WHAT SPARKS INNOVATION IN RURAL HEALTH ... Lloyd Thesis.pdfWhat ‘sparks’ innovation in rural health settings: A case study iv Abstract The case study is an empirical inquiry that

WHAT ‘SPARKS’ INNOVATION IN RURAL

HEALTH SETTINGS: A CASE STUDY

Sheree Lloyd

B (Bus) QUT, MTM Griffith

Submitted in fulfilment of the requirements for the degree of

Doctor of Philosophy

School of Public Health and Social Work

Faculty of Health

Queensland University of Technology

October 2019

What ‘sparks’ innovation in rural health settings: A case study ii

What ‘sparks’ innovation in rural health settings: A case study iii

Keywords

rural health, innovation, performance, high reliability, organisational factors,

contextual factors

What ‘sparks’ innovation in rural health settings: A case study iv

Abstract

The case study is an empirical inquiry that investigates the ‘case’ in depth and

within its real-world context and relies on multiple sources of evidence (Yin, 2014).

Through a case study the researcher can gain rich picture to analyse institutions,

persons, decision, events or other systems by one or more methods (Thomas, 2016).

Approximately 30% of the Australian population live in rural locations, and population

health is impacted by poor access to health services, higher rates of disease and poorer

health outcomes. Effective health care delivery is influenced by difficulties in

recruiting and retaining staff, fewer resources and less infrastructure. Innovation, the

use of evidence-based decision-making and the adoption of technology are

government priorities. Commonwealth and state health departments’ values and

mission statements focus on the identification of innovative solutions to rising health

costs, health system sustainability, an aging population, workforce and to address

health disparity.

The aim of this research was to investigate the organisational and contextual

factors that influence the adoption and sustainability of innovation and high

performance in rural health settings. A case study conducted in a rural health service

in northern New South Wales, Australia was the research methodology applied. Three

independent studies were conducted using a mixed-method approach. The studies

collected concurrently, qualitative and quantitative data. Data analysis from

interviews, surveys and publicly reported performance data and documents was

completed by the researcher to understand how innovation in rural health settings

occurs, how performance can be measured and described, and to ensure that the study

findings were reliable and valid.

This research has established how innovation can occur in rural health settings.

The research has identified the unique contextual and organisational factors that

support innovation in a rural health setting. The case study organisation was found to

have a culture receptive to innovation, and 78% of the innovations identified have been

sustained. Innovation is occurring despite many of the factors that theory suggests are

necessary, such as size (large), ‘slack resourcing’, administrative intensity and

departmental differentiation. Further, new knowledge regarding performance

measurement using publicly available information and how that might be used to

What ‘sparks’ innovation in rural health settings: A case study v

understand performance in rural health services has been obtained. The performance

study identified that currency of the data and the ability to compare similar peers is

important, and further work is needed on performance data sets to enhance usability.

The research results provide much needed evidence to understand rural health

organisations and to assist health service leaders to determine what could enable

further innovation and to harness that innovation to improve rural health services.

What ‘sparks’ innovation in rural health settings: A case study vi

Table of Contents

Keywords ................................................................................................................................ iii

Abstract ................................................................................................................................... iv

Table of Contents .................................................................................................................... vi

List of Figures ......................................................................................................................... ix

List of Tables ........................................................................................................................... xi

List of Appendices ................................................................................................................ xiii

Glossary and Abbreviations .................................................................................................. xiv

Statement of Original Authorship ........................................................................................ xvii

Acknowledgements ............................................................................................................. xviii

Chapter 1: Introduction............................................................................................. 1

1.1 Background to the research ............................................................................................ 1 1.1.1 Purpose ................................................................................................................ 5 1.1.2 Study design ......................................................................................................... 6

1.2 Context and setting for research ..................................................................................... 6

1.3 Aim of the research ........................................................................................................ 8 1.3.1 Research questions ............................................................................................... 8

1.4 Scope and definitions ..................................................................................................... 9

1.5 Research gap and contribution to knowledge .............................................................. 10 1.5.1 Impact ................................................................................................................ 11

1.6 Thesis outline ............................................................................................................... 13

Chapter 2: Literature Review ................................................................................. 14

2.1 Introduction .................................................................................................................. 14 2.1.1 Structure and scope of the literature review ...................................................... 14 2.1.2 Rural health challenges and the disadvantage in rural health services .............. 16

2.2 Factors driving innovation ........................................................................................... 18

2.3 Innovation and innovation theory ................................................................................ 19 2.3.1 History, types and definitions for innovation .................................................... 19 2.3.2 Determinants and antecedents of innovation ..................................................... 23 2.3.3 Sustainability and diffusion of innovation ......................................................... 25

2.4 Context and the role of place in innovation ................................................................. 26

2.5 Link between performance and innovation .................................................................. 28

2.6 Measurement of innovation and performance .............................................................. 29 2.6.1 Measures of innovation ...................................................................................... 29 2.6.2 Measurement of performance ............................................................................ 31 2.6.3 Challenges in the measurement of performance ................................................ 36 2.6.4 Examples of high performing health care organisations in the literature .......... 38

2.7 Case study research ...................................................................................................... 39

2.8 Rural health service research ....................................................................................... 42

What ‘sparks’ innovation in rural health settings: A case study vii

2.9 Theoretical and conceptual frameworks .......................................................................42

2.10 Research gap .................................................................................................................44

2.11 Summary and implications ...........................................................................................45

Chapter 3: Research Design .................................................................................... 47

3.1 Introduction ..................................................................................................................47 3.1.1 Research design framework ...............................................................................47 3.1.2 Approach to critical inquiry and rationale for case study approach ...................48 3.1.3 Context of the case study location ......................................................................50

3.2 Methodology .................................................................................................................52 3.2.1 Research design for the case study .....................................................................52

3.3 Participants and informants ..........................................................................................54

3.4 Instruments, sampling and data collection procedures .................................................55 3.4.1 Study 1 ................................................................................................................55 3.4.2 Study 2 ................................................................................................................56 3.4.3 Study 3 Workplace Innovation Scale Survey .....................................................57

3.5 Analytical methods .......................................................................................................58 3.5.1 Overview ............................................................................................................58 3.5.2 Data analysis Study 1 .........................................................................................59 3.5.3 Data analysis Study 2 .........................................................................................59 3.5.4 Data Analysis Methods Study 3: Workplace Innovation Scale Survey .............64 3.5.5 Corroboration of methods and studies ................................................................64

3.6 Ethics and data management ........................................................................................65 3.6.1 Ethics ..................................................................................................................65 3.6.2 Backup, retention data storage, privacy and confidentiality ..............................66

3.7 Bias and trustworthiness ...............................................................................................67

3.8 Conclusion ....................................................................................................................68

Chapter 4: Study 1 Results: Performance and Measurement of Performance in

the Case Study .......................................................................................................... 69

4.1 Introduction ..................................................................................................................69

4.2 Results ..........................................................................................................................69 4.2.1 Stream 1: Publicly reported performance data ...................................................70 4.2.2 Streams 2 and 3: Analysis of strategic documents and organisational data .......84 4.2.3 Summary of Streams 1, 2 and 3 ..........................................................................87

4.3 Conclusion ....................................................................................................................88

Chapter 5: Study 2 Results: Semi-Structured Interviews .................................... 92

5.1 Introduction ..................................................................................................................92

5.2 Results ..........................................................................................................................93 5.2.1 Dimensions of innovation culture ......................................................................94 5.2.2 Intention to be innovative ...................................................................................95 5.2.3 Context to support implementation of innovation ...........................................104 5.2.4 Knowledge and orientation of employees to support the thoughts and

actions necessary for innovation ......................................................................111 5.2.5 Infrastructure to support innovation .................................................................124

5.3 Conclusion ..................................................................................................................132 5.3.1 Enablers and barriers in the rural context .........................................................134

What ‘sparks’ innovation in rural health settings: A case study viii

Chapter 6: Results – Measurement of Innovation Culture ................................ 138

6.1 Introduction ................................................................................................................ 138

6.2 Analytical tools .......................................................................................................... 139

6.3 Demographics ............................................................................................................ 139

6.4 Survey results ............................................................................................................. 141 6.4.1 Organisational Innovation ................................................................................ 142 6.4.2 Innovation climate ........................................................................................... 144 6.4.3 Individual innovation ....................................................................................... 146 6.4.4 Team innovation .............................................................................................. 148 6.4.5 Workplace Innovation Scale ............................................................................ 149 6.4.6 Scale reliability ................................................................................................ 152

6.5 Conclusion ................................................................................................................. 152

Chapter 7: Analysis and Discussion ..................................................................... 154

7.1 Introduction ................................................................................................................ 154

7.2 Validity and reliability of methods and studies .......................................................... 155 7.2.1 Performance in rural health settings and its measurement ............................... 156 7.2.2 Corroborating the findings of Study 2 and Study 3 ......................................... 159 7.2.3 Organisational context/climate for innovation ................................................. 160 7.2.4 Infrastructure .................................................................................................... 161 7.2.5 Intention to be innovative ................................................................................ 161 7.2.6 Knowledge and learning .................................................................................. 162

7.3 Organisational and contextual factors in the case study organisation enabling and sustaining innovation ............................................................................................................ 162

7.4 How can we unleash further innovation in rural health settings? .............................. 165

7.5 Conclusion ................................................................................................................. 168

Chapter 8: Conclusions and Recommendations .................................................. 170

8.1 Introduction ................................................................................................................ 170

8.2 Measurement of performance and performance in rural health settings .................... 170

8.3 How innovation occurs in rural health settings .......................................................... 172

8.4 Impact ........................................................................................................................ 175 8.4.1 Knowledge Impact ........................................................................................... 175 8.4.2 Health Impact ................................................................................................... 175 8.4.3 Social Impact ................................................................................................... 176 8.4.4 Economic impact ............................................................................................. 176 8.4.5 Impact for the case study organisation............................................................. 177 8.4.6 Reach ............................................................................................................... 177

8.5 Researcher reflections ................................................................................................ 178

8.6 Limitations ................................................................................................................. 179

8.7 Opportunities for future research ............................................................................... 181

8.8 Contribution to practice ............................................................................................. 181

8.9 Conclusion ................................................................................................................. 182

References ............................................................................................................... 184

Appendices .............................................................................................................. 209

What ‘sparks’ innovation in rural health settings: A case study ix

List of Figures

Figure 2-1 Structure of literature review topics examined......................................... 15

Figure 2-2 Domains of innovation culture as identified by Dobni (2008) ................. 44

Figure 2-3 Identified research gap for this study ....................................................... 45

Figure 3-1 Research framework and methodological approach ................................ 49

Figure 3-2 Research design for the case study ........................................................... 54

Figure 3-3 Publicly reported indicators of performance examined ........................... 56

Figure 3-4 Four dimensions of innovation (Dobni, 2008) and the codes used to

analyse narrative data ................................................................................... 62

Figure 3-5 Analytical techniques applied in Study 2 ................................................. 63

Figure 4-1 Publicly reported indicators of performance examined for the case

study organisation ........................................................................................ 70

Figure 4-2 Comparison of NSW Major Regional Hospitals Cost per NWAU .......... 75

Figure 4-3 Hand hygiene compliance rates for case study hospital compared

with national benchmark .............................................................................. 78

Figure 4-4 Admitted patient survey 2017 most positive and fewest negative –

10 peer group C hospitals ............................................................................ 81

Figure 4-5 Number of significant positive and negative responses to patient

survey peer comparisons .............................................................................. 82

Figure 4-6 Hospital budget and NWAUs by year for case study site ........................ 86

Figure 5-1 Dobni’s (2008) innovation culture dimensions and factors ..................... 95

Figure 6-1 Workplace Innovation Scale Survey responses (n = 66) by age and

gender. ........................................................................................................ 140

Figure 6-2 Workplace Innovation Scale response by professional discipline ......... 140

Figure 6-3 Identification as a manager in the workplace innovation survey

results ......................................................................................................... 141

Figure 6-4 Seven-point Likert scale used for the Workplace Innovation Scale ...... 142

Figure 6-5 Workplace Innovation Scale organisational innovation level of

agreement, neutral responses and level of disagreement ........................... 143

Figure 6-6 Workplace Innovation Scale innovation climate level of agreement,

neutral responses and level of disagreement .............................................. 146

Figure 6-7 Workplace Innovation Scale individual innovation level of


Figure 6-8 Workplace Innovation Scale team innovation level of agreement,


What ‘sparks’ innovation in rural health settings: A case study x

Figure 6-9 Spider graph Workplace Innovation Scale’s 24 items across all

dimensions ................................................................................................. 150

Figure 7-1 Innovation types described by informants in the case study site ............ 165

Figure 8-1 Suggested measures for rural health care organisations’

performance scorecard ............................................................................... 172

Figure 8-2 Leverage points for further innovation ................................................... 174

What ‘sparks’ innovation in rural health settings: A case study xi

List of Tables

Table 1-1 Research impacts ....................................................................................... 12

Table 1-2 Thesis chapter structure ............................................................................. 13

Table 2-1 Determinants with positive and significant association with

organisational innovativeness as adapted from Greenhalgh,

Macfarlane, Bate, and Kyriakidou (2004) ................................................... 24

Table 2-2 Accreditation bodies by country ................................................................ 38

Table 2-3 Selected examples of high performing health systems identified in

the literature ................................................................................................. 39

Table 3-1 Framework for analysis of qualitative data adapted from Gale (2013) ..... 61

Table 3-2 Nodes used to analyse data collected in Study 2 ....................................... 63

Table 3-3 Ethics approvals for research ..................................................................... 66

Table 4-1 Median wait time to surgery at case study hospital compared with

peers ............................................................................................................. 71

Table 4-2 Percentage of patients who waited more than 365 days for surgery by

specialty ....................................................................................................... 72

Table 4-3. Percentage of patients who waited more than 365 days for intended

surgery by procedure.................................................................................... 73

Table 4-4. Emergency department data percentage of patients seen on time by

triage comparison with peers ....................................................................... 74

Table 4-5. Emergency department patients treated and discharged within 4

hours comparison with peers ....................................................................... 74

Table 4-6 Length of stay comparison with peer hospitals ......................................... 76

Table 4-7 Staphylococcus aureus bacteraemia infections comparisons to peer

by year .......................................................................................................... 77

Table 4-8 Blood stream infections rate per 10,000 bed days comparison with

peers ............................................................................................................. 77

Table 4-9 Results for the case study site for the questions related to safety and

quality with comparisons to a close peer hospital ....................................... 79

Table 4-10 Results from the admitted patient survey for the case study hospital

and a peer rural hospital for access and timeliness ...................................... 80

Table 4-11 Case study site and Griffith and the total number of significantly

higher agreement and significantly lower agreement across all 86

questions ...................................................................................................... 80

Table 4-12 Case Study Hospital People Matter Culture Index results compared

to Local Health District and Health Cluster (NSW Public Service

Commission, 2017) (NSW Public Service Commission, 2018b) and

(NSW Public Service Commission, 2018a) ................................................. 84

What ‘sparks’ innovation in rural health settings: A case study xii

Table 4-13 Documents analysed by the research and discoveries around

innovation and performance ......................................................................... 85

Table 4-14 Overall picture of performance in the case study organisation ............... 87

Table 4-15 Indicators sourced, data collection and peer grouping ............................ 89

Table 5-1 Breakdown of the 25 interview informants by gender and

identification as a manager .......................................................................... 93

Table 5-2 Professional backgrounds of the interviewees and management

responsibilities ............................................................................................. 94

Table 6-1 Workplace Innovation Scale organisational innovation descriptive

statistics ...................................................................................................... 142

Table 6-2 Level of agreement to statement on organisational innovation from

the Workplace Innovation Scale ................................................................ 143

Table 6-3 Level of agreement to statement on organisational climate from the

Workplace Innovation Scale ...................................................................... 144

Table 6-4 Workplace Innovation Scale innovation climate level of agreement,


Table 6-5 Individual innovation descriptive statistics .............................................. 146

Table 6-6 Workplace Innovation Scale individual innovation level of


Table 6-7 Team innovation descriptive statistics for the Workplace Innovation

Scale ........................................................................................................... 148

Table 6-8 Workplace Innovation Scale team innovation level of agreement,


Table 6-9 Highest levels of agreement and lowest agreement for the Workplace

Innovation Scale ......................................................................................... 151

Table 6-10 Results of Cronbach’s alpha test for the Workplace Innovation

Scale ........................................................................................................... 152

Table 7-1 Case study organisation performance on publicly reported indicators

compared with peers .................................................................................. 159

Table 7-2 Summary of innovations identified in the rural case study hospital ........ 164

What ‘sparks’ innovation in rural health settings: A case study xiii

List of Appendices

Appendix A Examples of high performing health organisations health

organisations identified in the literature .................................................... 209

Appendix B Letter of Support from Chief Executive of Case Study Site .............. 211

Appendix C COREQ Checklist: Consolidated criteria for reporting qualitative

studies (Tong et al., 2007).......................................................................... 212

Appendix D Instruments identified to measure innovation in the literature ............ 216

Appendix E Performance measures and indicators analysed, time periods and

analysis conducted by researcher ............................................................... 218

Appendix F Northern NSW Local Health District Ethics Approval ....................... 219

Appendix G Northern NSW Local Health District Ethics Site Specific

Assessment Approval................................................................................. 221

Appendix H Queensland University of Technology Ethics Approval ..................... 223

Appendix I Semi-structured interview questions posed to informants in the case

study site .................................................................................................... 225

Appendix J Participant Information Sheet used in Studies 2 and 3 ......................... 229

Appendix K Workplace Innovation Scale (McMurray & Dorai, 2003) .................. 231

Appendix L Participant Consent Form Study 2 – Interviews .................................. 235

Appendix M Participant Consent Form Study 3 – Workplace Innovation

Survey ........................................................................................................ 237

Appendix N Core values of the for the case study site ............................................ 239

Appendix O Study 2: Semi-structured interview codes developed for analysis

within NVIVO ........................................................................................... 240

Appendix P Mapping of study 2 and 3 data for corroboration purposes and to

understand commonalities and variances................................................... 241

Appendix Q Innovations identified by informants in the case study site ................ 244

Appendix R Comparisons of key factors identified in the literature as linked to

successful innovation compared to study findings .................................... 248

What ‘sparks’ innovation in rural health settings: A case study xiv

Glossary and Abbreviations

Term Explanation

Accreditation Public recognition awarded by a health care accreditation

body of the achievement of standards by the health care

organisation. An independent external peer assessment

reviews the health care organisation’s level of performance

against set standards (Australian Commission on Quality and

Safety in Healthcare, 2018).

ADEPT Advanced Emergency Performance Training (ADEPT) is a

two-day course teaching non-technical skills to critical care

doctors and nurses (Adept Faculty, 2018).

Agency for

Clinical

Innovation (ACI)

This Agency was established to work with health services,

clinicians and consumers to design better health care for NSW

(Agency for Clinical Innovation, 2019a).

Average Length

of Stay (ALOS)

The average time spent in hospital for a condition or treatment

episode.

Bureau of Health

Information NSW

(BHI)

An independent, statutory authority responsible for reporting

on the performance of the health system in New South Wales

(Bureau of Health Information, 2018a).

CAQDAS Computer-Assisted Qualitative Data Analysis Software.

Case study The study of an issue, examined in one or more cases within a

bounded system such as a setting or particular context

(Liamputtong, 2013).

Clinical

Excellence

Commission

(CEC)

Independent government agency in New South Wales (NSW).

The Commission is a board-governed statutory body

established under the NSW Health Services Act 1997. The

role of the CEC is to driving programs and initiatives with

clinicians, managers, health services and the consumers of

health. The purpose of the CEC is to provide ‘leadership in

safety and quality in NSW to improve health care for

patients’.

Content analysis The identification of codes and then searching for those codes

in the qualitative or quantitative data (Liamputtong, 2013).

Deductive method of data analysis.

Context the circumstances relevant to something under consideration

(Australian Oxford Dictionary) and the circumstances or facts

that surround a particular situation, event, etc. (Macquarie

Dictionary, 2017).

EMR Electronic Medical Record.

What ‘sparks’ innovation in rural health settings: A case study xv

Term Explanation

Health Education

and Training

Institute (HETI)

Division within NSW Health that is a provider of training and

education to support clinical and non-clinical staff, trainers,

managers and leaders across the NSW health system (NSW

Ministry of Health, 2018).

High performance ‘High performing hospitals consistently attain excellence

across multiple measures of performance, and multiple

departments’ (Taylor, Clay-Williams, Hogden, Braithwaite, &

Groene, 2015, p.1).

The achievement of specified targets, either clinical or

administrative (Dias & Escoval, 2013).

Pronovost (2017) suggests that a high performing health

system is one able to achieve its purpose.

Hospital

associated

infections (HAI)

Hospitals aim to have as low a rate as possible and it is used as

a measure of quality and safety.

Innovation The ‘generation, development, and implementation of new

ideas or behaviours’ (Damanpour, 1996, p.694). Innovations

might be new products, processes or services, technologies,

organisational structures or administrative systems, or new

plans or programs (Damanpour, 1996, p.694).

Key Performance

Indicator (KPI)

An indicator, that measures whether an organisation is

achieving goals in health, be that access to services, quality and

safety, effectiveness and sustainability, to mention a few.

MyHospitals A website that provides performance information on public and

private hospitals in Australia. The information is sourced from

the Australian Institute of Health and Welfare’s data

collections.

NWAU National weighted activity unit. Used to compare the costs and

complexity of activity in acute health care organisations.

Organisational

context

Contextual factors such as size, organisational structure,

economic and financial constraints, policy settings and

organisational strategy.

Organisational

climate

‘Climate is an aspect of culture and it represents the team’s

shared perceptions of organisational policies, practices and

procedures’ (Bower et al., as cited in Eriksson et al., 2015, p.5).

Organisational

culture

Many definitions identified and can be broadly described as the

shared rituals, values, beliefs and the expected behaviours with

an organisation (Dobni, 2008).

What ‘sparks’ innovation in rural health settings: A case study xvi

Term Explanation

Positive

organisational

climate

A climate exhibiting cohesion, collaboration, inclusion and

supports colleagues in their work (Braithwaite, Herkes,

Ludlow, Testa, & Lamprell, 2017).

Staphylococcus

aureus (S. aureus)

Bacterium (SAB).

Healthcare-associated bloodstream infections caused by a

bacterium called Staphylococcus aureus (S. aureus).

Semi-structured

interview

Interview based on questions with some probing (United

States Department of Health and Human Services, 2018).

Thematic analysis Identification of themes through analysis of data. Described as

an inductive method of data analysis (Liamputtong, 2013).

Triangulation A process of analysis that seeks convergence, corroboration,

correspondence of results from different methods.

Comparing different kinds of data (e.g. numbers and text,

narratives, images) and/or different collection methods (e.g.

survey, polls, document analysis and interviews) to see whether

they corroborate one another (Thomas, 2016; United States

Department of Health and Human Services, 2018).

Workplace

Innovation Scale

(WIS)

A scale developed by Adela McMurray and colleagues and

tested nationally and internationally. This scale is used to

measure innovation propensity in organisations. The scale

measures team innovation, individual innovation,

organisational innovation and innovation climate. This tool was

selected as it has been widely validated, has a reasonable

number of questions (24) and is suited to the health

environment.

What ‘sparks’ innovation in rural health settings: A case study xvii

Statement of Original Authorship

The work contained in this thesis has not been previously submitted to meet

requirements for an award at this or any other higher education institution. To the best

of my knowledge and belief, the thesis contains no material previously published or

written by another person except where due reference is made.

Signature:

Date: 12/10/2019

QUT Verified Signature

What ‘sparks’ innovation in rural health settings: A case study xviii

Acknowledgements

I would like to thank the important people who have assisted me to complete this PhD

research. First, to my supervisors, who have not only guided my research but mentored

and coached me to completion. Their interest in my research and scholarly direction

and input into my academic development is acknowledged. Professor Gerry

FitzGerald, Dr Cynthia Cliff and Assoc Professor Jean Collie – thank you for your

unwavering support and enthusiasm. Second, my family are the foundations and

strength for all that I achieve, and without their resolute support and freedom to

immerse myself in the learning, this research would not have been achieved.

During this time, the support from Queensland University of Technology

through the ethics and applied information skills for research modules were both useful

and informative. Supervisor wisdom and the motivation they provided has been

invaluable. Research support staff from QUT Faculty of Health have provided timely

and helpful guidance. My colleague Dr Patricia Lee from Griffith Health has assisted

with guidance on SPSS and statistical approaches.

Rebecca Lavery, A/Executive Officer and Alexandre Stephens, Director of

Research of Northern NSW Local Health District, thank you for the guidance and

encouragement through the ethical and site-specific assessment processes.

I would also like to extend my appreciation to Ms Roberta Blake who edited this

thesis, complying with Queensland University of Technology’s guidelines for editing

research theses. Alexandra Stevenson also for graphic design input into Figure 8-2

Leverage points for further innovation.

Finally, to the enthusiastic Case Study Hospital and Case Study Health Service

managers, clinicians and administrative staff who agreed to be interviewed and who

gave their time freely to participate. To those who completed the workplace innovation

survey I am grateful for the insights that this study has provided. To those I may have

forgotten – without their interest in my research, completion of this PhD would not

have been possible.

What ‘sparks’ innovation in rural health settings: A case study xix

Prologue

The origins of this research began when I worked in a rural health setting in the city

where I lived. My career in health up to that point had been carried out in large teaching

hospitals, a State Health Department, Regional Health Authority Office and working

with small- to medium-sized hospitals in metropolitan locations. Working in a rural

health setting, it was clear to me that there were anecdotal and observed disparities in

the physical, financial and human resources available. Yet patients are seen, treated

and cared for, and staff work hard to deliver services to their community year after

year. I could also see potential for improvements, new ways of working and

simplification of processes, many that had remained unchanged over long periods of

time. Working in a rural health setting you get to know all the actors, hear repeatedly

the ‘blame game’ between professions and clinicians and managers. You also see the

impact of historical alliances and professional siloing, but are witness to individuals

working together despite adversity and at times very difficult situations.

Rural health settings are fascinating (and sometimes frustrating) organisations to

work in, and new and old staff can see potential for improvement and change.

Innovations such as new models of care, processes and technologies are introduced

and are adapted to suit the particularities of the rural health context. My experience as

a health information manager and postgraduate with a master’s in technology

management, which focussed on strategy, innovation and the application of

technology, also stimulated my interest in understanding the role of innovation in rural

health settings and how performance in rural health settings might be measured and

linked with innovation. This was an ambitious focus of study for several reasons that

will be revealed in the thesis document.

There is no doubt that having worked in the rural health setting that was studied

helped me to secure the access needed to interview clinicians, executives and other

key personnel. Having the credibility and trust of staff to be able to speak frankly and

to gain the high degree of engagement that was attained from the clinical staff, who

were extremely enthusiastic and supportive of research conducted in their rural health

setting, was critical to the success of this research. Managing bias was an issue, and

this was carefully considered in the way that interviews were conducted, the questions

What ‘sparks’ innovation in rural health settings: A case study xx

asked, how they were asked, frameworks selected and the inclusion of a quantitative

study to measure innovation culture in the case study organisation.

In researching in a rural health setting, I wanted to be able to tell a story that was

important to tell and that reflects the potential and drive of rural health workers to

strengthen their health services through innovation. Understanding the factors that

enable innovation in rural health settings and conducting research in rural settings that

focuses on solutions (Bourke, Humphreys, Wakerman, & Taylor, 2010) is necessary

if we are to succeed in addressing rural health inequities.

Rural hospitals are under-utilised settings for health services management, and

this too was a motivator for completing the research for this doctoral thesis. The

enthusiasm of staff and delight that someone was interested in learning how innovation

occurs in rural locations kept me focussed on identifying practical solutions to the

issues that emerged from the findings. This influenced the tone and language of the

thesis document, with a deliberate emphasis on writing for a broad audience. While

conscious of the university requirements and interests of thesis markers, I tried to

incorporate but avoid writing in an overly formal way. I wanted to write so that the

thesis can be read, understood and applied by academics, rural health executives,

managers, clinicians, researchers and students in line with academic writing principles

as suggested by Mewburn, Firth, and Lehmann (2018) and Sword (2012). These

writers advocate that we write to engage, inspire and inform readers, noting that our

work only becomes consequential when it is understood by others (Boyer, as cited in

Sword, 2012).

I have included a prologue for the purposes of transparency and to share with

readers the key influences on the choice of topic and background to my research.

Openness and sharing of these key influences set the scene for the reader of this

dissertation and explain the origins of my interest in pursuing the topics investigated

and the methods applied.

1 Chapter 1: Introduction

Chapter 1: Introduction

The case study is an empirical inquiry that investigates the ‘case’ in depth and

within its real-world context and relies on multiple sources of evidence with data

converging in a triangulating fashion (Yin, 2014) and is good for gaining a rich

picture and analysing institutions, persons, decision, events or other systems by one

or more methods (Thomas, 2016).

This chapter outlines the background for the research and context of the rural setting

where the research was conducted. A compelling justification for the importance of

this research topic on innovation and high performance in rural health settings is

described. In determining the scope and significance of the research, it was identified

that the topics of innovation and performance are vast and have been well researched

in health and other industries. Despite an extensive review of the literature, almost no

research on how innovation in rural health settings occurs could be sourced by the

researcher. This gap in the literature and a paucity of research conducted in rural

settings was the motivation for conducting the study. The chapter describes the

background to the research, defines the questions that this research answers, explains

the scope, methods used, the limitations and an overview of the thesis.

1.1 BACKGROUND TO THE RESEARCH

In Australia and many other countries, rural communities are disadvantaged in terms

of their health outcomes and in their ability to access health services. For the 30% of

Australians who lived in rural and remote areas, the Australian Institute of Health and

Welfare (2014) reported that this group of citizens tend to have shorter lives, higher

rates of disease and poorer health outcomes. These outcomes occur across a range of

social, employment, health, income and educational backgrounds.

Effective rural health delivery is impacted by issues such as lack of staff,

access to health care services, the ‘dark side’ of relationship-based services and

community sustainability (Farmer et al. 2012). While relationships are fundamental

to the delivery of health care (Shelllner, 2007), health workers in rural settings are

particularly impacted, as even outside of work ‘they are never off duty’ (Farmer,


Munoz, & Threlkeld, 2012), and their assumptions of individuals with respect to

their health can be limiting (e.g. in delivering care to Indigenous Australians). Other

challenges include shortages of financial and human resources, the ageing of the

local health workforce and a lack of professional development opportunities and the

supporting health services that are necessary to provide comprehensive patient care

(Bourke et al., 2012). Rural communities have particular issues around ageing with

the out-migration of working adults from rural to urban areas and the in-migration of

former urban dwellers at retirement age (Hage, Roo, van Offenbeek, & Boonstra,

2013). This phenomenon is not unique to Australia, and similar issues are

experienced in Canada, the United States, the United Kingdom and Europe (Bourke

et al., 2012; Farmer, Munoz, & Daly, 2012; Hage et al., 2013; Murphy, Hughes, &

Conway, 2018).

Disparity in services, workforce, health status and well-being and health

outcomes is an extensively documented problem for rural communities. Addressing

gaps in rural health is a significant priority for governments in Australia

(Commonwealth of Australia, 2017b; NSW Ministry of Health, 2014). In 2017, the

first Rural Health Commissioner was appointed by the Commonwealth to give advice

on regional and rural health reform, an acknowledgment of its priority on the

government agenda (Commonwealth of Australia, 2017a). The academic and grey

literature documents at length the problems experienced in rural health (Australian

Institute of Health and Welfare, 2017b; Bourke, Humphreys, Wakerman, & Taylor,

2010; Farmer, 2012; Humphreys & Wakerman, 2018). Humphreys and Gregory

(2012) conveyed that rural health is a national priority, and more focus on rural health

and fairer resource allocation would provide the opportunity to support infrastructure,

the workforce and the services needed for rural health and well-being.

Innovation, the use of evidence-based decision-making and the adoption of

technology were mentioned in Commonwealth and State Health Departments’ values

and mission statements and identified as possible solutions to health disparity

(Commonwealth of Australia, 2017b; NSW Ministry of Health, 2014; Queensland

Health, 2015). The values for health services and the strategies in these policy and

strategy documents require health services to be agile and flexible to adapt to new

policies and reforms (Commonwealth of Australia, 2012; NSW Ministry of Health,

2014;Queensland Health, 2013).


The Federal Department of Health relates that there is a need to design, deliver

and support rural and remote health services using more flexible, innovative, and

locally appropriate solutions, without compromising the quality and safety of services

(Commonwealth of Australia, 2012). The Australian Productivity Commission (2015)

noted that Australians spend a lot of money on health through tax, private insurance

premiums and direct payment for items such as medication. The Commission further

explains that our health system produces good outcomes by international standards,

but notes that there is room for improvement (Australian Government Productivity

Commission, 2015).

The measurement of performance in the health system is complex, and there is

evidence of performance variation and inefficiency across the Australian health care

system including the following:

• complications as a result of a stay in hospital are common (Duckett, Jorm,

Danks, & Moran, 2018);

• the variation in costs for similar procedures across Australian Hospitals, taking

into consideration differences in hospital and patient characteristics (Duckett

et al., 2014);

• variable and often inappropriate care is provided (Runciman et al., 2012).

‘Within system’ reforms could be made by health services to improve health

outcomes and these include accelerating the creation and diffusion of effective care

delivery innovations (Australian Government Productivity Commission, 2015). Scott

(2014) identified 10 clinician driven strategies, including the need to ‘accelerate

creation and diffusion of value-adding innovation within rapid learning health care

organisations that constantly measure and benchmark outcomes of care, make changes

to improve care and re-evaluate’ (Scott, 2010, p.129). The Productivity Commission

in Australia in 2017 argued that innovation and diffusion of best practice are critical

to a well-functioning health system and that improvements in health could

(conservatively) reap benefits of $8.5 billion over a 5-year period (Commonwealth of

Australia, 2017c). Innovation is now considered essential for Australians to have the

best health system possible, that is sustainable and produces good outcomes for the

population (Australian Healthcare and Hospitals Association, 2017; Duckett et al.,

2014; Duckett et al., 2018).

Innovation and high performance in health care organisations is regarded by the

government funders of health services as vital to confront and address the documented


and described differences in health outcomes in rural health communities

(Commonwealth of Australia, 2009; NSW Ministry of Health, 2014). We know that

solving the disparities in rural health outcomes is complex, and the causes can be

related to numerous factors, including workforce issues, organisational culture,

educational, professional, socio-demographic and community issues (Bourke et al.,

2012; Commonwealth of Australia, 2012; Humphreys & Gregory, 2012).

Indicators of health and health outcomes are now regularly and publicly reported

on websites, reports and in data sets and can be examined and analysed to understand

health system performance (Australian Institute of Health and Welfare, 2017a; Bureau

of Health Information, 2018a; Bureau of Health Information, 2017, 2018c). But can

innovation be linked with performance? In a study of a public organisation by Mafini

(2015), a strong positive relationship between organisational performance and

innovation was noted. Likewise, research by Lee, (2015) found that there were positive

relationships between process innovations and organisational performance.

Innovation is required to make improvements in health settings, both in

metropolitan and rural settings, and the literature review identified studies that describe

the antecedents and determinants for innovation in health and characteristics of high

performance health care organisations (Fleuren, Paulussen, Dommelen, & Buuren,

2014; Fleuren, Wiefferink, & Paulussen, 2004; Greenhalgh, Robert, Bate, Macfarlane,

& Kriakryidou, 2005; Taylor et al., 2015). The factors from the literature that enable

innovation have been comprehensively described in Chapter 2, which describes the

literature review undertaken for this research.

Models of care that work well in urban systems may not be applicable to the

rural setting. The simple application of models tested in metropolitan health services

to rural settings is often inappropriate because of variations in health need and service

delivery capability. The access to staff, resources, organisational structures and other

contextual factors can be unique to each health setting. Every organisation also has

their own ‘uniquely patterned’ culture linked to the context and nature of tasks being

performed (Braithwaite, Ellis, Churruca, & Long, 2018). This can be particularly true

in rural health settings where ‘governance, management, level of autonomy, models

of care, the needs of service providers (given recruitment/ retention difficulties) and

local staff, infrastructure and culture. This results in heterogeneous organisations that

both enable and constrain health care, practice and change in different ways’ (Bourke

et al., 2012, p. 500). What is required are innovative approaches that aim to achieve


quality health outcomes using methods suitable for the rural context. Some of the

challenges found in rural health settings can be addressed through the adoption of new

technologies, such as e-health, innovative models of care and connected services. So,

it is important for rural health care settings to build organisational cultures that support

the adoption of innovative practices, enable creativity and seek to achieve performance

at a standard to meet the expectations of funders, the community and clinicians.

Performance of health systems is imperative as consumers of health services

want to ensure that they experience safe care, when and where they need it, at a

reasonable cost (Pronovost, 2017). Health expenditure consumes a significant amount

of Gross Domestic Product (GDP) and in countries such as Australia with a growing

burden of chronic disease and an ageing population, performance and cost is of

concern to the consumers and funders of health (Duckett et al., 2014; Duckett &

Willcox, 2015).

The review of the literature conducted for this research revealed that

performance and the measurement of performance for health care organisations is ill-

defined with no consistent definition (Ahluwalia, Damberg, Silverman, Motala, &

Shekelle, 2017; Pronovost, 2017). Performance has been described using measures

such as access, equity, cost, patient experience and the quality of care (Ahluwalia et

al., 2017; Pronovost, 2017). Taylor et al. (2015) defined high performing hospitals as

those that consistently attained excellence across multiple measures of performance

and multiple departments. Dias and Escoval (2013) provided an alternate definition,

that high performance is the achievement of specified targets, either clinical or

administrative. Definitional issues and the reasons for performance reporting, and

challenges in the measurement of performance will be described more fully in the

literature review in Chapter 2.

1.1.1 Purpose

If innovation as outlined above is a possible solution to sustain Australian health care

systems, then it is important to understand how innovation occurs in rural health

settings. The simple application of urban solutions to rural areas is often inappropriate

as the significant variations in health needs and service capability requires novel

solutions. New approaches are necessary to address well documented and described

differences in health outcomes in rural health communities. Some of the challenges


can be addressed through the adoption of new technologies, such as e-health,

innovative models of care and connected and integrated care. Others require the

application of existing technologies in new and innovative ways.

The intent of this study was to examine how innovation occurs in rural health

settings and to identify the factors contributing to sustaining them. Second, the

researcher wanted to determine how performance can be measured in rural health

settings and how a comprehensive picture of performance might be described.

1.1.2 Study design

A case study was the selected research methodology concurrently conducting both

qualitative and quantitative studies. A case study methodology was carefully chosen

to provide a rich and deep understanding of the complex and multidimensional topics

under study. The Workplace Innovation Scale (WIS) was used to measure the

innovation culture in the study site. At the same time, the contextual and organisational

factors for innovation were explored using semi-structured interviews with clinicians

and managers. An investigation of what performance might look like in rural settings

and how that might be measured was achieved by examining publicly reported

performance information and key strategic documents from the health service and

local health district website. The reason for combining both quantitative and

qualitative data was to better understand the research problem posed by converging

the broad numeric trends, gathered by the WIS, the study of performance data and the

detailed views reflected in the narrative data collected at interview (Cresswell, 2009a).

1.2 CONTEXT AND SETTING FOR RESEARCH

The case study site was based in a rural health service in northern NSW. The service

studied is approximately four hours south of Brisbane and provides a range of services

to support and treat the health of the population residing in the surrounding valley.

This health service was chosen pragmatically due to its proximity to the researcher and

willingness and support for the research by hospital executives. While undertaking the

research study, in (2016) the hospital was identified as a high performer by the Clinical

Excellence Commission NSW, and staff were interested to understand this further.


Three independent studies were conducted using a mixed-method approach. The

studies were conducted concurrently and collected qualitative and quantitative data.

Data analysis from interviews, surveys and publicly reported performance data and

documents was performed by the researcher to understand how innovation in rural

health settings occurs and to ensure that the study findings were reliable and valid.

Case study methodology is about seeing something as a whole (Thomas, 2016;

Yin, 2014). In this research, a case study enabled the researcher to understand how

and why innovation and high performance occurs through an in-depth exploration

(Ketokivi & Choi, 2014; Thomas, 2016; Yin, 2014). The scope of the study was limited

to one identified ‘high performing’ health service (Clinical Excellence Commission,

2016). In addition, due to the volume of data, complexity and possible variables

collected, and to gain a holistic view, it was judicious to study one rural health service.

The service under study was located in a Remoteness Area 2 (RA2) classified city in

NSW (Australian Government Department of Health, 2016a). The Commonwealth of

Australia (2012, p5) noted the importance of inner and outer regional health services,

such as the case study site, as they play ‘a key role in providing a hub for health care

for rural and remote communities, including preventative health care, specialist

outreach and emergency retrieval services, infrastructure and training centres’.

The case study health service studied in this research was chosen pragmatically.

While it could be potentially biased in terms of revealing a leadership willing to adopt

innovation, the barriers and enablers that have been identified in the study are likely

to be consistent across similar health services, although perhaps expressed in different

ways or levels. The findings may be transferable to other settings or could be applied

or adapted in other rural health settings, and to support innovation and efforts to

strengthen performance.

A case study methodology allowed the researcher to carry out a thorough inquiry

of the rural health care organisation. (Crowe et al., 2011; Thomas, 2016; Yin, 2014).

This methodology allowed the researcher to determine what happens when rural health

settings innovate, and how and why it happens (Thomas, 2016). Case studies are

particularly well suited to answering ‘how’ and ‘why’ questions.

Multiple sources of evidence were gathered in line with best practice case

study research (Silverman, 2017; Thomas, 2016; Yin, 2014). Case studies using

multiple sources and evidence types permit data triangulation (Gray, 2014; Yin,

2014). Gathering various sources of evidence and examining the case study


organisation from different angles can provide a three-dimensional picture or a

‘polyhedron of intelligibility’ (Foucault, 1981, as cited in Thomas, 2016).

Validity and reliability are critical considerations in any study (Cresswell,

2009; Silverman, 2017). To ensure these attributes, three studies were conducted, and

the researcher applied quantitative and qualitative methods. These studies provide a

broad picture of the contextual and organisational factors that explain how rural

health services innovate.

1.3 AIM OF THE RESEARCH

Using a case study methodology and collecting data in a rural health setting, this

research investigated the organisational and contextual factors that affect the adoption

and sustainability of innovation in rural health settings. The research aimed to provide

an understanding of how innovation occurs in rural health settings and how

performance might be defined and measured, and to discover new knowledge to

inform rural health settings and policy-makers interested in fostering greater

innovation and performance measurement and reporting.

1.3.1 Research questions

The questions that underpin this research were:

1. What factors affect innovation and high performance in rural health

organisations and how do they exert their influence?

o How does innovation occur in rural health settings?

o How can high performance be enabled in rural health settings?

2. How could the factors that are identified be addressed, to unleash

innovative solutions to improve rural health service performance?

The specific research objectives were:

1. To identify the factors that impede or facilitate the adoption of innovation in

rural health settings.

2. To explore how those factors exert their influence in rural health settings.

3. To identify potential for greater adoption of innovation in rural health settings

to contribute to improved performance.


1.4 SCOPE AND DEFINITIONS

Case studies collect vast amounts of data (Yin, 2014), and the topics of innovation and

performance have been well described in the literature. Consequently, the management

of the scope of the research was fundamental to the conduct of the study. The purpose

of this study was to understand the contextual and organisational factors that enable

innovation and high performance in rural health settings. Key terms and abbreviations

have been defined in the Glossary. Numerous definitions were identified in the

literature review for innovation and high performance.

While there was no singular definition of what performance in health is or agreed

measures (Ahluwalia et al., 2017; Pronovost, 2017), three definitions were considered.

Dias and Escoval (2013) defined performance as the achievement of specified targets,

either clinical or administrative, and suggested that a high performing health system is

one that is able to achieve its purpose, while Taylor et al. (2015, p. 1) applied the

definition that ‘High performing hospitals consistently attain excellence across

multiple measures of performance, and multiple departments’. Pronovost’s, and Dias

and Escoval’s definitions were considered too oblique, and Taylor et al. (2015)

definition selected. Consequently, multiple measures of performance for the case study

organisation were analysed in this research.

Public reporting of health information for transparency, accountability and for

clinicians to action to improve care is well recognised (Board & Watson, 2010). In

Australia, health information is routinely reported by Commonwealth and state

governments (Bureau of Health Information, 2018a; National Health Performance

Authority, 2016). While this data is publicly available and accessible, presenting this

information in ways that can show performance across multiple measures across time

is not easily achieved. This study has gathered, analysed and tested how this data can

be compiled in ways that can demonstrate to clinicians, health service managers and

patients the performance of a particular health service over time and multiple measures

in line with Taylor et al.'s (2015) definition. Novel methods to present the information

using visualisation tools have been developed and applied.

The critical analysis of the literature revealed that the topic of innovation has

been widely researched. Much has been written about the precursors to innovation,

determinants, antecedents and factors related to the adoption, sustainability and


diffusion of innovation (Crossan & Apaydin, 2010; Damanpour & Aravind, 2012;

Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004; Greenhalgh et al., 2017;

Greenhalgh et al., 2005). To manage the scope of the study, the research focussed on

what key authors described as the ‘inner context’ or ‘inner setting’ constructs of

innovation (Allen et al., 2017; Damschroder et al., 2009; Greenhalgh et al., 2004;

Greenhalgh et al., 2005). This is the ‘organisational context as it influences the

adoption, spread and sustainability of innovations’(Greenhalgh, 2005, p. 134).

Greenhalgh et al. (2004) and (2005) explain that the ‘inner context’ is both the ‘hard’

mediums of organisational structure and the softer ways of working, such as climate,

culture, knowledge sharing, leadership, infrastructure and resources. Similarly, Allen

et al. (2017) and Damschroder et al. (2009) mention cultural, networks and

communication and structural factors as characteristics associated with the

implementation and adoption of innovations. The definition for innovation that has

been adopted in this study is that innovation is the ‘generation, development, and

implementation of new ideas or behaviours’ (Damanpour, 1996, p.694). Innovations

might be new products, processes or services, technologies, organisational structures

or administrative systems, or new plans or programs (Damanpour, 1996). Importantly,

these new behaviours or ideas should be directed at improving health outcomes, cost

effectiveness, administrative efficiency and user experiences, and implemented

through coordinated and deliberate actions (Greenhalgh et al., 2004).

1.5 RESEARCH GAP AND CONTRIBUTION TO KNOWLEDGE

This research has established how innovation can occur in a rural health setting. The

critical review of the literature that follows determined that while there is an abundance

of research on the determinants and/or antecedents of innovation, and the

dissemination and sustainability of innovation, there are few empirical studies on

innovation in rural health settings. Studies were identified that linked innovation to

performance; however, there were no studies that explored innovation and

performance and how that occurred in the rural health setting.

In 2011, the public reporting of hospital performance data was mandated in an

effort to increase health care provider accountability and transparency so that

consumers can make decisions about their health; however, until recently this has

attracted little research (Canaway, Bismark, Dunt, & Kelaher, 2017a, 2017b, 2018).


Public reporting is also intended for doctors, nurses, academics, health service

managers, journalists and the community (Australian Institute of Health and Welfare,

2018). Research on performance measurement in rural health settings has received

little academic scrutiny.

1.5.1 Impact

In Australia, research impact is now based on the ‘contribution that research makes to

the economy, society, environment or culture, beyond the contribution to academic

research’ (Australian Research Council, 2018). Others note that the impact of

qualitative research should be described in terms of the intellectual, social and political

significance of the research (Lamont & White, 2005, as cited in Silverman, 2017).

The Australian Research Council and bodies such as the United Kingdom’s Research

England emphasise that impact should be considered at the outset of and efforts

focussed on translating research findings into better outcomes for society such as job

creation, policy underpinned by research and new programs (Australian Research

Council, 2018; Research England, 2019). The impacts from this study are shown in

Table 1-1.

Chapter 1: Introduction 12

Table 1-1 Research impacts

Domain Performance Innovation

Knowledge/

Intellectual

The study has identified new ways of analysing and interpreting

publicly reported and available performance information.

This can be used to provide a comprehensive and holistic picture

of performance in other rural health settings. Identification that

sense making of publicly reported data requires consolidation and

visualisation of the data items.

The factors enabling innovation in rural health have

been determined. Rural health settings do not have the

factors that previous studies have concluded as

important such as size (large), dedicated resources and

departmental differentiation (Greenhalgh et al., 2004;

Greenhalgh et al., 2005).

The culture in rural health settings is open to and has

the propensity for further innovation.

Health Measurement of performance can lead to improvements in health

outcomes, accountability and transparency (Canaway et al.,

2017a). A comprehensive scorecard for innovation has been

recommended by this study to support health services in

identifying trends and areas of focus for safety and quality

improvement initiatives.

Sustainability of health systems with an increasing

burden of disease and ageing population is critical for

Australia’s health care system. Determination of the

enabling factors for innovation in rural settings will

enable others to advance innovative practice.

Social Evidence of those wanting to recruit and attract to the rural

environment of the performance of a health service across

multiple measures. Improved performance gained by

understanding measures can lead to higher quality patient

experiences and quality and safety.

Evidence of potential for innovation in rural health

settings and recognition of the intellectual strengths

and creativity of those who live and work outside of

metropolitan cities.

Economic/Political Being rural adds a unique perspective, depth of understanding of

expressed experiences and perspectives and allows rural

researchers to achieve more informed or advanced study (Farmer,

Munoz, & Daly, 2012). This study was conducted by a researcher

who collected a comprehensive set of data drawn from informants

who live and work in the rural context.

Innovation and the uptake of innovation in rural health

settings can reap economic benefits to health care

organisations and rural health communities.

Innovations can reduce costs through the adoption of

technology, new processes and services or involve the

introduction of more efficient models of care delivery.

Chapter 1: Introduction 13

1.6 THESIS OUTLINE

The introduction has explained the background and reasons for the research and

presents the case for the research on how innovation occurs and is enabled in rural

health settings. Gaining a further understanding of meaningful performance

measurement and reporting in rural health settings has also been studied. The thesis

has been organised using chapters that include an extensive and critical review of

seminal and current literature. A significant proportion of the thesis describes the

research methodology, analysis and conclusions. The thesis concludes with a set of

recommendations and a process for disseminating the findings of the research. Table

1-2 shows the chapter structure for the thesis.

Table 1-2 Thesis chapter structure

Chapter Content

1 Introduction to the research and overview of the study

2 Literature review

3 Research methodology and design

4 Results Study 1: Analysis of publicly reported performance information

and documents

5 Results Study 2: Semi-structured interviews

6 Results Study 3: Workplace Innovation Scale

7 Analysis and discussion

8 Recommendations and conclusions

To understand the research gaps and to inform the design of the research, a

critical review of the literature is provided in Chapter 2. The chapter that follows has

critically analysed and synthesised current and seminal literature related to

innovation and high performance.

Chapter 2: Literature Review 14

Chapter 2: Literature Review

‘Success depends on intuition, on seeing what afterwards proves true but

cannot be established at the moment.’ Joseph A. Schumpeter, credited as the father

of innovation.

2.1 INTRODUCTION

Chapter 1 outlined the rationale for the research. A critical analysis of the literature

was used by the researcher to ‘frame’ the problem studied and to determine the scope

of inquiry (Cresswell, 2009; Gray, 2014). This chapter synthesises the literature and

describes the relevant theories in innovation, the enablers and barriers to innovation

adoption and sustainability, and the determinants and antecedents to innovation. The

literature review identified the dimensions of innovation culture. Factors such as

intention, resources, human infrastructure for innovation, the cultural environment and

support for innovation, and the knowledge and orientation of employees towards

adoption and their propensity for creativity and learning can all impact upon the degree

to which organisations successfully innovate. To understand performance

measurement in rural health settings the literature review examined the argument for

performance reporting, definitions of high performance and determined the status of

performance measurement.

The results of the literature review informed the design of the research, scope of

inquiry, definitions, confirmed the research gaps and provides an overview of previous

research.

2.1.1 Structure and scope of the literature review

The literature review was structured around the research and secondary research

questions and gaps in researcher knowledge about methods and data collection tools.

This is shown below in Figure 2-1, and the scope of the literature review is focussed

around these topics.


Figure 2-1 Structure of literature review topics examined

Scope

The literature review focused on the topics listed below.

• Innovation, high performance and performance measurement in health

• Contextual and organisational factors in rural health

• Barriers and enablers of innovation

• Antecedents and determinants of innovation

• Measures of innovation and performance

• Case study as a research methodology.

To inform the conduct of this research the following approaches to locate

relevant sources from the literature were applied:

• Systematic search of Scopus and Emerald databases for academic studies

• Snowballing from significant articles

• The literature review was also informed by the grey literature as the subject

matter of this study is an emerging area of inquiry.

• A weekly alert from BMC Health Services Research was reviewed and

relevant articles included.

Additional papers were sourced to inform the researcher on case study

methodology and the contextual and organisational challenges in rural health service

delivery.


The literature review discusses the background to the research, the factors

driving innovation, innovation theory, determinants and antecedents of innovation,

links between performance and innovation, measurement of performance and

innovation, and the key theories that will be used in this study.

2.1.2 Rural health challenges and the disadvantage in rural health services

Rural communities are disadvantaged in terms of health outcomes and their access to

health services. For the 30% of Australians who lived in rural and remote areas in

2012, the Australian Institute of Health and Welfare (2014) reported that this group of

citizens tend to have shorter lives, higher rates of disease and poorer health outcomes.

These outcomes occur across a range of social, employment, income and educational

opportunities and backgrounds.

Challenges in rural settings are also exacerbated by issues such as lack of health

professional staff, access to health care, relationship-based services and community

sustainability (Farmer et al. 2012). While relationships are fundamental to the delivery

of health care (Shelllner, 2007), health workers in rural settings are particularly

impacted, as even outside of work ‘they are never off duty’ (Farmer, Munoz, &

Threlkeld, 2012, p. 187) and their assumptions of individuals with respect to their

health can be limiting (e.g. in delivering care to Indigenous Australians). Workforce

shortages in rural and remote locations are extensively described in the literature

(Bourke, Humphreys, Wakerman, & Taylor, 2010; Bourke, Waite, & Wright, 2014;

Humphreys & Gregory, 2012; Schoo, Lawn, & Carson, 2016). Other challenges

include a lack of financial and human resources, the ageing of the local health

workforce, and the professional development and supporting health services necessary

to provide comprehensive patient care (Bourke et al. 2012). Hage et al. (2013) relate

that rural communities have unique issues associated with ageing with the out-

migration of working adults from rural to urban areas and the in-migration of former

urban dwellers at retirement age. Humphreys and Gregory (2012) argue that rural

health is a national priority and more focus on rural health and fairer resource

allocation would provide the opportunity to support infrastructure, work force and the

services needed for rural health and well-being. These issues are not unique to

Australia, and similar issues are experienced in Canada, the United States, the United

Kingdom and Europe.


Bourke et al. (2012) noted that solutions to rural health challenges tend to be

reactive and suggest a conceptual framework to better understand specific rural and

remote health situations. In particular, they focus on power and spatial isolation, and

state that comprehending rural health ‘requires understanding geographic isolation and

the rural space as it impacts on and is constructed by the rural locale (the local services

shaped by geographic isolation, local actors and broader systems)’ (Bourke et al.,

2012, p. 501). Similarly, Schoo et al. (2016) propose that solutions should move away

from narrow strategies and policy and focus on integrated approaches that

acknowledge the interplay of the organisation, community and the roles of professions

in rural health settings.

Others suggest that rural health research is ‘stuck’ on the challenges

experienced by rural health settings (Farmer et al., 2012). They state that researchers

need to look further than ‘how do we get doctors’ as the key solution to rural health

(Farmer, Munoz, & Daly, 2012). Humphreys (as cited in Farmer, Munoz, &

Threlkeld, 2012) notes that there is a need to progress rural health research from

simply more study of how to recruit doctors to intellectually challenging, robust and

future-oriented studies that fundamentally address the roots of the challenges of

improving health and providing services in rural locations. Bourke et al. (2010) argue

that remote and rural health researchers have greater opportunities to understand

community level factors. These