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Research
Policy
j ou rn a l h om ep a g e :w w w . e l s e v i e r . c o m / l o c a t e / r e s p o l
Hospitals
as
innovators
in
the
health-care
system:
A
literature
review
and
research
agenda
Taran
Thune
a,∗,
Andrea
Mina
baTIKCentreforTechnology,InnovationandCulture,UniversityofOslo,Norway bCambridgeJudgeBusinessSchool,UniversityofCambridge,UnitedKingdom
a
r
t
i
c
l
e
i
n
f
o
Articlehistory: Received6January2016
Receivedinrevisedform14March2016 Accepted14March2016
Availableonline7April2016 Keywords:
Health-caretechnology Healthinnovationsystem Hospitals
Medicalinnovation Userinnovator
a
b
s
t
r
a
c
t
Thispaperaimstoimprovetheunderstandingoftheroleofhospitalsinthegenerationofinnovations. Itpresentsasystematicandcriticalreviewoftheinterdisciplinaryliteraturethataddressesthelinks betweentheactivitiesofhospitalsandmedicalinnovation.Itidentifiesthreemajorresearchstreams: studiesofthecontributionofmedicalresearchandclinicalstafftoinnovation,analysesofnovelpractices developedanddiffusedinhospitals,andevolutionarystudiesoftechnicalchangeinthecontextofhuman healthcare.Thisisahighlyheterogeneousbodyofliterature,inwhichcomprehensivetheoretical frame-worksarerare,andempiricalstudieshavetendedtofocusonanarrowrangeofhospitals’innovation activities.Thepaperintroducesanddiscussesaframeworkintegratingdifferentperspectivesthatcanbe usedtoanalyzethefunctionsperformedbyhospitalsattheintersectionwithdifferentpartnersinthe healthinnovationsystemandatdifferentstagesofinnovationtrajectories.Onthebasisofcurrentgapsin theliterature,aresearchagendaisdiscussedforarelationalandco-evolutionaryapproachtothestudy ofhospitalsasinnovators.
©2016ElsevierB.V.Allrightsreserved.
1. Introduction
Studiesofinnovationrelatedtohumanhealthhaveemergedin greatabundance,ontopicsrangingfromadvancedbiotechnology toimprovementsinhealthservices.Manyofthesestudiesargue thathospitalsarecentralactorsinthisinnovation,yetthese orga-nizationsarerarelyaddresseddirectlyandexplicitlyininnovation studies.Instead, theyaretreated as contexts,partners, indirect selection mechanisms, and users in investigations of industrial developmentandthecommercializationofscience.Inthispaper, wefocusontheroleofhospitalsinthegenerationofmedical inno-vationsthroughasystematicreviewoftherelevantsocialscience literature.
Hospitals, in particular, university or research hospitals,are partofhealthinnovationsystems,whichcanbetheorizedas dis-tributedsystemsbecauseoftheirextensivedivisionoflaborand complexcollaborativeapproachtotheapplicationofuseful knowl-edge(Coombsetal.,2003;VonHippel,1988).Hospitalsperform multiplefunctionsinhealthinnovationsystems.Theyarethemajor providersofhealth-careservices.Theyareadoptersandusersof
∗ Correspondingauthor.
E-mailaddresses:t.m.thune@tik.uio.no(T.Thune),a.mina@jbs.cam.ac.uk (A.Mina).
newtechnologies(thusthedemandsideofexternallygenerated innovation).Theyarepotentialdevelopersofprocessesand orga-nizationalinnovations.Moreover,hospitalscanbeanintegralpart oftheeducationsysteminwhich newpractitionersaretrained, sothey canbe loci of clinicalexperimentation and large R&D-performinginstitutionsintheirownright.Overall,theyarekey sites forthe adoption, reproduction,and generationof medical knowledge.
Theroleofindividualdoctorsasinnovatorshasbeencovered extensivelyinthehistoryofmedicaltechnologiesbuthastobe understood withina complexinstitutional environment and in relationtolong-termepistemicandculturalchange(Blume,1992; Pickstone,2011).The role of hospitalsin theconsumption and implementationofinnovations—bothtechnicaland clinical—has alsobeencoveredextensivelyinthehealthmanagement,health economics, and health policy fields. However, despite notable exceptions(e.g.,DjellalandGallouj,2005,2007;Salge,2012;Salge andVera,2009),theorganizationalcapacityofhospitalsto gener-atemedicalinnovationshasbeenunderemphasized.Inthispaper, weareinterestedinassessingtheroleofhospitalsasgenerators ofmedicalinnovation,broadlydefinedas“newdrugs,devicesand clinicalpracticesintroducedovertimeintotheprovisionofhealth care”(ConsoliandMina,2009).Theriseofmoreopenmodelsof innovation(Chesbrough,2003,2006;DahlanderandGann,2010) makesitevenmoreimportanttofocusonthespecific contribu-http://dx.doi.org/10.1016/j.respol.2016.03.010
tionthathospitalsmakeorhavethepotentialtomakeinupstream innovationactivitiesasleadingorganizationsoraspartnerstoother organizationsinthemedicalindustrialcomplex.Forthisreason, weareespeciallyinterestedintheliteraturethatcovers universi-ties,researchhospitals,andacademicmedicalcenters,andtheir arguablygrowingimportance inmodernhealth innovation sys-tems.
Health-caresystemscompriseheterogeneousactorswho per-formdistinctbutrelatedtasks(Djellaland Gallouj,2005,2007). Althoughthereis adivision of laboramong theindividual par-ticipants,manyofthetasksperformedbyeach agentcannotbe completedwithoutthecontributionsofotheragents.Thusactor groups have multiple and mutual dependencies, which create thesystemicqualityofhealthinnovation(Windrumand García-Go ˜ni,2008).Hospitals,particularlyresearchoracademichospitals, becomecentralnodesinhealth-carenetworksbecausethey per-formmultiplerolesatkeyintersectionsofthesystem(Anderson etal.,1994;Ramloganetal.,2007).First,theseorganizations func-tionasbrokersamongdifferentdomainsandsourcesofknowledge, suchasscientific,clinical,technical,andcommercialknowledge. Second, they are bridges among different modes of learning, includinglearning through medical practice,through basic and appliedresearch,throughtechnicalexperimentation,and learn-ingbyadaptingnewtechnologiestolocalcontexts(Morlacchiand Nelson,2011;Rosenberg,2009).Third,hospitalsconnect health-caresystemsacrossstagesintheinnovationprocessastheycanbe involvedinideageneration,testing/verification,implementation, anddiffusion.
Hospitalscontributetonewideagenerationthrough experi-entiallearningin clinicalpracticeand research(bothbasic and clinical)byidentifyingproblemsandpotentialsolutions.Theyoften dosoincollaborationwithuniversitiesandfirmsundera vari-etyofinstitutionalarrangements(Rosenberg,2009;Schlich,2002). Theoutcomesoftheseactivitiesareresearchoutputs,insightsfor newinventions,andcandidatesfornewproductsandprocesses (Chatterjietal.,2008).Someoftheseideasmaybespunoutto formthebasisfornewcompaniesorarelicensedtoexistingfirms (FrenchandMiller,2012).
Hospitals can initiate some product development activities internally, particularly development of new procedures, new servicesandorganizationalarrangements,andnewtoolsand meth-ods.Intheproductdevelopmentphase,however,hospitalsmostly interactwithestablishedfirmstotransferknowledgeaboutthe clinical context in which the new product candidates can be used. They are then involved in testing and documenting the effectiveness, safety, and efficiency of newproduct candidates, thusinfluencingtechnologyselection(WindrumandGarcía-Go ˜ni, 2008).Activitieslinkedtolearningandadaptationintheuser con-textisafundamentalroleforhospitals,alongwithdevelopment ofarangeofserviceinnovationstosupporttheimplementation ofnewtechnologyornewtreatments.Inaddition,hospitalscan shapeopportunitiesfortechnologicallearningbecause experimen-talpracticecanleadtonewideageneration,bothasincremental improvementsuponexistingtechniquesorservices,andasideas fornewproducts(DjellalandGallouj,2005;Metcalfeetal.,2005). Fig.1describesthemultiplerolesthathospitalscanplayinthe generationofnoveltywithinhealthcareandmedicine,whichsets theparametersforthepresentstudy.Withoutimplyingstrict lin-earityinthesestagesordimensions,weproposethatatanypoint intimearangeofparallelandstepwiseinnovationactivitiesoccur inrelationtotheorganizationalcontextofahospital.
Thetwinobjectiveofthepaperis toprovideanoverviewof thestateoftheartonthisinterdisciplinaryproblemandto out-lineaconceptualframeworkthatcanbeappliedtothestudyof hospitalsfromaninnovationsystemperspective.Byhighlighting themultipleroleshospitalsplayindistributedhealthinnovation
systems,wearguethatthecontributionoftheseinstitutionsmust beunderstoodinrelationalandco-evolutionaryterms:hospitals aresourcesofnovelideasaswellasconduitsforinnovation gener-atedelsewhereisthesystem.Wearguethatamorecomprehensive perspectiveontheroleofhospitalsisimportanttobetterinform policybystressingthesystem-levelimpactshospitalshaveonthe innovativeperformanceofhealth-careserviceandmanufacturing activities.
Weuseasystematicreviewmethodologyandsamplewidelyin theheterogeneousandmultidisciplinaryresearchliteratureonthis topic.Inthenextsection,wepresentourmethodsanddata.Three thematicstrandsofcontributionsemergethatdifferintheir per-spectivesandlevelsofanalysis,whicharearticulatedinmoredetail inSection3.InSection4,wesynthesizeanddiscussthekey find-ings.Havingidentifiedcontributionsandknowledgegaps,Section 5concludesbyhighlightingemergingissuesforfurtherresearch.
2. Reviewmethod
Thepaper is basedon a systematic reviewapproach (Littell et al., 2008), which aims to make the literature selection and reviewprocess transparentandreplicable. Westarted fromthe factualpremise thatresearchonhospitalsandinnovationspans manydisciplines,empiricalapproaches,andpublicationchannels. Ahighlyheterogeneousbodyofknowledgepresentsthechallenge ofcapturingthebreadthofrelevantcontributionsand synthesiz-inginsightsandmainfindingsacrossseveralscientificdomains. Weaddressthischallengebyusingamaximumvariationsampling strategy(Suri,2014).
Toselecttheliterature forinclusion in theliteraturereview database, multiple searches were carried out on search terms suchas“medicalinnovation,”“medicaland/orhealth-care inno-vationsystems,”and“innovationandhospitals/academicmedical centers/universityhospitals/researchhospitals.”Identicalsearches wereconductedinthreedatabaseswithbroadcoverage:ISIWebof Science,Scopus,andPubMed.Thefirstsetofkeywordsearcheswas conductedinISIWebofScience(WoS;onthetitle,keywords,and abstract)ontheterms“innovationandhospitals,”yielding895 pub-lications.IdenticalsearcheswereconductedinScopusandPubMed toverifythatthesearchesgeneratedtherelevantresearch liter-ature,thusvalidatingourresearchstrategy.ScopusandPubMed havebroadercoverageofpublicationtypes,includingalsobooks, book chapters, and practitioner-orientedpublications. The pro-ceduredescribed inTable 1wasfollowed foreach database.In ScopusandPubMed,theinitialsearchesoninnovationand hos-pitalsyieldedalargernumberofhits(15,072and505).Inthese databases,wesetrequirementsthatpublicationsshouldincludean abstract,andsearcheswereconductedontitle/abstract/keywords, toenableareplicationofthesearchprocedures.
AsseeninTable1,searchingonthekeywords“hospital”and “innovation”generatesalargenumberofhits,whichhavetobe reducedtomeetreviewfeasibilityconstraints.Wethereforeadded athirdtermtonarrowthescopeofthesearch.Afterrunningthe threequeries,307abstractsfromWoS,638abstractsfromScopus, and203abstractsfromPubMedweredownloadedandreviewed—a totalof1148abstracts.Alltheseabstractswereread,andadecision wasmadeastowhetherthetextwasrelevantinaccordancewith theinclusionandexclusioncriteriainTable1.Theprocedurewas appliedonabstractsandthenonthefulltextofalldocumentsthat matchedthecriteria.
Asanadditionalmeasuretoensurethatwewerenotmissing rel-evantpublications,wealsosearchedforpublicationsthatincluded thekeywords“innovation”or“technology”intheirtitleinselected journalsthatpriorsearcheshadidentifiedasthefourthatpublished mostfrequentlyonthistopic.Thisprocedureprovidedinformation
Fig.1. Therolesofhospitalsininnovation.
Table1
Searchtermsandliteraturedatabase.
Steps Searchterms HitsinWoS HitsinScopus HitsinPubMed Hitsinfivetopjournals
1 InnovationANDhospitalsANDmedical innovationa
123(859) 147(15,072) 8(505)
2 Medicalinnovation 99 414 93
3 InnovationANDuniversityhospitals(OR researchhospitalsORacademicmedical center)
85 77 102
Totalliteraturedatabaseanalyzed 307 638 203 374
Inclusion/exclusionterms(twosteps) Onlynewinclusions 4 Abstracts:(a)Innovations,(b)hospitals,(c)not
onlyimplementation,(d)notpatienteffects, and(e)eitherconceptualorempiricalstudies
50 15 13 24
5 Fullpapers:(a)Innovations,(b)hospitals,(c) notonlyimplementation,(d)notpatient effects,and(e)eitherconceptualorempirical studies
29 6 6 5
WoS=WebofScience.
aNumbersinparenthesesisthenumbersofhitswithoutaddingthethirdsearchterm“medicalinnovation”tothealgorithm.
about374papers,ofwhich24wereaddedtothereviewdatabase aftertheselectionprocedurewasapplied,andanothersixtothe finalsetofpapers.
Tocapturetheliteraturethatwasrelevanttoourresearch inter-est,wedefinedtwobroadexclusioncriteria,asdescribedinTable1. First, we excluded the extensive literature that addresses only theadoptionanddisseminationofinnovationsinthehealth-care context.Hospitalsarelargepublicorganizationsperforming com-plextasksthroughwhichtheyaresimultaneouslyinvolved ina widerangeofinnovationprocesses.Theyinvolveadoptionchoices
andadaptivebehaviorsconnectedtotheimplementationofnew medicaltechnologiesandmanagerialpractices,whichtendtobe treatedinsomedetailinthehealth-caremanagementand main-streamhealtheconomicsliteratures.Theseincludetheadoption ofnewinformationandcommunicationtechnology(ICT)solutions asadministrativetools(e.g.,electronicmedicalrecords),also cov-eredratherextensivelyintheinformationsystemsliterature(for anoverviewofICT-mediatedserviceinnovation,seeBarrettetal., 2015).
0
20
40
60
80
100
1201960
19
80
20
00
2020
Publicaons in Scopus
Publicaons in ISI
Fig.2.PublicationsoninnovationANDhospitalsinScopusandWoS(1965–2014).
Table2
ToppublishingjournalsoninnovationandhospitalsinScopusandWoS.
Top10journalsScopus No.ofpublications Top10journalsWoS No.ofpublications
1 HospitalsHealthNetworksAHA 110 HealthAffairs 45
2 HealthCareManagementReview 61 HealthPolicy 29
3 SocialScienceandMedicine 57 ImplementationScience 25
4 AcademicMedicine 54 SocialScienceMedicine 22
5 HarvardBusinessReview 51 BMCHealthServicesResearch 20
5 HealthcareFinancialManagement 41 HealthCareManagementReview 20
7 HealthAffairs 34 JournalofNursingAdministration 20
8 QualityManagementinHealthCare 29 JournalofAdvancedNursing 15
9 InternationalJournalforQualityinHealthCare 28 JournalofClinicalNursing 14
10 MedicalCare 27 JournalofHealthcareManagement 13
WoS=WebofScience.
The vast literature on the implementation of medical or
administrativeinnovationmainlydescribeshowhospitalsmake
technologyadoptiondecisionsoruseinnovationsgenerated
out-sidethehospital,whichdoesnotplayaroleintheirgeneration.
Thisis nottosaythathospitalsdidnothave arolein
develop-ingrelevantnewknowledge,butthatthisaspectoftheinnovation
processisnotthespecificfocusofthestudiesexcludedfromour
database.Theyremainrelevantforunderstandingimplementation
processes,butarelessrelevantifourobjectiveistounderstand
howinnovationsareactivelygeneratedbyorjointlywithhospitals.
Articlesthatlinkimplementationtothegenerationofinnovations
havebeenincludedinthereview.Thesameexclusioncriterionwas
appliedtoliteraturethatdescribesonlytheimplementationofnew
treatmentregimes,andtoliteraturethataddressestheefficiency
andeffectivenessofnewinnovations,withoutinvestigatinghow
theseinnovationsweredevelopedorhowhospitalsorhospitalstaff
contributedtothegenerationoftheseinnovations.
Thesecondexclusioncriterionappliedtotheidentificationof
relevantpriorartconcernedliteratureotherthanresearchpapers,
thatis,papers thatdo notaimtoincrease scholarlyknowledge
aboutaparticularquestion.Thismeansthatweincludedpapers
thatpresenteithernewconceptualapproachesorempirical
stud-iesofinnovationinandbyhospitals,andexcludeopinionpieces,
teachingcases,letters,andotherkindsofpublisheditemsthatare
notsubjecttopeerreview.Themedicaldomainincludesmanysuch
items:theyhavebeenreadaspartoftheresearchcontext,buthave
notbeenincludedinthefinalreviewdatabase.
The search processes exposed the importance of searching
broadlyforresearchliteraturethataddressestheroleofhospitals
ininnovation,becausenumerousapproachestothetopicrootedin
differentdisciplinarysettingsexist,andeachhasdedicated
jour-nalsandspecialistaudiences.Awidevarietyoffieldshaspublished
onthistopic,withgrowingintensityoverthepast15years(Fig.2).
Medicalinnovationandinnovationinhospital/clinicalsettings havebeenaddressedineconomicsandmanagement,publichealth, health-carepolicyand management, innovationstudies,
sociol-ogy,scienceandtechnologystudies,aswellasinseveralmedical andhealthcare–relatedjournals.Thejournalsthathavepublished mostfrequentlyonthetopic,however,areinhealth-carepolicy andmanagement,aswellasinnursing-relatedjournals.AsTable2 shows,thereisnotagreatdealofoverlapintoppublishing jour-nalsinScopusandISI,exceptinthejournalsHealthAffairsandSocial ScienceandMedicine.
Forthefinalsetof46articlesthatmatchedalltheinclusion cri-teria,furtherdetailedanalyseswereconducted.Table3showshow thearticlesrepresentavarietyofresearchquestions, methodolo-gies,anddata.Thismakesitmoredifficulttogenerateacoherent pictureoftherelevantknowledgebase.Mostofthearticlesdescribe oranalyzeinnovationprocessesorinnovationsystemsinwhich hospitalsofdifferentkindsplayvitalroles.Theunitsofanalysis aretheinnovationprocess andthenetwork ofactorsthat over time have contributed tothedevelopment ofinnovations with specificresources.Theroleofhospitalsisaddressedinrelationto otheractorsorcomplementaryinputsthatconstitutethe innova-tionsystemofreference.Studiesaddressingtheroleofhospitalsor particulartypesofhospitalsdirectlyarerarer,andinthissample fewarticlesdealwithmanagementofinnovationinhospitals.
Therearemanydatacollectionapproaches,butonlyafewlarge quantitativestudies.Theyare eitherbasedonsurveysof a lim-itednumberofhospitalsorusebibliometricorpatentdata.The articlesaremostlycasestudiesofparticulardiseases,medical tech-nologies,orhospitals.Fourteenarticlesarecross-sectionalstudies comparingmultipleunits(mainlyseveralhospitals).
Inlinewiththereviewmethodologythatintegratesboth quali-tativeandquantitativestudies(Suri,2014),wecodedtheliterature onkeyparameters,suchasstudytopics,methods,anddatasources (Table3).Weusedmainlyastudy-orientedsynthesisapproach, inwhichwedescribebrieflythekeyfindingsofthetarget stud-ies,ratherthanaggregatefindingsacrossthearticlessampled.We interpretanddiscusstheliterature,butrefrainfromconductingany quantitativemeta-analysisofnumericalresultsfoundinthe empir-icalevidence:thiswouldbeneitherpossiblenoradvisablebecause
Table3
Researchquestions,data,andmethodologyinthefinalsample(N=46).
Keyfeaturesofthearticles Numberofarticles
Mainresearchquestionsaddressed
Characteristicsofmedicalinnovationprocesses 15
Characteristicsofmedicalinnovationsystems 12
Role/sofparticularparticipantsinmedicalinnovation(hospitals,clinicalstaff,medicaldoctors) 10
Managementandorganizationofmedicalinnovationinhospitals 7
Results/effectsofmedicalinnovationinhospitals 2
Methods Quantitativedata 17 Qualitativedata 13 Mixedmethods 8 Conceptual 8 Empiricalapproach
Medicalcasestudy(targetsparticularareasofmedicalpractice) 9
Technologicalcasestudy(targetsparticularmedicaltechnologies) 9
Hospitalcasestudy(targetsoneormoreparticularhospitals) 6
Cross-sectional(targetsseveralunits,multiplehospitals/technologies) 14
Notanempiricalstudy 8
offundamentaldifferencesintheissuesaddressed,datasources
used,andmethodologicalapproachesemployedintheliterature
(Suri,2014).
3. Threestrandsofliteratureonhospitalsandinnovation Wehavedividedtheinnovationliteraturethatdealswith hospi-talsandinnovationintothreestrandsbasedonthemainanalytical unitstheytrytodescribeorexplain.Thefirstgroupofstudieshasa micro-levelfocusinthatitaddressesthecontributionofparticular typesofhospitalstafftothegenerationofinnovations.The sec-ondgroupaddresses,eitherconceptuallyorempirically,hospitals’ innovationactivities,basedoncasestudiesorsmallsamplestudies ofparticularinstitutions.Ittypicallyfocusesontherole of hos-pitalsininnovationbylookingatinnovationactivitiesatspecific hospitalsorparticularunitsathospitals.Thethirdgroupincludes studiesoftechnologicalandepistemologicalchangeinmedicine,in whichtheunitsofanalysisarenetworksorsystemsofinnovation connectedtoparticularproblems,technologies,orareasofmedical practice.Onrareoccasions,paperswithaverybroadscopeappear inmorethanonegroup.Thefirstgroupofpaperstendstotakea health-careorgeneralmanagementperspective.Thesecondgroup isrelativelymoreheterogeneousinapproachandtheoretical per-spective,butpapersshareastrongfocusonorganizationalfeatures andonpracticesthatpromoteinnovation.Thethirdgrouphasa morecoherenttheoreticalperspectiveandhighlighttheproblem oflong-termsociotechnicalchangesinmedicalinnovation. 3.1. Health-carepractitionersandtheircontributionto innovation
Manystudiesfocusonparticulargroupsofindividualsactive athospitalsandthehealth-careindustrymoregenerally(Table4). Thesecontributionsdedicatespecialattentiontomedicaldoctors asgeneratorsofinnovationinalineofresearchwithstronglinksto vonHippel’s(1988)foundationalstudiesofuserinnovation. Med-icaldoctorsandclinicalstaffhaveplayedaprominentroleinthe developmentofnewtreatmentsanddevices(Chatterjietal.,2008; ChatterjiandFabrizio,2013;Kesselheimetal.,2014;Smithand Sfekas,2013;Weigel,2011).Thesestudiesrangefromquantitative analysesofpatentstatisticsasindicatorsofinventionby practi-tioners(Chatterjietal.,2008;ChatterjiandFabrizio,2013;Smith and Sfekas, 2013) tocase studies of particular medical devices (Kesselheimetal.,2014)ordrugs(XuandKesselheim,2014).
Theygenerallypointtotwointerrelatedrolesofmedicaldoctors asfarasinnovationisconcerned.First,theoriginalideasfornew
productsemergeinclinicalsettings,whendoctorsfind,for exam-ple,thatexistingdevicesdonotsolveproblemsoraddressneeds satisfactorilyintheclinicalsetting(Kesselheimetal.,2014). Sev-eralstudiesfindthatdoctorsareactivelyengagedindeveloping designsand earlystageprototypesand experimentwith differ-entsolutions.UtilizinginformationinUSpatentdataonmedical devices,Chatterjietal.(2008),ChatterjiandFabrizio(2013),and SmithandSfekas(2013)demonstratethatasubstantialproportion oftheproductideashadindeedemergedfromtheactivityof clin-icians.Thesepapersassesstherelevanceofideasthatoriginated withcliniciansonmedicaldeviceinnovationandfindthatthese ideashaveasignificantimpactonsubsequentinnovation.Chatterji andFabrizio(2013)alsoshowthattheinputfrompatentsheldby medicaldoctorsisgreaterinnewtechnologicalareasandinthe generationofradicalinnovations.Thesestudiesalsolinktherole ofdoctorsasinventorsofmedicaldevicestotheirroleasleadusers andkeypartnersformedicaldevicecompaniesthatfurtherdevelop andcommercializemedicaldevices(SmithandSfekas,2013),a pat-ternthatisconfirmedbythequalitativestudiesgroupedinthis researchstream(Kesselheimetal.,2014;Weigel,2011).
Thepaper byGarcía-Go ˜ni etal. (2007)relaxestheexclusive focusappliedinthisliteraturetotheroleofmedicaldoctors.This insightfulstudylooksatbothmanagersinhealth-care organiza-tions and frontline personnel. It considers theirmotivation for engagingininnovationprocessesconnectedtoimprovedservice provisionandcomparesdifferentdegreesofparticipationandof motivation among differentgroups of staff. Overall, their com-parativeempiricalanalysisofdifferenthealth-careprofessionals in six Europeancountries finds that managersare significantly moremotivatedandmoreinvolvedthanfrontlinepersonnel(even thoughtheirpreferencemayarguablybemoresensitivetocostand efficiencyconcerns).
Finally,anothercontributionthatwidensthefocusfrommedical doctorstootherstakeholdergroups—insideandoutside health-careorganizations—isthestudyofopeninnovationplatformsby Bullingeretal.(2012).Theroleofpatientsinmedicalinnovationis oftenhighlightedasimportant,butrarelyexplicitlyinvestigated. Bullingeretal.(2012)lookintotheideagenerationphaseofnew productsandservicesinhealthcarethatentailsopen communica-tion,particularlywithpatientsandotherinterestedstakeholders. Theyfindthatpatientsandinterestgroupsareactiveand impor-tantmembersofinnovationcommunities,particularlyincasesof rarediseases,andarebothsourcesofadequateproblemdefinitions aswellasinnovativesolutionstotheseproblems.
Table4
Overviewofpapersonpractitionersinhealthcareandtheirroleininnovation.
Paper Empiricalobject Data Keyissuesexplored Kindsof
innovations Roleofhospital/s Bullinger etal. (2012) Userinvolvementin innovationthrough openinnovation platforms Quantitative; communi-cation analysis
Investigatestheroleofuseroriented, openinnovationplatformsinhealth care
Productandservice innovations(ideas) Participantsinopen innovation(alongside otherusers) Chatterji and Fabrizio (2013)
MedicaldoctorsinUS Quantitative Investigatesthecontributionof medicaldoctorstoinnovationin medicaldevices
Productinnovation (medicaldevices)
Hospital-basedphysicians: ideagenerationand marketing Chatterji
etal. (2008)
Medicaldevicefirms Quantitative Investigatestheeffectofprior collaborationwithmedicaldoctorson innovationperformance(new products)
Productinnovation (medicaldevices)
Hospital-basedphysicians asleadusersofmedical devices
García-Go ˜nietal. (2007)
Hospitalmanagersand frontlinestaffinsix Europeancountries
Quantitative Investigatestheperceptionsand motivationsofdifferentkindsof hospitalstafftowardinnovationin health-careservicesprovision
Innovationin serviceprovision
Hospitalmanagersand frontlinestaff,attitudes, motivationanddegreeof involvementingenerating andimplementing innovations Kesselheim etal. (2014) Clinicaldoctorsas “physicianinventors”
Qualitative Investigatestheprocessesand individualsinvolvedincoronaryartery stents
Productinnovation Ideagenerationandearly experimentationinclinical practice
Smithand Sfekas (2013)
Medicaldevices Quantitative Investigatespremarketapproval applicationsfiledbymedicaldevice firmsandmedicaldoctorscontribution tothem
Productinnovation Ideagenerationandearly experimentationinclinical practice Xuand Kesselheim (2014) Patentsconnectedto stenttechnologies
Quantitative Contributiontomedicaldevicesby medicaldoctors
Productinnovation Ideagenerationandearly experimentationinclinical practice
3.2. Hospitalsasinnovativeorganizations
Approximatelyhalfthepapersweanalyzedaddresstherole(s) of differentkinds of hospitalsin the generationof innovations (Table 5). A common theme across these contributions is the attempttocaptureorconceptualizehospitals’innovativeness,on the grounds that this is undertheorized and underinvestigated (Djellaland Gallouj,2007;Salgeand Vera,2009; Windrumand García-Go ˜ni,2008).Thisisaperspectivesharedwiththeresearch literaturethattreatshospitalsas“hidden”researchsystems(Hicks and Katz, 1996; Lander, 2013; Lander and Atkinson-Grosjean, 2011). A common idea in this literature is that a considerable amountof R&Dand innovationisunderestimated becausethey involveactivities and participantsthat arenot adequately cap-turedbystandardindicators,suchaspublications,patents,andnew products.Thedevelopmentofnewknowledgeandideasfornew productsandservicesemergesfromacomplexinterplayamong sci-entificunits,clinicalunits,andcommercialunitsandofteninvolves incrementaltechnologyandprocessimprovementsthrough learn-ingbydoing,whichareratherdifficulttoobserveand measure systematically.
As can be seen in Table 5, this research stream is rather heterogeneousinterms ofkeyquestions,empiricalobjects,and methodology/data. These papers focus on hospitals in general (Djellaland Gallouj,2005,2007),hospitalsinparticular regions orcountries(e.g.,FrenchandMiller,2012;Salge,2012;Salgeand Vera,2009;Schultzetal.,2012;Weigel,2011;WuandHsieh,2011) orparticularkindsofhospitals,thatis,academicmedicalcenters (Anderson et al., 1994;Rosenberg, 2009).Within thesediverse empiricalcontexts,a rangeofissuesisexplored.Severalpapers attempttoconceptualizehospitalinnovativeness(Andersonetal., 1994;DjellalandGallouj,2005,2007;Rosenberg,2009)orexplore empiricallyhospitals’innovationprojects(Salge,2012;Salgeand Vera,2009).Otherpapersemphasizeparticularinnovation activ-itiesororganizationalpracticestosupportinnovation,including researchandcommercializationactivities(FrenchandMiller,2012; Lander and Atkinson-Grosjean, 2011; Rosenberg,2009).A final
groupofpapers addressesorganizational featuresand practices thatareconducivetoinnovation,developingconceptualizations, suchashospitalsascreativeandlearningorganizations(Diasand Escoval,2013,2015;Hernandezetal.,2013;LeeandHong,2014; Ugurluogluetal.,2013;Yang,2014).
Thesepapersalsodifferinthetypesofinnovationstheyselect andconsider.Manyfocusontheroleofhospitalsinthe genera-tionofneworimprovedproducts(e.g.,medicaldevicesornew treatments/drugs)(Chatterjietal.,2008;Rosenberg,2009;Weigel, 2011).However,themajority of studiesin this groupfocus on thegenerationandimplementationofnoveltyinmedicalservices (treatment regimes, organizational practices, and patient care) (Schultzetal.,2012;Thakuretal.,2012)oracombinationofproduct andprocessinnovations(Andersonetal.,1994;DjellalandGallouj, 2005,2007).
Djellaland Gallouj(2005),forinstance,conceptualize hospi-talsasserviceprovidersandfocusonthemultipleoperationsrun byhospitalsandontheiroutputs.Theirclaimisthatinnovation andimprovementworkcanoccurinallaspectsofhospitals’ oper-ations.Theythereforeproposethathospitalinnovationishighly diverse,encompassingadministrative,organizational,andmedical practicesthatarebundledtogetherinservices.
Anotherexampleofaninclusiveconceptualizationof innova-tionisfoundintheworkbySalge(2012)andSalgeandVera(2009), whodrawuponthedistinctionbetweenscience,technology, inno-vation(STI)anddoing,using,interacting(DUI)(Jensenetal.,2007) asmodesoflearning.Basedonthesenotions,theyidentifytwo cor-respondingmodesofhospitalinnovativeness:science-basedand practice-based.Theylookattherelationshipbetweeninvestment in differentkinds ofinnovation activitiesand performance and hypothesizethatinvestmentsinbothscience-basedand practice-based innovation are beneficial to hospital performance. More specifically,Salge (2012) investigates theorganizational factors thatinfluencesustainedinvestmentinthesedifferentkindsof inno-vationactivities(science-based andpractice-based).The results indicatetemporalpersistenceininnovationactivities,particularly ininvestmentsinscience-basedinnovations, andthattheseare
Table5
Overviewofliteratureonhospitalsasinnovativeorganizations.
Paper Empiricalobject Data Keyissuesexplored Kindsofinnovations Roleofhospital/s Andersonetal. (1994) Academicmedical centersinUS Conceptual/mixed methods
Rolesofacademicmedical centersininnovation
Productandprocess innovationwithinmedicine
Fiverolesforhospitals,generatorsof innovation,adoption,evaluative, advisory,training
DiasandEscoval (2015)
Portuguese hospitals
Mixedmethods Therelationshipbetween hospitalsaslearning organizationsandinnovation performance
Product,serviceandprocess innovations
Generationandadoptionofnew medicalpractices
DiasandEscoval (2015)
Portuguese hospitals
Mixedmethods Therelationshipbetween innovationandhospital performance
Product,serviceandprocess innovations
Generationandadoptionofnew medicalpractices
Djellaland Gallouj(2005)
Hospitals Conceptual Hospitalsasserviceproviders andtheirroleininnovation
Multipleformsofinnovationin hospitals,connectedto differentoutputsandservices performed
Multiple,dependentontypeof innovation
Djellaland Gallouj(2007)
Hospitals Lit.Review Discussdifferentperspectives onhospitalsininnovation
Hospitalinnovationasabroad category,includesboth process,productandservice innovations
Multiple,dependentontypeof innovation
FrenchandMiller (2012)
Hospitalsina Canadianregion
Qualitative Introducestheconceptofthe entrepreneurialhospital
Biomedicalresearchand innovation
Entrepreneurial,capitalizingoncare functionstoperformininnovation Hernandezetal. (2013) Driversof patient-centered innovationsin health-care organizations
Qualitative Theprocessofinitiating patient-centeredinnovations inhealthcare
Organizationalinnovations intendedtomakehospital servicesmorepatientfriendly
Generatinginnovationsinservice delivery,entailsgenerating organizationalinnovationswithinthe hospitals
HicksandKatz (1996) Collaboration betweenR&D performingsectors Quantitative bibliometric
Hospitalsasthehidden researchsystem
Researchinbiomedicineand health
Importantasavenueforresearch
Lander(2013) Translational medicine (immunology) Quantitative, bibliometric University-hospital collaboration
Researchinbiomedicineand health Integration Landerand Atkinson-Grosjean (2011) Hospital-based laboratories Conceptualand qualitative
Hiddenroleofhospitalsin innovation
Biomedicalinnovationand translationalmedicine
Integrationbetweenclinicaland biomedicalknowledge
LeeandHong (2014)
HospitalsinKorea Quantitative Determinantsofknowledge sharingandinnovation behavioramonghospitalstaff
Newideas,technicaltools,and methodsusedwithinhospitals
Generationofnewideas
Raadabadietal. (2014)
HospitalsinIran Quantitative Culturesofentrepreneurship inhospitals
Notspecific Generationandexperimentationwith newsolutions
Rosenberg(2009) Academicmedical centers
Conceptual/ qualitative
Institutionalizationtosupport hybridizationandlinkages betweenmedicineandnatural sciences
Medicalproductinnovations Collaborationbetweenhospitalsand universitiesinbiomedicalandmedical deviceinnovation
Salge(2012) Englishhospitals (NHS
organizations)
Quantitative Hospitalinvestmentsin innovation
Scienceandpractice-based innovation
Generationofinnovations
SalgeandVera (2009)
Englishhospitals (NationalHealth Service[NHS] organizations)
Quantitative Linkagebetweeninnovation investmentandclinical performance Science-basedand practice-basedinnovation Generationofinnovations Schultzetal. (2012)
Germanhospitals Quantitative Impactofinnovation managementofhospitals innovativeness
Diffusionofdifferentkindsof innovations;focusonmedical processinnovations/service innovations
Reallyaboutdiffusion?
Thakuretal. (2012)
Hospitalexecutives intheUS
Qualitative Definitionsofinnovations withinhealth-care organizations
Adoptionofbestpractices Adoptingandadaptingnewpractices tolocalcontexts Ugurluogluetal. (2013) Hospitalmanagers at250hospitalsin Turkey
Quantitative Characteristicsofhospitalsas learningorganizationsandits influenceoninnovation performance
Introductionofnewmedical procedures
Generationandadoptionofnew medicalpractices
Weigel(2011) Casestudyofone hospitalin Germany
Qualitative Thecontributionofthehospital toinnovationinaregional medicaldeviceindustry
Productinnovation(medical devices)
Ideagenerationandleadingpartnerin allstagesofdevelopment
WuandHsieh (2011)
HospitalsinTaiwan Quantitative Impactofinnovationson perceivedqualityofcare
Medicalandadministrative innovations(productsand services)
Adaptionanddevelopmentof improvedservicestowardpatients Yang(2014) HospitalsinTaiwan Quantitative Determinantsofinnovation
capabilityandperformancein Taiwanesehospitals
Innovativecapability(abilityto generatenovelty)
Generationandadoptionofnew medicalpractices
influencedbyspecializationlevels,financialslack,andthe strate-gic direction of hospitals over time. In addition, Schultz et al.
(2012)findthatmanagementapproachesthatencourageemployee involvementhaveapositiveeffectonoverallinnovation
portfo-lios(i.e.,thenumberandrangeofinnovationprojects)inGerman hospitals.
Inlinewiththisperspective,severalpapersaddressthequestion oforganizationalcharacteristicsandpracticesthatmaypromote innovationathospitals.Thesepapersattempttomapwhether hos-pitalorganizationsfosterlearning,creativity,andentrepreneurial attitudesamongemployees(DiasandEscoval,2015;García-Go ˜ni etal.,2007;Hernandezetal.,2013;LeeandHong,2014;Raadabadi etal.,2014)andtrytoidentifytheinfluencesuchfeatureshave onhospitals’innovativecapability(Ugurluoglu etal.,2013)and innovationperformance(DiasandEscoval,2013;Yang,2014).The resultsarenotconclusivebut,overall,seemtoindicatethat hos-pitalswitha strongfocusonlearningdisplayhigherinnovation performance,inlinewithgeneralinnovationtheory.Notably, how-ever,thesestudiesarenotexplicitaboutthetypesofinnovations hospitalspromoteandwhetherthesefeaturesarebeneficialforthe generationofnoveltyorimplementationofandexperimentation withinnovativesolutions.
Asurprisinglysmallnumberofpapersaddressthecommercial aspectsofhospitalinnovationactivities.FrenchandMiller(2012) focusontheincreasingcommercialethosofCanadianhospitals and attempt to outline features of the “entrepreneurial hospi-tal,”whichtheydefineas“onethatexplicitlyseekstoconstitute patientpopulationsandcaseinfrastructuresasdistinctiveassets (orresources)inpursuitofentrepreneurialaims”(p.718). Accord-ingtotheseauthors,thedatatheycollectedthroughinterviews indicateincreasingawarenessofthestrategicvalueofclinical facil-itiesandpatientsasassetsfor researchandinnovation,aswell asforcommercialexploitationofpromisingresults.Thisis inter-pretedasanindicationofchangesinvalueregimesorientednot onlytowardtheimprovementofhumanhealthbutalsotoward wealthcreation,whichconstitutesaculturalshift,withpervasive butnotwell-knownimplications.
Despitetheirdifferences,thepapers thatbelongtothis first groupof studieshave the distinction ofcombining a relational viewofhospitalsasoutward-lookingorganizationswithan intra-organizationalperspectivewitha focusontheheterogeneityof innovationactivitiesandconsiderabledifferencesthat character-izedifferentunitsinvolvedinthegenerationofnoveltyathospitals. Thesepapersconceptualizetherolesofhospitalsininnovationin differentways.Wecandistinguishbetweenpapersthatfocuson hospitalsaslargeandcomplexserviceorganizationsandthosewith asharperfocusoninnovativeproductsdevelopedinahospital con-text.Amongtheformer,akeymessageisthathospitalsperform multiplefunctionsbutthattheirroleisthatofsystemintegrators acrossfunctions(Andersonetal.,1994;DjellalandGallouj,2005, 2007;FrenchandMiller,2012;Rosenberg,2009;Salge,2012;Salge andVera,2009).Amongthelatterpapers, thefocusonproduct innovationisassociatedwithanemphasisontherolethat hospi-talsandclinicalsitesplayinideagenerationandmarketing,aswell asimplementationandpostimplementationimprovementsofnew medicaltreatmentsandtechnologies(Schultzetal.,2012;Weigel, 2011;WuandHsieh,2011).
3.3. Hospitals’rolesininnovationprocessesandsystems
Thelastgroupofstudiesidentifiedinourdatabasetakesa sys-temic and longer-termviewof medical innovation.They build, ontheonehand,ontherichresearchtraditioninthehistoryof medicineandthehistoryoftechnologyand,ontheother,on evo-lutionary approaches to innovation systems. They considerthe characteristics and dynamic interplay of actors endowed with different(competingandcomplementary) basesofcompetence. Severalpapersfocusonunderstandinginnovationand technolog-icaldevelopmentsinmedicinefromtheviewpointofa network ofindividualsandorganizationsthatsharethedivisionof
innova-tivelabor.Thesenetworks,whichoftenemergetosolveparticular technicalproblems,co-evolvewithchangesintheknowledgebase andunderpinchangesinthestructureandcompositionof medi-caltechnologymarkets(Mina,2009).Analysesofproblem-driven innovationprocessesrepresenttheempiricalcoreofthesestudies. Thestudiessampledforthisreviewareonlyjournalarticles, asweusedjournaldatabasesforliteraturesearches.Thesampled papersarecloselyrelated,however,and oftenbasedon histori-calandconceptualworkinthe1990sonsociotechnicalsystemsof medicaltechnologies(Blume,1992;GelijnsandRosenberg,1994; Rosenbergetal.,1995;Schlich,2002),oftenpublishedasbooks, bookchapters,andreports.Detailedstudiesofthe“careers”(Blume, 1992)of particular casesof medical technologies (e.g.,medical imaging technologies, cochlear implants, artificial heart valves, endoscopes)ledtoanumberofempiricalobservationsaboutthe generation and developmentof technologies in medicine, later summarizedandusedasthebasisforrenewedtheoreticalefforts inaseriesofpublicationsincludedinTable6.
AsTable6shows,severalpapers emphasizeparticular med-icalobjects(implants,heart valves,lenses,endoscopes,medical imagingtechnologies)ormedicalpractices(telemedicine, ambu-latory surgery, minimally invasive therapy, electronic patient records, patient registries) whereas others look at innovation fromthevantagepointofdifferentmedicalproblems(diseasesor medicalconditions,suchasinfectionwithHIV,heartdisease, glau-coma,deafness).Althoughtheempiricalbasisisdifferent,whatis commonisnonethelesstheambitiontotrackandexplorethe devel-opmentofknowledge,technologicalandmedicalsolutions,over time,withinthesedefinedcontextsorcases.Thepapers empha-size innovationsas the developmentof new productsbut also areembeddedinservicedelivery.Thus,theylookatinnovations asbothproducts(technicalsolutionsorartefactssuchassurgical tools,drugs,orparticularprocedures)andservices(theuseoftools intreatment/caresituations).Animportantpointisthatproducts andprocessinnovationsarelinkedandthatproductinnovations entailcustomizationandadaptation,aswellasthedevelopmentof innovationsinorganizationsandservicedeliverythroughout cus-tomizationandadoptionprocesses(PetrakakiandKlecun,2015). Comparedtothefirstgroupofpapers,thesestudiesareless het-erogeneousandfocusonsimilarresearchquestions,explanatory models,andresearchstrategies.Intermsofthelatter,thestudies aredescriptive,oftenusingacombinationofdatasourcesto gener-ateacomprehensiveimageofepistemological,technological,and socialdevelopmentsinthecasecontext.
Thesestudiesviewinnovationaslong-termproblem-solving processes,inwhichcollaborationbetweendifferentparticipants and competences is a key activity (Djellal and Gallouj, 2005, 2007;GalbrunandKijima,2009,2010;GeljinsandFendrick,1993; GeljinsandRosenberg,Rosenberg,1994;MeritoandBonaccorsi, 2007;Metcalfeetal.,2005;MorlacchiandNelson,2011;Nelson et al.,2011; Rosenberget al.,1995).A relatedfocus is onhow knowledge,technologies,markets,andinstitutionsco-evolveover a considerable time seen ex post as particular trajectories of change.Humanagencyand creativityare driversofinnovation, becauselocalizedsearchandrecombinationofknowledge consti-tutekeyelementsinproblem-solvingactivities.However,technical changes inmedicine do notinvolve only developmentand use ofknowledge;theinstitutionalframework,particularlyregulation anddemandformation,influencebothcreationanddissemination ofnewmedicalknowledgeandmedicalpractices(Metcalfeetal., 2005).
Furthermore, innovation processes in medicine are seen as recursive,withconsiderableinteractionamonginvention, devel-opment, dissemination, and the use of new knowledge and technology.Newmedicalinnovationsdevelopinanincremental mannerandrequiresubstantialadaptationinmanystages,
consid-Table6
Overviewofpapersoninnovationprocessesandsystemsinhealthandmedicine.
Paper Empirical
object/case
Data Keyissuesexplored Kindsofinnovations Roleofhospitals
Barbera-Tomasand Consoli(2012)
Implantable devices(artificial discs)
Mixedmethods Technologicalandscientificchange processesfocusingon
developmentsoftheknowledge baseandtechnologicaltoolsfor curingdegenerativediskdiseases
Productinnovations IdeagenerationClinical experimentationandtesting Leadusers
Procurementdecisionsandmarket ConsoliandMina
(2009)
Cardiologyand glaucoma
Mixedmethods Evolutionaryprocessesofmedical innovation,exemplifiedby researchontwoareasofmedical practice
Productandserviceinnovations connectedtotreatmentof particularmedicalconditions
Basicandtranslationalresearch, problemformulation,idea generation,experimentationand testing,leadusersandfeedback Consoliand
Ramlogan(2008, 2011)
Glaucoma Conceptual Mixedmethods
Processofknowledgegrowthinan areaofmedicine
Scientificdevelopmentand innovationsinmedicalpracticesin treatingglaucoma
Clinicalresearchandcollaborating withacademicresearchunits EssenandLindblad
(2013)
Rheumatology Qualitative Exploresapractice-driven innovationprocessesconnectedto establishmentandcontinuous improvementofanational rheumatologyregistry
Productandserviceinnovation(IT based)
Ideageneration,continuous improvement,users
GalbrunandKijima (2009,2010)
Medicalimaging technology
Qualitative Dynamicrelationshipsbetween setsofactorsthatovertimefoster innovationinmedicaltechnology
Productinnovation Experientiallearningleadsto innovationideasandextends usageoftechnology,
Leadusersandtestingfunctions, Gelijnsand
Fendrick(1993)
Minimallyinvasive therapy
Mixedmethods Dynamicsofmedicalinnovation Productsandprocedures Ideageneration,experimentation anddevelopmentof
supplementaryservice innovations;complexinterplay withotheragents
Gelijnsand Rosenberg(1994) Endoscopes, medicalimaging technologies Conceptual, qualitative
Developmentofnewmedical technologies,dependsonclose interactionbetweenproducersand users,andisinfluencedbychanges inregulationandfinancingof health-careservices,andpatterns ofmedicalspecialization.
Productinnovation(medical devices)
Adoptionandadaptionof technologiesdevelopedelsewhere formedicalpurposes
Clinicalexperimentationand incrementalimprovementsin practice
Meritoand Bonaccorsi(2007)
HIVtreatments Mixedmethods Co-evolutionofclinicalknowledge andtechnologyindevelopmentof HIVtreatments
Product(drugs)andservice (treatment)
Experientialknowledge, experimentationandtesting Developsthecomplementary socialtechnologiesneededfor widespreadadoption Metcalfeetal.
(2005)
Intra-ocularlenses Mixedmethods Dynamicsofcomplexand distributedinnovationprocessesin oneareaofmedicine
Serviceinnovation(modeof treatment/procedure)andproduct innovations(implants)
Ideageneration,experimentation, complementaryinnovations,lead users,marketing
Minaetal.(2007) Coronaryartery disease
Mixedmethods Evolutionarytrajectoriesof change;complex,co-evolutionary processesandpathdependence
Serviceinnovation(modeof treatment/procedure)andproduct innovations(cathetersandstents)
Ideageneration,research(clinical) andexperimentation
Morlacchiand Nelson(2011)
Leftventricular assistdevice
Qualitative Evolutionarystudyofinnovation withinoneareaofmedical practice,thatinvolvedinterplay betweenchangeinthreerelated areas:medicalpractice,science andtechnology
Productinnovation(hartimplant) andserviceinnovation(modeof treatment)
Problemformulationandidea generation,experimentationand testing,selection,develops complementaryinnovations
Nelsonetal.(2011)Mainlyconceptual, someexamples
Conceptual Innovationasanevolutionary processinvolvinglearninginthree domains
Serviceinnovations(innovationin treatmentofdiseases)
Clinicalpractice,integrationof differentsourcesofknowledge Nicolini(2010) Tele-cardiology Qualitative Developmentanddissemination
occurthroughnetwork,andcannot bemeaningfullydepictedinan orderedstage-likeform.Highlights thepoliticalnatureofhealth innovations
Productinnovation (tele-monitoring)andservice innovation(modeofcare)
Petrakakiand Klecun(2015)
Electronicpatient records(EPR)
Qualitative CustomizationofEPRsystemsin localsettings;how
implementationoftenrequires localorganizationalandservice innovations
Productandserviceinnovations Adopter,butcreatinglocal customizationandservice innovations
Ramloganetal. 2007)
Coronaryartery glaucoma
Quantitative Evolutionaryprocessesofmedical innovation,exemplifiedby researchontwoareasofmedical practice
Productandserviceinnovations connectedtotreatmentof particularmedicalconditions
Basicandtranslationalresearch, problemformulation,idea generation,experimentationand testing,leadusersandfeedback Windrumand García-Go ˜ni(2008) Ambulatory surgery Conceptualand qualitative
Systemsframeworkforexploring healthserviceinnovation
Serviceinnovation(modeof deliveryofhealthservices), organizationalinnovationand productinnovation
Developingandimplementinga newmodeofservicedelivery
erablefeedbackfromusers,andconsiderablepost-implementation development.Itishardtoseparatethecreationofnewknowledge andnewtechnologiesandthedisseminationanduseofthese tech-nologiesinmedicalpractices(Barbera-TomasandConsoli,2012; ConsoliandMina,2009;ConsoliandRamlogan,2008,2011;Essen and Lindblad, 2013; Merito and Bonaccorsi, 2007; Mina et al., 2007;PetrakakiandKlecun,2015).Withthisinmind,thepoint ismadethatthemainstreamhealth-caremanagementliterature alltoooftenseparatesimplementationfrominnovation(Essenand Lindblad,2013).
MorlacchiandNelson(2011)claim thatmedicalinnovations orimprovedmedicalpracticesaretheresultofdevelopmentsin three“co-evolving pathways”:advancesinbiomedical scientific understanding,improvementoftheabilitytodevelopnew medi-caltechnologies,andlearningin(clinical)practice.Thesepathways correspondinparttoorganizationsthat“harbor”them (univer-sities,firms,and hospitals),but since theyare alsointerrelated andrecursive,fluidnetworksandcommunities(ofpractices)that transgresseachpathwayareequallyimportant.Becausemedical innovationsdrawonseveralsourcesof knowledge,“rich ecolo-gies”oforganizations—includinguniversities,firms,hospitals,and researchinstitutes—areinvolvedindevelopinganddissemination ofmedicalinnovations(Nicolini,2010;Ramloganetal.,2007).At thesametime,studieshavealsofoundthatconflictsofinterest betweengroupsofprofessionalsathospitalsandbetween hospi-talsandotherorganizationscreatebarrierstoinnovationandthat thereisconsiderableresistancetodevelopinganddisseminating medicalinnovations(Blume,1992;Nicolini,2010).Increased spe-cializationandpotentialintraprofessionalcompetition,however,is alsoregardedasadriverfortechnologicalinnovationinmedicine (GelijnsandRosenberg,1994).
Hospitalsandclinicalsitesarefundamentalcomponentsof com-plexhealthinnovationprocesses(DjellalandGallouj,2005,2007; Geljinsand Rosenberg,Rosenberg, 1994; Metcalfe et al., 2005; MorlacchiandNelson,2011;Nelsonetal.,2011;Rosenberg,2009; Rosenbergetal.,1995).Thisreflectsagaintheimportanceof med-icalpracticeforidentifyingproblemsandsolutionsandpointsto theroleofhospitalsas“bridgingorganizations,”wheredifferent pathwaysmeetandarecross-fertilized.Inotherwords,hospitals areoneofmanynecessaryactorsinhealthinnovation,butthey haveakeybrokeringroleinbringingactorstogetherinwaysthat shouldnotbetakenforgranted(asifallnetworktieswere persis-tentovertime).Inthedistributedsystemofactorsthatareinvolved inthegenerationanddevelopmentofinnovations,hospitalsare oftenthehubsinthebroadernetwork.AsseeninTable6,most papersdescribe multiplerolesofhospitalsor particularclinical sitesathospitals,rangingfrominitialideagenerationto implemen-tationanddissemination.However,inthesepapers,thehospital isnotaddressedasaunit.Rather,thefocusisonclinicalsitesat hospitals,whichhavethiskeyexperimentallearningandlinking functionintrinsicallyconnectedwithinnovation.Clearly,manyof theinnovationsstudiedemergeoutofmedicalpractice,inwhich practitionersinhealth-caresystemsareinvolvedinincremental andpractice-drivenimprovementprocessesdirectedatimproving conditionsforpatients(EssenandLindblad,2013).
Asanextensionofevolutionarystudiesofhealthinnovation, withitsfocusonco-evolutionacrossdiversesetsofknowledgeas akeytomedicalinnovation,asystemperspectiveofinnovation inhealthandmedicineislogicallyconsistent.Amongthepapers includedin the review are severalattempts at conceptualizing healthinnovationsystemsintermsofparticipantsandmodesof interactions(ConsoliandMina,2009;DjellalaandGallouj,2005, 2007;GalbrunandKijima,2010;WindrumandGarcía-Go ˜ni,2008). ConsoliandMina(2009)arguethathealthinnovationsystems consistoftwo broaderdomains:(1)thescienceandtechnology domainand(2)thepracticaldomainorthehealth-caredelivery
system,withstronginteractionswithinacrossdomains.Hospitals arekeyactorsinbothdomains,aswellasbrokersbetweenthem. Galbrunand Kijima (2010)usetheconcept “clinicalinnovation system”todescribethedualroleofclinicalsitesinmedical inno-vation.Theyalsoclaimthattheroleofhospitalsandclinicalstaff shouldnotbeunderstoodmerelyintermsoftheirroleinscientific investigations,testingnewproducts,orimplementingproductsor services.Clinicalstaffcontributetothegenerationofnoveltyby experimentingwithtechnologiesintreatmentsituationsandby developingandimplementingthesocialtechnologiesorsoft inno-vations(e.g.,treatmentprotocolsoradviceforhealth-carepolicy onwhatsolutionstoprocure/reimburse),whicharenecessaryfor wide-scalechanges.Thisexperimentalfunctioniscarriedoutin clinicalsettingsand makes hospitalsthekeyarena for connec-tionsbetweenscience-basedknowledge,technologyandclinical practice,andbetweengeneration,selection,anddisseminationof innovations.
WindrumandGarcía-Go ˜ni (2008)emphasizea third domain withinthe system:the policydomain,which toa great extent contributestoshapinghowinnovationprocessesoccurandwhich innovationsareselected.Intraditionalinnovationmodels devel-oped for understanding private sector innovation, the market istheimportant selectionmechanism. Formedical innovations, selectionismuch morecomplexandtakesplaceinmulti-agent environmentswithmultipleselectioncriteria.Selectionisstrongly influencedbypolicyandpolicymakers,butpolicyalsoinfluences ideagenerationandregulateshownewinnovationdevelops.But thepolicydomaindoesnot operateinisolation:feedbackfrom medicalandscientificcommunitiesalsoshapespolicy-making,as dopatientsandpatientgroups.
Thesystems-orientedliteratureexpandsandsupplementsthe micro-levelinvestigationsofparticularcasesofmedicalpractice. Thebridgingroleofhospitalsloomsevenlarger,notleastbecause thesystemislargeandcomplexwithamultitudeofactorsthatare highlydifferentfromoneanotherinincentivesandcompetence bases.Inaddition,thesesystemsdifferfromrelatedtheoretical con-structsthatemphasizesectoralorgeographicboundariesorthat neglectthespecificnatureofpublicsectoractivitiesandtheroleof context-specificpolicy.
4. Synthesisoffindings
Themostobviousfindingthatemergesfromourinspectionof theliteratureisthattheevidencebaseishighlyheterogeneous. Rel-evantresearchhasbeenpublishedinseveralfieldsofscienceand variousjournals,andlittleconsensushasbeenreachedaboutkey questionsandoverarchinganalyticalframeworks.Mostempirical studiespublishedonhospitalsandinnovationareimplementation studies,particularlyimplementationofnewtreatmentregimes,ICT tools,oradministrativeroutinesinhospitalsettings,but investi-gationsoftheroleofhospitalsmorebroadlyinthegenerationof noveltyisamorerecentareaofinterest(SalgeandVera,2009). Multiplecasestudieshaveappearedonparticularhospitalsor spe-cificinnovationsinmedicaltechnologies,treatmentregimens,and drugs(seeTable6),butfewattemptshavebeenmadetosynthesize theevidenceacrossthislargelycase-basedrepertoireofempirical evidenceonhowhospitalspromoteinnovation.
Ourliteraturereviewhasidentifiedthreegroupsofstudies,in whichhospitalsareseenas(1)thecontextofoperationof innova-tivepractitioners(amicro-levelperspective),(2)theunitofanalysis fromanorganizationalviewpoint(ameso-levelperspective),and (3)acentralcomponentandinterfacewithinabroaderhealth inno-vationsystem(amoremacro-orsystem-orientedperspective).The firsttwostreamsofpapersencompasstheactivityofspecific hospi-talsorgroupsofindividualsathospitals,whereasthethirdfocuses
onproblemsand theoverall systemthroughwhich innovations inmedicineandhealthcareemerge,develop,andspread.These approachesemphasizeamultitudeofrolesforhospitalsand hos-pitalstaffininnovation,butdifferintheirfocusondifferentphases ininnovationprocessesandalsoinwhethertheyfocusmainlyon hospitalinternalrolesversusrolescarriedoutincollaborationwith externalactorsinthewiderhealthinnovationsystem.
Thedifferentstrandsofliteraturelargelyemphasizedifferent innovationactivitiesandthehospitals’rolesinthem.Fig.3maps thedifferentstrandsofliteratureonto thebroad perspectiveof hospitals’rolesininnovation,asdescribedinFig.3.
Fig.3distinguishesfourquadrantsthat representthe activi-tiesassociatedwithdifferentphasesordimensionsofinnovation: generation, development, verification/selection, and dissemina-tion/use.Thefigurealsodistinguishesbetweenaninner andan outerlayerofactivities,whichrepresent,respectively,core hos-pitalactivitiesininnovationandinnovation-relatedactivitiesthat hospitalsperforminsupportoforincollaborationwithexternal agents(includingfirmsandregulators).
Thefirststrandofcontributionsfocusesonindividualsor inno-vativepractitionersandontheirroleingeneratinginnovationsin medicineandhealthcare.Aswehavenoted,thisliterature ded-icatesspecialattentiontotheroleofmedicaldoctorsandlooks insomedetailattheroleofcliniciansasinventors,theirrolein developingnewproducts,andthewaysinwhichtheseactivities arecarriedoutincollaborationwithindustry.
Theliteratureonhospitalsasinnovativeorganizations(strand 2) is, as expected, mainly hospital-internal oriented (it covers the four inner quadrants). Some of this literature also has a particular focus on use and dissemination, particularly on the question of complementary service innovations, customization, and post-implementation improvements. This literature has a learning/organizationalperspective and tendstoemphasizethe organizationalfeaturesandmanagementpracticesthatpromote opennessandparticipationininnovationactivitiesamonghospital employees.
Theliteratureontechnologicaltrajectories(strand3)takesinto accountabroaderrangeofevolutionarypatternsinmedical inno-vationprocesses. It adoptsa theoreticalperspective thatis less explicitlyfocusedontheinternalorganizationofhospitalsbut,like strand2,connectsnewideagenerationwiththedevelopmentand diffusionofinnovationatthesystemlevel.
Onefundamental problemthathasreceivedsurprisingly lit-tle attention concerns the effects of technology selection and adoptiononthecurrentandfutureinnovativecapacityof hospi-tals.While technologyassessmentand technologyadoptionare well-researched themes in the field of health-care policy, the linksbetweenhealth-carepolicyandinnovationpolicyarenota well-understoodpartofthehealthinnovationsystem(Windrum and García-Go ˜ni, 2008).In particular,the relationship between resourcingofhospitalactivities(intermsofequipmentandskills), development of clinical practice and the growth of innovation capabilitieswithintheorganizationareinterestingandimportant avenueforfurtherresearch.Overall,moreresearchisneededon amicro-levelanalysisofpractitioners’incentivesforand engage-mentininnovation(includingnursesandadministrators)(Chatterji and Fabrizio, 2013; García-Go ˜ni et al., 2007; Kesselheim et al., 2014), onthesystem-level implicationsof health-care technol-ogyfundingandselection(WindrumandGarcía-Go ˜ni,2008),and arguablyontheconnectionbetweenthemicroandthemacrolevels ofanalysis.
Lookingattheliteratureasabodyofknowledgeabout hospi-talsandtheirroleinmedicalinnovationsystems,theperspectives, empirical strategies, data, and methodologies used in current researchhave limitations.First,severalstudieshavearelatively narrowscopeandareoftenbasedonalimitedsetofempiricalcases.
Veryfewstudiesarebasedondetailedinformationacrossmultiple hospitals.Althoughsomenotablestudiesareexemptfromthis(e.g., García-Go ˜nietal.,2007;Salge,2012;SalgeandVera,2009),most publishedworkdoesnotutilizeadministrativedatafromhospitals toalargeextent,althoughalargevarietyofdataisavailableon investmentsininnovation,innovationprocesses,andoutcomesin manycountriesandhealthsystems.
Second, because empirical studies have targeted particular empiricalobjects,theoreticaldevelopmenthasalsotendedtofocus onrelativelynarrowperspectives.Forinstance,asystems perspec-tiveisevidentinsomeofthisliterature(ConsoliandMina,2009; GalbrunandKijima,2010;WindrumandGarcía-Go ˜ni,2008),but delineationoftheboundariesofthesystemdiffersacrossstudies. Muchworkremains tobedoneinconceptualizingand describ-ingdifferentparticipants,activities,resources,relationships,and institutionalframeworksinhealthinnovationsystems.
Third,theheterogeneousliteratureonhospitalsandinnovation hasdrawnupon conceptualframeworksandinsightsdeveloped withinthefieldofinnovationstudiestoalimitedextent.The litera-tureontechnologicaltrajectoriesinhealthcareandmedicinedraws ontheoreticalconceptsfromevolutionarystudiesoftechnology (e.g.,ConsoliandMina,2009;Metcalfeetal.,2005;Morlacchiand Nelson, 2011), but they have not alwaysintegrated the useful insights that can be derived from the application of organiza-tionalandmanagerialperspectivesoninnovation.Theliteratureon hospitalsasinnovativeorganizationsaddresseshospital-internal mattersandhasfocusedondriversofinnovation,including orga-nizationalandmanagementfeaturesthatstimulatecreativityand learning(DiasandEscoval,2013,2015;García-Go ˜nietal.,2007; Salge,2012;SalgeandVera,2009).Butboththeinnovationsystems literatureonhealthcareandorganizationalstudiesofhospitalsas innovatorsoftenobscuretheunitofanalysisandneglect, respec-tively,theinternalorexternalinstitutionalcomplexityofhospitals.
5. Concludingremarksandissuesforfurtherresearch
Thematically,thereisnoshortageofissuesforfurtherresearch ontheroleofhospitalsasinnovators.First,asseeninFig.3,further researchisneededonhospitalsasselectionenvironmentfor inno-vationsandhowthisisrelatedtohospitals’roleingenerationof innovations.
Second,thegrowingandpervasiveemphasison“open” innova-tionmodelscallsforacarefulassessmentoftheopportunities,and thecosts,thatincreasedengagementininnovationwithexternal partnerscanbring.Interestinopeninnovationmodelsinhealth care,particularlyonpatientsandotherstakeholders’involvement ininnovation,isemerging(Bullingeretal.,2012).Thegovernanceof collaborativeinnovationrequiresexperienceaswellasdedicated resourceswithintheorganization.Italsorequiresagood under-standingandappropriatedesignofincentivesforresearchersand clinicalstaffthatarecompatiblewiththedeliveryofhealth-care services(Salgeetal.,2015).
Third,thecapacityofhospitalstocomplementinnovation activ-itiescarriedoutbyexternalorganizations(e.g.,tocollectevidence onexperimentationwithnewdrugsanddevices),combinedwith thestrongtiesthatresearch-intensivehospitalshavewiththe uni-versitysystem,candramaticallyincreaseincentivesforcompanies toestablishresearchfacilitiesinthevicinityofhospitalsinorder togainaccess topatientsandtovaluable knowledge.Thismay includethetalentofgraduatesfromresearch-intensive universi-tieswithstrengthinmedicineandthelifesciencesortheintangible assetsofsmallercompaniesspunofffromuniversitydepartments andincubatedinthelocalarea(MinaandProbert,2012). There-foreresearchhospitalscanbesignificantfactorsinthelocation decisionsofpharmaceuticalandmedicaldevicecompanies.
Fig.3.Therolesofhospitalsininnovationandthemainfociwithindifferentstrandsofliterature.
Fourth,newICTinvestmentsrelatedtotelemedicineandbig datacanprovidenewopportunitiesforlearning ifthe informa-tionsystemofthehealth-careorganizationisdesignedtotakefull accountoffeedbackmechanismstoguidefurtherexplorationin technologyandpractice.
To provide a more coherent evidence-based perspective on theroleofhospitalsininnovation,empiricalstudieswithwider coverageareneeded.Comparedtouniversitiesandtheirrole in innovation,whichhavebeenstudiedintensivelyoverthepastfew years,theempiricalbasisonhospitalsismuchweakerandthe con-ceptualandtheoreticalworkmoreheterogeneous.Inparticular, studiesareneededoninnovationactivitiesatthehospitallevel, whichcanbeaccomplishedbycollectingsurveydataateitherthe hospitalorunitlevelandtheindividuallevelorbycombining sur-veydatawithadministrativedata.Broaderempiricalstudiesand strongertheoreticalmodelsarealsoneededtounderpinemerging innovationpolicyfocusingonhealthandtoinformstakeholders (owners,managers, practitioners, and patients)about the chal-lengesofinnovation—orlackthereof—especiallyinpubliclyfunded health-caresystems.
Theliteraturereviewandanalyticalframeworkwepresentin thispaperprovideastartingpointforfurtheranalysisoftheroles ofhospitalsinthegenerationofinnovationasguidelinesthatcan beusedtomapactors,activities,relationshipsbetweenactorsand activities,theirgovernance, and theiroutcomes.Because ofthe
organizational andinstitutional complexity of hospitals,further empiricalworkshouldalsolookin somedetail atdepartments, professionalgroups,andmedicalspecialtieswithinandacross hos-pitalsonacomparativeandinternationalbasis.
Acknowledgments
ResearchforthisarticlewasfundedbytheResearchCouncilof Norwayundertheproject“Synergiesandtensionsininnovationin thelifesciences,”aswellasbytheSouth-EasternNorwayRegional HealthAuthorityandtheUniversityofOslo.Thefinancialsupport receivedisgratefullyacknowledged.Thepaperbenefitedgreatly frominsightfulcomments,criticism,andsuggestionsbythe par-ticipantsinmedicalinnovationworkshopsheldinOslo(2013)and Gothenburg(2014),aswellasbytwoanonymousreviewersand theeditorsofthespecialissue.Theusualdisclaimersapply. References
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