Organizations within the healthcare sector are susceptible to economic pressures and as a result are prone to continuous and transformational change (Melder, Burns, Mcloughlin, & Teede, 2018; Nicholson, Jackson, & Marley, 2014). This landscape has contributed to a climate ripe for innovative change for healthcare organizations at a local, regional, and global level. Opportunistic and motivated individuals and organizations continue to develop new products and services to the address the evolving needs of the workforce and community. Healthcare executives and decision-makers can facilitate effective service redesign and innovation by empowering and nurturing emerging leaders and clinicians (Melder et al., 2018). Executives and other decision-making leaders who encourage innovation and disruption actively create an organizational culture and pipeline process of identifying and growing new value (B. Antoncic & Hisrich, 2003). Employees within these organizations that can be characterized by their motivation to proactively identify and seize opportunities to acquire resources (human and capital) to implement innovations, change, or departures from the status quo are considered intrapreneurs (Altinay, 2004; Falola et al., 2018; Heinze & Weber, 2015; Park, Kim, & Krishna, 2014). The contextual landscape of public healthcare organizations is conducive to fostering cultures where the concept of intrapreneurship can be mobilized by the workforce to innovate and improve the delivery of healthcare services.
Innovative approaches to delivering education and case-based learning has become essential for large-scale organizations striving to achieve strategic and operational objectives, especially in the healthcare sector. This has been highlighted in more recent time in light of the global COVID-19 pandemic, where healthcare organizations have been forced to rapidly adopt virtual or telementoring platforms to sustain and support the learning needs of their workforce. Employees within these organizations have moved from first responding to the management and containment of the virus, to adopting new ways of delivering services beyond the outbreak. The landscape within this sector is now, more than ever one where organizations are juggling the need to innovate while remaining focussed on delivering high quality patient care and maintaining financial sustainability (Oderanti & Li, 2018).
Global events, including the more recent COVID-19 pandemic, have driven the cumulative growth in organizational utilisation of telementoring training programs as a mode of specialized workforce development and education delivery due to the distinct advantages of ameliorating geographic barriers and now more so to ensure compliance with social distancing etiquette (Gleason et al., 2020; Kay & Spicer, 2020). Telementoring is a virtual learning approach where real-time videoconferencing technology is used to provide a teaching and learning environment between content knowledge experts (based at central hubs) and participating frontline providers (working at multiple spoke sites) which contribute their local context expertise (Lewiecki, Boyle, Arora, Bouchonville Ii, & Chafey, 2017). Telementoring has become common within the public sector where government agencies have seen community expectations evolve, resulting in demand for higher quality, more variety and lower cost services (Mohsen et al., 2019; Wanna, Lee, & Yates, 2015). A number of telementoring models have been developed in efforts to generate value, productivity and efficiency in the public healthcare sector (Christian & Andreas, 2019; Clark & Goodwin, 2010; Oderanti & Li, 2018; Socolovsky et al., 2013; Tuerk, 2015). Project ECHO® (which stands for Extension for Community Healthcare Outcomes) is an established model of telementoring with a track record for improving health outcomes in North America (Arora et al., 2011). However, there is a gap in the literature regarding how innovative models such as Project ECHO® are implemented within established organizations.
The aim of this study is to capture the key learnings from the implementation of a telementoring pilot, to understand how intrapreneurship can embed innovation within an established organization to effect more integrated healthcare. Intrapreneurism is an organizational phenomenon which can be defined as entrepreneurship, or the process of discovering and advancing opportunities to create value through innovation, that occurs within existing organizations (B. Antoncic & Hisrich, 2003). Intrapreneurs are therefore most often employees within these organizations rather than entrepreneurs who are generally associated with new start-up ventures. This study will explore intrapreneurial strategies and tactics used by the project implementation team throughout the Project ECHO® pilot to embed the intrapreneurial dimensions of the innovation within Children’s Health Queensland Hospital and Health Service (CHQHHS), a large-scale paediatric public healthcare organization in Queensland, Australia.
Intrapreneurism is attracting growing interest from policymakers and executives within the healthcare sector at a regional and international level (Brown, Fishenden, & Thompson, 2014; Carpenter et al., 2018; Mundy & Hewson, 2019). This has been largely a result of evolving service needs of ageing populations and more recently, an increasing prevalence of chronic diseases that place pressure on healthcare organizations to sustain the delivery of high quality and economically-viable healthcare services (Mundy & Hewson, 2019; Oderanti & Li, 2018). These factors have created a landscape that is more conducive for intrapreneurs to explore and implement innovations that are aimed at integrating healthcare.
Prior research in this field (Moss, Hartley, Ziviani, Newcomb, & Russell, 2020) has explored the conscious decision-making processes of healthcare executives and the factors that influence these gatekeepers to invest in integrated healthcare innovations. Key findings from this and similar studies (Enslin, 2010; Falola et al., 2018; Gawke, Gorgievski, & Bakker, 2019; Guven, 2020; Heinze & Weber, 2015; Neessen, Caniëls, Vos, & de Jong, 2019; Park et al., 2014), indicate that intrapreneurial champions within organizations can positively influence decision-making processes resulting in organizational commitment to, and financial support of innovative pilots. Aside from these studies, empirical investigation of intrapreneurship within the Australian public sector is limited (Gapp & Fisher, 2007; O'Connor, Roos, & Vickers-Willis, 2007), with few studies exploring how intrapreneurial pilots are successfully implemented. With this in mind, this study sought to capture the key learnings from the implementation of a telementoring pilot to understand how intrapreneurship can embed innovation within an established public healthcare organization to effect more integrated healthcare. The findings of this study provide an illustration of intrapreneurship within the Australian public healthcare sector that can be replicated by other organizations across sectors at a regional level. Further, this study provides new knowledge in the field of integration intrapreneurship by exploring conceptual elements of intrapreneurial theory that have been identified in an Australian integrated care pilot.
Conceptual background for intrapreneurism
The concept of intrapreneurship has evolved in the management literature over the last forty years as a distinct theoretical construct to better understand the behavioural intentions of employees seeking to innovate within established organizations. To this point, Antoncic and Hisrich’s (2003) seminal study clarified the intrapreneurship concept and identified eight dimensions that characterize intrapreneurial processes, innovative activities and orientations to frame how intrapreneurs approach their particular innovation (see Table 1). Intrapreneurship can be illustrated as emergent behavioural intentions and behaviours that relate to departures from the status quo within existing organizations. While these dimensions highlight characteristics, the concept of intrapreneurism refers not only to the creation of new business ventures, but also to other activities and orientations that involve innovation (B. Antoncic & Hisrich, 2003). Within the context of the healthcare sector, the dimensions of intrapreneurship provide a useful lens by which to understand how innovation and integration within organizations and systems can be achieved. This study will use the dimensions to highlight and showcase exemplars gleaned from a telementoring pilot implementation through an inductive approach.
Eight dimensions of intrapreneurship, adapted from Antoncic and Hisrich (2003).
Intrapreneurship Dimension and definition
1. New ventures: Creation of new autonomous or semi-autonomous units or firms
2. New businesses: Pursuit of and entering into new business related to current products or markets
3. Product/service innovativeness: Creation of new products and services
4. Process innovativeness: Innovations in production procedures and techniques
5. Self-renewal: Strategy reformulation, reorganization, and organizational change
6. Risk taking: Possibility of loss related to quickness in taking bold actions and committing resources in the pursuit of new opportunities
7. Proactiveness: Top management orientation for pioneering and initiative taking
8. Competitive aggressiveness: Aggressive posturing towards competitors / sector / system manager(s)
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While intrapreneurial ventures can be defined by the eight dimensions in Table 1, the pursuit of the innovation itself can often fail without strategic insight and tactical considerations (Oderanti & Li, 2018). For intrapreneurism to succeed, particularly to achieve more integrated healthcare at a systems and organizational level, organizations must adopt tactical approaches to implementation (Heinze & Weber, 2015).
To complement these dimensions, Heinze and Weber (2015) identified eight strategies or tactical approaches which intrapreneurs can use to enable their innovations to be adopted at the organizational level. The strategies and tactics recommended by Heinze and Weber (2015) were shown to create and strengthen organizational free spaces aligned with the relevant dimensions of intrapreneurial innovations. Intrapreneurs can select and tailor these individual strategies/tactics to leverage the capacity required to develop and integrate the innovative change within the broader organization (Heinze & Weber, 2015).
Strategies recommended to support intrapreneurs, adapted from Heinze and Weber (2015).
Strategy and Definition
1. Leverage status in the institutional field: Where intrapreneurs build credibility in their broader profession by taking on roles that carry status and influence, including academia, associations, boards. This enhances their credibility and visibility internally to influence and legitimize the need for change.
2. Gain proprietary jurisdiction over resources: Where intrapreneurs directly and indirectly acquire and administer external funding sources to build and extend their program of work, thereby reducing dependence on and competition for resources and decision structures within the organization.
3. Create trading zones: Where intrapreneurs identify, prioritize, and participate in / attend spaces / forums where their ideas and knowledge can be exchanged in a low-stakes environment between internal stakeholders. This is particularly focused on engagement opportunities that are associated with learning and respectful inquiry rather than decision-making and endorsement processes. The intrapreneur may repurpose the agenda or direction of these forums to achieve mutual learning that aids the change objective(s).
4. Build a pipeline: Where intrapreneurs systematically build a core following of individuals that engage in the change dialogue and contribute to mobilising the change.
5. Use experimentation to build capacity: Where intrapreneurs can learn, reflect on, and refine their approaches, to improve effectiveness, to enable increased responsiveness and targetability for future opportunities. Experimentation supports the intrapreneur to learn how to improve their execution and gain greater acceptance of their change. Experiments can incorporate the refining of concepts, templates or resource development for future utility, and other similar building blocks activities that enhance the intrapreneur’s sensitivity to time-limited opportunities.
6. Establish formal free spaces with endowed resources and status (Requires strategies 1 and 2. When done well, this tactic also enhances the effectiveness of strategies 3, 4, 5): Where intrapreneurs can establish and formalize business units within the organization. This can include establishing dedicated roles, office accommodation and access to necessary facilities and ancillary supports.
7. Create and exploit opportunities for ongoing change: Where intrapreneurs maintain constant focus on horizon scanning activities to identify additional opportunities to bolster change efforts. This can include acquiring additional funding, fostering new partnerships, technological or operational enhancements, and personnel / organizational / system / political events.
8. Extensive and diverse representation / membership at multiple organizational forums / communities: Where the intrapreneur integrates their role and presence across several of the organization’s forums / communities. This is to sustain regular engagement with stakeholders to bed down the change and identify improvement / expansion opportunities.
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Antoncic and Hisrich’s work over the last two decades has been widely cited as providing a reliable criterion to identify an innovation as being intrapreneurial (B. Antoncic & Hisrich, 2001, 2003; J. A. Antoncic & Antoncic, 2011; Fitzsimmons, Douglas, Antoncic, & Hisrich, 2005). To expand on this conceptual framework, the strategies/tactics purported by Heinze and Weber (2015) provide a targeted and customisable approach that individuals or teams have referenced in almost 30 other studies to achieve successful intrapreneurial ventures within an organizational context. These approaches are defined in Table 2. Published literature has found that where intrapreneurial teams pursued one or more of the dimensions as cited by Antoncic and Hisrich (2003) in partnership with strategic/tactical posturing as presented by Heinze and Weber (2015), their implementations were well-received within the implementing organization (Amini, Arasti, & Bagheri, 2018; Burton-Jones et al., 2020; Di Lu & Heinze, 2021; Dimitratos, Voudouris, Plakoyiannaki, & Nakos, 2012; Eriksson & Ujvari, 2015; Fitzsimmons et al., 2005; Gapp & Fisher, 2007; Garbutt et al., 2019; Gerards, van Wetten, & van Sambeek, 2020; Grayson, McLaren, & Spitzeck, 2014; Hoogstraaten, Frenken, & Boon, 2020; Melder et al., 2018; Neessen et al., 2019). Given the aim of this study was to understand how intrapreneurship can be harnessed to embed innovation within an established organization to effect more integrated healthcare, we sought to assess key learnings from the intrapreneurial team against intrapreneurial approaches espoused in the literature. Consequently, the results from this study highlight how integral it is for intrapreneurs to consider the relevant dimensions of intrapreneurship when designing targeted strategies in their pursuit of innovation. We also highlight practical aspects of intrapreneurism that can be replicated by organizational decision-makers and leaders to innovate and change the status quo. There is a need to understand how intrapreneurial ventures like implementing Project ECHO® within dynamic sectors such as healthcare can support organizational advancement to meet market needs.
Project ECHO® in Queensland – new evidence of intrapreneurism in a public healthcare organization
The 2016 pilot implementation of a telementoring model called Project ECHO® (Arora et al., 2010; ECHO Institute, 2020a), in Queensland is presented in this study as new evidence that intrapreneurship is being actively pursued in public healthcare sector organizations to innovate and improve the way organizations provide more integrated healthcare. The Project ECHO® pilot was led by a general practice liaison officer and project manager employed at CHQHHS, the state’s tertiary paediatric provider (Children's Health Queensland Hospital and Health Service, 2019). The aim of the pilot was to achieve more integrated healthcare for children and young people across the healthcare continuum using the model to connect frontline providers across urban, regional, rural, and remote centres with the metropolitan-based tertiary healthcare centre. It was hypothesized that providing a telementoring service, using the ECHO model™, to mentor and upskill frontline health and other professionals across Queensland would achieve more integrated and comprehensive healthcare to patients in their local communities (Carter et al., 2019). By facilitating virtual access to interprofessional advice and support from mentors and colleagues in complimentary settings such as the tertiary paediatric hospital, there was thought to be potential to increase capacity for local service provision while reducing demands on the single paediatric facility as the default provider of all services (Carter et al., 2019). The project implementation team thought that this pilot would lend itself to being quickly scaled across other prevalent health conditions that were well-suited to a telementoring approach.
The Queensland-first pilot created a virtual ECHO® Network to support and enhance regional capability of service providers delivering healthcare to children with stable Attention Deficit Hyperactivity Disorder (ADHD). The ADHD pilot was used as a catalyst for the organization to consider using Project ECHO® more broadly to innovate and address service demands. Globally, the purpose of healthcare organizations using the ECHO model™ has been to improve access to healthcare for underserved communities, or priority populations who experience barriers to accessing best practice care locally (Arora et al., 2010; Furlan et al., 2019; McBain et al., 2019; Zurawski, Komaromy, Ceballos, McAuley, & Arora, 2016). Organizations which have implemented the ECHO model™ operate as ECHO® ‘hubs’ to leverage and scale their scarce internal workforce ‘content’ expertise by providing freely accessible, virtual case-based education in ‘communities of practice’ (Carpenter et al., 2018) to support peer to peer learning amongst frontline context experts in community ‘spoke’ centres located anywhere (Arora et al., 2010). The key point of difference between the ECHO model™ and other models of telementoring is the case-based learning component where spoke participants present on their own case scenarios to receive advice and support from colleagues participating in the ECHO® Network (Anderson et al., 2017; Damian et al., 2020; Furlan et al., 2019; Socolovsky et al., 2013; Tantillo, Starr, & Kreipe, 2019; Tosi et al., 2020; Zurawski et al., 2016). Evidence from North America has shown ECHO® Networks enabling the local management of complex cases by frontline providers supported by specialist teams to reduce barriers to accessing best practice healthcare and experiencing improved health outcomes at a regional level (Arora et al., 2011). In the CHQHHS scenario, the project implementation team consisted of four employees, who engaged clinicians from within the organization to leverage their paediatric content expertise to facilitate the pilot innovation as ECHO® Network panellists. These panel roles were fulfilled by a team of medical and allied health clinicians, educators, and parent representatives, with spoke participation from context experts including general practitioners, psychologists, and guidance officers across Queensland. This Queensland-based team launched the first paediatric ECHO® Network in Australasia in May 2017. From the ADHD pilot, early adopters from within the organization partnered with the project team to rapidly expand the model’s use within the organization across a wider range of paediatric health conditions. These included behaviour and mental health, diabetes, foot anomalies, obesity, palliative care, persistent pain, and refugee health.
In intrapreneurial terms, the implementation of the Project ECHO® hub at CHQHHS to deliver the ADHD ECHO® Network represented a clear departure from the customary provision of direct patient care in a hospital outpatient setting. The aim of providing the ADHD ECHO® Network was to provide participants in every region across Queensland with access to the telementoring platform to gain new knowledge and confidence in managing children with stable ADHD in their local communities through virtual case-based learning sessions using the ECHO model™. This change in practice was seen by the organization as a way to integrate the access and delivery of a broad array of healthcare services by decreasing frontline providers defaulting to referral of children to hospital outpatient services for sub-specialist management which was common practice nationally (Mitchell et al., 2015; Shaw, Mitchell, Wagner, & Eastwood, 2002; Thomas, Mitchell, & Batstra, 2013). This intrapreneurial approach by the project implementation team manoeuvred leaders within the organization to consider the pilot as a catalyst for ongoing change and innovation in other areas of the business. This in turn served as a tactic for the project team to embed the ECHO model™ within the organization as a business as usual solution to address service demands.