Lessons learned from a health authority research capacity-building initiative

Abstract

Health systems worldwide are under pressure to deliver better care to more people with increasingly complex needs within constrained budgets. Research capacity building has been shown to help alleviate these challenges and is underway at hospitals and health authorities across the country; however, approaches vary widely and little exists in the Canadian literature to share experience and best practices. This article describes how a health authority in British Columbia, Canada, implemented and evaluated a 5-year research capacity-building program in partnership with a provincial health research funder. We offer lessons learned for those leading similar innovation-focused change management initiatives, including vision and buy in, complexity thinking, infrastructure, leadership, and coalition development. We suggest that collective learning and building a more robust research capacity-building literature can help health organizations and their partners take significant steps toward integrating research and care for a more effective, efficient, and patient-centred health system.

Introduction

Health systems worldwide face significant challenges given growing and aging populations,¹ increasing migration,^2
–4 wealth disparities, and more.^5,6 In Canada, provincial^7,8 and national⁹ health systems struggle to deliver high-quality, evidence-informed care due to changing demographics,^10,11 advancing technologies,^12,13 fiscal constraints,^14,15 and rising public expectations.¹⁶

Research improves care and outcomes for patients, enhances processes and performance, and increases clinician satisfaction and confidence,^17

–20 but operational needs may override allocation of scarce resources for research and innovation and the infrastructure to support these functions. This article describes a health authority initiative to build capacity for and embed health research into ongoing operations, an evaluation of that initiative, and lessons learned going forward.

Health research capacity building

Health research capacity improves organizations’ abilities to conduct research and to use results effectively²¹ for the benefit of patients and society. In the United Kingdom, research is defined as a core function and supported by continuous RCB strategies to enable learning health systems.²² Suggestions for supporting RCB include developing skills, supporting linkages and partnerships, ensuring research is “close to practice,” developing dissemination, investing in infrastructure, and building sustainability and continuity.²³ In 2010, an initiative supported by the Michael Smith Foundation for Health Research (MSFHR), British Columbia’s (BC) health research funder, provided resources to support RCB in BC’s health authorities²⁴ to increase their health services and policy research capacity. Although Ellen et al.²⁵ proposed the need for infrastructure and tools in health organizations to enable better use of research evidence, the literature is thin on organizational experience with and learning from RCB initiatives in Canada, with most publications focusing on other countries or in specific clinical settings or professions.^{26

–34} The evidence base for RCB is growing; however, given the challenges facing health organizations and systems, and the potential of research to contribute to advance their effectiveness, increased efforts to share experiences and lessons learned are critical.

Island Health research capacity building: Overview

Island Health is a BC health authority that provides care to 790,000 people on/around Vancouver Island. Prior to 2012, research was undertaken at Island Health only by those who had the will and the wherewithal to participate. Organizational infrastructure and the breadth of expertise to support research and knowledge translation were limited, with little capacity to partner with academic researchers, industry and other external partners, and few supports for those wanting to engage in research. Prior attempts to build organizational research capacity were not comprehensive and therefore were ultimately unsuccessful. In 2012, Island Health launched a board-endorsed, $4.9 million, 5-year RCB partnership with MSFHR, in close collaboration with the University of Victoria, with a vision to develop a robust, self-sustaining health research community on Vancouver Island, supporting and contributing to the delivery of health services and improvements in health status and healthcare for the Island’s population. That year research became a part of Island Health’s purpose statement.

Our approach was framed around the question “What’s special about us?” The answer had three parts: (1) a bounded and stable population with a single provider of secondary/tertiary care, (2) a regional research-intensive university, and (3) the goal of a single electronic health record. Extensive stakeholder consultation resulted in a plan that required the creation of new roles at Island Health for leaders and teams who would enable six activity tracks: collaboration, capacity, compliance, research funding, patient/public engagement, and clinical research analytics. Goals and outcomes were set and indicators developed; annual progress was tracked to enable course corrections. The strategy of the RCB is shown in Figure 1; Figure 2 lists key activities.

Figure 1.

Strategic aims of the research capacity-building initiative.

Figure 2.

RCB logic model and outcome summary.

Research capacity-building evaluation

Summary of research scope

For context, the majority of the research conducted at and in collaboration with Island Health between 2012 and 2017 fell into the health services/policy and clinical research pillars, followed by population health, with fewer translational research studies. The largest research contract awarded, however, was a Genome Canada-funded translational program to develop a biomarker and triage tool for transient ischemic attack diagnosis. Clinical research focused on neurology (stroke, multiple sclerosis, dementia), endocrinology (diabetes), infectious disease (Clostridium difficile), and adult intensive care, while health services and population health research occurred across a wide breadth of program and clinical areas.

Evaluation methodology

An evaluation of the RCB initiative undertaken in 2018 covered nine questions (Table 1):

Table 1.

An evaluation of the RCB initiative

#	Evaluation question
1	Has the RCB initiative (RCBI) increased the number of excellent researchers in the Island Health research enterprise?
2	To what extent has the RCBI increased the volume and quantity of research produced?
3	To what extent has the RCBI strengthened the dissemination and uptake of health research evidence?
4	To what extent has the RCBI addressed the strategic priorities in the business plan?
	A. Has priority research in Seniors’ Health, Indigenous Health and Mental Health, and Substance Use occurred?
	B. Has the distribution of health research activity become more equitable across Vancouver Island?
5	Has the RCBI contributed to the self-sustainability of the health research enterprise?
6	What unanticipated outcomes have been realized as a result of the RCBI?
7	What high impact research or research support activity has RCBI funded or facilitated, with particular focus on direct improvements to healthcare?
8	Which elements of the initiative contributed most to the expected outcomes?
9	What have been the barriers and facilitators to progress?

Four evaluation phases—project initiation, administrative data analysis, stakeholder interviews, and case studies—enabled an iterative, mixed-methods evaluation. The focus on qualitative as well as quantitative data provided a rich picture about outcomes, successes, and challenges. Data sources included a new data management system (REDCap), administrative data (eg, granting, research ethics, finance, contracts), stakeholder interviews (n = 31), and case studies.

High-level findings

Figure 2 summarizes activities and outputs and progress toward short, medium, and long-term outcomes.

RCB met all short-term outcomes (within 2 years) and the majority of medium-term (3-5 years) outcomes.

Strong strategic and operational leadership was identified as one of the most critical enablers of the RCB’s success.

Unanticipated outcomes included a significant enhancement of quality improvement initiatives and leadership capacity within and outside of Island Health.

Among the quantitative findings, the number of Island Health Principal Investigators involved in clinical research increased from 40 to 65 and the number of collaborators and other research team members increased from 15 to 39. The number of students engaged in research increased from 10 in 2012 to 36 in 2017. The number of new studies led by a researcher external to (but engaged with) Island Health increased from 50 to 77, but the number of studies led by Island Health researchers (employees and affiliated physicians) remained relatively constant.

External funding directly to Island Health has been modest (just over $10.4 million), mostly in the form of grants with a substantial portion from one large contract in neurology ($9.6 million). Funding to academic collaborators was also enabled but not measured.

There is limited evidence of uptake of the evidence generated by regional research conducted over this time. However, the dissemination of evidence, particularly through the annual “Five Days in May” event, was seen as an important enabler by a majority of stakeholders. From 2012 to 2017, 41 events were held, involving 167 speakers, and over 2,100 attendees.

A modest increase in strategic research priority areas (seniors’ health; Indigenous health; mental health and substance use) was observed.

Although some important individual research projects were launched outside the greater Victoria area, there was little evidence of increased research in other areas of Vancouver Island.

Substantial progress was made in building and embedding the knowledge-based infrastructure within Island Health. New leadership positions included two directors (Research Capacity Building and Clinical Research Analytics) and five managers (Research Business Unit, Clinical Trial Unit, Data Management, Research Ethics/Compliance, and Patient and Public Engagement); other roles that enabled relationship development and supports for a broad range of stakeholders, both within and outside of Island Health.

Among some of the service and support findings: 186 projects took advantage of a new data management platform (REDCap); 15,400 patients enrolled in a Permission to Contact for Research program; 284 research privacy consultations enabled research; and 350 new contracts were negotiated.

Lessons and reflections

Leadership was a key success factor: the right people were in the right place at the right time, resulting in organizational commitment at multiple levels. Increased research activity and increased dissemination of research evidence are good markers of progress. Translation of research evidence into practice takes time and is very difficult to measure; hence, dissemination is used as a proxy and emergent strategies to mobilize evidence into practice and policy continue.

Some things went less well. Funding was a constant concern; several sources are required. We had limited success in increasing research capacity outside of Victoria and with hindsight may have sought to build research capacity there from the outset. There was also time pressure from competing priorities. Other systemic issues included two new hospitals under construction, and in our second largest centre, the timing clashed with a major initiative to introduce an expanded electronic health record, leading to competition for management attention and time and the interest of clinician-researchers.

Specific lessons include the following:

1. Strategically align with organizational priorities

It is critically important to align any RCB with organizational vision, values, challenges, priorities, and key partners. Organizations must create space for the work and allow time to understand the environment—rushing to implement without a sound foundation will severely limit potential.

2. New and existing infrastructure is essential

The success of RCB is predominantly due to enhanced capacity, building new infrastructure, and creating roles bringing new areas of expertise. Strong executive leadership, finance, legal, information technology, privacy, communications, and human resources are key enablers of building research capacity. Leaders planning these initiatives must understand that a research department is connected to other areas that will work, learn, and change together.

3. Create a strong, sustainable foundation

Required supports include high quality, secure data collection, and analysis; education; internal grants to enable regional research; clinical research analytics capacity; an efficient clinical trials unit; and expertise to create research teams, grants, and knowledge translation strategies. Leaders should understand that investing in building a sound foundation creates more opportunities and also supports future growth. The biggest lesson here was to resist actions that sounded progressive and outcome oriented (eg, hiring clinician scientists) which would fail without appropriate infrastructure (the foundation is now established to attract and support such scientists).

4. Make decisions through a complexity lens

The RCB initiative was an organic undertaking in a complex, dynamic environment, and irrespective of a well-executed annual planning process with clear milestones, its development and outcomes have been non-linear. For example, the positive impact on quality improvement work was not anticipated at the outset and the inherent structural challenges in tracking and supporting the adoption of research and quality improvement evidence were ambiguous and unpredicted. Decisions made during the RCB were adjusted in response to changes at Island Health and its environment; and along the way, opportunities for funding and partnerships arose that demanded nimbleness and risk tolerance.

Consider tools such as the Cenefin Framework³⁵ to help guide decision-making, approaches, and responses to emergent opportunities at the onset and throughout. When faced with complexity, the natural response is to try to simplify it rather than embrace and work with it.³⁶ To our knowledge, there is no literature on RCB that uses a complex systems models; this would be a productive avenue of research in the field.

5. Build, strengthen, and nurture partnerships

Developing coalitions and strengthening partnerships was a dominant theme in the RCB initiative. All of the LEADS in a Caring Environment³⁷ framework’s subdomains under “Develop Coalitions” were of paramount importance:

Purposeful Building of Partnerships and Networks to Achieve Results. Particularly impactful was the relationship with University of Victoria, which included shared oversight of the RCB initiative, an embedded Scholar in Residence, and collaborations on Island Health-funded research projects. Strong relationships and a commitment to work together created trust and shared meaning and mutual value. There is an understanding that the success of each is dependent on that of the other.

Demonstrate a Commitment to Customers and Service. Partnership with MSFHR and the shared vision to improve health outcomes was critical and enabled rich learning on grant administration, knowledge translation, more engagement in provincial initiatives, and more. Strategic guidance and other operational supports, such as provision of expertise for evaluation, were invaluable. Equally important were the internal coalitions formed with leaders and teams across internal program areas to enable research with the common goal of improving health and well-being for patients.

Mobilize Knowledge: The RCB established strong conduits between individuals and groups to collect, share, and exchange information with multiple partners and collaborators that went beyond individual research studies and into cross-organizational ties. Leaders undertaking RCB should build coalitions that enable access to broad expertise, information, and perspective.

Navigate Sociopolitical Environments: Demonstrating the leadership behaviours of Leads Self and communicating effectively are key attributes required for RCB. The lesson is that when done correctly—including a focus on relationship building and conflict resolution—it can bring more resources to bear than a health organization alone could ever access. Ongoing attention to collaborator perspectives are key, for example, although partners expressed confidence, concerns about long-term commitment of Island Health’s senior leadership, and the sustainability of the granting program surfaced. There also has to be an understanding that sometimes one side has to “give” in the interests of the long-term relationship.

6. Understand systems impacts on sustainability

Leaders building partnerships with academic collaborators should understand systems issues around research funding. Universities rely on attracting funding; sharing funding with partners hits their bottom line and potentially damages their prestige. Health authorities building research capacity need funding to sustain infrastructure, support research, and gain their own prestige. National funding policy does not allow health authorities to be directly eligible for research support funds to sustain research infrastructure and working with groups like HealthcareCAN to advocate for change to support innovation within the health system is important. In this context, leadership needs to engage at the national level, take risks, and focus on the long game.

7. The importance of leadership

The development of organizational research capacity is essentially a leadership undertaking. The ultimate goal of the RCB initiative was to help develop an organizational culture in which research and evidence-informed decision-making are integrated into everyday practice. This was not anticipated to occur within 5 years, but stakeholder feedback indicates important steps have been taken.

Executive leaders, backed by Island Health’s Board, committed to the investment, accepted the risks, and realized the strategic importance in partnering with a funder and included research in Island Health’s publicly stated purpose. Michael Smith Foundation for Health Research and partnering university leaders demonstrated commitment and a willingness to collaborate. The buy in of clinical and operational leaders to support the growth of research was vital and required learning, risk tolerance, and shifts in perspective.

Although the research department brought in new expertise, new leaders initially lacked knowledge of the organization, the health system, and systems’ thinking ability. Humility to learn, and a committed effort to develop and take advantage of the myriad of leadership development opportunities offered by Island Health, built a team that has integrated into and is functioning as part of, not separate from, organizational culture.

The future

The need for improved results and sustainability from available funding is driving collaborations and new province-wide approaches to health research. Island Health’s investment in research capacity building has changed it into a research hospital, one that can be a meaningful contributor to the transformation into a learning health system within its walls and within in BC, with the foundation in place to enable and strengthen both innovation and the integration of research into practice.

Footnotes

Acknowledgments

The authors recognize the roles and contributions of the Island Health Research Capacity Building Department and the initiative’s academic partners, including the University of Victoria, University of British Columbia (UBC), UBC Island Medical Program, Vancouver Island University, and Royal Roads University as well as its life sciences partners. Also recognized are the many clinicians and health services and executive leaders at Island Health who have both conducted and enabled research and the many researchers and students who have partnered to conduct research. Howard Waldner and Dr. Lynn Stephenson are noted for their vision and investment in the RCB and the professionals at the Michael Smith Foundation for Health Research also provided superb support. Thanks to Penny Cooper and Associates for conducting the complex evaluation and to Annie Moore for her editing finesse. Finally, and so importantly, we sincerely thank the many patients, families, and people with lived experience who have partnered with us and continue to enable this journey.

ORCID iD

Cindy Trytten, CHE, MSc

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