Key elements and contextual factors that influence successful implementation of large-system transformation initiatives in the New Zealand health system: A realist evaluation

Abstract

Abstract Background Despite three decades of policy initiatives to improve integration of health care, delivery of health care in New Zealand remains fragmented, and health inequities persist for Māori and other high priority populations. An evidence base is needed to increase the chances of success with implementation of large-system transformation (LST) initiatives in a complex adaptive system. Methods This research aimed to identify key elements that support implementation of LST initiatives, and to investigate contextual factors that influence these initiatives. The realist logic of enquiry, nested within the macro framing of complex adaptive systems, formed the overall methodology for this research and involved five phases: theory gleaning from a local LST initiative, literature review, interviews, workshop, and online survey. We explained variations in success (outcomes) by identifying mechanisms triggered by various contexts in which LST initiatives are implemented. Results The research found that a set of 10 key elements needs to be present in the New Zealand health system to increase chances of success with implementation of LST initiatives. These are: (i) an alliancing way of working; (ii) a commitment to te Tiriti o Waitangi; (iii) an understanding of equity; (iv) clinical leadership and involvement; (v) involved people, whānau, and community; (vi) intelligent commissioning; (vii) continuous improvement; (viii) integrated health information; (ix) analytic capability; and (x) dedicated resources and time. The research identified five contextual factors that influenced implementation of LST initiatives: a history of working together, distributed leadership from funders, the maturity of Alliances, capacity and capability for improvement, and a continuous improvement culture. Conclusions Use of informal trust-based networks provided a critical platform for successful implementation of LST initiatives in the New Zealand health system. Maturity of these networks depends on the key mechanism of trust, that is built and nurtured over time through sharing of power by senior health leaders by practising distributed leadership. The role of central agencies and government is to provide the policy settings and conditions in which trust-based networks can flourish. The evidence base for successful implementation of LST initiatives produced in this research is transferrable to other regions and countries.