Innovation potential
The discussion underlying this exchange about a restaurant chain as model for optimizing hospital service revolves around the question of quality assurance in healthcare and how to improve it. Berwick [
27] summarizes the two traditional approaches as “the era of professional dominance”, where the individual professional is responsible for the quality of his/her own performance, based on respect for his/her unique expertise, and “the era of accountability”, where quality control is guaranteed by formalization: process design, measurement and material incentives. However, as research has shown, neither the formal properties of an organization nor the characteristics of individual professionals suffice as predictor for the lasting impact of quality improvement initiatives [
20].
Rogers, in the most influential theory of innovation in the public sector [
28], even draws the conclusion that “formalization (defined as the degree to which an organization emphasizes following rules and procedures in the role performance of its members) was found to be related negatively to organizational innovativeness” [
29]. As to the influence of characteristics of individual professionals on the innovation potential of an organization, there is a wide variety of research denying any significant connection between a person’s age, education, experience or gender and the ability to adopt change. For more on this topic, see for instance Cummings and Worley [
30] and Bakken et al. [
31] who explore questions like “Why is change so difficult even when everyone and everything is aligned around the goal” and “Why is the gap so great between our intentions, even our decisions - and what we are actually able to bring about” [
32].
One of the conclusions of the systematic review by Greenhalgh et al. [
20] into the conditions for diffusion of innovation in health organizations is that the ability of an organization to realize change and its capacity for innovation cannot be derived from its formal properties (as “rational productive systems”) nor be reduced to the characteristics of individuals being part of that organization (as “adaptive social system”). Key factor in determining an organization’s potential for change according to Greenhalgh et al. is the set of values which constitute the corporate culture [
20]. It is this aspect of culture as a set of values where Berwick [
27] sees the domain of a third era of quality assurance and improvement in healthcare. He calls it the “moral era” where the community of (medical) professionals adheres to a set of values which convene on aspects of professional decency and shared responsibility.
Compound character of health delivery organizations
Rogers’ standard handbook does not address the problem of the compound nature of organizations in the health care sector as an impeding factor in the adoption of innovation aimed at quality improvement. A number of studies have pointed to the challenges posed by institutional complexity where multiple institutional logics and competing interests interact and collide.
Reay and Hinings [
33] describe the tension between “the logics of medical professionalism and business-like health care” each with “their own organizing principles and different set of behaviors”. Provan and Kenis [
34] refer to the “struggle for legitimacy among participants in different internal networks” leading to tensions and instability in the organization. Kirkpatrick et al. [
35] argue that calling medical professionals to management roles and thereby “turning poachers into gamekeepers” have had a positive effect on “quality improvement and innovation design with positive consequences for patient safety and satisfaction”. Degeling et al. [
36] plead for a strengthening of clinical governance by combining the interests of “both clinical practice and organizational structure”, thereby “integrating financial control, service performance and clinical quality”. Greenwood et al. [
37] explore “the repertoire of strategies and structures that organizations deploy to cope with multiple, competing demands” from “plural institutional logics”, and Glouberman and Mintzberg [
38] as early as 2001 posed the question why “overall social control of the systems of healthcare is so enormously different to effect”—describing the sector as being “differentiated into four different worlds – four sets of activities, four ways of organizing, four unreconciled mindsets – care, cure, control, community”. The way in which competing systems of situational logic hampered the implementation of an evidence-based technological improvement in patient care is studied in detail by Greenhalgh et al. who conclude that “the GPs or administrators refused fully to comply (with the implementation of the new technology) because they believed that the innovation threatened to subvert a dimension of valued professional commitments” [
39]. Lee [
17] and Lee and Kim [
18] point to the “variety of stakeholders including patients, physicians, nurses and others” who are needed to “create a more comprehensive view of health service quality”. Kabat [
40] in
Getting risk right sums up “different groups – scientists, regulators, health officials, lay advocates, journalists, business men, lawyers – are shaped by different backgrounds and motivated by different beliefs and agendas. Depending on the issue at hand, the interests of these parties may conflict or may align and reinforce one another”.
The organization as a social system
In his theory of innovation in the public sector, Rogers [
29] lists four aspects relevant to the implementation and adoption of innovation: the character of the innovation, dynamics of the communication channels, the time dimension and the nature of the social system involved. Key element is the organization as a social system which Rogers describes as “a set of interrelated units that are engaged in joint problem solving to accomplish a common goal” [
29]. For its continuity, the system depends on structure: “We define structure as the patterned arrangements of the units in a system” [
29]. In addition to the formal structure, Rogers defines informal structures as the “interpersonal networks linking a system’s members, tracing who interacts with whom and under what circumstances” [
29]. These networks form “patterns of communication” which “predict, in part, the behavior of individual members of the social system, including when they adopt an innovation” [
29]. In that way, the formal and informal structure of a social system “can facilitate or impede the diffusion of innovations” [
29]. However, in describing a social system as a set of relationships, Rogers’ model does not account for the phenomenon of the development of an organization in reaction to a changing environment or to internal dynamics.
In order to include the aspect of organizational evolution, we refer to the theory of Luhmann. In applying Luhmann’s concepts, we follow the lead of Wolf and Meissner [
41] and Meissner and Sprenger [
23] who have demonstrated the added value of systems theory as a paradigm to address and explain the central issue of corporate culture as key factor in creating and sustaining innovation.
A social system as conceived by Luhmann is more than the formal definition of Σ = (M, ℜ), in which M is a finite number of elements and ℜ is a number of relations R1, R2, R3, …, Rn in M. To this static definition, Luhmann adds the dynamics of “autopoiesis”—the development of identity in self-awareness expressed internally—defining the system’s elements and their possible relationships—and externally in temporal en spatial relationships: to the system’s remembered past and expected future and to the environment it perceives as the other. In this experience of the temporal and spatial other as alter, a system experiences itself simultaneously in its identity as auto.
According to Luhmann [
42], the means by which a system develops and maintains its identity over time is communication. Communication is the
organon of autopoiesis. Communication, be it verbal or non-verbal, direct or transmitted, factional or fictional, is more than just transferring information from an addresser to an addressee. It is the form of social interaction through which “…cultures are transmitted, relationships are sustained, identities are affirmed and social structures of all sorts are reproduced” [
43,
44].
Within this context, Luhmann [
42] identifies the organization as a specific kind of autopoietic social system which reproduces itself by means of a specific kind of communication: through decisions, “…implying the awareness and communication of alternatives and continuous reference to previous decisions” [
45‐
47]. So, whereas a generic social system (or a
function system like the judicial system or the science system) is defined by the phenomenon of communication in action addressing and transmitting values such as right/wrong or true/false, the organization as a system is characterized by its teleology which is expressed in a particular type of communication, the decision, with
success and
failure as (surrogate) end point values.
The organization as a decision-making system operates within an environment characterized by
complexity, which presents itself as a potentially unlimited variety of states of affairs as context for possible decisions and ensuing actions. A system’s operations however can only absorb a limited amount of complexity before being stalled in perpetual potentiality or
stasis. The process of decision-making depends on an organization’s capacity for complexity reduction, dealing with the tension between the secure and the insecure and the remembered and the expected. Control as condition for continuity can only be accomplished on the basis of operational simplification of the perceived reality in its complexity. According to Luhmann [
42], organizations even “…arise primarily as a means to deal with complexity”, thereby acting upon “…a tangled world that entails complexity” in order “to get things done” [
45]. So communication in organizations is based on complexity reduction in order to be able to reach decisions.
But communication is never
a-topic, developing in a social void, but is always situational—happening in time and place—and as such context dependent. Communication as a model shows the process of interaction whereby an addresser transmits signs as bits of information referring to a state of affairs to an addressee through a medium, periodically checking the status of the transfer [
48]. The actual realization of the elements in the model is the outcome of choices, limited by the context in which communication happens.
In communication-in-action, the context determines just who can act as addresser (sender) and addressee (receiver) and whereas the communication model states that communication is about a subject (referent), the context determines which subjects (or states of affairs) are permissible topics in any actual conversation and what might be the value of arguments concerning that topic. The question to be answered here is what determines the value of an argument in a discussion leading to a valid decision? Here, we ask about the sources of impact of an argument as they appear in the rules of discourse (defining a group as a particular social system): what makes one argument more effective than another in reaching a shared decision and what does that tell about the organization where the discussion takes place?