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Table 3 Key themes in relation to the components of the Greenhalgh model

From: Why do GPs hesitate to refer diabetes patients to a self-management education program: a qualitative study

Components of the diffusion of innovation model Strategies used to enhance implementation Key themes
1. Attributes of the innovation
To be successfully and widely adapted, an innovation must be seen by potential adopters as having:
• Relative advantage
• Simplicity
• Compatibility with existing values and ways of working
• Trialability
• Observability
• Potential for reinvention
• theory-driven program based on current evidence
• well-trained diabetes educators
• integrated in primary care
• no financial threshold for patients
• possibility of home visit
• extra administrative workload
• motivation of patients requires extra consultation time
• doubts about the added value of the service
• potential benefits not visible enough
• distance to the centre
2. Concerns of potential adopters
Adoption is a process, not a one-off event, and is influenced by concerns, including:
• Prior to adoption (what are its properties and potential benefits? What will it cost me?)
• During early use (how do I make it work?; when and how should I use it?)
• During established use (how can I alter or improve it?)
• interdisciplinary care protocol with clear job descriptions
• strengthening of GPs' role in diabetes care
• referral by GP obliged
• advice regarding the target groups
• fear of further fragmentation of diabetes care
• fear of negative interference with the doctor-patient
• fear of losing control over therapy
• uncertainty about job boundaries
• doubts about which of their patients will benefit (the most)
• lack of motivational skills
• patients are not asking for the service themselves
3. Communication and influence
An individual's decision to adopt an innovation is influenced by:
• Mass media
• Interpersonal influence
• information campaign targeting GPs, patients and other health care providers • confusion regarding the aims of the project
• limited awareness of the program among patients
• negative attitude of peers towards the program
4. Organisational antecedents for innovation Organisations may be more or less innovative. Differences are explained by several factors:
• Absorptive capacity for new knowledge
• Leadership and management
• Risk-taking climate
• Effective data capture systems
• Slack resources
• establishment of a local steering group
• appointment of a program manager
• involvement of regional stakeholders
• sufficient financial resources (for the course of the pilot)
• no tradition with the initiation of care innovation in primary care
5. Organisational readiness for innovation
Readiness includes:
• Innovation-system fit
• Tension for change
• Balance between supporters and opponents
• Specific preparedness
• survey among health care providers at the start of the project, exploring the needs regarding diabetes care in the region • non-referral as a way to express dissatisfaction with their current role in the health care system
• disbelief that project results can influence health policy
6. The implementation process
Implementing a complex innovation, and making sure it becomes business as usual, is a highly non-linear process, typically characterised by shocks and setbacks. Critical success factors include:
• Appropriate of change model
• Good project management
• Human resource issues
• Alignment between new and old routines
• establishment of a local steering group
• establishment of study groups
• appointment of a program manager
• balanced implementation plan ('help it happen' strategy)
• tend to forget about the service
7. Linkage
Innovation is more likely when there is:
• Early and ongoing dialogue between developers of the innovation, the change agents charged with promoting its adoption, and its users
• Communication within the organisation and between similar organisations
• involvement of GPs in program development, initial via their QPRGs, later on via the study groups
• involvement of all health care providers involved in diabetes care via study groups
• not used to being involved in care innovation development
8. The broader context
Innovation in organisations is more likely to be successful when there is a 'following policy wind', a conductive socio-political climate, and specific incentives and mandates at national level
• integration of the program in primary care
• financial resources provided by project funding
• regular contact with the commissioners of the study
• feelings of frustration and insecurity regarding GPs' position and role in health care
• disbelief that project results can influence health policy
• uncertainty about continuity of the program