The ELIAS framework: A prescription for innovation and change

Abstract

Healthcare is a complex adaptive system with multiple stakeholders and dynamic environments. Therefore, healthcare organizations must continuously learn, innovate, adapt, and co-evolve to be successful. This article describes a systematic, comprehensive, and holistic performance management framework that healthcare managers can use to achieve these goals. The framework involves the ongoing assessment, modification, or replacement of current programs or services aimed at adapting successfully to achieve the organization’s strategic objectives. This is engendered by the presence of a culture that is premised on continuous learning and innovation. The foundation of the framework is based on accountability, the organization’s strategy, and its culture. This then acts as the basis for an ongoing process of measurement, disconfirmation, contextualization, implementation, and routinization that enhances learning, innovation, adaptation, and sustainability within the healthcare organization.

Introduction

Healthcare environments can be described as complex adaptive systems. These systems can react to stimuli in unexpected non-linear ways and jolts to the healthcare system such as the COVID-19 pandemic can make it challenging to predict how they will respond.^1,2 Nevertheless, complex adaptive systems can allow for learning, innovation, and adaptation by utilizing dynamic capabilities based on Organizational Learning Mechanisms (OLMs) that incorporate action learning, interdisciplinary teams, and practice-based evidence as well as the presence of a culture of learning and innovation.^3

–7 The Enhances Learning, Innovation, Adaptation, and Sustainability (ELIAS) framework (Figure 1) incorporates these characteristics into its design with the intent of enhancing learning capabilities and innovation within healthcare organizations and systems.^4,8

–11

Figure 1.

The ELIAS framework. ELIAS indicates enhances learning, innovation, adaptation, and sustainability.

Learning and innovation

Innovation has been defined as “a novel idea, product, service or care pathway that has clear benefits when compared to what is currently done.”¹² An innovation can arrive from continuous incremental change or from radical or disruptive change. Most innovations follow an incremental path for financial and human resources reasons. Nevertheless, there are occasions when disruptive innovations demonstrate major gains in effectiveness and efficiency for patients and providers.^7,13

–16 Innovations are accepted and diffused if they can demonstrate relative advantage over previous practice; there is a fit between the innovation and current culture; the benefits can be easily tried and observed under local contexts, and there are organizational networks for spreading the innovation.^{13
–15,17,18} A learning organization can be described as one that continuously creates, acquires, and routinizes knowledge and modifies its behaviour to reflect the new knowledge.¹¹ A positive correlation has been observed between learning capability and innovation capacity. Therefore, an organization that learns continuously through external knowledge acquisition or from knowledge creation and experimentation improves its chances of service and process innovation.^4,8,19
–21 The culture of organizations dictate how they respond, learn, and adapt to changing environments. A culture of learning and innovation increases an organization’s successful pursuit of continuous improvement and environmental adaptation as a result of learning and innovation. The characteristics of a learning and innovation culture are outlined in Table 1.^{3,9,11

–20}

Table 1.

Characteristics of a culture of learning and innovation

A recognition that healthcare is a complex adaptive system and a commitment to co-evolution aimed at both adapting to and influencing healthcare environments

The use of accountability mechanisms such as performance measurement and management

Participation of all stakeholders including medical staff and frontline personnel in the design of performance measurement systems

A data-driven entity that emphasizes continuous improvement and performance driven change

The usage of organizational learning mechanisms (OLMs) that incorporate action learning, feedback, shared reflection, and low-risk ethical experimentation to engender individual and team learning

The utilization of facilitated learning techniques such as collective reflection, simulations, e-learning, and case presentations to enhance problem assessment and solution generation

The use of integrated information systems and knowledge management practices aimed at improving the organization’s capacity to generate, acquire, and integrate knowledge into organizational services and processes to transform and adapt to changing environments

The utilization of interdisciplinary teams and organizational networks to collaboratively develop, test, and implement solutions, spread innovations, and implement changes

The continuous development of a psychologically safe environment that is reflected in fair organizational policies and practices as well as tangible management support

Leadership that actively promotes a climate of openness to innovation

Leadership that demonstrates transparency, honest communication, collegiality, and inclusiveness that is aimed at building trust throughout the organization

The ELIAS performance management framework

The ELIAS framework is a dynamic capability based on OLMs that integrate action learning, shared reflection, and continuous improvement aimed at increasing the absorptive capacity for learning and innovation.^4,8,10,22,23 Organizational strategy, accountability, and culture are critical aspects of the framework (Figure 1). Measurement helps to clarify cause and effect relationships thereby directly affecting learning, innovation, and improvement capability. Gaps in performance highlighted by measurement information leads to deliberate reflection aimed at developing evidence-based solutions to close the gap.^23

–27 Disconfirmation of the processes and activities designed to achieve the outcomes of programs and services being assessed is an important step in the framework.^{10

–16,28
–30} This leads to a search for solutions and innovations and then testing them within the organization’s context to improve performance (contextualization). This process is an important source of learning and innovation.^4,5,7,16,25 Following evaluation and acceptance of proposed solutions, the next phase is implementation of the innovations. These innovations then become incorporated into standard operational procedures and policies and procedures in the routinization phase (Figure 1).^{15,17,31
–33} Although the ELIAS framework is represented as cyclical, moving from one stage to the next may not always be linear because evaluation may cause a shift to a previous stage due to unanticipated factors such as inadequate resources, changes in strategic direction, or poor performance of proposed solutions.¹⁰

Using the ELIAS framework

Measurement

Performance measures are best designed by a multi-disciplinary team that includes patients as well as those who will use, affect, and be affected by the measures being contemplated.^{24,26,28,29,34} This enhances ownership of the measures and makes it easier to accept the information provided by the measures when they signal a gap in performance. The operational level of the organization (program, unit, department) is reflected in most performance measures because cause and effect associations between processes and outcomes can be determined at this level and is where interventions to improve performance are made. A balanced set of domains represented by process and outcome measures can be reported in dashboard formats. This makes assessment easier since the multiple visual representation of related measures has been shown to enhance understanding.^{24,26
–28,34} Gaps in performance initiate assessment, reflection, and solution development using improvement strategies such as Plan Do Study Act (PDSA), Lean, or Six Sigma. The search for and testing of solutions generates knowledge, learning, and innovation that is reflected in modified processes or new innovations.^{8,10,14,19,20}

Disconfirmation

This stage of the ELIAS framework is reflected in an awareness of a performance gap between observed and expected performance. Unfortunately, sometimes the awareness of a performance discrepancy is not enough to cause the disconfirmation of current practices and a search to close the performance gap.^{10,16,28,29,31} This is the reason emphasis was placed on input in measurement design from all stakeholders affected by the measures or who affect them. This way there is an improved chance of acceptance of the information provided by the measures. In addition, the presence of a culture that embodies the precepts outlined in Table 1 is also important for the acceptance of the information provided by performance measurement.^3,9,31
–33

Contextualization

The development of solutions to close the perceived performance gap involves all stakeholders who act on the performance measures, as well as those who affect and are affected by them. It is done using OLMs based on action learning, shared reflection, and experimentation.^4,8,10,23,29 Methods used to generate solutions can include logic models, failure mode effects analysis, root cause analysis, Lean, and Six Sigma.^26,28,34 Solutions represent a congruence between the resources of the organization; the organization’s culture; its strategic direction, and the criteria for success set out by stakeholders involved in solution generation.^{23,29,31,32,35} Solutions must also demonstrate practice-based evidence reflected by local pilot testing to assess their viability within the organizational context where it will be implemented. This makes it easier for previous practices to be discontinued (disconfirmation) and innovations to be implemented. This form of practice-based evidence or social proof is critical for successful implementation of the innovation.^{17,29,31
–33}

Implementation and routinization

The successful implementation of innovations must consider the beliefs of those who will be recipients of the change.³⁰ These organizational members readiness for change is affected by the following: perceptions of a discrepancy in actual versus expected performance; the perceived appropriateness of the innovation; tangible management (principal) support for the change; perceptions of efficacy regarding implementation of the innovation; personal valence for the innovation; and the presence of purposeful facilitation to enhance implementation of the innovation.^17,30

–33 Employees must perceive implementation of the innovation as being necessary. This is the reason for stakeholder involvement in the design of performance measures. This enhances the legitimacy of a perceived discrepancy between current and expected performance.^27

–32 The acceptance of a discrepancy and disconfirmation of current practices initiates the development of solutions (innovations) that demonstrate their appropriateness for implementation. The innovation must be perceived as being able to close the perceived performance gap.^16,30 As outlined in the contextualization phase, this is enhanced by choosing innovations compatible with the culture, resources, and strategic direction of the organization. This helps to overcome resistance and enhances perceptions of the innovation’s appropriateness.^{3,29,31
–33}

Implementation of innovations will not occur without management (principal) support. Management must ensure that financial, technical, and human resources are in place to support the change.^15,30

–33 In addition, people charged with performing the new tasks must feel a sense of efficacy in their capability to successfully perform them.^{14,19,30,31,33} Management can enhance this perception by providing the necessary training, resources, and support for performing the new behaviors for successful implementation of the innovation. It is also important for management to show those who will be affected by the change that they will benefit directly and indirectly from it. This increases their personal valence and commitment to performing at high levels.^{14,18,30
–32}

Change agents and champions must possess the requisite skills and organizational supports to guide purposeful facilitation of implementation of the innovations. Examples of these include experience with the innovation, as well as the utilization of social, clinical, and technical networks and communication channels to enhance collaboration, coordination, and implementation. Champions must also be empathetic to the concerns of change recipients and initiate regular feedback conversations and sessions to maintain commitment to the change.^{14,15,17,18,29} Routinization is an extension of the implementation phase and is accomplished when the innovation becomes integrated into standard operating procedures and institutionalized as policies and procedures. Routinization is also greatly enhanced if the readiness for change factors outlined previously has been addressed and collaboration, networking, and connectivity among stakeholders are maximally utilized.^{14,15,17,19,33}

Examples of cases mapping onto the ELIAS performance management framework

The three case studies are from healthcare facilities within the Nova Scotia Health Authority (NSHA). The NSHA possesses and stresses the importance of a culture of continuous improvement, learning, and innovation (Table 1). It is accepted within the organization that the presence of such a culture is the key driver for developing and maintaining a high performing health system. These cases all had tangible senior management support and was conducted by interdisciplinary teams in a climate of collaboration and support.

Case study 1: Tenecteplase for ST elevation myocardial infarction

Tenecteplase (TNK) is a lifesaving thrombolytic drug administered to patients with ST Elevation Myocardial Infarction (STEMI). Best practice is to administer the drug within 30 minutes of arrival at hospital. Measurement time from arrival at the hospital to administration of TNK revealed performance below the 30-minute benchmark (discrepancy) and directly conflicted with the beliefs held by clinical staff. All stakeholders then collaborated on a refined data collection and performance assessment (Measurement) protocol that was presented at specified interval over several months. Assessment of the performance information and team reflection led to a shift in the mindset of clinical staff. They accepted that there was indeed a performance gap (discrepancy) and clinical care could be improved (Disconfirmation). The search for solutions then began with audits of the current processes and all staff advised on process improvements appropriate to their local emergency department (Contextualization). Examples included making a dedicated stretcher for performing ECGs and developing “Code STEMI,” a process to mobilize key staff. Frontline staff took ownership of the project (Implementation) and it was successful because it was designed and led by the local care team. Monthly meetings were held to review performance and tweak processes to ensure sustained improvement (Routinization). This combination of regular meetings to collaborate and reflect on performance information and learn what was working and what needed to be changed, as well as discussing the associated process drivers, resulted in more modifications and eventual routinization of this innovation. This success and resulting team efficacy reinforced the learning and innovation culture and staff became open to reviewing other areas to determine whether improvement may also be needed.

Case study 2: Pressure injury prevention and management

Pressure injuries are a major concern in health systems across the world. Within Nova Scotia, there has been a dedicated focus on the prevention and management of pressure injuries for 5 years. Annual prevalence studies provide key information on the extent of pressure injuries as well as contributing factors. Initially, staff and management were resistant to data indicating that pressure injuries were an issue (discrepancy). However by collecting, analyzing, and disseminating this information on a regular basis (Measurement), attitudes have now shifted (Disconfirmation), with stakeholders now focused on improving this situation. Since each jurisdiction is different, each area is responsible for developing a local improvement plan that is contextualized to their population and facility (Contextualization). This ensures that the selected improvement methods will fit each jurisdiction rather than assuming a one size fits all approach (Contextualization). Interdisciplinary teams developed and implemented solutions in their respective locations. Outcomes were evaluated using accepted benchmarks and results were analyzed and reflected upon by team members. Modifications were made to care processes using PDSA type iterations. Each cycle of improvement has produced substantive gains (Contextualization, Implementation, and Routinization). This process has also served to reinforce the benefits of a culture of learning and innovation (Table 1).

Case study 3: Information sharing during COVID-19

COVID-19 forced a rapid transition in the approach to analytics and operational decision-making at the NSHA. An Emergency Operations Centre and several Incident Management Teams were implemented; each with unique analytical needs to support rapid decision-making. Daily information to support operational decisions and strategic planning was needed. This shift in the utilization of analytics and decision-making resulted in a need to alter existing processes within the Performance and Analytics Team. The team had been producing operational reports and dashboards on a quarterly basis and it became apparent that this strategy would be unsuccessful given the new environmental realities and needs of decision-makers (Disconfirmation). The team developed solutions to fulfill the information needs of each team of decision-makers. The information each team needed was slightly different so team-specific indicators and modes of presentation were developed collaboratively to meet each teams’ specifications (Contextualization). Although the new way of producing information was effective and efficient, ongoing education was required to support key leaders understanding and use of it (Implementation, Efficacy, Facilitation). A shared learning situation emerged whereby senior management learned how to use the new technology (visualization platform) and to incorporate new information at a much quicker pace into their decision-making. At the same time, the Performance and Analytics Team learned to maximize the utility of this new technology and make the information a routine aspect of decision-making (Routinization). A real innovation has emerged as often does with complex adaptive systems such as healthcare. In addition, increased investment in the team and the technology has continued and has led to an innovation-driven transformation in the use of analytics within the NSHA.

Conclusion

Healthcare organizations need to continuously learn in order to innovate and adapt to their changing environments.^{7,15,19
–21} The ELIAS framework (Figure 1) is specifically designed to enhance learning, innovation, and adaptation by using performance measurement systems that are already being utilized by healthcare organizations for accountability and improvement. Therefore, in terms of the costs and benefits of utilizing the ELIAS framework, this makes it a valuable extension of what is already being done. The presence of a culture of learning and innovation is an important aspect of the successful functioning of the ELIAS framework and leadership is important for building and reinforcing this culture (Table 1).^3,6,9,19,35 The ELIAS framework uses measurement to inform on the ongoing success of current practices while appraising the need for change. If change is necessary, the framework can then be used to develop, test, implement, and routinize evidence-based solutions. The execution of these processes within the organization’s context is where learning and innovation occurs and allows for the resulting evidence-based innovations to be implemented and routinized thereby leading to adaptation to changing environments.^{4,14,18,19,28} The paper’s prescriptive intent provides management with methods that can be integrated into standard operating procedures and adapted to their individual contexts. The result is the development of a culture where beliefs and mindsets naturally lead to the development of learning systems and where innovation and adaptation to changing environments becomes the norm.

Footnotes

ORCID iD

D. David Persaud

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