Te Tai Ōhanga- The Treasury, 1 The Terrace, 6011, Wellington, New Zealand.
Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 34 Princes Street, Auckland CBD, 1010, Auckland, New Zealand.
BMC Health Serv Res. 2024 Jan 10;24(1):54. doi: 10.1186/s12913-023-10497-5.
Despite three decades of policy initiatives to improve integration of health care, delivery of health care in New Zealand remains fragmented, and health inequities persist for Māori and other high priority populations. An evidence base is needed to increase the chances of success with implementation of large-system transformation (LST) initiatives in a complex adaptive system.
This research aimed to identify key elements that support implementation of LST initiatives, and to investigate contextual factors that influence these initiatives. The realist logic of enquiry, nested within the macro framing of complex adaptive systems, formed the overall methodology for this research and involved five phases: theory gleaning from a local LST initiative, literature review, interviews, workshop, and online survey. NVivo software programme was used for thematic analysis of the interview, workshop, and the survey data. We identified key elements and explained variations in success (outcomes) by identifying mechanisms triggered by various contexts in which LST initiatives are implemented.
The research found that a set of 10 key elements need to be present in the New Zealand health system to increase chances of success with implementation of LST initiatives. These are: (i) an alliancing way of working; (ii) a commitment to te Tiriti o Waitangi; (iii) an understanding of equity; (iv) clinical leadership and involvement; (v) involved people, whānau, and community; (vi) intelligent commissioning; (vii) continuous improvement; (viii) integrated health information; (ix) analytic capability; and (x) dedicated resources and time. The research identified five contextual factors that influenced implementation of LST initiatives: a history of working together, distributed leadership from funders, the maturity of Alliances, capacity and capability for improvement, and a continuous improvement culture. The research found that the key mechanism of trust is built and nurtured over time through sharing of power by senior health leaders by practising distributed leadership, which then creates a positive history of working together and increases the maturity of Alliances.
Two authors (KMS and PBJ) led the development and implementation of the local LST initiative. This prior knowledge and experience provided a unique perspective to the research but also created a conflict of interest and introduced potential bias, these were managed through a wide range of data collection methods and informed consent from participants. The evidence-base for successful implementation of LST initiatives produced in this research contains knowledge and experience of senior system leaders who are often in charge of leading these initiatives. This evidence base enables decision makers to make sense of complex processes involved in the successful implementation of LST initiatives.
Use of informal trust-based networks provided a critical platform for successful implementation of LST initiatives in the New Zealand health system. Maturity of these networks relies on building and sustaining high-trust relationships among the network members. The role of local and central agencies and the government is to provide the policy settings and conditions in which trust-based networks can flourish.
This study was approved by the Victoria University of Wellington Human Ethics Committee (Ethics Approval Number 27,356). The research was supported by the Victoria University of Wellington research grant (222,809) and from the University of Auckland Department of Medicine research fund (H10779).
尽管三十年来一直在推行政策以改善医疗保健的整合，但新西兰的医疗保健服务仍然分散，毛利人和其他高优先级人群的健康不平等现象仍然存在。需要有一个证据基础，以增加在复杂适应系统中实施大型系统转型（LST）计划成功的机会。
本研究旨在确定支持 LST 计划实施的关键要素，并研究影响这些计划的背景因素。探索性询问的现实主义逻辑，嵌套在复杂适应系统的宏观框架内，构成了这项研究的总体方法，包括五个阶段：从当地 LST 计划中汲取理论、文献综述、访谈、研讨会和在线调查。使用 NVivo 软件程序对访谈、研讨会和调查数据进行主题分析。我们确定了关键要素，并通过识别 LST 计划实施的各种背景下触发的机制，解释了成功（结果）的变化。
研究发现，新西兰卫生系统需要具备 10 个关键要素，才能增加 LST 计划实施成功的机会。这些要素是：（i）结盟的工作方式；（ii）对《怀唐伊条约》的承诺；（iii）对公平的理解；（iv）临床领导力和参与；（v）相关人员、家庭和社区；（vi）明智的委托；（vii）持续改进；（viii）综合健康信息；（ix）分析能力；和（x）专用资源和时间。研究确定了影响 LST 计划实施的五个背景因素：共同工作的历史、资金提供者的分布式领导力、联盟的成熟度、改进的能力和能力，以及持续改进的文化。研究发现，信任的关键机制是通过高级卫生领导人通过实践分布式领导力来分享权力，随着时间的推移建立和培养的，这继而创造了共同工作的积极历史，并提高了联盟的成熟度。
两位作者（KMS 和 PBJ）领导了当地 LST 计划的制定和实施。这种先前的知识和经验为研究提供了独特的视角，但也带来了利益冲突和潜在的偏见，这些通过广泛的数据分析方法和参与者的知情同意得到了管理。本研究产生的成功实施 LST 计划的循证依据包含了负责领导这些计划的系统高级领导人的知识和经验。这个证据基础使决策者能够理解成功实施 LST 计划所涉及的复杂过程。
在新西兰卫生系统中，使用基于非正式信任的网络为 LST 计划的成功实施提供了一个关键平台。这些网络的成熟度取决于网络成员之间建立和维持高信任关系。地方和中央机构以及政府的作用是提供政策环境和条件，使基于信任的网络能够蓬勃发展。
本研究已获得惠灵顿维多利亚大学人类伦理委员会的批准（伦理批准号 27,356）。该研究得到了惠灵顿维多利亚大学研究基金（222,809 美元）和奥克兰大学医学系研究基金（H10779）的支持。
