Implementation of large-system transformation initiatives in the New Zealand health system

Health systems worldwide are trying to shift towards a learning system to deliver people-centred, holistic and equitable health care. Large-system transformation (LST) initiatives that capitalise on key features of complex adaptive systems may be more likely to achieve the desired shift.

By LST initiatives, I mean “interventions aimed at co-ordinated, system wide change affecting multiple organisations and care providers, with the goal of significant improvements in the efficiency of health care delivery, the quality of patient care, and population-level patient outcomes” (p 422) [1].

This research had three aims: (1) to identify the key elements that support successful implementation of LST initiatives; (2) to construct a maturity matrix that describes different stages of maturity for each of these elements; and (3) to investigate and report on contextual factors that influence successful implementation of LST initiatives. Collectively, the three aims revealed the programme architecture that underpins efforts to successfully implement LST initiatives in the New Zealand health system.

The realist logic of enquiry, nested within the macro framing of complex adaptive systems, formed the overall methodology for this research. This research used insights from a New Zealand LST initiative (the System Level Measures programme), evidence from literature, and evidence from knowledge of those working in the health system, to analyse and describe this programme architecture.

The research resulted in three key sets of findings.

First, the research found that a set of 10 key elements needs to be present in the New Zealand health system and work in harmony to increase the chances of successful 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, whanau and community; (vi) intelligent commissioning; (vii) continuous improvement; (viii) an integrated health information; (ix) analytic capability; and (x) dedicated resources and time.

Second, a self-assessment maturity matrix for the key elements was developed with New Zealand health system leaders to provide a practical tool for them and informal trust-based networks (such as Alliances) to improve their understanding of the different stages of maturity for the key elements, to assess their readiness for change, and to develop capacity and capability needed for system transformation.

Third, a realist logic of enquiry was used to investigate how the key elements work in different contexts to influence the successful implementation of LST initiatives. At a local level, (i) the history of working together and quality of relationships, (ii) distributed leadership from commissioners of health services, and (iii) the maturity of informal trust-based networks, such as Alliances, emerged as key contextual factors that influenced successful implementation of these initiatives. The key mechanism of trust was triggered with a positive history of working together, which built strong relationships and facilitated a distributed leadership style among health system agents through informal networks. The high-trust environment built and nurtured over time strengthened relationships among health system agents, which then provided the foundation for health system transformation.

At a national level, the distributed health system leadership, the application of ‘new power’ approach to design and implementation of LST initiatives, and the system accountability environment emerged as key contextual factors. The existing accountability framework, which solely focussed on financial performance of District Health Boards and outputs, suffocated the notion of a learning system as health system leaders placed more effort on achieving targets and outputs rather than on continuous improvement. A culture of continuous improvement supported the notion of a learning system; it encouraged iterative learning using methods such as plan-do-study-act cycles and fostered innovation. Use of ‘new power’ values such as collaborative policy design and implementation harnessed the intrinsic motivation of health system agents and built trust between policy makers and health service providers, which lead to sustained collective engagement with transformation efforts. A collective engagement to achieve a shared vision built strong and resilient health system leadership.

The research concluded that transformation of health systems depended on senior system leaders’ understanding of the programme architecture that underpins efforts to successfully implement LST initiatives.