A hospital hive mind? : A critical realist analysis of a high performing hospital

In the context of rising demand for health care, growing clinical complexity, and increasing rates of medical intervention, hospitals and health systems around the world are under strain. As pressures on health systems grow, aspects of performance failure are progressively revealed and compounded. Health services, '...perceived to be inaccessible, disease-oriented, inflexible, disjointed, error-prone, and inconsistent, and to be delivered by overworked, unmotivated staff' (Greenhalgh et al. 2009), are not easily improved. This thesis sought to examine public hospital performance and the ways in which hospital performance may be improved, by conducting an in-depth case study of Alfred Health, a high-performing hospital network, located in Melbourne, Australia. Although there is a reasonable volume of research and scholarly writing on the topic of hospital performance and performance improvement, the state of knowledge is poor. Theoretical understandings are often criticised as rudimentary and overly-simplistic, and empirical evidence is highly contested and largely inconclusive. Two literature reviews informed the development of research aims and questions for this study. The first review surveyed the entire spectrum of theories and explanations of relevance to hospital performance, and the second assessed the state of empirical evidence in support of those theories. A key finding of the two reviews was that the literature on hospital performance tends to be deeply splintered along disciplinary and theoretical lines. As scholars have sought to test the veracity of one isolated explanation for hospital performance (e.g. a funding instrument, or a policy change, or organisational structure, or leadership, or a particular improvement strategy) they have generally missed the significance of the dynamic interactions between each of these elements at play. As suggested here, there is little utility in understanding one or more organisational elements (splinters) deeply, without also understanding how altering those elements might influence the entire ecology of the system. This study, therefore, was designed to both deepen and broaden knowledge and understanding of public hospital performance and performance improvement. Adopting a critical realist perspective, the research was driven by an overarching pragmatic goal to contribute to public benefit as much as to contribute to the academic corpus. In particular, the study aimed to explore how and explain why various environmental, organisational and strategic factors came to influence the performance trajectory of Alfred Health, a hospital network that appeared to have consistently improved performance over several decades. Two research questions guided the in-depth case study: 1. What were the key contextual conditions and organisational factors that gave rise to Alfred Health's trajectory of high performance and sustained performance improvement? 2. How and why did these key contextual conditions and organisational factors come together to produce this result? Documentary and interview data were collected from the case site, eliciting information and prompting reflection on and explanations for the organisation's performance trajectory over an approximate 30-year period. This particular timeframe for study was selected as it corresponded with a severe 'jolt' within the organisation's history: a near closure of The Alfred Hospital during the mid-1990s. Nineteen interviews were conducted and were subject to thematic analysis, drawing on Braun and Clarke's thematic analysis method, in combination with critical realist abductive and retroductive modes of inquiry. A key finding of the empirical study was that Alfred Health seemed to have developed an alternative social structure to that of the traditional hierarchy. This social structure is best described as a heterarchy. As observed in some eusocial species (e.g. honeybees), heterarchies function by continually redistributing power to the members of the social group that are best informed or positioned to use that power through their decisions or actions. That is, although hospital administrators might be well-placed to make decisions regarding more global aspects of the organisation, such as: the overarching organisational structure, financial model, or recruitment and employment policies; administrators often lack the necessary knowledge to adequately frame problems or devise solutions affecting the clinical or departmental coalface. A more fluid (yet nonetheless structured) exchange of decision-making power appears to have provided Alfred Health with a solution to this dilemma, helping to facilitate organisational improvements that could be enacted relatively quickly, and sustained over time. Research findings identified the organisational components and factors that appeared to facilitate a more heterarchical exchange of power throughout Alfred Health. As theorised by 'the hive model' these organisational components included the presence and function of four distinct organisational cultural attributes, three routinised feedback loops, and two managerial tendencies. That is, the social structure of Alfred Health seemed to operate as a relatively ordered pattern of relations and routine practices, held together by a common set of values and attitudes, which in concert, enabled the organisation to learn, adapt, grow, improve and to do so in a way that maintained a homeostatic balance. Evidence for the development and origin of the theorised 'hive-like' improvement capacities and organisational components pointed to a combination of both environmental factors (e.g. government reforms, availability of resources, demographic or technological changes) and strategic efforts (e.g. changes to organisational structure, the active pursuit of new opportunities for learning or innovation etc.). According to analysis, what seemed to matter most was the interactive and creative match between the two. Viewed from the perspective of power and agency, this study argued that successive leaders of Alfred Health took steps to influence culture in order to (indirectly) influence performance. And importantly, this was achieved through a somewhat flexible, opportunistic and, where needed, insulative approach to shifts in the external environment. Further, findings from the analysis indicated that the theorised hive-like tendencies evolved in a series of non-linear (dynamic, somewhat vacillating, partially overlapping and mutually reinforcing) evolutionary steps. That is, some of the hive cultural attributes and feedback loop routines appeared to be in use before others, and a theorised path-dependent relationship between these earlier and later organisational components was proposed. Intra-organisational trust was identified during the analysis as a key rate-limiting (or rate-facilitating) factor that allowed for the progression from one evolutionary level to another more sophisticated level. A comparison of the research findings with existing theory and empirical knowledge concluded that the hive model and theory was compatible with, and provided support to, most of the existing relevant theories available within the scholarly literature. However, the hive model was found to go beyond the span of existing knowledge, particularly in the way in which empirical knowledge was integrated to form a whole-of-organisation explanation for performance. For example, although the academic literature commonly draws a relationship between a less hierarchical organisational structure and higher performance, what appears to be absent from scholarly work is an intact theorised model for the social structure that had replaced hierarchy. The hive model, therefore, offers a novel empirical contribution to the literature by describing the heterarchical social structure both analytically (e.g. by identifying the key components of the model) and synthetically (e.g. by charting the functional and dynamic mechanisms that allow these components to work at a systems level). Strong (although somewhat partial) alignment between the hive model and the complexity lens was an important finding, and particularly useful for supporting an overarching synthesis of knowledge, thus bringing together various existing theories towards some form of theoretical pluralism. Various study limitations were noted, including methodological limitations and possible researcher biases. In particular, it was apparent that the necessity to develop a novel critical realist approach to thematic analysis rendered the study vulnerable to a degree of error. In contrast, this also provided opportunities for methodological innovation, in turn, forming new contributions to the critical realist literature. Further, the minimal use of research delimitations was also a point of both strength (allowing new questions to be explored and existing knowledge to be synthesised) and weakness (risking a lack of depth) for the research. Recommendations for future research included: conducting a series of abductive hospital case studies that followed on from the current study, including the addition of the hive model to the set of deductive theories considered; and, subsequently, developing an instrument to 'test' refined theory upon a larger pool of hospital sites, via the fuzzy-set comparative case study analysis method. Procedural recommendations for researchers who may wish to conduct a critical realist thematic analysis were provided, alongside a further methodological innovation which related to the critical realist notion of theoretical generalisability. That is, drawing on and synthesising the 'theory-borrowing' literature (ironically, borrowed from the management literature), a decision-support tool was developed and presented, to help policy-makers and hospital administrators consider which components of the hive model may be applicable to their own environments, and to support the possibility of l...