policy aims and tightening performance management of solution implementation, frequently to no avail. We propose activity theory (AT) as an alternative approach to identifying and understanding the challenges of addressing complex healthcare problems across diverse settings. AT challenges the KT conceptual separations between levels of policy, management and clinical care. It does not regard knowledge and practice as separable, and does not understand them in the commodified way that has typified some versions of KT theory. Instead, AT focuses on "objects of activity" which can be contested. It sees new practice as emerging from contradiction and understands knowledge and practice as fundamentally entwined, not separate. From an AT perspective, there can be no single best practice. The contributions of AT are that it enables us to understand the dynamics of knowledge-practice in activities rather than between levels. It shows how efforts to reduce variation from best practice may paradoxically remove a key source of practice improvement. After explaining the principles of AT we illustrate its explanatory potential through an ethnographic study of primary healthcare teams responding to a policy aim of reducing inappropriate hospital admissions of older people by the 'best practice' of rapid response teams.

Delivering feedback on learning organization characteristics--using a Learning Practice Inventory.

RATIONALE, AIMS AND OBJECTIVES: Learning is recognized to be at the heart of the quality improvement process in the National Health Service (NHS). However, the challenge will be how to ensure that learning becomes embedded within the NHS culture. The aim of this study is to identify a robust feedback process and format in which practices could receive data on their responses to a Learning Practice Inventory (a diagnostic instrument designed to identify a practice's capacity for collective learning and change). METHOD: Five practices volunteered to test the instrument, and it was distributed to all members of the primary care team. A process was worked through to identify different formats for presenting scores within and between practices. The preferred method of data presentation was sought, and an evaluation gathered information on the preferred form of feedback, the usefulness of the data, the clarity of the questions and the level of interest in receiving further information. RESULTS: Eighty-five staff from five practices completed the questionnaire, and 61 individuals completed the evaluation forms. In most cases, there was a spread of scores by staff within practices and across the scale of 1-10. Medians were clustered at the learning practice end for all five practices. However, despite this skew, there were sometimes quite large differences between practices in their median scores. CONCLUSION: Our study suggests that a robust feedback process on collective capacity for learning and change can be identified that is useful and feasible. A key implication is that some form of educational support is required, and this work will take place as part of an ongoing programme of research by the authors.

The Learning Practice Inventory: diagnosing and developing Learning Practices in the UK.

BACKGROUND AND SETTING: This paper outlines the development of a diagnostic tool to help Primary Care general practitioner (GP) Practices diagnose the extent to which they are developing effective techniques for collective learning and if their Practice culture supports innovation. This project is undertaken by the University of St Andrews and NHS Education for Scotland. METHODS: Based on Learning Organization and Organizational Learning theory, and using a modified Behaviourally Anchored Rating Scale, the Learning Practice Inventory (LPI) identifies attitudes, behaviours, processes, systems and organizational arrangements associated with being a Learning Practice. The LPI is a self-assessment, fixed-choice, survey-feedback tool that surveys all Practice members. RESULTS: The survey-feedback tool empowers Practice members to view, assess and prioritize the developments they wish to make collectively to Practice life. The LPI assumes complexity and non-linearity in change processes, used longitudinally it tracks the impact of change on Practice life through time. Practitioners and Practices involved in its development give favourable feedback on the tool, and its potential usefulness. DISCUSSION: This contributes to our wider understanding in three main ways: first, it applies the ideas of Learning Organizations and Organizational Learning to health care settings. Second, as a practical advance, the tool assumes complexity, non-linearity and systemic knock-on effects during change in Primary Care. Third, it offers practitioners who work together the opportunity to share knowledge and learning in practical ways helping them to change by themselves and for themselves and their patients.