VA Center for Organization, Leadership and Management Research

Importance of Studying 

Context

Martin P. Charns, DBA

Director, Center for Organization

Leadership & Management Resea
VA Center for Organization, Leadership and Management Research

Implementing Evidence

Research Practice

Evidence

Transmitter(s) Receptor(s)
VA Center for Organization, Leadership and Management Research

Implementing Evidence

Research Practice

Evidence

Transmitter(s) Receptor(s)

Primary Focus
VA Center for Organization, Leadership and Management Research

Microsystem

OrganizationalContext

Policy Context
VA Center for Organization, Leadership and Management Research

Microsystem Organizational

Context

Policy Context

OrganizationalContext

Microsystem

OrganizationalContext

Microsystem

OrganizationalContext

Microsystem

New Policy
VA Center for Organization, Leadership and Management Research

Microsystem Organizational

Context

Policy Context

OrganizationalContext

Microsystem

OrganizationalContext

Microsystem

OrganizationalContext

Microsystem
VA Center for Organization, Leadership and Management Research

Why?

• The whole premise of policy making 

we can substantially influence organizational functioning by setting 

• So why do researchers so often igno

organizational context, while at the stime believing the effect of policy on organizations?
VA Center for Organization, Leadership and Management Research

Ignoring Policy & Organization

Contexts

• Just because new policies or directiv

implement new practices often do noimplemented is not a reason to ignopolicy context

• Experience & literature indicates the 

to consider the organizational contexstudying implementation
VA Center for Organization, Leadership and Management Research

VA Experience

Example of Negative Effect of Co

• In the mid- to late 1990s VAMCs and VISNs “he

Ken Kizer favored implementation of service line structures

• Nearly all VISNs & 3⁄4 of the VAMCs “implemente

service lines

• Full implementation was hindered by many facto• A key factor was the power of traditional service 

– Did not favor the new structure– Used their power to alter or stop the impleme

• Implications for actual practice• Implications for our research on effects of servic
VA Center for Organization, Leadership and Management Research

Private Sector Experience

Example of Positive Effect of Co

• Academic health center needed to e

medical staff in QI

• Provided resources to academic div

to compensate for time of physicians (resources)

• Removed barrier to physician engag• Allowed QI projects to flourish
VA Center for Organization, Leadership and Management Research

Private Sector Experience

Example of Positive Effect of Co

• Hospital engaged in QI for several years 

increasing emphasis

• A large project stalled due to lack of 

engagement of several key members of t

– These members’ department heads indicated 

need for department work not to be compromproject teams

• Hospital CEO clearly indicated importanc

hospital QI effort
VA Center for Organization, Leadership and Management Research

Private Sector Experience

Example of Positive/Negative Effec

Context

• Hospital with strong history of QI (+)• Organization of separate QI structur

hospital & medical staff (-)

– Projects that required physician involve

disadvantaged by this structure

– Major difficulty in attaining involvement 

coordination of physicians in hospital Q
VA Center for Organization, Leadership and Management Research

Private Sector Experience

Example of Positive/Negative Effec

Context

• Hospital making good progress in pr

to manage patients with diabetes (+

• Unable to negotiate changes in third 

payment (-)

• Led to discontinuation of program th

having positive health care outcomebecause there was not a business cquality
VA Center for Organization, Leadership and Management Research

VA Experience

Example of Positive/Negative Eff

Context

• Major VISN-wide project to impleme

hand hygiene practices

• Highly supported by VISN director

– Allocated considerable resources to effort– Voiced his support frequently

• Mixed support from VAMC directors

– Success in VAMCs with quadrad support– Relative failure in VAMCs without quadrad su
VA Center for Organization, Leadership and Management Research

What is Organizational Contex

• No standard definition• Many theoretical perspectives support pr

that context affects implementation

– Greenhalgh et al review identified “system 

antecedents for innovation” & “system readininnovation”

– Pettigrew et al describe “receptive context”– PARiHS framework describes “quality of the – Lukas et al identifies “5 drivers of change” & 

attributes of the organization
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Greenhalgh et al System Anteceden

Structural Determinants with

Significant Association with Innovativ

• Administrative intensity (+)• Centralization (-)• Complexity: specialization, functional 

differentiation, professionalism (+)

• External communication: external profess

activities (+)

• Functional differentiation: division into diff

units (+)
VA Center for Organization, Leadership and Management Research

Greenhalgh et al System Anteceden

Structural Determinants with

Significant Association with Innovativen

• Internal Communication (+)• Managerial attitude toward change (+)• Professionalism: professional knowledge • Slack resources (+)• Specialization: number of specialties in 

organization (+)

• Technical capacity: technical resources (
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Greenhalgh et al System Anteceden

Absorptive Capacity For New Knowl

• “An organization that is systematica

to identify, capture, interpret, share, and modify new knowledge

• “to link it with its own existing knowle

base, and

• “to put it to appropriate use will be b

able to assimilate innovations.”
VA Center for Organization, Leadership and Management Research

Greenhalgh et al System Anteceden

Absorptive Capacity For New Knowl

• “An organization that is systematically ab

identify, capture, interpret, share, refine, amodify new knowledge

• “to link it with its own existing knowledge 

and

• “to put it to appropriate use will be better 

assimilate innovations.”

• This is not a description of a passive rece
VA Center for Organization, Leadership and Management Research

Greenhalgh et al System Anteceden

Absorptive Capacity For New Knowl

Prerequisites

• Existing knowledge & skills base

– (esp its store of tacit, uncodifiable knowledge)

• Pre-existing related “technologies”• Learning organization culture• Proactive leadership directed toward sharing kn
VA Center for Organization, Leadership and Management Research

Greenhalgh et al System Anteceden

Absorptive Capacity For New Knowled

• “The knowledge that underpins adop

dissemination & implementation ... is objective

• “...it is socially constructed and frequ

contested and must be continually negotiated among members of the organization
VA Center for Organization, Leadership and Management Research

Greenhalgh et al System Anteceden

Absorptive Capacity Social Facto

• Strong, diverse, organic intraorganizational netw

– (esp opportunities for interprofessional

teamwork &

– Involvement of clinicians in manageme

networks )
VA Center for Organization, Leadership and Management Research

Greenhalgh et al System Anteceden

Receptive Context for Change

• Strong leadership• Clear strategic vision• Good managerial relations• Visionary staff in pivotal positions• Climate conducive to experimentatio

risk taking

• Effective data capture systems
VA Center for Organization, Leadership and Management Research

Greenhalgh et al System Readin

for Innovation

• Tension for change• Innovation-system fit• Assessment of implications: are implicatio

innovation fully assessed & anticipated?

• Support & advocacy• Dedicated time & resources• Capacity to monitor & evaluate the innova
VA Center for Organization, Leadership and Management Research

Pettigrew et al Receptive Cont

• Change agenda & its locale: fit between the agenda 

in the local, external environment that might influencchange efforts 

• Cooperative inter-organizational networks: links with 

agencies 

• Environmental pressure: pressures from influential a

external to the organization 

• Key people leading change: roles in which an individ

influences others 

• Quality & coherence of policy: vision’s congruence a

related “goals”

• Simplicity & clarity of goals• Managerial-clinical relations• Supportive organizational culture
VA Center for Organization, Leadership and Management Research

PARiHS Framework Contex

Components

• Organizational culture

– Values, beliefs, attitudes

• Leadership

– Teamwork, control, decision m

structure, empowerment

• Evaluation

– Measurement, feedback
VA Center for Organization, Leadership and Management Research

Lukas et al Organization 

Transformation Model:

Five Drivers of Change

• Impetus to transform• Leadership• Improvement Initiatives• Alignment• Integration
VA Center for Organization, Leadership and Management Research

Organization’s History

• What receptive & non-receptive elements have 

shaped by history

• Hard elements

– Systems & policies developed– Resources acquired– Interorganizational relationships

• Soft elements

– Workforce skills, experience– Culture - expectations– Readiness for change

• Cf Harrison & Kimani Denver Health
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Ferlie: The Nonspread of Innova

• “Social and cognitive boundaries between 

different professions retard spread, as indprofessionals operate within unidisciplinacommunities of practice.”

• Need to examine whether an innovation t

implemented depends on interdependent professional groups – i.e. does it cross inorganizational boundaries?

• If so, what are the positions of the differe

stakeholders?
VA Center for Organization, Leadership and Management Research

To Consider

• We have found context to be so importan

understanding & evaluating implementatiorganization change

• Led us to inclusion of contextual factors i

evaluation of Implementation & QI

• Further led to examination of how to chan

contextual factors to facilitate implementa

• Led to recognition of the importance of th

of improvement projects in changing organization context
VA Center for Organization, Leadership and Management Research

Questions?
VA Center for Organization, Leadership and Management Research

References

• Greenhalgh T, Robert G, MacFarlane F, Bate P

Kyriakidou O: Diffusion of innovations in service organizations: Systematic review and recommenMilbank, 82 (4) (2004): 581-629.

• Pettigrew A, Whipp R: Managing change and co

performance. In: European industrial restructurin1990s. Edited by Cool K, Neven DJ, Walter I. 

Houndmills, Basingstoke, Hampshire: Macmillan Academic and Professional; 1992.

• Pettigrew A, Ferlie E, McKee L: Shaping Strateg

Change: Making Change in Large OrganizationsCase of the National Health Service. London: SaPublications; 1992.
VA Center for Organization, Leadership and Management Research

References

• Kitson A, Harvey G, McCormack B: Enabling the 

implementation of evidence-based practice: a coframework. Quality in Health Care 7 (3) (1998), 

• Rycroft-Malone J , Harvey G, Seers K, Kitson A

McCormack B, Titchen A: An exploration of the fthat influence the implementation of evidence inpractice. Journal of Clinical Nursing, 13 (2004): 

• Lukas CV, Holmes SK, Cohen AB, Restuccia J, 

IE, Shwartz M, Charns MP: Transformational chhealth care systems: an organizational model. HCare Manage Rev, 32(4) (2007): 309-320.