Developing a Theory of Implementation for Better Chronic Healthcare Management: A Cognitive Mapping and System Dynamics Approach

摘要

While chronic disease is viewed by some as the ‘healthcare challenge of this century’, and academics and practitioners around the world extol the virtues of chronic care management programmes, we are still a long way from fully specifying the causal connections that are needed to design and implement them successfully. Whilst the factors that are important in such systems of care are well articulated in the literature, it is less clear what the relationships between them are, and it is unclear how those factors can be implemented in a way that retains the integrity of the system they are a part of. The result is that despite strong clinical and management support, progress in implementing such programmes is slow.The goals of this research are therefore to:• develop a better understanding of the system of causality underpinning the key factors known to be important in implementing new models of chronic health care management,• understand how context influences this system, and• use the answers to the above questions to provide a model of implementation that can inform both theory and practiceThe research uses in-depth interviews with seven clinical, management and policy leaders within the New Zealand health system to develop a ‘theory of implementation’ that is described using System Dynamics. The research uses the cognitive mapping method to elicit the key concepts in the ‘expert’ theories by analysing both the individual maps and a composite map developed by combining data from all seven interviews. The cognitive maps are then used to inform the development of a causal loop diagram that depicts the key causal connections that are seen to be important in implementing such programmes and provides the basis for a simulation model.The findings from this research fall into two groups. The first group are findings that relate directly to the challenge of implementing programmes to improve care for people with chronic conditions. Within this group are findings that emphasise the importance of clinicians’ self-efficacy, the paradox that striving to implement best practice may, in some contexts, decrease performance and the acknowledgement that implementation will always be a ‘local affair’. The second group of findings relate to the process of implementation research. The world of implementation is a world of multiple, interacting variables that change over time and this research provides an approach, combining qualitative and quantitative data, that can be used in other contexts where the interest is in understanding how innovative ideas are implemented in practice.The research has therefore some implications for the practice of implementing new health innovations in primary care and provides a set of heuristics to inform such endeavours. The research also describes an approach for those who want to conduct research into the complex world of practice, by exploring the dynamics of many interacting factors, rather than isolating individual factors from each other and the context within which they exist.