서비스기관에서 혁신의 전파(Systematir Review) (Milbank Q. 2004)
Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations
TRISHA GREENHALGH, GLENN ROBERT, FRASER MACFARLANE∗, PAUL BATE, and OLIVIA KYRIAKIDOU∗
University College London; ∗University of Surrey
전체 보고서는 Greenhalgh et al. 2005a
Because of the size and scope of our re- view, we cannot describe all our findings or discuss all our sources in this article. Instead, we encourage interested readers to read the complete project report (Greenhalgh et al. 2005a).
서비스 기관에서의 '혁신'을 다음과 같이 정의하였다.
We defined innova- tion in service delivery and organization as
a novel set of behaviors, routines, and ways of working
that are directed at improving health outcomes, administrative efficiency, cost effectiveness, or users’ experience and
that are implemented by planned and coordinated actions.
우리는
- Diffusion(피동적 전파),
- Dissemination(도입을 위한 능동적, 계획적 설득),
- Implementation(주류에 대한 능동적, 계획적 노력),
- Sustainability (진부해질때까지 혁신을 루틴으로 만드는 것)을 구분하고자 했다.
그러나 우리는 Sustainability의 모호함을 언급해놓고자 한다(혁신이 더 오래 지속될수록, 한 조직이 추가적인 혁신에 개방적일 가능성이 낮다.
We distinguished among
- diffusion (passive spread),
- dissemination (active and planned efforts to persuade target groups to adopt an innovation),
- implementation (active and planned efforts to mainstream an innovation within an organiza- tion), and
- sustainability (making an innovation routine until it reaches obsolescence).
But we did note an ambiguity in the notion of sustain- ability (i.e., the longer an innovation is sustained, the less likely the organization will be open to additional innovations).
헬스케어 관련 서비스 영역에 집중
Our search strategy was designed to concen- trate on the service sector, particularly health care.
meta-narrative review라는 새로운 방식을 도입
To help explore this large and heterogeneous literature, we developed a new technique, which we called meta-narrative review. It is summarized in Box 1 and explained in detail in a separate paper (Greenhalgh et al. 2005b).
여섯가지 카테고리로 구분
We then divided the pri- mary studies’ findings into six broad categories:
- (1) 혁신 그 자체 the innovation itself;
- (2) 프로세스의 도입과 축적 the adoption/assimilation process;
- (3) 의사소통과 영향주기 communication and influence (diffusion and dissemination, including social networks, opinion leader- ship, champions, and change agents);
- (4) 내부 맥락 the inner (organizational) con- text, including both antecedents for innovation in general and readiness for particular innovations;
- (5) 외부 맥락 the outer (interorganizational) context, including the impact of environmental variables, policy incentives and mandates, and interorganizational norms and networking; and
- (6) 도입과 시행 the implementation process.
연구자마다 Diffusion, Dissemination, Implementation을 다르게 개념화하고 다르게 사용함...등등 차이.
Because different researchers in different traditions generally...
- concep- tualized their topic differently;
- used different language and metaphors for diffusion, dissemination, and implementation;
- asked different ques- tions;
- privileged different methods; and
- used different criteria to judge “quality” and “success,”
그래서 narrative한 방식 사용.
we used narrative, rather than statistical, syn- thesis techniques (Dixon-Woods et al. 2004).
모델(Fig3)을 개발
Based on the evidence from the primary studies, we developed a unifying conceptual model (Figure 3)
근거를 다음과 같이 grade함.
We graded the overall evidence supporting each of our conclusions using a modified version of the World Health Organization Health Evidence Network (WHO-HEN) criteria (Øvretveit 2003):
- 강력한 직접적 근거 Strong direct evidence: consistent findings in two or more empirical studies of appropriate design and high scientific quality undertaken in health service organizations.
- 강력한 간접적 근거 Strong indirect evidence: consistent findings in two or more empirical studies of appropriate design and high scientific quality, but not from a health service organization.
- 중등도의 직접적 근거 Moderate direct evidence: consistent findings in two or more empirical studies of less appropriate design and/or of acceptable scientific quality undertaken in health service organizations.
- 중등도의 간접적 근거 Moderate indirect evidence: consistent findings in two or more empir- ical studies of less appropriate design and/or of acceptable scientific quality, but not from health service organizations.
- 제한된 근거 Limited evidence: only one study of appropriate design and acceptable quality available, or inconsistent findings in several studies.
- 근거 없음 No evidence: no relevant study of acceptable scientific quality available.
13개의 연구영역 - 대체로 상호독립적임 - 이 관련 근거토대를 마련해줌
We identified 13 research areas that had, largely independently of one another, provided evidence relevant to the diffusion of innovations in health service organizations (Table 1).
이 중 네 개의 연구전통은 '초기 확산 연구'라고 볼 수 있음
Four of these traditions can be classified as “early diffusion research”:
1. 농촌 사회학 Rural sociology,
for which Everett Rogers (1995) first developed the concept of diffusion of innovations: In this concept, innovations were defined as ideas or practices perceived as new by practi- tioners (in this case, farmers). Diffusion was seen as the spread of ideas among individuals, largely by imitation. Interventions aimed at spreading innovation harnessed the interpersonal influ- ence of opinion leaders and change agents, and research mapped the social networks and adoption decisions of targeted individuals.
2. 의료 사회학 Medical sociology,
in which similar concepts and theoretical expla- nations were applied to doctors’ clinical behavior (most notably, the 1966 study by Coleman, Katz, and Menzel on the spread of prescribing of newly introduced antibiotics): Early studies in med- ical sociology set the foundations for network analysis—the sys- tematic study of “who knows whom” and “who copies whom”— and led to the finding that well-networked individuals are gen- erally better educated, have a higher social status, and are earlier adopters of innovations (Burt 1973).
3. 의사소통 연구 Communication studies,
in which innovations were conceptualized as new information (often “news”), and spread was seen as the trans- mission of this information by either mass media or interpersonal communication: Research measured the speed and direction of the message’s transmission and studied the impact of altering key variables such as the style of message, the communication chan- nel (spoken, written, etc.), and the nature of exposure (Rogers and Kincaid 1981).
4. 마케팅 Marketing,
in which innovations were conceptualized as products or services, and the adoption decision was seen as a rational (quasi- economic) analysis of costs and benefits: Research measured the success of efforts to increase the perceived benefits or reduce the perceived costs of an innovation in the eyes of potential adopters. An important stream of research in this area centered on devel- oping mathematical models to predict adoption behavior (Bass 1969).
그러나 이 연구들은 이론적 한계가 있었는데 다음과 같은 잘못된 가정을 하고 있었다.
But the work had a num- ber of theoretical limitations, notably the erroneous assumptions that
- (1) 분석단위가 개인 the only relevant unit of analysis is the individual innovation and/or the individual adopter;
- (2) 혁신은 반드시 좋은 것이라는 생각 an innovation is necessarily better than what has gone before and adoption is more worthy of study than is non-adoption or rejection;
- (3) 도입adoption의 패턴이 고정된 성격특성을 반영한다는 것 patterns of adoption reflect fixed personality traits; and
- (4) 연구결과가 변함없이 새로운 세팅/맥락으로 전이가능할 것이라는 생각 the findings of diffusion research are invariably transferable to new contexts and settings.
그 이후에 더 발전하여 등장한 연구영역은...
Research areas that emerged as developments— and sometimes as breakaways—from such conceptual models include
• 개발 연구 Development studies,
in which research on the spread of innovations was explicitly broadened to include an exploration of the polit- ical, technological, and ideological context of the innovation and any dissemination program, and of particular innovations’ different meaning and social value in different societies: Diffusion of innova- tions was reframed as centrally pertaining to the appropriateness of particular technologies and ideas for particular situations at partic- ular stages in development.
Two important contributions from this tradition have been
- (1) that the meaning of an innovation for the agency that introduces it may be very different from that held by the intended adopters and
- (2) that “innovation-system fit” (related to the interaction between the innovation and its potential context) is generally a more valid and useful construct than “innovation at- tributes” (often assumed to be fixed properties of the innovation in any context) (Bourdenave 1976).
• 건강 증진 Health promotion,
in which innovations were defined as good ideas for healthy behaviors and lifestyles, and the spread of such innovations was expressed as the reach and uptake of health promotion programs in defined target groups: Health promotion research has tradition- ally used social marketing, developed from marketing theory, as its theoretical basis. More recently, a more radical “developmental” agenda has emerged in health promotion, with parallels to devel- opment studies, in which a one-way transmission of advice from the change agency to the target group has been replaced with var- ious models of partnership and community development (Potvin, • Haddad, and Frohlich 2001).
• 근거 기반 의학 Evidence-based medicine,
in which innovations were defined as health technologies and practices supported by sound research evidence: Until recently, the spread of innovation in this tradition was seen as a linear and technical process at the level of the individual and hence was described as changes in clinicians’ behavior in line with evidence-based guidelines (Granados et al. 1997). Many evidence- based medicine researchers subsequently (and perhaps somewhat be- latedly) recognized that the implementation of most clinical guide- lines requires changing the system and, hence, organizational as well as individual change (Grimshaw et al. 2004). A more recent conceptual development is the notion that the evidence base for par- ticular technologies and practices is often ambiguous and contested and must be continually interpreted and reframed in accordance with the local context and priorities, a process that often involves power struggles among various professional groups (Ferlie et al. 2001).
조직, 경영 분야에서는 다음이 관련된다.
In the organization and management literature, we found the follow- ing areas that were relevant to our review:
• 조직 개혁의 구조적 결정요인 연구 Studies of the structural determinants of organizational innovativeness,
in which innovation was seen as a product or process likely to make an organization more profitable: Organizational innovativeness was regarded as primarily influenced by structural determinants, es- pecially
- size,
- functional differentiation (an internal division of la- bor),
- slack resources, and
- specialization (the organization has a clear “niche” in which it offers expertise and specialist resources).
In this area, research focuses on collecting quantitative data about the for- mal structures of organizations, usually by sending questionnaires to the chief executive. Such studies were among the few in our re- viewthat were amenable to meta-analysis (Damanpour 1991, 1992, • 1996).
• 조직의 프로세스/맥락/문화에 관한 연구로서, 혁신의 adoption/assimilation/routinization에 관심을 두는 연구 Studies of organizational process, context, and culture, whose research focus was the adoption, assimilation, and routinization of an in- novation:
Here, the exploration of an organization’s innovativeness concentrated on the “softer,” nonstructural aspects of its makeup, especially the prevailing culture and climate, notably in relation to
- leadership style,
- power balances,
- social relations, and
- attitudes toward risk taking.
This area used mainly qualitative (often ethno- graphic) methods and centered on people and their relationships and behavior. This research often overlapped with the mainstream change management literature, in addition to a distinct innovation subarea (Kanter 1988; Van de Ven et al. 1999).
• 조직간연구 Interorganizational studies,
which examine an organization’s innova- tiveness in relation to the influence of other organizations, partic- ularly
- interorganizational communication,
- collaboration,
- competi- tion, and
- normsetting:
This area applied social network theory (the notion that people are “networked” to friends and colleagues and that these networks formchannels of communication and influence [Granovetter and Soong 1983]) to the level of the organization (e.g., the concept of the opinion-leading organization was introduced and explored). Interorganizational norms (“fads and fashions”) were seen as a key mechanism for spreading ideas among organizations • (Abrahamson 1991; Abrahamson and Fairchild 1999).
• 조직의 혁신에 대한 지식-기반 접근법 Knowledge-based approaches to innovation in organizations,
in which both innovation and diffusion were radically redefined as the construc- tion and distribution of knowledge (Nonaka and Takeuchi 1995): A critical new concept was the organization’s absorptive capacity for new knowledge. Absorptive capacity is a complex construct incor- porating
- the organization’s existing knowledge base,
- “learning or- ganization” values and goals (i.e., those that are explicitly directed to capturing, sharing, and creating new knowledge),
- technolog- ical infrastructure,
- leadership and knowledge sharing, and
- effec- tive boundary-spanning roles with other organizations (Zahra and • George 2002).
• 내러티브 조직 연구 Narrative organizational studies,
in which one important dimen- sion of organizational innovativeness—the generation of ideas—was viewed as the creative imagination of individuals in the organiza- tion: In this field, an innovative organization is one in which new stories can be told and that has the capacity to capture and circu- late these stories (Czarniawska 1998; Gabriel 2000). This research area emphasizes the rule-bound, inherently conservative nature of large professional bureaucracies and celebrates stories for their in- herent subversiveness.
- Because the principal constructions in stories are surprise, tension, dissent, and “twists in the plot,” and
- because characters can be assigned positive virtues such as honesty, courage, or determination,
stories can offer “permission to break the rules” (Buckler and Zein 1996). In the narrative tradition, the diffusion of innovations within organizations gives a shared story a new end- ing. Hence, interventions to support innovation are directed toward supporting “communities of practice” with a positive story to tell (Bate 2004).
• 복잡도 연구 Complexity studies
are derived from general systems theory and re- gard innovation as the emergent continuity and transformation of patterns of interaction, understood as complex responses of humans relating to one another in local situations: The diffusion of innova- tions is seen as a highly organic and adaptive process in which the organization adapts to the innovation and the innovation is adapted to the organization (Fonseca 2001).
서비스기관에서의 확산모델
A Model of Diffusion in Service Organizations
Figure 3 shows the unifying conceptual model that we derived from our synthesis of theoretical and empirical findings. As noted later, the model is intended mainly as a memory aide for considering the different aspects of a complex situation and their many interactions. It should not be viewed as a prescriptive formula.
혁신 그 자체
The Innovation
사람들은 서로 다른 혁신을 받아들이고, 서로 다른 속도로 전파시킨다. 어떤 혁신은 아무에게도 받아들여지지 않으며, 어떤 혁신은 버려진다. 사회학의 여러 근거가 다음과 같은 혁신의 특성이 영향을 줌을 보여준다.
Individual people adopt different innovations and then spread them at different rates to other individuals. Some innovations are never adopted at all; others are subsequently abandoned. A very extensive evidence base from sociology (including medical sociology) supports the notion of key attributes of innovations (as perceived by prospective adopters), which explain much of the variance in innovations’ adoption rates.
상대적 장점 Relative Advantage.
효과성, 비용-효과성에 대한 명확한 장점이 있는 경우. 상대적 장점은 필수불가결한 것이다.
Innovations that have a clear, unambiguous ad- vantage in either effectiveness or cost-effectiveness are more easily adopted and implemented (for strong indirect and moderate direct evidence, see Dirksen, Ament, and Go 1996; Marshall 1990; Meyer, Johnson, and Ethington 1997; and Rogers 1995). If potential users see no relative advantage in the innovation, they generally will not consider it further; in other words, relative advantage is a sine qua non for adop- tion (for strong direct and moderate indirect evidence, see Rogers 1995).
그러나 상대적 장점만으로 충분하지 않다. 근거-기반 혁신조차 오랜 기간동안 adopter들과 협상을 거쳐야 하고, 이는 토론/검증/리프레임의 과정이다. 그러한 담화가 혁신의 상대적 장점이 어떻게 (좋게 또는 나쁘게) 인식되느냐를 바꾼다.
Nevertheless, relative advantage alone does not guarantee widespread adoption (for strong direct evidence, see Denis et al. 2002; Fitzgerald et al. 2002; and Grimshaw et al. 2004). Even so-called evidence-based innovations undergo a lengthy period of negotiation among potential adopters, in which their meaning is discussed, contested, and reframed. Such discourse can increase or decrease the innovation’s perceived relative advantage (for moderate direct evidence, see Ferlie et al. 2001).
호환성 Compatibility.
의도한 adopter들의 가치/규범/유구에 잘 맞을 때. 기관 혹은 전문직의 규범/가치/근무방식에 자 맞을 때
Innovations that are compatible with the intended adopters’ values, norms, and perceived needs are more readilyadopted(for strong direct evidence, see Aubert and Hamel 2001; Denis et al. 2002; Ferlie et al. 2001; Foy et al. 2002; and Rogers 1995). Compatibility with organizational or professional norms, values, and ways of working is an additional determinant of successful assimilation (for strong direct evidence, see Denis et al. 2002; Fennell and Warnecke 1988; and Ferlie et al. 2001).
복잡성 Complexity.
사용하기 쉬운 것. 실제 경험이나 시험을 통해서 'perceived complexity'를 줄일 수 있음. 혁신을 manageable part로 나눠서 점진적으로 도입하면 더 쉽게 도입될 수도 있음. 조직 세팅에서 reponse barrier가 적으면 쉽게 축적됨.
Innovations that are perceived by key players as simple to use are more easily adopted (for strong direct evidence, see Denis et al. 2002; Grilli and Lomas 1994; Marshall 1990; Meyer and Goes 1988; Meyer, Johnson, and Ethington 1997; and Rogers 1995). Per- ceived complexity can be reduced by practical experience and demon- stration (for moderate direct evidence, see Plsek 2003). If the innovation can be broken down into more manageable parts and adopted incremen- tally, it will be more easily adopted (for strong indirect and moderate direct evidence, see Plsek 2003; and Rogers 1995). If an innovation in an organizational setting has few response barriers that must be over- come, it will be assimilated more easily (for strong indirect and moderate direct evidence, see Rogers 1995).
시도가능성 Trialability.
limited basis로 실험해볼 수 있는 혁신이 더 쉽게 도입됨. “trialability space” 가 필요
Innovations with which the intended users can exper- iment on a limited basis are adopted and assimilated more easily (for strong direct evidence, see Grilli and Lomas 1994; Plsek 2003; Rogers 1995; and Yetton, Sharma, and Southon 1999). Such experimentation can be encouraged by providing “trialability space” (for strong indirect and moderate direct evidence, see Øvretveit et al. 2002; Plsek 2003; and Rogers 1995).
관측가능성 Observability.
혁신의 benefit이 쉽게 눈에 보일 때
If the benefits of an innovation are visible to intended adopters, it will be adopted more easily (for strong direct evidence, see Denis et al. 2002; Grilli and Lomas 1994; Meyer and Goes 1988; and Øvretveit et al. 2002).
재발명Reinvention.
잠쟂거 adopter들이 혁신을 refine, modify해서 스스로의 요구에 맞게 변형시킬 수 있을 때
If potential adopters can adapt, refine, or otherwise mod- ify the innovation to suit their own needs, it will be adopted more easily (for strong direct evidence, see Meyer, Johnson, and Ethington 1997; and Rogers 1995).
재발명은 “good ideas in practice” 의 방식으로 자발적으로 떠오르는 혁신에서 특히 중요하며, 비공식적/비중앙화된/수평적 네트워크로 전파된다.
Reinvention is especially important to those innovations that arise spontaneously as “good ideas in practice” and spread through informal, decentralized, horizontal social networks (for moderate indirect evidence, see Rogers 1995; see also “fuzzy boundaries”in this article).
불분명한 경계 Fuzzy Boundaries.
Complex innovation은 "굳건한 핵심"과 "부드러운 가장자리"로 구성된다. "부드러운 가장자리"의 adaptiveness가 혁신이 도입되기 위한 핵심이다.
Complex innovations in service organizations can be conceptualized as having a “hard core” (the irreducible elements of the innovation itself ) and a “soft periphery” (the organizational structures and systems required for the full implementation of the innovation); the adaptiveness of the “soft periphery” is a key attribute of the innovation (for moderate direct evidence, see Denis et al. 2002).
위험 Risk.
불확실성이 높고, 개개인이 risky하다고 느끼면 잘 도입이 안된다. 그러나 혁신의 '위협'은 한 조직내에서 균등하게 분배되는 것이 아니므로, risk and benefit의 밸런스를 맞추는 것이 조직 내의 power base를 반영하고, 그래야 더 혁신이 축적된다.
If the innovation carries a high degree of uncertainty of out- come that the individual perceives as personally risky, it is less likely to be adopted (for strong direct evidence, see Meyer and Goes 1988; and Meyer, Johnson, and Ethington 1997). Because an innovation’s risks and benefits are not evenly distributed in an organization, the more the bal- ance between risks and benefits reflects the organization’s power base, the more likely the innovation is to be assimilated (for moderate direct evidence, see Denis et al. 2002; and Ferlie et al. 2001).
업무 관련성 Task Issues.
사용자의 업무와 관련된 경우, 업무능력을 향상시켜줄 경우. feasible, workable, easy to use해야 함.
If the innovation is relevant to the performance of the intended user’s work and if it improves task performance, it will be adopted more easily (for moderate direct evidence, see Yetton, Sharma, and Southon 1999). If the innovation is feasible, workable, and easy to use, it will be adopted more easily (for strong direct evidence, see Dobbins, Cockerill, and Barnsley 2001; Foy et al. 2002; Meyer and Goes 1988; and Yetton, Sharma, and Southon 1999).
사용에 필요한 지식 Knowledge Required to Use It.
사용에 필요한 지식이 성문화되어 transfer될 수 있을 때
If the knowledge required for the inno- vation’s use can be codified and transferred from one context to another, it will be adopted more easily (for strong indirect and moderate direct evidence, see Adler, Kwon, and Singer 2003; Aubert and Hamel 2001; and O’Neill, Pouder, and Buchholtz 2002).
지지 Augmentation/Support.
지지(augmented product)가 공급될 때.
If a technology is supplied as an “augmented product” (e.g., with customization, training, and a help desk), it will be assimilated more easily (for strong moderate direct evidence, see Aubert and Hamel 2001).
그러나 이 특성들은 stable한 것도 아니며, 혁신 도입의 sure determinants도 아니다.
Our full report gives a number of examples of studies that failed to support the importance of even the most well-established attributes in certain settings (Greenhalgh et al. 2005a). This finding illustrates the important principle that the attributes are neither stable features of the innovation nor sure determinants of their adoption or assimila- tion. Rather, it is the interaction among the innovation, the intended adopter(s), and a particular context that determines the adoption rate.
개인에 의한 도입 Adoption by Individuals
사람들은 혁신의 수동적 수용자가 아니다. 오히려 혁신을 탐색하고, 실험해보고, 평가하고, 의미를 찾고, 감정을 develop하고, 도전하고, 걱정하고, 불평하고, 주변에서 서성거리고, 경험을 쌓고, 특정 업무에 맞게 변형시키고, 재-디자인 하곤 한다. 이러한 다양한 행동과 감정은 혁신의 도입과정에서 발생하는 복합성을 보여주며, explanatory variable로서 잘못 적용되며 널리 인용되어온 "adopter category" (초기수용자, Laggard...)와 배치되는 것이다. 이 adopter category에서 나타나는 stereotypical, value-laden 한 용어의 실제적 근거는 거의 없으며, 이 카테고리는 adopter를 복잡한 혁신과 능동적, 창의적으로 상호작용하는 actor로서의 adopter를 놓친 것이다.
People are not passive recipients of innovations. Rather (and to a greater or lesser extent in different persons), they seek innovations, experiment with them, evaluate them, find (or fail to find) meaning in them, de- velop feelings (positive or negative) about them, challenge them, worry about them, complain about them, “work around” them, gain experience with them, modify themto fit particular tasks, and try to improve or re- design them—often through dialogue with other users. This diverse list of actions andfeelings highlights the complex nature of adoptionas a pro- cess and contrasts markedly with the widely cited “adopter categories” (“early adopter,” “laggard”) that have been extensively misapplied as explanatory variables. There is little empirical support for these stereo- typical and value-laden terms, which fail to acknowledge the adopter as an actor who interacts purposefully and creatively with a complex innovation.
일반적인 심리학적 선조들 General Psychological Antecedents.
We identifieda large literature from cognitive and social psychology on individual traits associated with the propensity to try out and use innovations (e.g., tolerance of ambiguity, intellectual ability, motivation, values, and learning style).
맥락-특이적 심리학적 선조들 Context-Specific Psychological Antecedents.
동기부여가 되어있고 더 able한(가치/목적/스킬 등등) 사람이 더 잘 adopt한다. intended adopter의 identified need를 충족시켜준다면 더 잘 adopt할 것이다.
An intended adopter who is motivated and able (in terms of values, goals, specific skills, and so on) to use a particular innovation is more likely to adopt it (for strong direct evidence, see Ferlie et al. 2001; Gladwin, Dixon, and Wilson 2002; and Yetton, Sharma, and Southon 1999). If the innovation meets an identified need by the intended adopter, he or she is more likely to adopt it (for strong indirect evidence, see Hall and Hord 1987; and Wejnert 2002).
의미 Meaning.
혁신의 '의미'가 도입 결정에 큰 영향을 준다. 개인에게 부여된느 의미가, 상위 관리자/서비스 사용자/다른 이해관계자의 의미와 잘 맞을 때 더 잘 도입된다.
The meaning of the innovation for the intended adopter has a powerful influence on the adoption decision (for strong indirect and moderate direct evidence, see Dearing and And 1994; and Timmons 2001). If the meaning attached to the innovation by individual adopters matches the meaning attached by top management, service users, and other stakeholders, the innovation is more likely to be assimilated (for moderate indirect evidence, see Eveland 1986).
도입 결정 The Adoption Decision.
개별 조직 내에서의 특정 혁신도입에 대한 결정은 다른 결정에 무관하지 않다. contingent, collective, authoritative할 수 있다.
The decision by an individual within an orga- nization to adopt a particular innovation is rarely independent of other decisions. It may be
- 대표 contingent (dependent on a decision made by some- one else in the organization),
- 집단 collective (the individual has a “vote” but ultimately must acquiesce to the decision of a group), or
- 권력 authoritative (the individual is told whether or not to adopt it) (Rogers 1995).
권력(자)의 결정은 초기 도입의 가능성을 높여주나, 성공적으로 implementation되고 routinize될 가능성을 낮춘다.
Au- thoritative decisions (e.g., making adoption by individuals compulsory) may increase the chance of initial adoption by individuals but may also reduce the chance that the innovation is successfully implemented and routinized (for moderate indirect evidence, see Rogers 1995).
'Adoption'이란 결과event라기보다는 프로세스이며, 각 단계마다 서로 다른 우려사항이 발생한다. 개인 차원에서 도입 프로세스는 다섯 단계를 거친다.
Adoption is a process rather than an event, with different concerns being dominant at different stages. The adoption process in individ- uals is traditionally presented as having five stages:
- awareness,
- per- suasion,
- decision,
- implementation, and
- confirmation (Rogers 1995).
그러나 우리는 조금 덜 잘 알려진 Concerns Based Adoption Model 을 사용하여 설명할 것이다.
However, we found that a lesser-known model, the Concerns Based Adoption Model developed for innovation in schools, better explained the findings of empirical studies of complex service innovations in an organizational context.
전-도입 단계의 우려 Concerns in Preadoption Stage.
중요한 전제조건은 adopter들이..
Important prerequisites for adoption are that the intended adopters
- 혁신에 대한 '인지aware' are aware of the innovation;
- 그것이 무엇이며 어떻게 사용해야 할지에 대한 충분한 정보 have sufficient information about what it does and how to use it; and
- 그 혁신이 어떻게 자기에게 영향을 미칠지가 확실해야 are clear about how the innovation would affect them personally, for example, in terms of costs (for strong indirect evidence, see Hall and Hord 1987).
초기 사용 단계의 우려 Concerns during Early Use.
intended adopters 가 지속적으로 혁신에 대한 정보에 접근가능할 때, 지속적으로 충분한 훈련과 지지가 있을 때
Successful adoption is more likely if the intended adopters have continuing access to information about what the innovation does and to sufficient training and support on task issues (i.e., about fitting the innovation to daily work) (for strong indirect evidence, see Hall and Hord 1987).
이미 확립된 사용자의 우려 Concerns in Established Users.
혁신의 결과에 대해서 적절한 피드백에 제공될 때. 도입한 사람들이 혁신을 adapt and refine할 수 있는 기회/자율성/서포트가 충분히 제공될 때
Successful adoption is more likely if adequate feedback is provided to the intended adopters about the con- sequences of adoption (for strong indirect evidence, see Hall and Hord 1987) and if the intended adopters have sufficient opportunity, auton- omy, and support to adapt and refine the innovation to improve its fitness for purpose (for strong indirect evidence, see Rogers 1995).
시스템에 의한 도입/축적
Assimilation by the System
혁신의 전파에 대한 대부분의 연구는 단순한, 산출물 기반의 혁신에 초점을 두고 있다.
Most of the research on the diffusion of innovations focused on simple, product-based innovations, for which the unit of adoption is the indi- vidual, and diffusion occurs by means of simple imitation (Rogers 1995).
즉, 조직과 경영 분야의 연구는 성공적인 '개인의' adoption을 유일한 요소로 보고있다는 것이다.
In other words, empirical work in the field of organization and management clearly shows that successful individual adoption is only one component of the assimilation of complex innovations in organizations.
축적 The Assimilation.
대규모, high-quality 연구에서 조직도 개인처럼 단계를 거친다고 했다.
Although one large, high-quality study (Meyer and Goes 1988) demonstrated an organizational parallel to the “stages” of individual adoption, comprising
- 지식-인식 “knowledge-awareness,”
- 평가-선택 “evaluation- choice,” and
- 도입-시행 “adoption-implementation,”
그러나 이후 연구결과는 이보다 더 messy한 모델과 더 잘 부합하는데, initiation/development/implementation 사이를 왔다갔다하며, 충격/훼방/놀람이 막 끼어든다.
the remaining empirical evi- dence was more consistent with an organic and often rather messy model of assimilation in which the organization moved back and forth between initiation, development, and implementation, variously punctuated by shocks, setbacks, and surprises (for strong direct evidence, see Van de Venetal. 1999).
전파
Diffusion and Dissemination
혁신의 확산은 pure diffusion과 active dissemination 사이에 있다.
The various influences that help spread the innovation can be thought of as lying on a continuum between
- pure diffusion (in which the spread of innovations is unplanned, informal, decentralized, and largely horizon- tal or mediated by peers) and
- active dissemination (in which the spread of innovation is planned, formal, often centralized, and likely to occur more through vertical hierarchies; see Figure 2).
메스미디어와 다른 impersonal 채널들이 혁신에 대한 awareness를 만들어낸다면, 대인관계적 영향이 사회적 네트워크를 따라서 diffusion의 주된 메커니즘이 된다.
Whereas mass media and other impersonal channels may create awareness of an innovation, interpersonal influence through social networks (defined as “the pattern of friendship, advice, communication and support which exists among members of a social system” [Valente 1996, 70]) is the dominant mecha- nism for diffusion.
네트워크 구조 Network Structure.
개인이 혁신을 도입하는 것은 사회적 네트워크의 구조와 퀄리티에 따라 달라진다. 직군마다 사회적 네트워크 유형이 다르다. 예를 들어 의사는 비공식적/수평적 네트워크로 작동하며, 간호사는 보다 공식적/수직적 네트워크를 갖는다.
The adoption of innovations by individuals is powerfully influenced by the structure and quality of their social net- works (for strong indirect and moderate direct evidence, see Fennell and Warnecke 1988; Valente 1996; and West et al. 1999). Different groups have different types of social networks.
- Doctors, for example, tend to operate in informal, horizontal networks, and
- nurses more often have formal, vertical networks (for moderate direct evidence, see West et al. 1999).
세회적 네트워크마다 사용되는 양상이 다르다.
Different social networks also have different uses for different types of influence; for example,
- 수평적 네트워크는 동료에게 영향을 미치거나 의미를 리-프레이밍하는 것을 서포트해줌
horizontal networks are more effective for spreading peer influence and supporting the construction and re- framing of meaning; - 수직적 네트워크는 성문화된 정보가 아래로 전달되고, 권력자의 결정을 전달하는데 효과적
vertical networks are more effective for cascading codified information and passing on authoritative decisions (for moderate indirect evidence and limited direct evidence, see Rogers 1995; andWest et al. 1999).
동질성 Homophily.
집단이 동질적(socioeconomic, educational, professional, and cultural)이면 더 잘 전파됨.
The adoption of innovations by individuals is more likely if they are homophilous—that is, have similar socioeconomic, educational, professional, and cultural backgrounds—with current users of the in- novation (for strong direct evidence, see Fennell and Warnecke 1988; Fitzgerald et al. 2002; and West et al. 1999).
오피니언 리더 Opinion Leaders.
어떤 사람은 동료들의 신념/행동에 대해서 특정한 영향력을 갖는다.
Some persons have a particular influence on the be- liefs and actions of their colleagues (for strong direct evidence, see Becker 1970; and Coleman, Katz, and Menzel 1966).
- 전문가 오피니언리더 Expert opinion leaders ex- ert influence through their authority and status, and
- 동료 오피니언리더 peer opinion leaders exert influence through their representativeness and credibility (for mod- erate direct evidence, see Fitzgerald et al. 2002; and Locock et al. 2001).
오피니언 리더는 긍정적/부정적 영향을 모두 미칠 수 있다.
Opinion leaders can have either a positive or negative influence.
오피니언 리더의 영향력을 활용 Harnessing the Opinion Leader’s Influence.
자연적 상황에서의 사회적 영향력이 강력할지라도, 그러한 개개인들을 planned change effort에 포함시키려는 시도의 결과는 실망스러웠다. 오피니언리더를 훈련시켜서 동료들에게 영향을 미치게 하고 싶을 때, 그 impact가 일반적으로 긍정적이기는 하나, 그 magnitude가 크진 않다. 진정한 오피니언리더를 찾는데 실패한다면 (즉 monomorphic과 polymorphic의 구분에 실패한다면) 개입 전략이 성공하지 못할 수도 있다.
Even though the powerful impact of social influence (such as that of opinion leaders) in natural- istic settings is well established, attempts to engage such individuals in planned change efforts have often had disappointing results. In cases in which opinion leaders have been trained to influence the behavior of their peers (e.g., to persuade fellow clinicians to follow a new guideline), the impact is generally positive in direction but small in magnitude (for strong direct evidence, see Thomson O’Brien et al. 2003). The failure to identify the true opinion leaders and, in particular, the failure to distin- guish between
- monomorphic opinion leaders (influential for a particular innovation only) and
- polymorphic opinion leaders (influential across a wide range of innovations)
may limit the success of such intervention strategies (for strong indirect and moderate direct evidence, see Locock et al. 2001; and Rogers 1995).
key individual이 자신의 사회적 네트워크에 있을 때 개개인은 혁신을 더 잘 도입한다.
The adoption of an innovation by individuals in an or- ganization is more likely if key individuals in their social networks
지지자 Champions.
지지자는 혁신을 서포트할 의지가 있는 사람이다. 다양한 역할을 맡을 수 있다.
are willing to support the innovation (for strong indirect and moderate direct evidence, see Backer and Rogers 1998; Markham1998; Meyer and Goes 1988; and Schon 1963). The different champion roles for organiza- tional innovations include
- (1) 개척자 the organizational maverick, who gives the innovators autonomy from the organization’s rules, procedures, and sys- tems so they can establish creative solutions to existing problems;
- (2) 변혁의 리더 the transformational leader, who harnesses support from other members of the organization;
- (3) 조직의 버퍼 the organizational buffer, who creates a loose mon- itoring system to ensure that innovators properly use the organization’s resources while still allowing themto act creatively; and
- (4) 네트워크 촉진자 the network facilitator, who develops cross-functional coalitions within the organiza- tion (for moderate indirect evidence, see Shane 1995).
경계 확장가 Boundary Spanners.
조직은 조직의 내부와 외부에 social ties가 유의미한 사람이 있고, 이들이 조직을 외부세계와 연결시켜줄 의지가 있을 때 혁신을 더 잘 도입한다. 이러한 개개인이 pivotal role을 하게 된다. development and execution of boundary-spanning roles 을 잘 할 수 있게 도와주는 조직이 더 빨리 혁신을 인지하고 시행한다.
An organization is more likely to adopt an in- novation if those people who have significant social ties both inside and outside the organization are able and willing to link the organiza- tion to the outside world in relation to this particular innovation. Such individuals play a pivotal role in capturing the ideas that will become or- ganizational innovations (for strong indirect evidence, see Rogers 1995; for moderate direct evidence, see Kimberly and Evanisko 1981). Or- ganizations that promote and support the development and execution of boundary-spanning roles are more likely to become aware of and as- similate innovations quickly (for moderate direct evidence, see Barnsley, Lemieux-Charles, and McKinney 1998; Ferlie et al. 2001; and Tushman 1977).
공식적 확산 프로그램 Formal Dissemination Programs.
다음의 경우에 더 잘 이뤄진다.
When a planned dissemination pro- gramis used for the innovation (e.g., led by an external change agency), it will be more effective if the program’s organizers
- (1) 잠재적 adopte를 충분히 고려할 때(요구, 관점, 관심, 비용-효과 밸런스) take full account of potential adopters’ needs and perspectives, with particular attention to the balance of costs and benefits for them;
- (2) subgroup의 특징에 따라 전략을 tailoring할 때 tailor different strategies to the different demographic, structural, and cultural features of different subgroups;
- (3) 적절한 스타일의 메시지 활용 use a message with appropriate style, imagery, metaphors, and so on;
- (4) 적절한 커뮤니케이션 채널의 발굴과 활용 identify and use appropriate communication channels; and
- (5) 철저한 평가와 모니터링 incorporate rigorous evaluation and monitoring of defined goals and milestones (for strong indirect evidence, see Rogers 1995).
대부분의 확산 연구는 proactively developed innovations 을 위주로 이뤄져왔으며, 이 때 전파의 주된 메커니즘은 중앙에서 유도하여 통제된(dissemination이라 정의한) 방식이다. 그러나 많은 수의 혁신은 로컬 서비스에서 "괜찮은 아이디어"로 판명난 것이 비공식적으로, uncontrolled way로 퍼져나가는 것이다(diffusion)
Most dif- fusion research has addressed proactively developed innovations (e.g., technologies or products developed in formal research programs) whose main mechanism of spread is centrally driven and controlled (what we have defined as dissemination). But many innovations in service delivery and organization occur as “good ideas” in local services, which spread informally and in a largely uncontrolled way (diffusion).
시스템 차원에서의 혁신의 선행조건
System Antecedents for Innovation
서로 다른 조직마다 혁신의 맥락이 다르며, 구조적/문화적 특징이 혁신의 성공적 assimilation의 가능성에 영향을 준다.
Different organizations provide widely differing contexts for innova- tions, and some features of organizations (both structural and “cultural”) have been shown to influence the likelihood that an innovation will be successfully assimilated (i.e., adopted by all relevant individuals and incorporated into “business as usual”).
혁신의 구조적 결정요인 Structural Determinants of Innovativeness.
4개의 메타분석과 15개의 empirical studies.
We identified four previ- ous meta-analyses that included both manufacturing and service orga- nizations and 15 additional empirical studies
다음의 경우에..
They suggest that an organization will assimilate innovations more readily
- 규모가 크고, 성숙mature하고, 기능적으로 분화되고, 특성화될수록(with foci of profes- sional knowledge) if it is large, mature, functionally differentiated (i.e., divided into semi- autonomous departments and units), and specialized, with foci of profes- sional knowledge;
- 느슨한(여분의) 자원이 새로운 프로젝트로 유입될 때 if it has slack resources to channel into new projects; and
- 탈-중앙화된 의사결정 구조일 때 if it has decentralized decision-making structures (strong direct evi- dence).
규모Size는 다른 determinant의 proxy이다.
Size is almost certainly a proxy for other determinants, including slack resources and functional differentiation.
비록 이러한 구조적 결정요인이 유의하고/긍정적이고/일관되지만, 다 합해봐야 variation의 15% 이하만을 설명해줄 뿐이다. 더 나아가서 구조적 결정요인과 혁신과의 관계는 다른 요인들에 의해서 moderate된다.
Although these structural determinants are significantly, positively, and consistently associated with organizational innovativeness, together they account for less than 15 percent of the variation among compa- rable organizations. Furthermore, the relationship between structural determinants and innovativeness is moderated by and/or contingent on additional factors (e.g., the radicalness of the innovation, whether it is administrative or technical, and the stage of adoption).
구조적 결정요인을 다룬 문헌들의 약점은, 그 요인들을 variable로 다룸으로써 각자의 영향이 고립되어 독립적으로 정량화될 수 있다고 보는 것이다.
One important weakness of the literature on structural determinants of innovativeness is the assumption that they can be treated as variables whose impact can be isolated and independently quantified.
- 예컨대, 조직의 사이즈를 "size effect"로 일반화하려고 한다.
For exam- ple, the empirical studies of organizational size implicitly assume that there is a “size effect” that is worth measuring and that is to some extent generalizable.
다수의 질적연구로 제안된 대안적인 이론적 접근법은 조직의 혁신성은 복잡하고/예측불가능하고/일반화불가능하다는 것이다.
An alternative theoretical approach(House, Rousseau, and Thomas-Hunt 1995), supported by a number of recent detailed quali- tative studies (Champagne et al. 1991; Ferlie et al. 2001), is that the determinants of organizational innovativeness interact in a complex, un- predictable, and nongeneralizable way with one another.
새로운 지식의 흡수역량 Absorptive Capacity for New Knowledge.
다음의 조직이 혁신을 더 잘한다.
An organization that is system- atically able
- 새로운 지식을 도출하고/잡아내고/해석하고/공유하고/리프레임하고/recodify하는
to identify, capture, interpret, share, reframe, and recodify new knowledge; - 그것을 기존의 지식기반과 연결짓는
to link it with its own existing knowledge base; and - 그것을 적절히 사용하는
to put it to appropriate use
will be better able to assimilate innovations, especially those that include technologies (for strong direct evidence, see Barnsley, Lemieux-Charles, and McKinney 1998; and Ferlie et al. 2001).
흡수역량의 전제조건은
Prerequisites for absorptive capacity include
- 조직의 기존 지식기반, 기술기반과 기존의 관련 테크놀로지
the organization’s existing knowledge and skills base (especially its store of tacit, uncodi- fiable knowledge) and preexisting related technologies, - "학습하는 조직"으로서의 문화
a “learning or- ganization” culture, and - 지식 공유를 향한 적극적 리더십
proactive leadership directed toward sharing knowledge (for strong direct evidence, see Barnsley, Lemieux-Charles, and McKinney 1998; Ferlie et al. 2001; and Zahra and George 2002).
강력한/다양한/유기적인/유연한/Adaptable한/자생적 조직 내 네트워크
Strong, diverse, and organic (i.e., flexible, adaptable, and lo- cally grown) intraorganizational networks (especially opportunities for interprofessional teamwork, and the involvement of clinicians in man- agement networks and vice versa) facilitate the development of shared meanings and values in relation to the innova- tion (for moderate direct evidence, see Barnsley, Lemieux-Charles, and McKinney 1998; and Ferlie et al. 2001).
어떻게 연구근거가 확인되고/회람되고/평가되고/사용되는가에 대한 연구를 보면, 연구근거가 조직 차원의 변화 이니셔티브에 기여하기에 앞서서, 지식은 먼저 enact되고, social하게 되어서, 구조화된 지식의 stock에 들어가서 다른 사람과 공유되어야 한다.
A major overview of high-quality qualitative studies of how research evidence is identified, circulated, evaluated, and used in health care organizations (Dopson et al. 2002) confirms other findings from the mainstream knowledge-utilization literature, which suggest that before it can contribute to organizational change initiatives, knowledge must be enacted and made social, entering into the stock of knowledge constructed and shared by other individuals.
변화에 수용적인 맥락 Receptive Context for Change.
receptive context 에는 다양한 것이 있다.
The receptive context for change incor- porates a number of organizational features that have been independently associated with its ability to embrace new ideas and face the prospect of change (Pettigrewand McKee 1992).
In addition to an absorptive capacity for new knowledge, the components of receptive context include
- strong leadership,
- clear strategic vision,
- good manage- rial relations,
- visionary staff in pivotal positions,
- a climate conducive to experimentation and risk taking, and
- effective data capture systems (for strong indirect and moderate direct evidence, see Anderson and West 1998; Barnsley, Lemieux-Charles, and McKinney 1998; Dopson et al. 2002; Gosling, Westbrook, and Braithwaite 2003; Newton et al. 2003; Nystrom, Ramamurthy, and Wilson 2002; Pettigrewand McKee 1992; and Van de Ven et al. 1999).
리더십은 조직구성원들이 수렴적 사고와 규범화된 루틴을 깨고 나오는데 도움이 될 수 있다.
Leadership may be especially helpful in encouraging organizational members to break out of the convergent thinking and routines that are the norm in large, well-established orga- nizations (for strong direct evidence, see Van de Ven et al. 1999).
System Readiness for Innovation
변화를 향한 긴장 Tension for Change.
If staff perceive that the current situation is intol- erable, a potential innovation is more likely to be assimilated successfully (for moderate direct evidence, see Gustafson et al. 2003).
혁신-시스템 적합도 Innovation-System Fit.
An innovation that fits with the organization’s existing values, norms, strategies, goals, skill mix, supporting technolo- gies, and ways of working is more likely to be assimilated (for strong indirect and moderate direct evidence, see Gustafson et al. 2003; Rogers 1995; and the related concept of “fuzzy boundaries” in this article).
(혁신의) 함의에 대한 평가 Assessment of Implications.
If the implications of the innovation (in-cluding its subsequent effects) are fully assessed and anticipated, theinnovation is more likely to be assimilated (for strong indirect and mod- erate direct evidence, see Gustafson et al. 2003; and Rogers 1995).
지지와 지원 Support and Advocacy.
If the supporters of the innovation outnumber and are more strategically placed than its opponents are, it is more likely to be assimilated (for strong indirect and moderate direct evidence, see Champagne et al. 1991; Gustafson et al. 2003; Rogers 1995; and also “champions,” in this article).
시간과 자원의 투자 Dedicated Time and Resources.
If the innovation starts out with a bud- get and if the allocation of resources is both adequate and continuing, it is more likely to be assimilated (for strong indirect and moderate direct evidence, see Gustafson et al. 2003; and Rogers 1995).
혁신에 대한 평가능력 Capacity to Evaluate the Innovation.
If the organization has tight sys- tems and appropriate skills in place to monitor and evaluate the impact of the innovation (both anticipated and unanticipated), the innovation is more likely to be assimilated and sustained (for strong indirect and moderate direct evidence, see Gustafson et al. 2003; Plsek 2003; and Rogers 1995).
외부 맥락: 조직간 네트워크와 협력
The Outer Context: Interorganizational Networks and Collaboration
비공식적 조직간 네트워크 Informal Interorganizational Networks.
한 조직이 혁신을 도입할지 말지 결정할 때 중요한 영향을 미치는 것 중 하나는, 비슷한 다른 조직(homophilous)들이 일정 비율 이상 그 혁신을 이미 도입하였거나 앞으로 그럴 가능성이 있느냐이다
An important influence on an organization’s decision to adopt is whether a threshold proportion of comparable (homophilous) organizations have done so or plan to do so (for strong direct evidence, see Burns and Wholey 1993; Fennell and Warnecke 1988; Robertson and Wind 1983; and Westphal, Gulati, and Shortell 1997).
“cosmopolitan” 조직은 이러한 영향에 더 취약하며(외부 네트워크를 잘 형성한 조직), 조직간 네트워크는 그 혁신이 "규범"으로서 인식된 이후에 혁신의 도입을 촉진한다. 그때까지는 혁신이 뚜렷한 장점이 없다고 인식할 경우, 오히려 혁신을 도입하는데 네트워크는 오히려 장애가 될 수 있다.
A “cosmopolitan” organization (one that is externally well networked with others) is more susceptible to this influence (for strong direct evidence, see Burns and Wholey 1993; Fennell and War- necke 1988; Robertson and Wind 1983; and Westphal, Gulati, and Shortell 1997). Interorganizational networks promote the adoption of an innovation only after this is generally perceived as “the norm.” Until that time, networks can also serve to dissuade organizations fromadopt- ing innovations that have no perceived advantages (for strong indirect and moderate direct evidence, see Abrahamson 1991; Fitzgerald et al. 2002; and Westphal, Gulati, and Shortell 1997).
의도적인 확산전략 Intentional Spread Strategies.
아이디어와 지식의 공유를 위해서 만들어진 공식적 네트워킹 이니셔티브 (quality improvement collaboratives, 종종 "Beacon"이라 불림)는 종종 (그러나 항상은 아님) 효과적이다. 이런 이니셔티브는 비용이 많이 드는 겨웅가 있고, 그 gain을 측정하기 어렵다.
Formal networking initiatives such as quality improvement collaboratives (Øvretveit et al. 2002) or “Beacon” schemes (RashmanandHartley 2002), aimed at sharing ideas and knowl- edge construction, are sometimes but not always effective (for moderate direct evidence, see Flamm, Berwick, and Kabcenell 1998; Horbar et al. 2001; Leape et al. 2000; O’Connor et al. 1996; Øvretveit et al. 2002; Rashman and Hartley 2002; and Rogowski et al. 2001). Such initiatives are often expensive, and the gains from them are difficult to measure;
더 넓은 환경 Wider Environment.
환경적 변인이 조직의 혁신에 미치는 영향에 대한 근거는 적은 편이다. 환경적 불확실성은 혁신에 작은 긍정적 영향이 있거나 거의 영향이 없다.
The evidence for the impact of environmental variables on organizational innovativeness in the service sector is sparse and heterogeneous, with each group of researchers exploring somewhat different aspects of the “environment” or “changes in the environment.” Environmental uncertainty has either a small positive impact or no im- pact on innovativeness (for moderate direct evidence, see Kimberly and Evanisko 1981; and Meyer and Goes 1988),
정치적 지시 Political Directives.
정치적으로 도입의 초기 단계에 "push"하는 것은 성공의 가능성을 높이며, 무엇보다 dedicated funding stream을 만들어내기 때문일 것이다. 외부적 강요(정치적 must-do's)는 조직의 지향(동기부여)을 높여주나, capacity를 높여주는 것은 아니다. 이러한 강요(혹은 그로부터 느끼는 공포)는 조직을 혁신에서 멀어지게 만들 수도 있는데, 지역적으로 생성된 아이디어와 우선순위에 초점을 두기보다는 '그 다음에 무엇을 해야하는가'에 대한 second-guess에 초점을 두게 되기 때문이다.
A policy “push” occurring at the early stage of implementation of an innovation initiative can increase its chances of success, perhaps most crucially by making available a ded- icated funding stream(for strong direct evidence, see Exworthy, Berney, and Powell 2003; Fitzgerald et al. 2002; Granados et al. 1997; and Hughes et al. 2002). External mandates (political “must-dos”) increase an organization’s predisposition (i.e., motivation), but not its capacity, to adopt an innovation (for moderate direct evidence, see Taylor et al. 1998). Such mandates (or the fear of them) may divert activity away from innovations as organizations second-guess what they will be required to do next rather than focus on locally generated ideas and priorities (for strong indirect evidence, see Meyers, Sivakumar, and Nakata 1999; for moderate direct evidence, see Exworthy, Berney, and Powell 2003).
도입과 루틴화
Implementation and Routinization
Meyers, Sivakumar, and Nakata define implementation as “the early us- age activities that often follow the adoption decision” (1999, 295).
조직 수준에서 '혁신을 고려'하는 단계에서 '혁신을 루틴화'하는 단계로 나가아는 것은 비선형적 과정으로 무수한 충격과 실패와 예상하지 못한 사건을 겪는 과정이다.
At the organizational level, the move from considering an innovation to successfully routinizing it is generally a nonlinear process characterized by multiple shocks, setbacks, and unanticipated events (Van de Ven et al. 1999).
조직구조 Organizational Structure.
수용적이고 유연한 조직구조, 의사결정을 양도devolve하는 구조와 프로세스가 도입과 루틴화의 성공 및 가능성을 높여준다.
An adaptive and flexible organizational structure, and structures and processes that support devolved decision making in the organization (e.g., strategic decision making devolved to departments, operational decision making devolved to teams on the ground) enhance the success of implementation and the chances of rou- tinization(for strongindirect anddirect evidence, see Meyers, Sivakumar, and Nakata 1999; and Van de Ven et al. 1999).
리더십과 관리 Leadership and Management.
최고위자의 지지와 도입절차의 지원, 지속적 헌신이 루틴화의 성공을 이룩하는데 도움을 준다. 혁신이 top과 middle manager의 목표와 일치할 때, 리더가 적극적으로 involve해서 자주 조언을 얻을 때.
Top management support, advocacy of the implementation process, and continued commitment to it enhance the success of implementation and routinization (for strong indirect and moderate direct evidence, see Green1998; Gustafsonet al. 2003; Meyers, Sivakumar, and Nakata 1999). If the innovation aligns with the earlier goals of both top management and middle management and if the leaders are actively involved and frequently consulted, the innovation is more likely to be routinized (for moderate direct evidence, see Gustafson et al. 2003).
인적자원 이슈 Human Resource Issues.
성공적인 루틴화는 개별 수행자practitioner의 동기부여/능력/역량에 달려있다. (공식적인 촉진 이니셔티브를 통해서) 초기부터 폭넓게 모든 레벨의 staff들이 involvement함으로써 도입과 루틴화를 성공시킬 수 있다.
Successful routinization of an innovation in an organization depends on the motivation, capacity, and competence of individual practitioners (for moderate direct evidence, see Gustafson et al. 2003). The early and widespread involvement of staff at all lev- els, perhaps through formal facilitation initiatives, enhances the success of implementation and routinization (for strong indirect evidence, see Meyers, Sivakumar, and Nakata 1999; for moderate direct evidence, see Kitson, Harney, and McCormack 1998).
직무의 변화가 적거나 명확할 때, 양질의 훈련자료가 있을 때, 적시에 OTJ 트레이닝이 있을 때. 복잡한 테크놀로지를 도입할 때는 팀 기반의 훈련이 개별 훈련보다 더 효과적일 수 있다.
When job changes are few and clear, high-quality training materials are available, and timely on-the- job training is provided, successful and sustained implementation is more likely (for strong indirect and moderate direct evidence, see Green 1998; Gustafson et al. 2003; Meyers, Sivakumar, and Nakata 1999; and McCormick, Steckler, and Mcleroy 1995). Team-based training may be more effective than individual training when the learning involves implementing a complex technology (for moderate direct evidence, see Edmondson, Bohmer, and Pisano 2001).
펀딩 Funding.
헌신적, 지속적 펀딩이 있을 때
If there is dedicated and ongoing funding for its implemen- tation, the innovation is more likely to be implemented and routinized (for strong direct evidence, see Elliott et al. 1998; Fitzgerald et al. 2002; Green 1998; Gustafson et al. 2003; and Hughes et al. 2002).
조직내 소통 Intraorganizational Communication.
조직 내에서 구조 간 경계를 넘나드는 효과적 의사소통. 네러티브 접근법(i.e., the purposeful construction of a shared and emergent organizational story of “what we are doing with this innovation”) 이 파워풀할 수 있다.
Effective communication across structural (e.g., departmental) boundaries within the organization en- hances the success of implementation and the chances of routiniza- tion (for strong indirect evidence, see Meyers, Sivakumar, and Nakata 1999). A narrative approach (i.e., the purposeful construction of a shared and emergent organizational story of “what we are doing with this innovation”) can serve as a powerful cue to action (for moderate indirect evidence, see Gabriel 2000; for limited direct evidence, see Bate 2004).
조직간 네트워크 Interorganizational Networks.
implementation이 복잡할수록 조직간 네트워크가 중요하다.
The more complex the implementation that is needed for a particular innovation, the greater the significance of the interorganizational network will be to the implementation’s suc- cess (for moderate indirect evidence, see Meyers, Sivakumar, and Nakata 1999; and Valente 1995).
피드백 Feedback.
정확한, 적시의 정보.
Accurate and timely information about the impact of the implementation process (through efficient data collection and review systems) increases the chance of successful routinization (for strong in- direct and moderate direct evidence, see Green 1998; and Grimshaw et al. 2004).
적응과 재발명 Adaptation/Reinvention.
국지적 맥락에 적용될 때
If an innovation is adapted to the local con- text, it is more likely to be successfully implemented and routinized (for strong indirect and moderate direct evidence, see Gustafson et al. 2003; Øvretveit et al. 2002; and Rogers 1995).
모델의 요소들을 연결하기
Linkage among Components of the Model
개발 단계에서의 연결 Linkage at the Development Stage.
중앙에서 개발된(리서치 센터) 혁신이, 개발 단계에서부터 사용자의 관점을 잡아내서 반영하기 위한 목적으로, 개발자들에 의해서 잠재적 사용자들에게 link with 된다면 더 성공적으로 도입될 것이다.
An innovation that is centrally de- veloped (e.g., in a research center) is more likely to be widely and success- fully adopted if the developers or their agents are linked with potential users at the development stage in order to capture and incorporate the users’ perspective (for strong indirect evidence, see Rogers 1995).
이러한 linkage는 단순히 "스펙"을 위한 것이 아니며, 혁신의 의미와 가치에 대한 공유된, 유기적 이해를 위한 것이다.
Such linkage should aim not merely for “specification” but also for a shared and organic (developing, adaptive) understanding of the meaning and value of the innovation in use and should also work toward a shared language for describing the innovation and its impact.
변화 관리자의 역할 Role of the Change Agency.
만약 변화관리자가 dissemination program의 한 부분을 맡고 있다면, 의도된 adopter organization과의 어떠한 linkage도 성공적 도입에 영향을 줄 수 있을 것이다. 특히,
If a change agency is part of a dissemination program, the nature and quality of any linkage with intended adopter organizations will influence the likelihood of adoption and the suc- cess of implementation (strong indirect and moderate direct evidence). In particular,
- 인간의 관계는 긍정적이고 지지적이어야 한다.
human relations should be positive and supportive; - 두 시스템이 공동의 언어와 의미와 가치관을 가지고 있어야 한다.
the two systems should have a common language, meanings, and value sys- tems; - 자원을 공유해야 한다.
they should share resources; - 변화 agency가 네트워킹과 협력을 촉진해야 한다.
the change agency should enable and facilitate networking and collaboration among organizations; and - 변화의 결과가 협력적으로 펴가되어야 한다.
the consequences of innovations should be jointly evaluated.
변화관리자는 이러한 능력이 있어야 한다.
The change agency should have the capacity, commitment, technical capability, com-munication skills, and project management skills to assist with opera-tional issues. This is particularly important in relation to technology-based innovations, which should be disseminated as augmented products with tools, resources, technical help, and so on (for moderate direct evi-dence, see Lomas 2000; and Rogers 1995).
외부 변화 관리자 External Change Agents.
외부 변화 관리자가 더 유용한 경우는 외부변화관리자가....
Change agents employed by external agen- cies will be more effective if they are
- (1) selected for their homophily and credibility with the potential users of the innovation;
- (2) trained and sup- ported to develop strong interpersonal relationships with potential users and to explore and empathize with the user’s perspective;
- (3) encouraged to communicate the users’ needs and perspective to the developers of the innovation; and
- (4) able to empower the users to make independent evaluative decisions about the innovation (for strong indirect and limited direct evidence, see Rogers 1995).
고찰과 향후 연구 권고
Discussion and Recommendations for Further Research
다양한 요소들을 unpack하기 위한 것.
This is, arguably, an inherent char- acteristic of any systematic review that addresses complex interventions and seeks to unpack the nuances of their implementation in different social, organizational, or environmental contexts. In this respect, a meta- narrative review can be thought of as a particular application of a realist review, in which the reviewer’s interpretive judgments are integral to the synthesis process and can never be fully rationalized or standardized (Greenhalgh et al. 2005b; Pawson et al. 2005). The findings presented here, and especially the model in Figure 3, should therefore be seen as “illuminating the problem and raising areas to consider” rather than “providing the definitive answers.”
문헌에서 드러난 여러 주제를 확인시켜주었다.
Our review affirmed many well-described themes in the literature,
또한 문헌의 '악마'를 드러내주었는데, 예를 들자면..
We also exposed some demons in this literature, such as
- 흔히 인용되는 "adopter trait"의 불충분한 근거
the lack of em- pirical evidence for the widely cited “adopter traits”; - 중앙에서 출발하여 공식적 채널로 전파되는 혁신에 초점을 두는 것
the focus on innova- tions that arise centrally and are disseminated through official channels at the expense of those that arise peripherally and spread informally; - (프로세스 혁신이 아니라) 산출물-기반의 혁신의 한정된 일반화가능성
the limited generalizability of the empirical work on product-based inno- vation in companies to process innovation in service organizations; and - 복잡한 서비스혁신의 지속가능성에 대한 문헌 부족
the near absence of studies focusing primarily on the sustainability of complex service innovations.
internal politics에 관한 이슈도 잘 다뤄지지 않음.
Conspicuously absent from most empirical work in the service sector, for example, is the important issue of internal politics (e.g., doctor-manager power balances), which was identified in a single qualitative study as one of sev- eral critical influences (Champagne et al. 1991).
운영그룹steering과 프로젝트시행자worker 사이의 power relations도 중요해 보이나 systematically explore하기 어려움
In an evaluation of five projects to implement complex service innovations in primary health care, our own team found that power relations (especially between a project steering group and the main project worker) were critical to suc- cessful implementation but that they were extremely difficult to explore systematically and raised ethical issues for the research team (Hughes et al. 2002).
연구들은 여러 요소들의 interaction을 보여주지 못하고 있음
Most studies concentrated on a few of the components depicted in our model and failed to take account of their different in- teractions and contextual and contingent features.
shifting baseline과 confounding variable의 문제
The shifting baseline of context and the multiplicity of confounding variables must be stripped away (“controlled for”) to make the research objective (Pawson et al. 2005).
그러나 여기 역설이 있다. Context와 Confounder는 diffusion과 dissemination, implementation의 중심에 있다. 이것들은 연구에 있어서 extraneous한 것이 아니며, 연구의 integral part이다. 특정 맥락과 세팅에서 벌어지는 다양한(그리고 예측불가능한) 상호작용은 혁신의 성패를 결정하는 바로 그것이다.
But herein lies a paradox. Context and “confounders” lie at the very heart of the diffusion, dissemination, and implementation of complex innovations. They are not extraneous to the object of study; they are an integral part of it. The multiple (and often unpredictable) interactions that arise in particular contexts and settings are precisely what deter- mine the success or failure of a dissemination initiative.
방법론적 권고
Based on the findings of this review, on some of the methodological recommendations made by others (Green 2001; Pawson et al. 2005; Rootman et al. 2001), and on feedback from policymakers who read drafts of this review, we suggest that the next generation of research on diffusion of health service innovations should be
• 이론-기반 Theory-driven:
Empirical studies should explore an explicit hypoth- ecated link between an intervention or programand a defined out- come. Specifically, researchers should refine their understanding of the mechanism by which the determinants produce (or fail to produce) the outcome of interest in a particular context.
• 프로세스 지향 Process rather than “package” oriented:
Researchers should avoid ques- tions framed in terms of causal inferences, such as “Does programX work?” or “Does strategy Yhave this effect?” Rather, research ques- tions should be framed so as to illuminate a process; for example, “What features account for the success of programXin this contextand the failure of a comparable programin a different context?”
• 생태학적 Ecological:
Research should recognize the reciprocal interaction be- tween the program that is the explicit focus of research and the wider setting in which it takes place. The latter provides a dynamic, shift- ing baseline against which any program-related activity will occur; each influences the other. Program-setting interactions form an important element of data and are a particularly rich source of new hypotheses about mechanisms of success or failure.
• 공통의 정의/척도/도구 Addressed using common definitions, measures, and tools:
Empirical work should adopt standardized approaches to measuring key variables and confounders (e.g., quality of life, implementation success) to enable valid comparisons across studies.
• 협력적, 조직화된 Collaborative and coordinated:
Research teams should prioritize and study research questions across multiple programs in a variety of contexts, rather than small isolated teams “doing their own thing.” In this way, the impact of place, setting, and context can be systematically studied.
• 다학제간, 다방법론적 Multidisciplinary and multimethod:
Research should recognize the in- herent limitations of experimental approaches to researching open systems and embrace a broad range of research methods emphasizing interpretive approaches.
• 세심한 디테일 Meticulously detailed:
Studies should document the unique aspects of different programs and their respective contexts and settings to allow for meaningful comparisons across programs. Such detailed descriptions, perhaps stored centrally as electronic appendices to published papers and reports, could be usedby future research teams to interpret idiosyncratic findings and test rival hypotheses about mechanisms.
• 참여적 Participatory:
Because of the reciprocal interactions between context and program success, researchers should engage “on-the-ground” service practitioners as partners in the research process. Locally owned and driven programs produce more useful research questions and data that are more valid for practitioners and policymakers.
Innovations
- How do innovations in health service organizations arise, and in what circumstances? What mix of what factors tends to produce “adoptable” innovations (e.g., ones that have clear advantages beyond their source or- ganization and low implementation complexity and are readily adaptable to new contexts)?
- How can innovations in health service organizations be adapted to be perceived as more advantageous, more compatible with prevailing norms and values, less complex, more trialable, with more observable results, and with greater scope for local reinvention? Is there a role for a central agency, resource center, or officially sanctioned demonstration programs in this?
- How are innovations arising as “goodideas” inlocal healthcare systems reinvented as they are transmitted through individual and organizational networks, and how can this process be supported or enhanced?
- How can we identify “bad ideas” likely to spread so that we can intervene to prevent this?
Adopters and Adoption
- Why and how do people (and organizations) reject an innovation after adopting it? (In the more than 200 empirical research studies covered in our review, only one explicitly and prospectively studied discontinuance; see Riemer-Reiss 1999).
- What are the transferable lessons fromcognitive and social psychology about the ability and tendency of individuals to adopt particular innova- tions in particular circumstances? For example, what can we glean from the mainstream literature about how individuals process information, make decisions, apply heuristics, and so on? A particularly fruitful area is likely to be the psychological literature on the interaction between humans and computers as it applies to the adoption and assimilation of information and communications technology (ICT) innovations in the service sector.
Dissemination and Social Influence
- What is the nature of interpersonal influence and opinion leadership in the range of different professional and managerial groups in the health service, especially inrelationto organizational innovations? Inparticular, how are key players identified and influenced?
- What is the nature and extent of the social networks of different players in the health service (both clinical and nonclinical)? How do these networks serve as channels for social influence and the reinvention and embedding of complex service innovations?
- Who are the individuals who act as champions for organizational innovations in health services? What is the nature of their role, and how might it be enabled and enhanced?
- Who are the individuals who act as boundary spanners among health service organizations, especially in relation to complex service innova- tions? What is the nature of their role, and howmight it be enabled and enhanced?
The Organizational Context
- To what extent do “restructuring” initiatives (popular in health ser- vice organizations) improve their ability to adopt, implement, and sus- tain innovations? In particular, will a planned move from a traditional hierarchical structure to one based on semiautonomous teams with in- dependent decision-making power improve innovativeness?
- How can we improve the absorptive capacity of service organizations for new knowledge? In particular, what is the detailed process by which ideas are captured from outside, circulated internally, adapted, reframed, implemented, and routinized in a service organization, and how might this process be systematically enhanced?
- How can leaders of service organizations set about achieving a recep- tive context for change; that is, the kind of culture and climate that supports and enables change in general? A systematic review centering on the mainstream change management literature (which we explicitly excluded from this review) is probably the most appropriate first step for this question.
- What is the process leadingto long-term routinization(withappropri- ate adaptation and development) of innovations in health service delivery and organization?
System Readiness for Innovation
- What steps must be taken by service organizations when moving toward a state of “readiness” (i.e., with all players on board and with pro- tected time and funding), and how can this overall process be supported and enhanced? In particular,
- (1) How can tension for change be engen- dered?
- (2) How can innovation-systemfit best be assessed?
- (3) How can the implications of the innovation be assessed and fed into the decision- making process?
- (4) What measures enhance the success of efforts to secure funding for the innovation in the resource allocation cycle? and
- (5) How can the organization’s capacity to evaluate the impact of the innovation be enhanced?
- What are the characteristics of organizations that successfully avoid taking up “bad ideas”? Are they just lucky, or do they have better mech- anisms for evaluating the ideas and anticipating the subsequent effects?
The Outer Context
- What is the nature of informal interorganizational networking in different areas of activity, and howcan this be enhanced through explicit knowledge management activities (such as the appointment and support of knowledge workers and boundary spanners)?
- What is (or could be) the role of professional organizations and infor- mal interprofessional networks in spreading innovation among health care organizations?
- What is the cost-effectiveness of structured health care quality collab- oratives and comparable models of quality improvement, and how can this be enhanced? To what sort of projects in what sort of contexts should resources for such interorganizational collaboratives be allocated?
- What are the harmful effects of an external “push” (such as a policy directive or incentive) for a particular innovation when the systemis not ready? What are the characteristics of more successful external pushes promotingthe assimilation and implementation of innovations by health service organizations?
Implementation
- By what processes are particular innovations in health service delivery and organization implemented and sustained (or not) in particular con- texts and settings, and can these processes be enhanced? This question, which was probably the most serious gap in the literature we uncovered for this review, would benefit fromin-depth mixed-methodology studies aimed at building up a rich picture of process and impact.
- Are there any additional lessons from the mainstream change man- agement literature (to add to the diffusion of innovations literature re- viewed here) for implementing and sustaining innovations in health care organizations?
Greenhalgh, T., G. Robert, P. Bate, O. Kyriakidou, F. Macfarlane, and R. Peacock. 2005a (forthcoming). Diffusion of Innovations in Health Service Organisations: A Systematic Literature Review. Oxford: Black- well.
Milbank Q. 2004;82(4):581-629.
Diffusion of innovations in service organizations: systematic review and recommendations.
Author information
- 1University College London, Room 403, Holborn Union Building, Highgate Hill, London N19 5LW, UK. p.greenhalgh@pcps.ucl.ac.uk
Abstract
Comment in
- PMID:
- 15595944
- PMCID:
- PMC2690184
- DOI:
- 10.1111/j.0887-378X.2004.00325.x
- [PubMed - indexed for MEDLINE]
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