All authors are investigators on the evaluation of the Global Digital Exemplars Programme (
The Global Digital Exemplar (GDE) Programme was designed to promote the digitisation of hospital services in England. Selected provider organisations that were reasonably digitally-mature were funded with the expectation that they would achieve internationally recognised levels of excellence and act as exemplars (‘GDE sites’) and share their learning with somewhat less digitally-mature Fast Follower (FF) sites.
This paper explores how partnerships between GDE and FF sites have promoted knowledge sharing and learning between organisations.
We conducted an independent qualitative longitudinal evaluation of the GDE Programme, collecting data across 36 provider organisations (including acute, mental health and speciality), 12 of which we studied as in-depth ethnographic case studies. We used a combination of semi-structured interviews with programme leads, vendors and national policy leads, non-participant observations of meetings and workshops, and analysed national and local documents. This allowed us to explore both how inter-organisational learning and knowledge sharing was planned, and how it played out in practice. Thematic qualitative analysis, combining findings from diverse data sources, was facilitated by NVivo 11 and drew on sociotechnical systems theory.
Formally established GDE and FF partnerships were perceived to enhance learning and accelerate adoption of technologies in most pairings. They were seen to be most successful where they had encouraged, and were supported by, informal knowledge networking, driven by the mutual benefits of information sharing. Informal networking was enhanced where the benefits were maximised (for example where paired sites had implemented the same technological system) and networking costs minimised (for example by geographical proximity, prior links and institutional alignment). Although the intervention anticipated uni-directional learning between exemplar sites and ‘followers’, in most cases we observed a two-way flow of information, with GDEs also learning from FFs, through informal networking which also extended to other health service providers outside the Programme. The efforts of the GDE Programme to establish a learning ecosystem has enhanced the profile of shared learning within the NHS.
Inter-organisational partnerships have produced significant gains for both follower (FF) and exemplar (GDE) sites. Formal linkages were most effective where they had facilitated, and were supported by, informal networking. Informal networking was driven by the mutual benefits of information sharing and was optimised where sites were well aligned in terms of technology, geography and culture. Misalignments that created barriers to networking between organisations in a few cases were attributed to inappropriate choice of partners. Policy makers seeking to promote learning through centrally directed mechanisms need to create a framework that enables networking and informal knowledge transfer, allowing local organisations to develop bottom-up collaboration and exchanges, where they are productive, in an organic manner.
Digitisation of healthcare systems is now central to many national policies to address the challenges associated with ageing populations, rising demands and the pressure to deliver high quality care in tightening economic climates [
Given the limited national budget and uneven digital maturity of provider organisations, the GDE strategy involved supporting relatively digitally-mature acute, mental health and ambulance provider organisations (hereafter GDEs) to achieve internationally recognised levels of digital excellence and thereby serve as exemplars for the wider NHS. GDEs were paired with somewhat less digitally-mature Fast Follower sites (hereafter FFs) to promote knowledge transfer [
There is currently a limited literature around inter-organisational knowledge transfer, particularly within health systems [
This paper examines how the formal pairing of organisations, establishing partnerships between exemplar (GDE) and follower (FF) sites, has promoted knowledge transfer and supported digital transformation between paired organisations within the national GDE Programme. In doing so, we build on related work in progress that examines the role of other formal and informal inter-organisational knowledge sharing established as part of the GDE Programme [
The study reported here is part of an independent longitudinal formative evaluation of the GDE Programme [
This work was classified as a service evaluation and the study therefore did not require NHS Research Ethics Committee approval. Following standard practice for studies that fall outside of the remit of NHS National Research Ethics Service, we obtained ethical approval from The University of Edinburgh’s School of Social and Political Science Research Ethics Committee (27.11.2017). Participants gave written informed consent.
We conducted a combination of interviews, observations and documentary analyses in 12 in-depth case study sites, 8 GDEs (6 acute and 2 mental health providers) and 4 FFs (3 acute and 1 mental health provider) and collected further data in 24 additional case study sites (15 GDEs, 9 FFs). Twelve FFs in the GDE Programme were not included in the study, comprising nine sites that joined the programme later and three that merged with their GDE in the course of the Programme. All GDEs participating in the Programme had relatively high levels of digital maturity, and in most cases embarked on major upgrades in core information infrastructures such as Electronic Health Record (EHR) implementation as part of the Programme.
Researchers purposefully sampled members of local GDE management teams who had knowledge and insights into the digital strategy and digital systems used at that site, and who represented various different professions and backgrounds, including Chief Information Officers (CIOs), Chief Clinical Information Officers (CCIOs), Programme Managers, and Project Leads. Our initial point of contact was the local GDE Programme Manager. In the in-depth case studies we also used snowball sampling to increase the size and diversity of our sample of respondents by requesting interviewees to recommend further participants, asking explicitly for those with differing involvements and varied viewpoints on the GDE Programme.
The research team comprised five researchers with backgrounds in science, technology and innovation studies and policy research, and four researchers with operational experience from NHS consultancy.
Data collection consisted of semi-structured interviews (see
• Background and role of interviewee(s) |
• Implementation strategy and benefits realisation strategy |
• New digital functions being introduced as part of GDE programme and other current/recent changes |
• Overall thoughts on GDE Programme |
vBenefits realisation and reporting |
• Blueprints |
• Relationship with vendors |
• Knowledge management, networking and learning (formal and informal) |
• What do you think was most important factor that contributed towards learning and knowledge exchange to help achieve Global Digital Exemplar (GDE) programme aims? |
• Relationship between the Fast Follower (FF) and GDE site? |
• Other relationships/sources of information, e.g. international partners; other sites. Can you describe any collaboration and work that you are doing with other GDE or fast follower sites? |
• What can be done on a national level to promote the most effective networks? |
• How can central expertise support digitisation beyond GDE? |
• Lessons learnt and way forward |
Interviews were digitally recorded and transcribed verbatim by a professional transcribing service.
We uploaded transcripts, documents and observation notes into qualitative analysis software NVivo 11 and thematically analysed them, applying both deductive and inductive methods. Four researchers formulated a coding framework based on the existing literature, the questions asked in the interview topic guide and their knowledge of the GDE Programme. The coding framework evolved in line with emerging findings. Data were initially analysed
Our data consisted of 508 interviews, 163 observations, and analysis of 325 documents in 36 provider organisations. A detailed breakdown of these sources has been published in a previous paper [
Table 2 in
We found that most interviewees believed the formally established GDE/FF relationship had enhanced knowledge exchange and accelerated adoption of technologies. Participants stated that this knowledge transfer was not just about technical matters–it included, for example information governance, training, change strategies, care pathways and advice on clinical engagement.
Respondents highlighted the time and cost saving resulting from the GDE/FF relationship. Rather than starting from scratch, sites felt able to take on board solutions developed by their partners in the knowledge that these solutions had proved safe and effective in similar organisation.
Though the GDE Programme’s terminology suggests a one-way flow of information from exemplar (GDE) to follower (FF), most respondents pointed to two-way knowledge transfer, with GDEs also learning from their FFs.
Some FFs were not happy with the label Fast Follower where they did not see themselves as lagging behind in competence and capability and it therefore did not reflect the actual relationship. One FF noted that they were ahead of their GDE in implementing the same EPR system.
In another case, participants stated that knowledge was not effectively shared between a GDE and FF adopting the same system as the FF was implementing a newer version of the package and did not feel they had much to learn from their GDE.
It was also highlighted that in some cases, the GDE/FF relationship resulted in cycles of improvement where FFs tested a newer version of the system and this in turn had the potential for GDEs to save valuable time when implementing the same upgrade.
However, we also observed a few sites where the formal programme pairing arrangements were perceived as less effective. These sites expressed concern about how their GDE/FF combinations had been chosen. These pairings had been set up under time pressures resulting from the short timeframes in which the GDE Programme had been developed and launched. Participants reported that sites generally sought to establish partnerships with organisations they were already collaborating with. However, this was sometimes perceived to conflict with the programme strategy, which, for example, encouraged partnerships between sites using the same core platform. In addition, acute hospital providers were only allowed to pair with other acute hospitals, and mental health services with other mental health services. Thus, the CIO of an acute GDE, partnered with an FF using the same platform but two hours’ drive away, would have preferred to have a local mental health provider, which they later merged with, as their FF.
Where the GDE/FF pairing did not emerge from existing links, interviewees highlighted that there was a need to build relationships with consequent greater uncertainty about outcomes.
Although the design of the GDE Programme conceived the GDE/FF relationship as revolving around the production of and adoption of Blueprints, there was little evidence in participants’ accounts that these were a significant channel for knowledge transfer between the GDE and FF. One reason highlighted was that GDEs were so busy implementing new systems they did not initially have time to write Blueprints, which were produced at a later stage. Knowledge was instead transferred between the GDE and FF through direct contacts: site visits, phone calls and videoconferences and other electronic exchanges, and/or attending each other’s committees. Participants perceived these to be a more effective vehicle for sharing and support than a formal Blueprint document [
Knowledge transfer, and in particular the explosion of informal networking, was according to participants driven most immediately by the benefits participants derived from exchanging knowledge and experience with their peers. By examining perceived variation in the experience and effectiveness of knowledge exchange between sites, we can identify various enabling and inhibiting factors at play. The uneven contours of informal networking described by interviewees reveal the factors that enhanced the benefits and reduced the learning and coordination costs of knowledge sharing.
Where an FF had the same core technology platform as its GDE (e.g. EHRs and Hospital Electronic Prescribing and Medicines Administration [HEPMA] Systems), learning was viewed to be more readily applied and offer greater benefits as sites could readily adopt elements of their solutions (including system configurations and workflows which had often been arduous to produce) without much need to amend them.
According to participants, many of the GDEs had selected FFs that were in close proximity. This was stated to be useful in terms of reducing the time and money costs of travel. It thus also facilitated more intense forms of collaboration according to participants. They reported that one GDE/FF partnership decided to create a joint procurement team as a result of their successful collaboration. In another provider organisation, an interviewee reported that the proximity of the GDE site meant a clinician could come over and test their system.
Participants highlighted that proximity was also associated with other enabling factors related to knowledge transfer, including inter-personal (see below) and institutional linkages. They reported that nearby sites were often within the same STP/ICS–the emerging regional coordination structures, which have become increasingly salient in the course of the GDE Programme. These institutional linkages were seen to help in developing a common digital strategy and broader outlook.
That said, we also found evidence of successful GDE/FF partnerships at greater distance. Geography was not seen as a barrier when the benefits of learning and sharing were perceived to be substantial, with networking often facilitated by other enablers such as prior collaborations, interpersonal relationships, similarity of platform and a shared philosophy of sharing for the benefit of the NHS.
Non- clinical digital leader:
Senior manager:
Proximity was also perceived to be related to the greater likelihood of prior linkages between the individuals and groups in the organisations involved. Participants reported that some interpersonal relationships of key staff resulted from previous experience of working together or from staff movements between sites. In the case of Site M, the project manager for implementation of the Clinical Data Repository (CDR) had previously worked on the same project for the GDE. At Site F, the CIO already knew staff at the FF site some distance away. Some relationships were reported to be based on pre-GDE collaborations. One respondent observed that these kinds of links could encourage greater openness to external ideas.
Participants reported that most GDE/FF pairings resulted in enhanced inter-organisational knowledge transfer and accelerated technology adoption in participating organisations. They were seen to be most effective where they were buttressed by a growth in informal networking that was driven by the mutual benefits of knowledge sharing. Perceived variations between sites in the intensity of informal networking highlighted incentives and barriers at play. Thus, participants reported that the benefits of knowledge sharing were enhanced where there were common technological platforms and comparable context. Physical proximity and prior linkages were stated to reduce, respectively, the travel and coordination costs of networking. In contrast to the Programme’s terminology that projected a one-way flow of knowledge from Exemplar to Fast Follower, knowledge transfer was seen to be bi-directional, characterised by reciprocal and ongoing exchanges. Sites felt a partnership model would have been more effective.
We have collected a wealth of qualitative data from different sources over an extended timeframe to get contemporary insights into the formal knowledge sharing processes put in place nationally in the English National Health Service by pairing organisations to share digital transformation knowledge. Although the longitudinal qualitative nature of data collection has allowed us to gain insights into unfolding relationships over time, it has not been sufficient to allow us to link identified processes to implementation outcomes. This shortcoming reflects a general issue with complex transformational programmes, where outcomes emerge gradually and are often difficult to attribute [
This work contributes to the currently sparse literature around inter-organisational knowledge sharing in digital transformation in healthcare settings [
Inter-organisational knowledge sharing is characterised by a variety of informal as well as formal networks that change over time [
Our work shows that formal inter-organisational partnerships can provide an effective mechanism for knowledge sharing and collaboration, particularly where buttressed by informal knowledge networking. This is further reinforced by the overall success of the Programme in stimulating digitally enabled transformation and the sharing of knowledge between participating provider organisations. GDE/FF partnerships were one knowledge sharing mechanism that helped, together with others e.g. Blueprinting and Learning Networks, to promote an ethos of shared learning to promote Programme aims and learning in the wider NHS.
Where networking allowed lessons and solutions from other sites to be reliably re-used, the saving in time and effort could reduce the costs and increase the speed of change. Informal knowledge networking, driven primarily by the mutual benefits of knowledge sharing, was encouraged by common technological systems (offering more immediate applicability of knowledge, experience and solutions), by geographical proximity (though effective knowledge transfer also arose in some circumstances between geographically dispersed organizations [
The strategic partnerships observed in our work were formed through various mechanisms and channels of communication, both formal and informal. Knowledge sharing is therefore difficult to plan and may have many unanticipated benefits and/or difficulties. We found that, while flows of knowledge can be promoted and channelled to some degree through formal means, strategic decision makers need to be mindful of the importance of bottom-up knowledge exchange, driven by the benefits of sharing, which often follows different paths than planned knowledge transfer. Support should seek to align formal support with organic, bottom-up networking to achieve the mutual strengthening of both. This may for example be achieved through giving sites a degree of choice of partners they consider appropriate to their current organisational strategies at any point in time.
The partnerships established under the GDE/FF programme helped to promote collaboration and knowledge transfer between participating sites to achieve the shared goal of improved patient care and improved clinician experience and contributed to the overall success of the Programme. This study has also illustrated the unpredictability of knowledge flows and highlighted the importance of informal knowledge exchanges driven by the mutual benefits of knowledge sharing. There are important lessons for healthcare digitisation programmes seeking to promote knowledge sharing to accelerate technology implementation. Sharing core architectures and geographical proximity may facilitate informal networking that synergises with formal mechanisms and encourages the establishment of a broader inter-organisational digital health learning ecosystem.
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PONE-D-20-35004
Promoting inter-organisational knowledge sharing: a qualitative evaluation of England’s Global Digital Exemplar and Fast Follower Programme
PLOS ONE
Dear Dr. Hinder,
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AS was a member of the Working Group that produced " Making IT Work" and was an assessor in selecting GDE sites. BDF supervises a PhD partly funded by Cerner, unrelated to this paper"
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Reviewer #1: This is a well crafted and well written paper assessing lessons to be drawn from efforts to promote the digitalisation of hospital services in England. The methodology is clear. The analysis has a good structure and makes excellent use of quotations. Based on multiple interviews and observations, the case for paying heed to informal knowledge networking and the potential benefits of two-way flows of information is well made and based on an interesting exposition of the evidence.
A few minor revisions might be helpful.
1. The abstract indicates that the research draws on socio-technical systems theory. The introduction might explain what this is and how it orients the research in a particular way.
2. Figure 1 comes at the end of the discussion. Something should be said about the figure in the text, i.e. it is a summary ….
3. Line 360 where references are made to the literature – should the text read something like ‘networking, consistent with findings in other contexts’ since the literature is not specifically about health systems. The subtitle indicates it is a discussion of the wider literature but it would help to clarify here.
4. Line 372 should the sentence starting ‘This is illustrated …’ read something like. These findings from studies in the socio-technical systems tradition are illustrated by GDEs and FFS in our sample that were sharing knowledge …
5. Line 385 ‘These strategies partnerships …’ Here is this in reference to your empirical study partnerships or is this statement made in relation to similar partnerships. Unclear whether the discussion in this section is meant to refer to this study primarily or to generalisations from it to similar situations.
Small corrections
Line 279. Should it read ‘the GDE site meant a clinician [came or could come] over and could test their system’
Line 308 greater likelihood [of] priori linkages
Reference 29. Citation seems incomplete.
Reviewer #2: Thank you for this interesting paper.
It is interesting to have some insights into the GDE program.
The study is well -executed.
I am interested in several points:
1.What is the digital maturity of the participants? The complexity and sophistication of the knowledge transfer regarding implementing an EMR is quite different to sharing knowledge for implementing a basic LIS.
It was difficult to truly understand the program from the text. Would it be possible to represent the program diagrammatically? Map out the realtionships of the GDEs and FFSs and perhaps indicate the size and digital maturity of each facility in the diagram and the nature of the relationships. How many were positive, negative, neutral? Which ones had unidrectional or bidirectional information flows? This would allow a more detailed and granular understanding of the program, particularly for international readers.
2.Did digital maturity across the NHS as a whole increase during the GDE program? I take the author's point that it is impossible to attribute any granular outcomes to the program, however I think it is important to understand did the NHS as a whole complex adaptive system, continue to undertake digital transformation ? How many EMRs were implemented during the GDE program? How many other applications were implemented? It would be critical to know, for example , if the number of EMRS deployed actually decreased or stalled during the program. Conversely, it would strengthen the conclusion and discussion of the paper to know how many systems were implemented in the FFS during the program. There is no data to suggest how many applications were actually adopted by the FFs during the program, which as I understand it, was the primary intent of the program. IF interorganisational knowledge transfer was effective, we would at least expect ongoing implementation of new systems in the FFs. and this should be reported.
Minor point: be consistent on the venison of NVivo used, it changes throughout text
Reviewer #3: Thank you for the opportunity to review this qualitative evaluation of the Global Exemplar and Fast Follower Programme in England. This programme is of interest to many jurisdictions across the world.
My main comments relate to some of the overly quantitative language used to present qualitative findings and the methods utilised for sample selection. Some clarification/revision here may help acceptance and translation of this work.
Specifically:
Abstract
-The results state that partnerships enhanced learning and accelerated adoption. However the study does not attempt to answer this question. It assesses users' opinions of the pairings, and there is no comparison to non-paired arrangements. The conclusions and language in the actual paper is more moderate and I think the abstract should reflect this.
Methods
The study deliberately sampled members of local GDE teams via the GDE program manager. Presumably many (if not most) of these individuals' jobs are funded by- and dependent on the success of this program. How was this potential conflict of interest and bias in sampling managed?
Data collection(Table 2). The table outlines the type of data collection methods. However we are not shown the proportion of data collected (interviews, meetings, etc)from GDE v FF. Given that there were twice as many in depth case study sites that were GDEs(p5 Line 96), is this sample disproportionately from a GDE perspective? Again a perspective that might be more likely to be positive.
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PONE-D-20-35004R1
Promoting inter-organisational knowledge sharing: a qualitative evaluation of England’s Global Digital Exemplar and Fast Follower Programme
PLOS ONE
Dear Dr. Hinder,
Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.
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While one of the reviewers is happy with the revision, the second reviewer still some issues.
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Reviewer #3: Partly
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The
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Reviewer #3: No
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Reviewer #3: Thank you for the opportunity to review this revised manuscript and the associated response to reviewer comments document.
Although you have attempted to address most of the comments, I feel these revisions neds to go further to adequately address the comments.
With respect to the comment about presenting qualitative findings as quantitative conclusions(especially in the abstract), this has been addressed in the results summary in the abstract but the conclusion. This type of language still exists throughout the main manuscript, even though the limitations section has been expanded.
With respect to the snowballing and targeting negative perceptions in the methods, how was this done? How would a researcher at another centre reproduce the method to gain comparable results?
Figure 1 is a simplified schematic that in my opinion doesn't address the suggestion from reviewer 2 which I think would add a great deal to the paper. This aligns with reviewer 3 comment 3. It doesn't have to be a detailed analysis of the influence of size and maturity on the results, just a representation of these aspects and relationships of the study participants to better contextualise the findings.
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Response to Reviewers
Reviewer 3
Point 1: With respect to the comment about presenting qualitative findings as quantitative conclusions (especially in the abstract), this has been addressed in the results summary in the abstract but the conclusion. This type of language still exists throughout the main manuscript, even though the limitations section has been expanded.
Response: We have made clear in the Results and Discussion sections that the findings were based on user perceptions and not on quantitative measures of learning and adoption.
Point 2: With respect to the snowballing and targeting negative perceptions in the methods, how was this done? How would a researcher at another centre reproduce the method to gain comparable results?
Response: We asked interviewees for recommendations of further participants to interview, asking explicitly for those with differing involvements and varied viewpoints on the GDE Programme. We have now made this clearer in the Methods section.
Point 3: Figure 1 is a simplified schematic that in my opinion doesn't address the suggestion from reviewer 2 which I think would add a great deal to the paper. This aligns with reviewer 3 comment 3. It doesn't have to be a detailed analysis of the influence of size and maturity on the results, just a representation of these aspects and relationships of the study participants to better contextualise the findings.
Response: We have amended Figure 1 to represent the flow of knowledge from GDEs to FFs as intended in the GDE Programme and we now describe in more detail in the text how practice varied from this plan. We have, in addition, substantially reworked the detailed breakdown of GDE/FF pairings in Table 2 (Appendix). We have added a column noting any prior relationships between GDE and FF and indicate the size of the hospitals by including numbers of beds (where available). We have replaced specific details of local regional groupings with a Yes/No column on whether GDE and FF are in the same regional group.
In almost all of the GDE and FF pairings the knowledge transfer was bi-directional. We cannot add this information relating to specific providers as this would compromise the agreed terms of access for the evaluation which included a firm commitment not to identify specific provider organisations or individuals.
Finally, assessments of the digital maturity of providers across the NHS (based on self-assessments) are held centrally within the NHS and not publicly available. We did not collect data on the number of electronic health records and other digital systems implemented in the rest of the NHS during the time period of the GDE Programme. We are therefore unable to add this context to the paper and have noted this in the Discussion section as a limitation.
We trust that these revisions are to your satisfaction and that we are now in a position to proceed with publication. Please do not however hesitate to contact me if you require any further details.
With kind regards,
Susan Hinder (on behalf of the co-authors)
Submitted filename:
Promoting inter-organisational knowledge sharing: a qualitative evaluation of England’s Global Digital Exemplar and Fast Follower Programme
PONE-D-20-35004R2
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PONE-D-20-35004R2
Promoting inter-organisational knowledge sharing: A qualitative evaluation of England’s Global Digital Exemplar and Fast Follower Programme
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