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    Quality improvement interpreted as a complex adaptive system : implications and opportunities : a thesis submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy at Massey University, Palmerston North, New Zealand
    (Massey University, 2024-11-01) Wilson, William
    The effectiveness of quality improvement (QI) methods in healthcare has been challenged, especially under circumstances of high complexity. This thesis examines the implications for quality improvement if complex socio-technical systems such as healthcare are interpreted as complex adaptive systems (CAS). The research followed a mixed-method design. Informed by the complex systems and quality management literature, a conceptual model for quality improvement within CAS was developed — the complex quality improvement network (CQIN). An agent-based simulation model was then used to establish the plausibility and face validity of the model constructs and their interaction. Thematic analysis and crisp-set qualitative comparative analysis (QCA) were then used to examine the evidence for CQIN constructs within published quality improvement case studies. One applied case study was also conducted for deeper insight into the practical difficulties of interpreting a real-world quality improvement project as a CAS. Finally, the findings of the simulation modelling and the secondary data analysis were integrated into a Bayesian network model. Empirical evidence, in the form of consistency across cases and coverage within cases, was found for eleven of the twelve CQIN constructs. Multiple sets of sufficient conditions for reported improvement success were identified across cases. These sets were minimised to four strategies for successful quality improvement; i) strengthening agent network communication paths; ii) building shared understanding of problem and context amongst networked agents; iii) increasing problem-solving effectiveness; and iv) improved system signal integration. If the evolutionary foundations for CAS are in some way inhibited, the likelihood of quality improvement success is reduced. Healthcare quality improvement can be plausibly simulated using fundamental CAS principles. The first contribution to quality improvement discourse is the CQIN model, a CAS model of change applied specifically to quality improvement. A second contribution of this research is a complex quality improvement risk assessment model, the CQIN Bayesian Network. Practitioners can use this model to examine and test identified CAS-informed improvement strategies. The individual CQIN constructs make a third contribution by providing new categories of causal factors for the comparison of disparate quality improvement case studies.
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    An exploration of the organisational excellence architecture required to support an award-winning business excellence journey : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy at Massey University, Palmerston North, New Zealand
    (Massey University, 2024-12-09) Baig, Mirza Atif
    The Business Excellence (BE) approach and its underlying philosophy are now established means of enhancing organisations’ performance. BE is institutionalised through BE models to achieve excellence in strategies; business practices; and, stakeholder-related performance results. In turn, these activities contribute to the organisation becoming best in their respective market. While numerous studies have examined different aspects of BE, there remains a lack of research on the actual BE implementation required to guide researchers, consultants and practitioners. The absence of a unified framework has led to inconsistent practices across organisations, of which some has resulted in results less than expected. To bridge this gap, this research introduces the novel concept of Organisational Excellence Architecture (OEA). OEA refers to the formal support structure, resources, processes and assessment tools used to assist the implementation of BE within an organisation. This research explores the OEA supporting award-winning BE maturity. A sequential mixed methods approach was adopted that resulted in participation from 50 organisations across 17 countries. Contributions were acquired by way of an online survey, followed by optional structured interviews to identify BE their implementation approaches and best practices. The empirical data guided the iterative development of the OEA model established from the literature and the subsequent refinement of the final OEA model. This model is supported with an OEA design toolkit. The toolkit includes OEA design tool guidelines; an OEA design assessment tool; best practices examples; and, four research articles. This study makes a contribution to the BE literature, providing detailed, updated research on BE implementation approaches and best practices. It offers practical insights for BE practitioners and organisations, enhancing the understanding of effective BE implementation strategies. Future research is now invited to validate and refine the OEA model and the OEA design toolkit to improve their applicability and effectiveness across diverse organisational contexts.
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    The key factors driving successful improvement in primary care : a mixed methods investigation of the determinants of quality improvement success in Aotearoa New Zealand : a thesis with publication presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy, Massey University, Palmerston North, Aotearoa New Zealand
    (Massey University, 2023-11-30) Cullen, Jane
    Primary care is where the population receives most of their health care and where successful quality improvement (QI) can have the biggest impact on health, wellbeing, equity, and health system performance. A better understanding of the factors that influence QI in primary care is urgently needed to support a high-performing primary healthcare system. Most prior studies into the determinants of effective QI have focused on secondary care organisations and large-scale collaborative efforts. Primary care services such as general practice present a different set of challenges. Various key contextual factors have been identified in the literature, but few studies explain how they relate to each other and QI success. This study sought to answer the following questions: 1. What are the contextual factors influencing primary care improvement interventions? 2. How do the contextual factors, improvement content (topic and planned changes) and the implementation process influence each other and the improvement outcomes in primary care? 3. How applicable for primary care assessment is the Model for Understanding Success in Quality (MUSIQ), a tool for assessing modifiable contextual factors developed in secondary care? This research was an explanatory sequential mixed methods study based in the Aotearoa, New Zealand (NZ) primary care setting of general practice and Primary Health Organisations (PHOs). Amulti-case mixed methods approach was followed in the first stage. Mainly qualitative data were collected from primary care interviews guided by the Consolidated Framework for Implementation Research (CFIR). This was compared with quantitative data from the MUSIQ survey. The second stage consisted of a national survey where emerging theory was tested by partial least squares structural equation modelling (PLS-SEM). The findings revealed that most teams did not use formal QI methods, instead relying on their people-centred relationship skills and networks to drive QI via distributed leadership. Teams were intrinsically motivated by community and patient need and drew on strengths developed within the complexity and uncertainty of the primary care settings to drive QI. The collaborative skills which are increasingly required in the modern primary care setting support the shared social processes of sensemaking for enacting change. The key success factors driving QI in primary care are identified and how they relate to each other explained. A primary care adaptation of MUSIQ has been proposed that may aid improvement practitioners and researchers to assess primary care contexts. The key strengths should be developed and supported across primary care services and capability, capacity and resources supported centrally to increase the ability of primary care to improve services more easily and effectively.
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    A global study on how the national business excellence (BE) custodians design BE frameworks and promote, facilitate, and award BE in their countries : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Engineering at Massey University, Manawatu Campus, New Zealand
    (Massey University, 2021) Ghafoor, Saad
    Business Excellence (BE) is a philosophy and a collection of BE Frameworks (BEFs) for organisations to follow to achieve excellence in strategies, business practices, and stakeholder-related performance results, to ultimately become the best they possibly can be. This research aimed to investigate the current state of and best practices in designing BEFs and deploying (promoting, facilitating, and awarding) BE on a national and/or regional level. The aim of this research was met through first conducting a systematic review of BE literature followed by collecting data directly from BECs. A mixed methodology and pragmatic philosophy were used in this research, thus collecting and analysing both quantitative and qualitative data. With regards to the participants of the research, 29 BECs from 26 countries undertook a 46-question survey. Of the survey participants, 13 BECs also undertook optional follow-up online structured interviews. It was found that while the BE literature comprises of 415 journal papers, no research covers how BECs support BE in their countries. There are 74 countries and four regions with BE Custodians (BECs) that promote BE within their countries, of which 57 actively hold BE Awards (BEA) with their last award held in 2018 or after. A key finding of this research is that BECs focus more on their BEA activities than their BE promotion and facilitation activities and report low levels of BE awareness and usage levels. A general framework for designing and reviewing a BEF is provided along with recommendations for BECs to improve their BE promotion, facilitation, and award activities. The findings of this research will help the national BECs to better understand their strengths and opportunities for improvement and to learn from other BECs’ practices. This will assist the BECs to better foster a culture of BE in their countries’ organisations that follow or aim to undertake a BE journey (of using a BE and adopting outstanding practices to achieve results) to ultimately benefit all of their stakeholders and lead to improved economic and societal benefits at a national level.
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    Accepting complexity, creating order : using complexity theory as a lens through which to understand limitations of target-based quality improvement approaches in primary care, and to design interventions for the future : a thesis presented in partial fulfilment of the requirements for the Masters of Quality Systems at Massey University New Zealand, Manawatū, New Zealand
    (Massey University, 2020) Mercer, Chloe Evelyn Temple
    A strong primary care system is essential for improving health outcomes, and Quality Improvement (QI) science and methodologies are seen as useful approaches for reducing variation in outcomes. QI science has its origins in industrial settings dominated by mechanistic, linear approaches. By contrast, health care (including primary care), is increasingly being understood through the lens of complexity science, as a complex, non linear system, or more specifically a Complex Adaptive System (CAS). In order to design QI approaches that work in health care understanding the interaction between the system and a QI approach and matching the approach to the environment is important. This exploratory research utilised a complexity lens as a worldview or metaphor in which to gain an insight into General Practitioner (GP) views of Target Based Performance Programmes (TBPP), as an example of a current QI approach. The aim was to understand if viewing primary care as a CAS could explain limitations of a TBPP approach, and if the same lens could offer ways to adapt and improve QI programmes in primary care, and in complex systems more broadly. More specifically the research aimed to understand if there was a relationship between complexity of problems (which were the focus of a TBPP), and how effective GPs believed the targets were, as well as whether there was a relationship between the complexity and their engagement in achieving targets. A philosophy of pragmatism was applied in designing the research. The epistemology and methodology (research design and methods) applied in this research were positivist in nature. The research tool used was a single-stage exploratory survey. The participants of the research were GPs. There were 27 surveys used in the analysis, which while small provided rich insight. Quantitative methods were used to analyse the data, with qualitative data providing detail to themes. The main findings of this research are that there is a relationship between how complex a problem is perceived to be by GPs, and the extent to which targets are believed to be a good QI approach. Targets where the problem-in-focus is understood as complex, are less likely to be seen as an appropriate approach. To a lesser extent there is also a relationship between increased engagement and decreased complexity. More generally the research suggests there may be a negative relationship between target-based approaches and engagement. Complexity is only one component that needs to be considered in developing QI approaches in primary care; strength of evidence, adequate resourcing, knowledge of QI methods, and consideration of social determinants were also highlighted. This research has shown that a complexity lens provides useful insight into the health system, and that Cynefin, or similar, as a framework for matching problems to approaches could be a useful tool to support and augment QI approaches in primary care. While this research specifically focusses on health care as a CAS, the discussion, approach and findings may be applicable when considering other systems or organisations which can be viewed as displaying characteristics of CAS.
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    Diagnosing and designing process stability and adaptability at Transpower New Zealand Limited using the Process Warrant of Fitness and the Viable Process Model : a thesis presented in partial fulfilment of the requirements for the degree of Master of Quality Systems at Massey University, Palmerston North, New Zealand
    (Massey University, 2019) Lemaire, Gregory Michael
    This research developed an evaluative model and tool incorporating principles and practices of the Work Systems Method (WSM) and Viable System Model (VSM) to assess the viability of processes at Transpower NZ Limited, a New Zealand State Owned Enterprise. The assessment tool looks for opportunities to sustain process identity, as well as identifying the potential for enhanced planning, control, and coordination of the work, and preserving connections to the outside world, including suppliers, customers, and regulators. Eight employees took part in interviews to reveal Transpower’s collective process requirements. These requirements became a key input into the assessment tool, called the Process Warrant of Fitness (WOF). The tool was tested on a range of Transpower processes, successfully identifying viability enhancement opportunities. The assessment tool was then tested on two non-Transpower processes to gauge its applicability outside of Transpower. To lower the barriers to adoption of the tool, an end to end user participation format, called the Viable Process Model (VPM) was also developed, further drawing on WSM and VSM principles. The VPM guides the user to identify processes to assess, apply the assessment tool, and undertake post-assessment activities. While each workplace may appear to have its own unique process viability challenges, the assessment tool and user participation format showed potential as a universal pathway to process viability, having identified opportunities in the organisations that had its processes assessed.