Whole Health System Change in Ireland: A Collaborative Inquiry Into the Enablers and Challenges of Implementation


 BackgroundAcross the world, health and care systems are struggling to contain costs and improve quality of services by improving prevention, developing wellness programmes, and providing person-centred coordinated health and care. The development of the National Clinical Programmes (NCPs) in Ireland in 2009 coincided with a profoundly challenging period for the Irish economy and consequently for publicly funded health services. These programmes are focused on implementing clinical and operational models of care that have access, quality and value at their core. By 2012, there was a clear recognition among senior health leaders that the desired outcome of nationalising best practice and achieving whole system change had not been achieved through the NCPs and a series of world café events were then planned to assess the challenges that had been experienced by the programmes in order to inform the next phase.MethodsA Multi-Stakeholder Engagement Process using the World Café method of collaborative participatory inquiry, was conducted to obtain a rich, in-depth understanding of the development and implementation of health service reform in Ireland. Three keys questions were explored through an inductive approach to analysis of themes that emerged from conversations with key stakeholders.ResultsThere were 59 participants. A total of 408 responses were received. Using an inductive approach to analysis of themes 5 key themes emerged; Integrated care; Patient Centred Care; Clinical Governance; Funding models and e-Health.ConclusionHaving a clear vision, a prescribed methodology and clinician buy and involvement in the design of new models of care is not sufficient to ensure implementation. A whole system approach to the design and implementation of new models of care must be supported by essential enablers such as policy, financial and human resource models and knowledge management systems. This research informed the planning and design for the second phase of the programmes and sought to overcome the barriers and work with operations and policy makers to improve outcomes for patients by implementing person centered evidence-based models of integrated care.


Abstract
Background Across the world, health and care systems are struggling to contain costs and improve quality of services by improving prevention, developing wellness programmes, and providing person-centred coordinated health and care. The development of the National Clinical Programmes (NCPs) in Ireland in 2009 coincided with a profoundly challenging period for the Irish economy and consequently for publicly funded health services. These programmes are focused on implementing clinical and operational models of care that have access, quality and value at their core. By 2012, there was a clear recognition among senior health leaders that the desired outcome of nationalising best practice and achieving whole system change had not been achieved through the NCPs and a series of world café events were then planned to assess the challenges that had been experienced by the programmes in order to inform the next phase.

Methods
A Multi-Stakeholder Engagement Process using the World Café method of collaborative participatory inquiry, was conducted to obtain a rich, in-depth understanding of the development and implementation of health service reform in Ireland. Three keys questions were explored through an inductive approach to analysis of themes that emerged from conversations with key stakeholders.

Results
There were 59 participants. A total of 408 responses were received. Using an inductive approach to analysis of themes 5 key themes emerged; Integrated care; Patient Centred Care; Clinical Governance; Funding models and e-Health.

Conclusion
Having a clear vision, a prescribed methodology and clinician buy and involvement in the design of new models of care is not su cient to ensure implementation. A whole system approach to the design and implementation of new models of care must be supported by essential enablers such as policy, nancial and human resource models and knowledge management systems. This research informed the planning and design for the second phase of the programmes and sought to overcome the barriers and work with operations and policy makers to improve outcomes for patients by implementing person centered evidence-based models of integrated care.

Background
Across the world, healthcare service delivery seeks to control costs and improve quality of services for all by increasing access to preventive services, wellness programmes and continuous medical care (1). The HSE (Health Service Executive) National Clinical Programmes (NCPs) in Ireland are a series of clinically led quality improvement initiatives that were established by the Irish health system in 2009. They were initiated in response to a growing awareness of inadequate implementation of clinical standards and regional variation in practice revealed by a series of inquiries into serious adverse events in Irish hospitals during the early 2000s (2,3).
The National Clinical Programmes are a joint initiative and have formed a powerful guiding coalition through a partnership between HSE and Clinicians through the Forum of Postgraduate training colleges, the Irish Association of the Directors of Nursing and Midwifery and the Therapy Professions Committee and most importantly, in partnership with patients. The programmes are focused on implementing models of care that simultaneously seek to pursue improving access, quality and cost-e ciency.
Although the approach to achievement of these goals was very much at the discretion of each individual programme, common aspects across the programmes include: (1) a de ned governance structure (2) detailed description of how cost savings would be made, The adoption of the NCPs coincided with a profoundly challenging period for the Irish economy and consequently for publicly funded health services. Very large funding and sta ng cuts have been imposed on the Irish health system since 2009. Despite this, evidence from several quality metrics indicates that services have been maintained or enhanced since the cuts. However, after 3 years, despite the improvements indicated above, there was clear recognition that the desired outcome of nationalising best practice and achieving whole system change had not been achieved and a series of engagement events were then planned to assess the challenges that had been experienced by the programmes in order to inform the next phase of the improvement initiatives.

Methods
A Multi-Stakeholder Engagement Process utilising the World Café method of participatory inquiry (4,5), was conducted with 59 key stakeholders involved in the Clinical Programmes including clinicians, managers, academics and patients to access the participants' experience and expertise of the Clinical Programmes to date to inform phase 2. An inductive approach using qualitative thematic analysis of the written material was used to determine themes for identi cation. This was chosen as it provides a exible and useful research methodology, which can potentially provide a rich and detailed, yet complex account of data obtained. Participants were required to respond to 3 key questions presented during the World Café and to write their responses verbatim for submission to the investigators. Questions were designed with health system redesign in mind to elicit responses that would capture the participants' subjective experiences of the healthcare system regarding the implementation the clinical programmes.

Participants
Participants were either national clinical leads, GP leads, programme managers, and/or members of the postgraduate medical training forum. Participants also included key stakeholders such as patients and patient advocacy organisations and representatives from academic institutions. At the time of the study, all participants were actively engaged in quality improvement work with the National Clinical Programmes.

Procedure
Purposive sampling was used to identify participants. This method was chosen because the programmes are very diverse and heterogeneous, and it was felt that participants needed to re ect the breadth of the programmes without too many participants being involved to make the running of the events and meaningful dialogue di cult. Identi ed participants were then invited to participate by a letter from the National Director. 2 world café events were held.

Conduct
Developed by Juanita Brown and David Isaacs the World Café is a participatory method that seeks to facilitate change by bringing together key stakeholders of a system of interest and using a highly structured movement process, enables evolutionary conversations that generates collective discoveries that are gathered and shared (4,5). This approach recognises that answers to di cult questions often exist in the collective knowledge of networks of individuals with a shared interest. It was designed as a means of cultivating and harnessing the power of 'conversations that matter' and follow seven core design principles: (6) 1. There must be a clear purpose and parameters in which collaborative learning will develop.
2. The event must be hosted in a hospitable space 3. It should explore questions that matter to participants. . There should be collective listening to identify patterns, insights and discoveries.
7. The collective discoveries are harvested and shared.
The objective of the sessions was to obtain the views of the invited participants on the following three questions which were consciously orientated towards the principles of appreciative inquiry and developed as 'provocative propositions' (7)

Make one suggestion on how to improve the Clinical Programmes
The café sessions considered each of the three questions in turn.
The World Café setting created a relaxed environment where participants were grouped at tables of 6-8. A draw was used for the allocation of tables.
Only one question was presented at a time. Every table "chatted" about the question and when doing so jotted down their comments on the cards provided -one card per comment. 30 minutes per question was allocated.

Data collection
At the end of each session the cards were collected. No names or table numbers were on the cards so that feedback was totally anonymous.
The feedback comments were entered in an excel spreadsheet for analysis and reporting. The themes were not identi ed prior to examination of the comments. Only as the comments were analysed did the themes come together.

Ethical Approval and Consent to Participate
This activity was conceived as a collaborative inquiry with the primary purpose of developing a shared understanding of challenges to implementation to inform the next phase of the programmes. The activity was screened in accordance with HSE Research Ethics guidance and was deemed not to require research ethics committee review. The work observed the ethical principles articulated within the Belmont Report (8) All written comments and notes were captured anonymously. Verbal consent was obtained from participants at the start of the events. Participants were informed in the invitation and at the start of the meeting that the written notes would be collected and analyzed and used to create a report from the activity. Participants were informed that they would have access to a draft report for their feedback prior to the wider circulation of the report.

Data Analysis
The 6 phases of thematic analysis according to Braun and Clarke were observed (9) . Three investigators analysed the data. The investigators familiarised themselves with the data by reading and rereading the written submissions and noting down initial ideas. Codes were initially given to certain recurring words or ideas. These codes were then simpli ed and expanded into interpreted categories and themes as patterns in the data emerged. The themes were then expanded on and further revised. The nal stage was to re ne themes and de ne why they were interesting and what was interesting about them. Finally, a report was produced.

Results
In-depth analysis of responses resulted in a signi cant number of initial codes, which were further analyzed to a set of nal codes and then categories. These categories were evident across majority of participants. The process is summarized in Figure 1.  Participants described the importance of a partnership approach to the Clinical Programmes. One comment stated, "College involvement gives the NCPs credence and credibility" with another commenting that the multidisciplinary nature of the programmes "Harbour better understanding between the various disciplines and health settings". There were many comments on the lack of integration across the programmes with one comment being "The programmes are at risk of becoming silos" Theme 2: Patient centred Participants described the importance of patient centredness. One comment stated that "It's the right thing to do" and that there is a "Sincere genuine interest in patients". Other comments stated that the NCPs offered the opportunity to "Identify the real priorities vs political priorities" and that "Patient and patient groups must be included in all stages of health planning".

Theme 3: Clinical Governance
Participants described the importance of clear Clinical Governance. And one commented that currently that "wasn't clear". Another comment stated that there is a need for "proper governance to get national policy Programmes implemented" and another comment was that there was a "Lack of evaluation of impact of change".

Theme 4: Funding Model
Participants described the need for clear funding models to support the work of the Clinical Programmes.
One representative comment was that there was "In-su cient funding" and another that participants "Cannot secure money that is saved" and another that there was "No autonomy re spend".
Theme 5: eHealth Participants described severe challenges with Information and communications technology (ICT) and procurement with one representative comment stating "ICT procurement and approvals process is very slow and cumbersome even for relatively small project and for larger Programmes -directorate approval" A sense of frustration was evident form the comments and one comment highlighted the "Need for better national records / registers and information technology in general".

Discussion
How to successfully engage with key stakeholders was a big challenge at this stage of development of the Clinical programmes. The country was in deep recession and the initial enthusiasm that new initiatives have, had started to wane. The importance of successful engagement was identi ed as a major priority to sustain involvement and participation and to harness the collective knowledge existing within the clinical programmes.
The experience of the facilitators and participants was very positive and showed that the World café approach was successful and allowed the participants to make sense of how they perceived themselves as participants in the clinical programmes, in relation to colleagues, clinical and non-clinical and what resources and systems needed to be in place to support the next phase of the programmes.
This approach facilitated the development of a new experience in engagement and knowledge generation; a conversational process that helped the participants to engage in constructive dialogue around matters of importance to them, to build social networks and to foster collaborative learning. In relation to other participatory and collaborative approaches, the World Café was powerful in terms of cross-pollination of ideas and perspectives and the connection of diverse viewpoints into a coherent vision. The sensemaking that took place through the highly structured process, yet in a relaxed nonthreatening environment, enabled co-evolutionary creative conversations that generated discoveries that were harvested and shared.
While the considerable achievements of the programmes were clear, analysis of the themes reveals the essential need to maintain and enhance clinical leadership, develop clinical pathways that are truly patient-centred, and seamlessly cross organisational and professional boundaries. There is a recognized requirement to; align programme design with service priorities, enhance evidence-base and performance and outcome measurement, ensure structured and consistent implementation and ensure alignment with key enabling functions such as Finance, Human Resources (HR) and ICT. The output from this participatory inquiry supported the development of the Integrated Care programmes which are now underway. These integrated care programmes are now playing a key role in improving patient care and are a key pillar of national health policy.

Limitations
There is very little in the scienti c literature about using a World Café approach in healthcare however, we feel that this method ts well within the action research family of approaches as it relies on an appreciation of local knowledge and co-design and co-evolution of solutions (10)

Conclusion
The World Café method encouraged purposeful, collaborative engagement with the heterogeneous groups of stakeholders involved in the clinical programmes The approach allowed a collective and collaborative sensemaking of the enablers and barriers to change in the health system and allowed a coproduction of next steps. It was recognized that having a clear vision, a prescribed methodology and clinician buy and involvement in the design of new models of care is not su cient to ensure implementation. For new models of health and social care to be successful, a whole system approach to design and implementation must be taken, adequately supported by key enablers including; policy, nancial and HR models and knowledge and information management systems. The World Café approach proved to be a very powerful method of engagement that facilitated a collective intelligence about the challenges of implementation from many different perspectives and allowed the co-creation of solutions to inform the next phase of the programmes. Abbreviations part of the work are appropriately investigated and resolved. All authors read and approved the nal manuscript. Figure 1 Codes, Categories and Emergent Themes