Health Systems Innovation
The sociology of space as a catalyst for innovation in the health sector
A number of studies have been conducted on the conditions required to promote health innovation (Mumford et al., 2007; Akrich et al., 2002; Chidamber and Kon, 1994). For example, Kalua et al. (2009) argue that sustained success in promoting and delivering innovation in health care depends on linkages and net- works running through government institutions, private companies and a wide variety of end-user groupings at national, regional and sectoral levels. Mugabe (2005) asserts that health innovation depends on the policy regime that determines the mutual interactions among various actors. According to Greenhalgh et al. (2008) and Harrison and Mort (1998), health service champions are influential in the success of health innovation. Donaldson et al. (2004) cite the availability of funding as crucial to producing desirable health innovation outcomes. All these studies are conspicuous by their focus on the role of leadership, networking, policy and funding in driving health innovation. However, less attention has been paid to the influence of space in promoting innovation. We address this gap by examining the intricate relationship between space and innovation with reference to health care delivery. In this paper, we draw on the sociology of space to explore the social practices, institutional forces and material complexity of how people and spaces interact for the creation of innovations in healthcare. Previous studies focused on the link between space and organisations, for example Kornberger and Clegg (2004) examined the power implied by spatial organisations, both in negative and positive terms. Taylor and Spicer (2007) applied Henri Lefebvre's theory of spatial production to explore how organisational spaces are practised, planned and imagined, while Peponis et al. (2007) discussed how workplace design and spatial layout support productivity in an organisation. Zhang et al. (2008) explored hyper-organisational spaces and the kinds of resistive and oppositional practices they engender, while Low (2008) € examined the structuration of spaces through the simultaneity of effect and perception. The key findings of these studies are summarised in Table 1.
Kornberger and Clegg (2004) called for studies on the meaning of spaces in various settings, as what is generative in one context may not be in another. This paper particularly addresses space as a catalyst for innovation in a healthcare setting. We focus on the social production of space with particular reference to how it facilitates interaction and mutual learning to- wards creating solutions for social, particularly health, benefit. We review the physical creation of the material setting to advance an understanding of the phenomenological and symbolic experience of space as mediated by social processes. We assess how space can transform people's social experiences into scenes and actions that trigger innovation. Our review uses empirical examples from the Innovation Programme at Groote Schuur Hospital to illustrate how innovation hubs serve as transformative spaces and simultaneously socially produced entities, which provide neutral spaces for inspiring creativity, innovation and collaboration.
2. The social production of space
Space is a product of social translation, transformation and experience in which spatiality is culturally mediated and acts as a material force reflecting social processes (Kellerman, 1989; Soja, 1989). It is an outcome of action, which brings both social production practices and bodily deployment into focus (Low, 2008 € ). Space is conceptualised as containing networks of organisations and individuals (Taylor and Spicer, 2007). This human ecology approach argues that geographical proximity gives rise to strong social networks that determine important outcomes in social life (Johnston and Pattie, 2011). For example, geographic location of a particular space can increase the likelihood of marriage, friendship, or the adoption of innovations (Hagerstrand, 1968 € ). The geographic concentration of people in a given space is attributed to social networks, which promote inter-personal relationships and inter- organisational relations, thus facilitating transmission of knowledge across organisational boundaries (Taylor and Spicer, 2007; Jaffe et al., 1993). Eisenhauer et al. (2000) assert a reciprocal rela- tionship between places in nature and social interactions. Social networks are linked to the space in which they occur. Spaces, by virtue of their particular attributes, enable or constrain a range of experiences that shape social networks. Sack (1997) links nature, culture and social relations in the creation of space, and notes that some places are richer in certain elements than others. Wilson (1995) sums it up by stating that spaces provide fixed positions and permit circulation; they carve out individual segments and establish operational links; they mark places and indicate values.
The social production of space corresponds with its materiality in terms of where people are positioned, where tools or resources are distributed, and how these are used (Taylor and Spicer, 2007; Dale, 2005). Building on the assertion that space is socially produced, Lefebvre (1991) identified a set of three interactive processes that give rise to social space. The first is spatial planning, which refers to the careful application of technocratic knowledge and rationality in the distribution of objects, symbols and people within a space to stimulate certain types of behaviour. The second process is lived space, which emerges through the meaningful and phenomenological aspects of human experiences, embodied in dynamic engagement with a given physical space. The third process is spatial practice, which comprises the acts of movement, inter- action and dwelling within a given space. This makes space a ‘social construct’ (Low, 2006; Lefebvre, 1991 € ) embracing various contexts other than just the notion of place. Space can be thought of socially, in terms of the ways in which people fill it with meanings. Thus, space can be interpreted as a relational arrangement of living beings and social goods, which according to Low (2008) € , underlines the simultaneous practice of placing humans on the one hand, and linking together objects perceived to form spaces on the other hand.
Space is one of the most powerful tools for inducing culture change, speeding up innovation projects and enhancing the learning process (Tom, 1992). The materiality of space has social meanings; for example, the physical attributes of a room may tell nothing about it unless the meanings it contains, represses, opens up, or resonates with become apparent (Kornberger and Clegg, 2004). In this regard, space serves as both the medium and outcome of the actions it recursively organises. It is capable of setting limits and/or opening up possibilities of further social construction within it (Rosen et al., 1990). Space has some positive power implications for its users, thus instead of being merely a passive container for actions, it contributes positively towards human capacities. According to Foucault (1998), space is a construct that creates a specific type of person. It is both a field of action offering its extension to the deployment of projects and practical intentions, and a basis of action where energies derive and whither (Lefebvre, 1991). Low (2008) € similarly argues that space is simultaneously a collection of things and objects and of tools and the use of tools, which make action possible and is itself the field of action. Space influences human interaction in various ways. Bauman (2013) uses the metaphors of cultivation to constitute different spaces in which various social practices could be conceptualised as either blooming or withering. An inviting space generates good ideas, which are rarely created when sitting at one's desk alone, but rather during creative encounters between human beings (Markus and Cameron, 2002). A well-designed space contributes to some- thing of a cultural revolution, triggering openness, creativity and teamwork, leading to productive conversation between people who meet (Murray et al., 2010; Cox, 2005; Kornberger and Clegg, 2004).
Creative interactive encounters and teamwork are influenced by the layout of available space (Markus and Cameron, 2002; Grajewski, 1993), which encourages certain patterns of behaviour and interaction (Taylor and Spicer, 2007; Arge, 2000). For example, creating more flexible spaces using open plan areas, hot-desking and bright and airy design facilitates information sharing and creativity (Meyerson and Ross, 2003). However, what determines the social outcome is the level of spatial integration or segregation of the specific workplace, and not its type as labelled and designed (Markus and Cameron, 2002). Architecturally, space is designed to manipulate the movement of people between different sub-systems and departments on the premise that the traffic pattern in any space has a direct effect on communication (Kornberger and Clegg, 2004). One way to counter undesired physical separation is to create space that is shared by groups whose physical separation might otherwise inhibit communication (Zhang et al., 2008; Markus and Cameron, 2002). The premise is that contact and communication with potential discussion partners is the prime vehicle for transmitting ideas, concepts and other information necessary for ensuring effective work performance (Kornberger and Clegg, 2004).
3. Innovation hubs as spaces for purposeful human interaction
Innovation hubs are dedicated physical environments characterised by spaces in which groups of people engage with each other in order to explore and extend their creative thinking beyond the normal boundaries (Magadley and Birdi, 2009). Carstensen and Bason (2012) argue that innovation hubs provide workshop space for interaction and mutual learning in creating new solutions for society. They are a neutral zone for inspiring creativity, innovation and collaboration by providing space where multiple stakeholders can engage in dialogue and development activities (Carstensen and Bason, 2012; Sørensen and Torfing, 2011; Bason, 2010). Innovation hubs are based on the notion that the competencies and mindsets needed for systematic innovation are not the same as those required for stable, daily operations and service delivery at the front line (Carstensen and Bason, 2012; Chan et al., 2010). The argument is that an attractive and novel environment, which is different from the usual workplace, is required to stimulate innovation. Thus, innovation hubs are designed in such a way that they create a certain ambience that allows creativity to flourish in an environment that is stimulating and non-threatening (Carstensen and Bason, 2012; Magadley and Birdi, 2009). The architectural uniqueness of the hubs facilitate individual and team creative thinking about existing problems in a new ways (Magadley and Birdi, 2009; Lewis and Moultrie, 2005).
Innovation hubs provide a stimulating space for different actors to interact, as new ideas mainly arise from internal institutional sources, such as employees, and to a much lesser degree, via external stakeholders (Gryszkiewicz and Friederici, 2014; Carstensen and Bason, 2012; Eggers and Singh, 2009). Innovation efforts are typically driven by a few isolated individuals, dependent on their personal initiative and willpower, hence the need for providing suitable space to support them (Carstensen and Bason, 2012; Bason, 2010). Against such a background, innovation hubs create space for harnessing the lived experiences of individuals in identifying problems and providing solutions (Sanders and Stappers, 2008). Innovation hubs are particularly important in public sector organisations, as the space in such institutions is typically not conducive to innovation (Bason, 2010). For example, incentives for sharing tasks and knowledge amongst public sector organisations are not very high, and internal politically-motivated competition tends to overrule collaboration towards innovation (Carstensen and Bason, 2012).
Many such organisations are hierarchical and bureaucratic; these conditions stifle innovation, despite the need for it (Osborne and Gaebler, 1992). In many cases, public sector organisations are highly sectorialised - vertically between administrative levels and horizontally between distinct policy domains - which makes it difficult to navigate from one end to another (Carstensen and Bason, 2012). The space to cooperate across these divisions is not always present, in spite of a growing demand for coherent and enhanced interaction. Eggers and Singh (2009) cite organisational silos, traditional roles and lack of cross-cutting coordination as bottlenecks to innovation. Thus, public sector organisations lack a conducive environment for conducting innovation (Osborne and Brown, 2005); this results in a climate that counters, rather than fosters, the exploration of new ideas and solutions (Wilson, 1989).
Innovation hubs are being developed as an organisational response to the challenges to innovation in the public sector. They create a self-sustaining ecosystem for accelerating the development and adoption of products, services, and quality standards to obtain good outcomes (Youtie and Shapira, 2008). The hubs seek to provide approaches, skills, models and tools beyond what most people possess in their conventional work environment (Carstensen and Bason, 2012). This is achieved by creating dedicated ‘safe’ spaces, and opportunities for collaboration on innovation across units, departments and sectors (Bason, 2010). According to Kao (2002), innovation lives in spaces; thus, it requires a home, such as the one provided by an innovation hub, where the process is given adequate attention as a professional activity and not an isolated or singular event. The space allows the like-minded to convene, while bringing together people with different backgrounds and knowledge to experiment, ideate and prototype new solutions (Price and Delbridge, 2015). This is not possible in the work environment where creative practices are strongly directed to defined goals, leaving no room for open experimentation and creative chaos.
The design and layout of innovation hubs is associated with positive changes in the use of space to support innovation. Typically, the physical structure of an innovation hub consists of a dedicated open space and temporary co-working spaces enacted for a short periods of time to serve particular purposes. (Murray et al., 2010). The open layout makes group projects visible, while the pop-up spaces, which are often wrapped with glass and white board surfaces, are used for activities ranging from brainstorming, workshopping and collaborative work to break-away sessions for quiet and individual work (Gryszkiewicz and Friederici, 2014). The open space plan is meant to facilitate sustained patterns of inter- action beyond assigned work group or department, and sometimes outside the organisation (Peponis et al., 2007). The deliberate choice to physically break down walls creates a sense of transparency and encourages frequent unplanned interaction and serendipitous communication of members, including those who rarely have direct contact (Bachmann, 2014; Gryszkiewicz and Friederici, 2014). Optional and flexible arrangements convert open spaces into activity-oriented areas, especially cubicles for work stations. The changes in the layout of space are aimed at providing an intelligible framework within which innovation is continuously explored, represented, interpreted, and transformed in relation to assigned projects (Peponis et al., 2007). The reconfigurable environment conveys a sense of the possible, adapts to evolving activities and uses the range of spaces for many activities (Churchill et al., 2012; Harrison et al., 2003). Such flexibility denotes the adaptability of an innovation hub to evolving uses, and ensures that its activities, furniture, and operational systems can shift responsively over time.
4. Space for innovation at Groote Schuur Hospital
The Innovation Programme at Groote Schuur Hospital was the first in a public sector hospital in South Africa. The programme was implemented as a partnership between Groote Schuur Hospital, the Faculty of Health Sciences at the University of Cape Town, and the Bertha Centre for Social Innovation and Entrepreneurship, a specialised unit of the Graduate School of Business at the University of Cape Town, while Groote Schuur Hospital provided physical space for the programme in the form of the Innovation Hub. The programme was aimed at supporting staff to develop and implement solutions to some of the hospital's challenges related to patient service delivery. The motivation was to grow a culture of innovation that would sustain beyond the initial funding. The programme was structured to give staff the chance to think creatively, and to develop solutions that they thought were needed, thereby driving innovation. To make it inclusive, the programme was open to every staff member of Groote Schuur Hospital with an interest in improving patient care. It targeted people who had innovative ideas with the potential of making a positive impact on processes, programmes, events and interventions to improve patient outcomes.
As part of the preparations for implementation of the GSH Innovation Programme, the Bertha Centre, supported by the London-based Innovation Unit, a not-for-profit social enterprise which aims to use innovation to improve public services, conducted a scoping exercise in June 2014. The scoping exercise identified the pressing challenges that were hindering healthcare delivery at Groote Schuur Hospital from both staff and patient perspectives. A total of 10 strong themes emerged, which were then further synthesised and refined to allow for eight final challenges appropriate for innovation. The themes and the innovation opportunities that were proposed (Patel and van Niekerk, 2015) are shown Table 2. A call for innovation proposals was issued to the staff at GSH. The proposals were reviewed, and ten projects were selected for further implementation on the basis of their scope in addressing the health challenges at Groote School Hospital. Although innovation is broadly defined in the Oslo-Manual of the OECD (Mortensen and Bloch, 2005) as the implementation of a new or significantly improved product, a new marketing method, a new organisational method in business practices, workplace organisation and external relations, or a process, the Innovation Programme focused only on the latter. Process innovation comprises new or significantly improved production or delivery methods, which include substantial changes in techniques, equipment and/or software, with the aim of achieving major reductions in process cost or time, and enhancing improvements in quality, flexibility and organisational goals (Davenport, 2013).
Implementation of the GSH Innovation Programme comprised of various activities, which were staggered at intervals. It started with the scoping exercise aimed at identifying key challenges in healthcare service delivery from the perspective of front line staff at Groote Schuur Hospital. This was followed by stimulating the project members to come up with as many innovative thoughts as possible. The final activity involved incubating the thought elements into novel ideas suitable for innovation. The activities and the timeline for their implementation are shown in Fig. 1. The implementation of the GHS Innovation Programme involved interactive meetings such as innovative chat, seminars, workshops and peer learning sessions which facilitated networking and sharing of ideas as shown in Fig. 1. Central to all the activities was the Innovation Hub, which provided the required space for implementation.
The Innovation Hub was not in the original plan for the GSH Innovation Programme, but it came about when it was realised that the different groups of innovators needed physical space to interact with each other. It was then that the idea of establishing an Innovation Hub was mooted. The Innovation Hub ran separately from, but simultaneously with the GSH Innovation Programme, with events and workshops curated for the benefit of the Western Cape healthcare community as a whole, rather than for the sole use of GSH Innovation Programme participants. The solutions that emerged from the Innovation
Programme are as follows: ▪ A kidney care clinic was developed to redesign the way in which care is provided to adolescent and new adult outpatients by engaging the patients themselves in the clinic design. ▪ A tool was implemented which allowed staff to design their own staffing patterns after observing the impact their shifts have on throughput of patients. ▪ Novel methods were developed for managing inpatient and outpatient referrals, particularly an electronic patient care management tool was developed. ▪ A coaching programme was delivered through videos across the hospital with the aim of supporting staff to reach their full potential. ▪ A streamlined patient record was developed that addressed the needs of the clinician and the nurse, to facilitate timely decision-making and reduce patient safety incidents.
▪ New methodologies were developed to aid informed consent conversations with families of potential organ donors. ▪ A medication storage device was developed that supported the education of patients about their chronic medication.
▪ A walk-in resource centre was established, which offered support through online resources, books, and trained health navigators.
▪ A technique was created for interacting with electronic radiological images during surgery via use of a hands-free system.
Thus innovations were proposed that had the potential to make a positive impact on the delivery of healthcare at Groote Schuur Hospital. Most of the innovations were adjustments to existing solutions as they were meant to improve the performance of established services. This, according to Antadze and Westley (2010), is typical of social innovations, which are inclined towards incremental refinements as opposed to radical disruptions. Disruptive innovations often initially result in worse performance compared with established products and services (Christensen et al., 2012), as they introduce products and value propositions that disturb prevailing consumer habits and behaviours (Markides, 2006). Such innovations are rarely driven by demand, and usually result from a supply-push process originating from those responsible for developing new technologies (Markides and Geroski, 2004).
5. The GSH Innovation hub as a dedicated and pop-up space for innovation
The physical space, layout, and furnishings of the GSH Innovation Hub were designed and chosen to spark and facilitate innovation. The space comprised individual and co-working areas, a brainstorming/meeting room, quick check-in areas, a communal planning/prototyping area, a reading and relaxation area, and space for presentations with a capacity of 50 people. The Hub was appointed with furnishings in the form of custom-made work surfaces, chairs, sofas, whiteboard surfaces, window projection surfaces, light shades, electronics, books, shelves and decorative finishing in the form of wall art. The open space of GSH Innovation Hub is shown in Fig. 2.
The Innovation Hub also provided pop-up spaces in the form of co-working and desk space as well as office infrastructure which made it more attractive for its convening function. The pop-up spaces are shown in Figs. 3-5.
The GSH Innovation Hub provided a physical embodiment of a dedicated office and co-working space, a meeting and event location, and a prototyping and fabrication space, with an explicit mission of fostering innovation. The space was designed to promote the sharing of ideas and acted as a social networking platform. The open layout, with its modular structure and absence of assigned work stations, encouraged flexible co-working, informal interactions, creativity, collaborative innovation and a sense of community. The branding of the Hub was meant to be inspirational; particularly the use of a green thematic colour, which was chosen to create a sense of hope and the feeling that change was possible.
5.1. Meeting point for team formation and multidisciplinary collaboration The Innovation Hub was planned to serve as a site for moulding a community of like-minded innovators, in which membership was fluid and people from various strands of life and work were welcome. For example, the establishment of the Innovation Hub was driven by the need to provide a physical space for the pro- gramme participants to interact with an innovation consultant from the Bertha Centre, and a designer from a design school, as well as with health innovators, entrepreneurs, students, clinicians, and practitioners across Cape Town, the Western Cape, and South Africa as a whole. In this regard, the Innovation Hub would act as an event space and creative working platform that was open to all. Such a set-up was expected connect frontline innovators, policy makers, consultants and subject matter experts, and to facilitate the formation of teams. Spaces occupied by different users in this manner encourage multi-disciplinary collaboration, which allows challenges to be viewed from different perspectives (Low, 2008 € ). They allow social networks to emerge from multi-disciplinary collaboration created by a relational arrangement of living beings and social goods (Viitanen, 2016; Low, 2008 € ). At the GSH Innovation Hub, project members from different disciplines, such as nurses, surgeons and other healthcare professionals, would occupy the same space at the same time. This is important in creating a sense of community in which the members view themselves differently as bound together for a common cause (Johnston and Pattie, 2011; Taylor and Spicer, 2007).
5.2. A strategic centre that enhances proximity The placement of several entities in a single location enhances the intensity, frequency and openness of collaborative activities, thereby promoting the innovation process and increasing the visibility of innovators. It resonates with the human ecology approach by Johnston and Pattie (2011), which argues that geographical proximity gives rise to strong social networks that determine important outcomes in social life. For example, the location of the Innovation Hub would enable inclusive use of the space by GSH staff, University of Cape Town employees and students, and members of the broader healthcare community in stimulating the development of creative solutions and innovations aimed at strengthening the delivery of services and building the capacity of community members to be healthcare innovators.
5.3. A fluid environment for innovation The Innovation Hub was intended to provide a platform that would support innovation without coercing innovative activities from its members, particularly for the Innovation Programme. Such a platform does not set rigid targets, but rather encourages emerging ideas while supporting the members in taking initiative, thereby creating an environment in which innovation is lived and experienced (Gryszkiewicz and Friederici, 2014). Thus, the Innovation Hub was developed to serve a vital role in contributing to and strengthening the innovation ecosystem, and to be a venue where the practitioners and project teams interacted with one another, became acquainted with the principles and methodology of innovation, and inspired others who were interested in designing innovative products, interventions, processes and programmes.
5.4. A space that instills a sense of identity and belonging The geographic concentration of diverse stakeholders in a common space serves as a catalyst for social networks, and pro- motes inter-personal relationships and inter-organisational relations, thus facilitating transmission of knowledge across organisational boundaries (Taylor and Spicer, 2007; Jaffe et al., 1993). Importantly, the provision of a physical innovation space outside the formal work environment provides potential innovators the luxury of discussing their ideas, thought processes and potential solutions in a neutral and stimulating environment (Murray et al., 2010). Thus, provision of a common space in the Innovation Hub could be expected to create a sense of identity and belonging among the different project members, to foster relationships, and to build networks.
5.5. A less bureaucratic place which alleviates fear of failure
The interaction amongst users of the space in the Innovation Hub was expected to translate into enhanced mental activation, inspiration and motivation towards innovation. This would help in alleviating the fear of failure through what Leifer et al. (2001) describe as a less bureaucratic, non-hierarchical and open relational structure among project members. Such an environment would diminish innovation obstacles, such as fear of failure and reluctance to share ideas. It is attributed to the function of ‘lived space’, which emerges through the meaningful and phenomenological aspects of human experiences, embodied in dynamic engagement with a given physical space (Lefebvre, 1991). Thus, the Innovation Hub was conceived to promote innovation as a function of teamwork, in which engagement is a collective process driven by the sharing of common values while blurring the boundaries be- tween the physical, economic, social and cultural spaces. The existence of such a space outside the normal workplace was designed to allow for new combinations of knowledge that would otherwise not occur.
5.6. A place for positive behavioural change
The overlapping spatial dimensions of an innovation hub pro- mote behavioural and cultural expectations associated with innovation, and this emanates from the fact that a person's sense of space affects his/her motivation, learning and overall engagement (Murray et al., 2010; Kornberger and Clegg, 2004). It is linked to the assertion by Taylor and Spicer (2007) and Arge (2000) that space creates specific types of people who display different patterns of behaviour and interaction. An inviting space generates good ideas, which are rarely created when sitting at one's desk alone, but rather during creative encounters with others (Markus and Cameron, 2002). The Innovation Hub was designed to provide project members with a social experience they would not access within their everyday workplaces. It was envisaged that the experience would nurture collaboration, creative thinking and problem solving in the same way that the space of a library demands silence and reading.
This work is based on research supported by the South African Research Chairs Initiative of the Department of Science and Technology and the National Research Foundation of South Africa (Grant No 98788). The authors wish to acknowledge the management at Groote Schuur Hospital for its support in allowing us to study its facility, the GSH Innovation Hub.
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