The field of healthcare encompasses a broad array of organizations, trends, and topics. With such a wide variety of initiatives that are important and have a significant impact on the field and its organizations, there is a plethora of potential items that can serve as a focus for further analysis and research. Given that the healthcare industry continually occupies a major role in the political and social arenas, the implications of dedicating efforts to uncovering important findings can prove to be of significant benefit to the larger society. Having completed an overarching evaluation of the ongoing concerns and topics in the healthcare field, a recurring theme that was identified is the concept of healthcare innovation and change. This particular concept has a far-reaching impact on the field, and it affects many different components of operations and organizations. Since change has such a significant role in shaping the entities and future direction of the field of health care, it will serve as the focus of this undertaking. Change at both the micro-level and macro-level in the field of healthcare will be addressed through a comprehensive review and analysis.
A literature search on the topic of change in the field of healthcare provides exposure to a broad array of research and articles and highlights significant trends. The method that was applied centered around the use of educational databases and Google Scholar. To retrieve the most insightful writings and journal articles, the selection of search terms was carefully considered. When applied, the terms used included healthcare, health care industry, health care organizations, hospitals, change, theory of change, macro-level change, micro-level change, and applications of change.
Organizations operating in the health care industry face pressures stemming from political, economic and technological sources related to their operations and the need for change, and this force has been encouraging attempts to restructure and redesign the field itself.1 Motivated by the desire to improve efficiency and effectiveness, this impetus for change in the broader field has a direct impact on the makeup of organizations and their role in the industry.1 Although the focus on intended changes seeks to improve the integration of various providers for enhanced communication and proactive patient care, the actual methodology behind actualizing these goals requires the reorganization of highly complex dynamics within and across companies in the industry.1 The characteristics of the change itself may vary greatly, and some alterations can be gradual and minor while others can be sudden and drastic.1 The implications of this array of approaches towards implementing and achieving change need to be carefully considered and evaluated for their true impact on the field and health care organizations.1
Given that there is a major focus on enhancing integration and collaboration which is driving the future of the field of health care, the mechanisms and implementation efforts necessary to realizing these trends must be considered.1 Additionally, marked trends such as the continuing aging of many countries’ populations and rising health care costs are providing an impetus for the incorporation of change into an organization’s practices because these forces need to be managed in order for organizations to continue operating successfully. 1 These factors, therefore, create a framework upon which the concept of change and its implementation in the health care field can be more fully explored. Particular research has focused on evaluated successful examples of radical organizational change, and the insights from this analysis center around the components which make up change1
Content, mechanisms, and process are three aspects of change, and they represent factors that can be utilized by organizations to enact alterations to their structure and outlook.1 Organizations need to consider what changes need to occur in their systems, values, and structures in order to successfully move from one method of care delivery to another, and they also need to understand which mechanisms can facilitate or constrain the changes. 1 Change is a process that must be undertaken, and the specific way in which the change is achieved is a critical area of study and information from which other organizations can learn.1 Change takes place over time, so an effective evaluation of organizational change must apply a longitudinal approach in order to see how the change evolves across systems and time.1 When there is a radical change enacted in an organization, this macro-level change actually proceeds in a non-linear manner through micro-changes throughout the system.1
Radical change begins with a broad view of the goals and vision for the transition, and the supporting mechanisms in the micro-level changes allow for the organization to be propelled towards the final desired outcome.1 Planning is important but the change ultimately develops through emergent, dynamic processes that evolve and take shape during the length of the project.1 A radical change can be supported and its successful attainment can be facilitated through a commitment to a desired outcome that justifies the radical change.1 When change is implemented across an organization, the perspective of various powerful groups and stakeholders must be considered and managed because a lack of support can thwart the success of attempts at change.1 Support by individuals from various levels, especially those who will be on the front lines of implementing the radical change, can enhance the successful implementation of the project. 1 Radical change will inevitably be characterized by setbacks so persistence and a long-range view are needed to avoid discouragement and failure.1 Breaking down a radical change agenda into smaller components makes the transition smoother and incentivizing the move to a new model can help to improve its adoption by all stakeholders.1
As change is implemented in organizations, the role of the health care professional in contributing to or supporting such transitions is important to acknowledge and analyze.2 Particularly, the impact of the identity that the professional has cultivated should be recognized since the factors shaping the individual’s ability to respond to change and new roles can have a significant effort on attempts at organizational change.2 Published research has considered that the willingness of an employee to effectively support or adopt a shift in professional logistics is based upon social identity factors. 2 The particular findings of a study centered around the impact of health care professionals on organization change efforts were able to demonstrate that the success of a new logistical approach in an organization is dependent upon the consistency of this new shift with the professionals’ social identity. 2 In cases where the shift presents a conflict to the qualities of the professionals’ social identity, this incompatibility can serve as a barrier to change.2
These findings have implications for managing large scale change in health care systems, as the impact of this factor can greatly affect the widespread attempts to enact change in the broader health care industry.2 When large-scale reforms are being considered for a health care system, the impact that these changes will have on professional identity should be included as a topic of study and evaluation. 2 Resources and formal methods addressing this factor should be incorporated into the plan, and Individuals who have been tasked as change agents should play a proactive role in supporting professionals as they are required to process identity change and reformatting their identities.2 Perceptions regarding a loss of status or feelings of inadequacy about technical knowledge may arise during the transition process, and these factors should be addressed in the implementation plan to mitigate the negative effects and enhance outcomes.2
Defining the various types of change which can occur in the health care industry is a helpful undertaking as it provides distinctions that assist with understanding the implications of different organizational changes.3 Radical change relates to a process where the entire orientation of an organization is cast aside in pursuit of an overall transformation, while convergent change is perceived as more of a finetuning of the existing organizational structure and practices. 3 Radical change can be further differentiated into either evolutionary change or revolutionary change.3 The distinctions can be found in the pace and extent of the upheaval and adjustment, and evolutionary change occurs in a gradual, slower manner. 3 In contrast, revolutionary change happens quickly and affects basically all aspects of the organization at one given time.3
Evaluating the application of the concept of radical change to an organization can provide fruitful outcomes since this analysis considers the factors and implications of the process of undergoing such rapid, significant change. 3An organization in the health care field can present resistance to change, and this expected occurrence can be traced to the embeddedness of an organization and its position in the institutional context of the field.3 Another important concept related to radical change is that there are different standards based on the type of industry that affect the pace of the change itself, and the contributing factors depend upon how insulated or distinct the industry is from the effect of trends in other fields. 3 Organizations within the same industry may also respond to rapid change differently, and this separateness can be linked to organizational structure, culture, and dynamics. 3
Utilizing existing theories, such as system and diffusion innovation theory, can provide a measure of insight into understanding organizational change, but the ongoing study of organizational factors and institutional context will also offer pertinent, valuable insights to explain the role and influence of change. 3 The field of health care provides constraints and parameters for organizational behaviors and standards, but the organizations themselves have distinct values, capacities, and interests which will also have a direct effect on the manner in which change occurs. 3 Change relates to the introduction of new ideas and approaches into existing structures, fields, and organizations, and the decisions by organizations of how they will utilize their capabilities to implement and manage the change will shape the final outcomes of radical change. 3
These valuable resources have provided coverage of the extent and content of the topic of change in health care organizations. They assist in providing a conceptualization of the meaning of change, and they also offer an understanding of how the topic of change is pertinent to organizations operating currently in the field of health care. Given the current trends affecting the health care industry, change is a significant factor that has to be addressed by all organizations in this field.
With the understanding that change in the health care industry will affect the entire organization, it is imperative to assess the factors which affect the organization’s ability to adopt and implement a significant change. There are a variety of methods that can be utilized to appreciate how this topic is applied to organizations and industry overall. The first step that allows for this progression in appreciating the full scope and impact of change is identifying how organizations identify and deal with change. A critical factor that will influence the success of a system-wide change being implemented is the initial readiness of the oragnzation.4 Readiness itself can be understood as a concept that explains the extent to which the people involved are both individually and collectively prepared, motivated and technically capable of implementing a change.4 As determining readiness is an invaluable component to preparing for a major change, there are certain factors that can be evaluated to assess how prepared the organization is to execute a change. 4
For a health care organization gearing up to implement a system-wide change, the psychological factors of the people being asked to make the change should be evaluated. 4 Structural factors, which encompass the situational circumstances surrounding the proposed change, must also be considered. 4 A comprehensive analysis of the effects that will be experienced by the organizational and individual levels and the characteristics of these levels must be completed. Change is often precipitated by significant trends in the larger culture or society, and this impetus can often require the adoption of practices in order to respond to significant, growing issues in the community.5 The type of issue which prompts swift, sweeping changes has a strong, material impact on health and well-being and will often relate to ethical and moral implications for a community. 5 Implementing change is a process that requires diverse parties and entities to confront an issue and transform practices, attitudes, and actions in a way that will lead to a culminating response to redress the issue. 5 For matters that have the ability to have a marked effect on the community and affect a substantial portion of the population, there is a necessary response that galvanizes parties to achieve accomplishments that contribute to the realization of a large-scale change. 5 These actions taken add to a framework upon which a wider, more extensive change can be built and grow. 5
True examples show the actual realization of this tactic, and the confluence of a variety of smaller events and changes can lead to a wider acknowledgment of an issue and development of a plan to address such trends. 5 One action can often prompt another faction to institute a decision and implement a change, and this ripple effect can realize a major change that was not perceived as a possibility. 5 Since different groups will have different skills and resources, this combination of inputs can help to make a more significant impact than the actions of one group alone could ever achieve. 5 This approach toward change is necessary because it allows for diverse groups to collaborate on the undertaking that unites them and has a significant potential impact that will be shared by a wider portion of society. 5 Finding commonality through a shared understanding of the importance and implications of an issue that warrants a response can allow for collaboration to take place and extensive change to be enacted. 5
Especially within the field of health care, there are consistently alterations made to existing rules and regulations and these new standards have an effect on the organizations in the field. 6 The manner in which an organization responds to new regulations will impact the general structure and the specific employees whose programs are subject other application of new regulations. 6 When institutional change is sought, it is necessary to evaluate the structures and mechanisms which will affect the implementation of the organizational change.6 An existing irony which can be regularly observed is that support for an institutional change by top healthcare management does not translate into benefits for those to whom the new initiative is intended to help. 6 New programs are intended to help employees but they can face resistance from their managers and this often results in an observable conflict between middle managers and subordinate employees that have competing interests. 6
Relational spaces are defined as spots of isolation, inclusion, and interaction which permit these two groups of opposing employees to develop a cross position that is collective for change, and this concept is increasingly recognized as an approach that can facilitate successful organizational change. 6 When there is an environment when manager and subordinates are uncomfortable with challenging the status quo and existing roles, this stymies the change process. 6 Relational spaces allow for these two sets of employees to feel safe and free from judgment or threat as they explore new roles and tasks which are characteristic of the proposed organizational change. 6 These spaces are helpful in order to overcome the trend of managers obstructing the use of new practices that could benefit their subordinates because the program threatens their own interests. 6 Understanding how true changes do occur in response to regulation is critical to explore, and the analysis of successful examples highlight important qualities in the process. 6 There needs to be support from various subgroups within the organization, and leaders from each component should be selected for a role in implementing the change. 6 In addition, organizations fare better in adopting new policies in response to regulations when the legal implications for such a change are clearly communicated and the culture stresses adherence and punishes noncompliance. 6
The theories and concepts of organizational change in the field of health care are necessary to understand and they provide a valuable framework upon which an analysis of timely and significant current trends in the industry can be conducted. Advancing to an understanding of the practical applications of the theories and perspectives can occur when empirical research and real-world findings are considered. This can be facilitated by diving deeper into specific aspects of change that face organizations in the field of health care. Information technology is a helpful tool that has increasingly begun to play a part in the core operations of health care organizations, and this core role occupied by this organizational function raises a number of interesting and impactful issues.7 Information technology has the capability of transforming and enhancing the efficacy and efficiency of care for patients, but the evolving nature of this topic can also introduce risk to organizations. 7 To achieve a deeper appreciation for the impact of this component of operations in an organization, a comprehensive analysis was undertaken to evaluate how information technology affects safety and quality from a regulatory perspective. 7
The parameters of the study involved a review of healthcare regulator inspection reports and digital maturity scores. 7
These items were selected as the best measures for evaluating the impact of information technology in the field of health care, as the current landscape offers limited options to support this initiative.7 Since there is a shortage of reliable resources for accumulating broad empirical evidence, the utilization of the digital maturity scores is a valuable tactic. 7 Attempting to assess digital maturity in an organization is a challenge but the Clinical Digital Maturity Index developed by England’s National Health Service does offer a sense of standardized measurement of this feature in organizations. 7 Additionally, the field is lacking a robust supply of data to evaluate the effectiveness of monthly regulatory inspections in finding best practices and highlighting potential problems or risks related to information technology in health care. 7 The absence of such available information prevents organizations and the broader field from accessing a body of data that could assist in characterizing the challenges and benefits of utilizing information technology. 7
By their very nature, these regulatory judgments may represent a valuable repository of information.7 The framework of a comprehensive system of feedback and insights into information technology would be helpful in highlighting issues of safety and risk related to digital systems and their impact on patient care.7 Access to such insights would provide benefits when new technologies are being created, implemented and assessed, and the lack of such available information demonstrates that there is inherent risk associated with information technology, and this risk needs to be an area of high importance for further studies. 7 Areas of risk in using information technology in the health care field which have been identified include the lack of general usability of the technology, poor accessibility to the system, and incorrect utilization of the technology.7 Change arising from information technology is inevitable in health care, and it imperative to develop a greater understanding of the risks and benefits of this topic so that all stakeholders can be informed and empowered as future practices and regulations develop.7
Nations around the world that can be characterized as fully develop are experiencing extensive changes which are affecting and shaping the future of the health care industry.8
Patients have been able to become more informed about their conditions, and those who are suffering from a range of chronic conditions have placed extensive demands on the field as they expect higher levels of treatment and better outcomes. 8 The population is aging and this is contributing to the nature and scope of treatment and presented ailments. 8 Correspondingly, there is also a great amount of pressure facing the health care industry to streamline its finances while maintaining the same level of care or even improving the level of service to patients. 8 This combination of factors is placing a great deal of stress upon the system and challenging its ability to maintain its viability and success going into the future. 8
In order to prevent a collapse of the system, it must transition from the current model and adopt changes that will allow it to meet the transitioning needs of the population and marketplace. 8 There is a significant focus on providing the highest possible levels of performance related to quality, efficiency, and equity and these demands are presenting a huge challenge to the health care field. 8 Health care organizations such as hospitals have been tasked with creatively finding ways to redesign their systems and engage their staff members in the pursuit of a new model that can sustain the new operational standards. 8 Given that there is an innumerable amount of organizations that are facing similar challenges in the health care field, it is beneficial to evaluate the best practices in terms of which theories, models and features are assisting organizations in achieving widespread change. 8 The duality of how organizations are changing and which tools they are using to facilitate these changes represents an especially important area of research, and the findings from an evaluation of hospitals revealed the important approaches and models that are being employed. 8
Change is being achieved by hospitals through the use of the progressive patient care model, the patient-centered approach and the lean approach.8 The progressive patient care model seeks to circumvent organizational structures that are more traditional and instead utilize models that are transversal and horizontal. 8 This seeks to organize the flow of patients around the severity of their condition and not the specialty with which they are concerned.8 Older models were rife with delays, cancellations, inefficiencies, and waste, so the new perspective seeks to merge units and share resources across specialties. 8 The patient-centered approach focuses on enforcing the progressive patient care model and incorporating it into a philosophy that shapes all decisions and drives the organization to make changes so the new model works. 8
This focus builds upon the progressive patient care model and fleshes out the organizational approaches so that all support initiatives also fulfill the new clinical processes. 8 The lean approach is also connected to the other models, and it serves to prove the methods and tools necessary to affect the transition to a patient-centered approach that enables the progressive patient care model. 8 It is important for the future of the industry to identify the effects of implementing new models and adapting best practices so that these findings can be utilized by other organizations and policymakers in the field as they seek to facilitate smooth, effective transitions in health care organizations. 8
Extensive reviews of management and health literature can provide valuable insights into how change in healthcare can be implemented through evidence-based approaches.9 There is a wide body of principles related to change that are based upon evidence that fail to provide benefits for organizational practices and policies and investigating this limitation can offer helpful perspectives.9 Organizational factors based upon change were considered in how they could be utilized to offer knowledge that would assist an organization in the health care field. 9
Within this evaluation of factors that were examined, a number of categories were developed to organize the findings.9 It was found that networks that span individual and institutional levels can play a critical role in facilitating change in health care organizations.9
Additionally, the relationships between people in terms of power dynamics, team structures, and social relations can also offer an integral role in affecting change and translating into actual practice.9 There are existing conflicts between the disciplines of management and health sciences, and it is important for the future development and advancement of the health care field that these two disciplines work together to synthesize research.9 By uniting the research and efforts of these two disciplines which approach the same situation from different perspectives, deep insights can be gleaned and this evidence can provide the groundwork for immense transformation in the field of health care.9
Considering a timely example of these core principles in practice will offer a situation that demonstrates a real-world implementation of change in a health care organization. The decision to integrate various oncological service providers in Québec and implement a cohesive service network provides a case study that can be analyzed extensively.10 To better understand the application of change to the structure of organizations in the health care industry, the occurrences throughout the process in Québec will be examined. 10 A focus on determining how much of an impact the strong clinical relationship has on the positive transformation of a health care system will serve as the primary intention for this undertaking. 10 Additionally, the role of the leadership will be analyzed especially given that the change leads to significant changes in the relations between professionals and organizations.10
The use of clinical leadership was analyzed in the circumstances of this particular situation.10 The manner in which the leadership was enacted, the tactics that were utilized, the specific initiatives that were selected, and the associated consequences of these actions were all considered. 10 The final perspective demonstrated that clinical leadership is effective but occupies a limited role in shaping the successful implementation of change in a health care organization. 10 Instead, the combination of leaders that arose from different levels and backgrounds provided to have much more of a positive impact on the realization of beneficial change in a health care organization. 10
The rapid alterations to the field of health care and the forces shaping such trends are greatly impacting the industry, and they offer a unique opportunity for enhancements to organizational outcomes and performance.11 If an organization is able to recognize the forces causing the change and harness these trends to their advantage as they implement organizational transformational, the major alternations occurring in the field can be a positive development. 11 A review of attempted initiatives and major transitions in health care organizations demonstrate that they often fail, even if they have the support of the organization’s executives. 11 Managers are the drivers of resistance in many cases because change threatens their attempts to exert control within the organizational environment, and they are often averse to accepting any sort of risk or significant change.11
Recognizing these dynamics related to change in an organization is a critical first step if transformation and reinvention are to successfully occur in the health care field. 11 Accepting the inherent risks and challenges associated with change will allow for the utilization of strategies that can reduce the chance of failure and encourage the effective management of and participation in the project by individuals at all levels of the organization. 11 Developing a comprehensive appreciation for the various change strategies, their associated challenges and success, the ability to overcome barriers, and the role of the leader in the process will provide valuable tactics for organizations that are considering the implementation of a major change. 11 Organizations will gain insights that will enable them to craft an approach with steps to support success in change efforts and provide alternative strategies to manage all potential variables. 11
There is an increased sense of competition in the health care organization as customers are more value-conscious and apply this principle to purchasing decisions related to their health care options.12 Organizations in this field are faced with the challenge of distinguishing themselves by highlighting the quality of their service, and this requires a number of tactics to be utilized in the pursuit of this goal. 12 Clinical teams utilizing approaches such as the microsystems framework to obtain this distinction have not been fully assessed to determine the effectiveness of this particular method. 12 By evaluating the microsystems approach across a large health care system in the United States, the implementation, results, and lessons learned from the use of this tactic over a period of time could be identified. 12
This specific approach was found to improve cohesion, team effectiveness, and organizational support but the findings also demonstrated that there are challenges to the utilization of a microsystems approach. 12 A lack of resources such as technical support and free time to participate in the implementation was one identified challenge, and tensions due to makeup of the workforce and conflicting perspectives from different levels can also make it difficult to successfully adopt an improvement approach that is driven by data. 12 A microsystems approach can assist organizations in building teams and enhancing quality improvement skills but the attempt to achieve purposeful changes across the entire organization at a macro level and micro level must go beyond reliance on one particular approach. 12 This tactic is helpful but it should be combined into a large effort at improving patient care and outcomes that also utilizes other approaches.12
As this process has demonstrated, change is an inevitable component of operating in the field of health care. The robust body of research and literature that currently exists and is regularly updated provides a valuable compass. Through an evaluation and synthesis of these resources, the theories, empirical findings, and methodologies can be applied to generate a deep understanding of the role and impact of change in the health care industry. At both the macro-level and micro-level, organizations within this field will encounter change and must decide how to handle it. Given the wide array of findings that have been uncovered and utilized to develop additional, novel insights into this topic, there are concrete conclusions that can be generated.
Change will have significant practice and policy implications for any organization, and health care organizations are facing particularly significant trends in their field. With the rate of change swiftly increasing for the industry and its organizations, it is imperative that they acknowledge the necessity of understanding change and responding effectively. Each organization is distinct and faces challenges that it will not share with other organizations as it responds to demands by its patient population and manages internal and external organizational characteristics. This reality allows for the response to change to be unique within certain parameters. There is no one solution that will meet the needs of every organization in the healthcare field as they seek to effectively navigate the forces of change. However, the principles and tools which have been highlighted through this process do offer valuable insights and resources for all organizations. The manner of implementation can vary but there will be commonalities that organizations will jointly share as they embark on the journey of addressing change and developing approaches that can be implemented to manage the change.
This diversity in the field of health care also provides grounds for further research opportunities. Since there are so many avenues and specialties that can be considered and explored, there will be no shortage of topics for fruitful, insightful research efforts. From the undertakings that were completed during this process, there were certain areas that were highlighted for a lack of comprehensive knowledge. There were particular areas that had been touched upon in the research that was uncovered during the literature review but were still worthy of further evaluation. Many of the concepts, methods and empirical research had only begun to reach below the surface level. They had exposed very interesting findings and these had encouraged the pursuit of additional efforts that could dig deeper into the possible trends that had been glimpsed. Since the research provided a fleeting view of a trend or development that could have larger implications, it would be beneficial to critically analyze areas of inquiry that were raised and still unanswered by the current body of research. Additional research is needed to gain deeper insights into the longer-term implications of change efforts currently being undertaken in the field. Focusing on a particular approach can offer far-reaching findings that can improve the management of change by organizations on a macro-level and micro-level. Through the use of diverse participant populations, greater findings of the success and effectiveness of particular methods and tactics can offer direction and assistance for the healthcare field as it must manage the inevitable stream on ongoing change.
1. Chreim S, Williams B, Coller KE. Radical change in healthcare organization. Journal of Health Organization and Management. 2012;26(2):215-236. doi:10.1108/14777261211230781.
2. Kyratsis Y, Atun R, Phillips N, Tracey P, George G. Health Systems in Transition: Professional Identity Work in the Context of Shifting Institutional Logics. Academy of Management Journal. 2017;60(2):610-641. doi:10.5465/amj.2013.0684.
3. Greenwood R, Hinings CR. Understanding Radical Organizational Change: Bringing together the Old and the New Institutionalism. The Academy of Management Review. 1996;21(4):1022. doi:10.2307/259163.
4. Holt DT, Helfrich CD, Hall CG, Weiner BJ. Are You Ready? How Health Professionals Can Comprehensively Conceptualize Readiness for Change. Journal of General Internal Medicine. 2010;25(S1):50-55. doi:10.1007/s11606-009-1112-8.
5. Lawrence TB. High-Stakes Institutional Translation: Establishing North America’s First Government-sanctioned Supervised Injection Site. Academy of Management Journal. 2017;60(5):1771-1800. doi:10.5465/amj.2015.0714.
6. Kellogg KC. Operating Room: Relational Spaces and Microinstitutional Change in Surgery. American Journal of Sociology. 2009;115(3):657-711. doi:10.1086/603535.
7. Martin G, Arora S, Shah N, King D, Darzi A. A regulatory perspective on the influence of health information technology on organisational quality and safety in England. Health Informatics Journal. 2019:146045821985460. doi:10.1177/1460458219854602.
8. Gabutti I, Mascia D, Cicchetti A. Exploring “patient-centered” hospitals: a systematic review to understand change. BMC Health Services Research. 2017;17(1). doi:10.1186/s12913-0172306-0.
9. Harlos K, Tetroe J, Graham I, Bird M, Robinson N. Mining the Management Literature for Insights into Implementing Evidence-Based Change in Healthcare. Healthcare Policy/Politiques de Santé. 2012;8(1):33-48. doi:10.12927/hcpol.2012.23016.
10. Touati N, Roberge D, Denis J-L, Cazale L, Pineault R, Tremblay D. Clinical leaders at the forefront of change in health-care systems: advantages and issues. Lessons learned from the evaluation of the implementation of an integrated oncological services network. Health Services Management Research. 2006;19(2):105-122. doi:10.1258/095148406776829068.
11. Appelbaum SH, Wohl L. Transformation or change: some prescriptions for health care organizations. Managing Service Quality: An International Journal. 2000;10(5):279-298. doi:10.1108/09604520010345768.
12. Pandhi N, Kraft S, Berkson S, et al. Developing primary care teams prepared to improve quality: a mixed-methods evaluation and lessons learned from implementing a microsystems approach. BMC Health Services Research. 2018;18(1). doi:10.1186/s12913-018-3650-4.