Proteolytic enzymes and airway diseases
Authors: JA Nadel, RA Stockley
Journal: European Respiratory Journal (1998)

<h3>Objectives</h3> The introduction of change, in particular where it carries a strong sense of innovation, remains a contested area of knowledge and practice. In health care, where expectations associated with innovation are especially weighty, the development of a body of practical knowledge about innovation management is a priority. This paper reports a case study, in which technology to support health care, and specifically to change the pattern of care provision, is introduced into a care team to create a form of practice known as ‘telehealth’. The study was based on an interview guide that explained the study purpose as ‘to gather an account, from a variety of different perspectives and experiences, of the implementation of diabetes telehealth in this Clinical Commissioning Group’. This paper seeks to contribute to development of an understanding - practically-based, but with theoretical foundations - of the processes of adoption and assimilation of innovative change in health care. <h3>Method</h3> The case study was drawn from analysis of interviews with eight individuals directly involved in the process of introducing telehealth – a Technologist, Service Managers, Project Manager, Consultant Physician, General Practitioner, and Nurse Specialists. The five substantive sections of the interview were intended to cover the chronology and process of implementation, as follows: 1) The Health care innovation, 2) The processes of decision and pre-arrival planning for use, 3) The arrival of the technology and first steps to implementation, 4) Trialing, learning and review – who involved, where was first use etc., 5) Bedding in (routinisation – becoming ‘unproblematic’, a normal part of practice). Our reading of the interviews focused on identifying and extracting: (first reading) the basic chronology of events; (second reading) identification of key themes – governance, legitimation, alignment; and (third reading) the pattern of forms of institutional work and the way the socio-technical system started to reform. <h3>Results</h3> Quotes from the analysis indicated, for example, the sorts of ‘translation’ work that testing the telehealth system and learning how it could become an integral part of the care process involved. Introduction of the technology into the care process used various means of testing and revealing the ‘trustworthiness’ of the technology. Changes to practices led to changes in the boundaries of work – who does what, who takes responsibility for what? And it also meant renegotiation of professional authority and its translation into a different form of practice – tweaking the parameters. It revealed how practices are adjusted to accommodate the new technology – indeed, new practices are created fusing technology and clinical authority, a ‘data base’ of clinical readings – co-created by patient, technology and clinician – for joint review. <h3>Conclusions</h3> Following proponents of the theory, we see institutional work building a new or allowing insertion of new practices in a relatively inertial and uncoordinated system to co-produce change not only to practices, but also to boundaries of responsibility – for example, boundaries between specialist nurse and patient (a highly institutionalised boundary), between technology and clinician (the system replaces the nurse, or substitutes for a part of the nurse). These may lead to changes to routinised patterns of care that have institutional significance. Such work requires sustained attention to embed change. The types of institutional work are not concentrated in time or space per se, but are carried through in cycles, repeated. Changes in work may also move and take different forms as the process proceeds. So an ‘authorisation to proceed’ allows telehealth to be pursued, but further translations are required and performed to allow the technology to be implemented and assimilated.