Increasing Capacity for Innovation in Bureaucratic Primary Care Organizations: A Whole System Participatory Action Research Project

Paul Thomas; Juliet McDonnell; Janette McCulloch; Alison While; Nick Bosanquet; Ewan Ferlie

doi:10.1370/afm.309

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Table 1.

Emergence of the Study Design

Year	Intended Study Design for the Year	Events Within the Year Requiring Design Change
PCG = Primary Care Groups; PCT = Primary Care Trust.
First year (2000)	Comparative case studies of clinical governance programs of 4 PCGs	Local facilitators never started in-practice work and withdrew from the project
	Intervention PCGs used local multidisciplinary teams to facilitate change within practices	Unexpected announcement of fast progress toward PCT status altered priorities of clinical governance groups
	Amalgamated near-clinical indicators from practice computers would contribute to comparative data	Near-clinical indicators impossible to gather from practice computers
Second year (2001)	Comparative aspects of the study abandoned  At request of intervention sites, facilitators refocused away from the clinical governance programs to support reflection and action inside the clinical governance subcommittees themselves. Doing so focused on effective meeting behavior and how to carry into the PCT their most valuable work  Studies of nurses and financial directors took place here	Emerging enthusiasm among stakeholders that ideas about learning organizations and participatory action research help to understand learning and change in the health care system  Recognition among the stakeholders that facilitation of learning and innovation had less to do with formal structures and more to do with facilitative processes that free up conversations and reflections throughout the system, helping local people to make “top down” models relevant within their specific context
Third year (2002)	Refocus away from structures and roles within PCGs toward analysis of what things help and hinder people to do things for themselves	The start of PCTs and a realization among participants that their size and complexity requires rethinking about the meaning of leadership in primary care

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Supplemental Appendix. Clarification of Whole System Participatory Action Research.

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The Article in Brief

Background: This study looked at how Primary Care Groups (clusters of general practices in the United Kingdom) encouraged innovation and change in their organizations.
What This Study Found: Five features increase the ability of Primary Care Groups to innovate and change: (1) clear organizational structures and rules, and leadership that wants the organization to learn and change; (2) opportunities for people at all levels of the organization to reflect and learn, and sharing of what is learned, so that innovative thinking in one part of the organization can be built on elsewhere; (3) medical professionals and managers in leadership roles and encouragement of participation; (4) a change initiative at the right time and tailored to the needs of the local group; and (5) instructors/leaders from outside the organization, who can be useful if they help people make sense of their experiences and guide them in achieving their change plans.
Implications:
� When combined, these features may support innovation in health care organizations.
� Primary care organizations can increase their ability to learn when people from different backgrounds develop innovative interpretations of new information.