Secondly, the research will adopt an integrative multi-stakeholder perspective (employees, patients and managers) in determining the factors  affecting the implementation of cost-effective healthcare innovations.  The project will take account of the respective core concerns of these three stakeholder groups, namely quality of labour (employees), quality of  care (patients) and efficiency (managers). Thirdly, the research will distinguish between innovations deemed to have medical, strategic and fiscal  benefits – and which may be radical or incremental. This will facilitate consideration of how the nature of the innovation affects adoption and  implementation.  Progress beyond the state of the art  International healthcare systems face the common, enduring and pivotal challenge of achieving higher quality, for less cost (Dopson, 1994). As a  result, there is a strong pragmatic imperative to identify the factors which hamper the successful implementation of cost-effective healthcare  innovations. In considering the implementation of innovations, research to date has alluded to the potential impact of 1. the nature of the  innovation, which may be radical or incremental, depending upon its impact on strategically-important priorities and the number of staff involved  in its delivery (West & Farr, 1990); 2. the national context in which the innovation is to be implemented (Bhagar, Harvesto & Triandis, 2002).; 3.  the organizational context in which the innovation is to be implemented (Pettigrew, Ferlie & McKee, 1992); 4. the behavioural  change (or inertia) of employees, as innovation implementation requires healthcare workers who are willing,  capable and engaged to change their work behaviour (McNulty & Ferlie, 2002), 5. the role of patients (Bate  & Robert, 2006) and 6. cost efficiency and managerial support (Dopson, 1994). Our research design will allow us to simultaneously consider  these different factors to assess their individual and combined impacts on the implementation of selected innovations.  We define innovation in line with Crossan and Apayin (2010) as ‘the production, adoption or assimilation and exploitation of a value-added  novelty in economic and social spheres’ (p. 1155). Although innovation can be conceptualized as both a process or an outcome, here we focus  on the latter, using the term synonymously with the label ‘intervention’ which has common currency in a healthcare setting. Innovation may be  absolute or relative, derived from within or alternatively arising from external linkage, and is not just  a creative process but also involves adoption - where a decision is made to enact the innovation - and implementation - where stakeholders  direct their energies towards ensuring that the innovation becomes embedded in organizational functioning. According to Crossan and Apayin  (2010) there is a research gap in  our understanding of these latter phases which needs to be addressed, since if an innovation is poorly executed, or its implementation seriously  delayed, the innovation may fail to deliver the anticipated results.  Innovation implementation considerations are applicable whether the innovation is incremental or radical, technical or administrative or product,  service or process-oriented (although implementation considerations may be more pressing for innovations which are radical in orientation).  Furthermore, innovations may arise in any specialist area (Shipton et al., 2006). For example, in a healthcare setting, an innovation may either  be led by a group of clinicians or else initiated by management (as discussed below). We suggest that understanding the impediments and  predictors for innovation implementation may boost the creative propensity of various stakeholder groups, heightening the perception that new  ideas will move beyond the initial phase. This orientation may, in turn, yield a context which is open to change.  In this study we distinguish between innovations which are:   1) medical and individualistic in orientation   2) fiscal-managerial and   3) strategic (Greer, 1984).   Although distinctions across the three categories are sometimes blurred, this approach allows us to examine in detail interventions that integrate  individual, community, organisational and societal systems. Innovations that are medical and individualistic in orientation tend to be driven by  expert physicians for use in clinical practice, with outcome measures taking account of patient welfare and clinical improvements. Fiscal-  managerial innovations, by contrast, expand or upgrade the service offerings of healthcare organizations and/or reduce costs. Financial  managers and accountants are involved in these decisions, and outcome measures represent the extent of utilization, cost-benefits, and the  market potential of the technology. Strategic innovations imply significant alterations in the mission of the healthcare organization. For these  innovations, the board of the healthcare organization and chief executive officers tend to set the agenda. The main outcome measure for this  type of innovation is the strategic value for the healthcare organization concerned.  To structure the research programme, in addition to a project management and coordination, the perspectives of the three stakeholders –  employees, patients and management are considered as vertical ‘pillars’. The pillars are linked together by focusing on several innovations  which fall into one or another of the categories defined above. Next, the potential role of the three stakeholder groups in relation to the adoption  and implementation of the innovations are considered.  The employee perspective: quality of labour. The presence of multiple professional healthcare groups, each operating in a distinct community of  practice with strong social and cognitive boundaries makes the enactment of healthcare innovations more complex, while bureaucratization and  institutional inertia may be additional impediments (Ferlie, Fitzgerald, Wood, & Hawkins, 2005). A variety of organization level initiatives,  including clinical directorate structures and clinical management roles have been introduced in different European countries, as potential  remedies to professional boundary issues. In addition, recent work (e.g. Michie & West, 2004) has argued that people management practices  may improve the performance of healthcare employees (and subsequent organizational outcomes) in several ways: by promoting a supportive  culture where staff feel comfortable about reporting errors (e.g. Edmondson, 1999) by adopting strategies and practices to increase employee  involvement and control over work and by building employee knowledge  and skills. Appraisal and performance management systems, as one element of a Human Resource Management (HRM) system clarify where  responsibilities lie and offer support to individuals as they acquire  the skills necessary to work effectively. Furthermore, an HRM system may promote an exploratory learning focus. Through project working, job  rotation and visits to parties external to the organization, employees can achieve the attitudinal change required to question and challenge  existing ways of operating (Cross, Parker, Prusak & Borgatti, 2001), leading in turn engagement with innovation implementation.  The patient perspective: quality of care. Although the employee perspective has been shown to affect successful implementation, incorporating a  patient-perspective is also increasingly accepted as important. In describing quality care, a report by the Institute of Medicine in the US entitled  ‘Crossing the Quality Chasm’ identifies patient-centredness and safety as among ‘six aims for improvement’ (cited in Berwick, 2004).  Safety entails a reduction in medical injuries to patients, while patient centred care refers to ‘constellations of qualities of care that can give  patients and carers power, knowledge, dignity, self-efficacy skills, respect for their diversity and freedom of action.’ (Berwick, 2004: 408). The  issue of patient-centred care is rising internationally. In service-improvement terms, patient-centred care is evident in a variety of initiatives, such  as co-design of services and service-improvement with patients (Bate & Robert, 2006). Bate and Robert (2006, p. 307) note the emergence of  ‘design science’ and ‘experience based design’ ‘in which the traditional  view of the user as a passive recipient of a product or service has begun to give way to the new view of users  as integral to the improvement and intervention process’.  Management perspective: productivity/efficiency. Efficient and effective management of healthcare processes is extremely complex, and requires  balancing the interests of all involved stakeholders. In addition  to the employee and patient stakeholder concerns detailed above, and spurred by increasing expenditures, healthcare managers are paying  rising attention to efficiency concerns. As a result, providers are increasingly  forced to rethink the way their processes are organized. Healthcare managers often lack training in operations management skills, and current  information systems in hospitals are not geared to supply the required information for intelligent planning and control. Moreover, the cost-  effectiveness of innovations is generally not known. As a result, recently developed healthcare process planning and control concepts, including  ICT, quality management, finance and logistic have only had a marginal impact in practice, and healthcare innovation implementation is lagging  far behind manufacturing planning and control.  Our research will explore a broad range of innovations from the perspectives of these three stakeholder groups. This will facilitate consideration  of the impact of the nature and scale of the innovations on adoption and implementation. The selected innovations encompass initiatives across  the three previously identified categories of medical-individualistic, fiscal-managerial and strategic innovations.  Medical-individualistic innovations  1. Thromboembolism (VTE). Salisbury Foundation Trust (a major rural hospital in the UK) identified venous thromboembolism (VTE) as a major  issue for patient safety, with the same level of importance as infection control. A thrombosis committee developed a strategy for risk assessing all  inpatients at the point of decision to admit. When the VTE policy was written, the trust’s compliance for documented risk assessment of all  inpatients and targeted thromboprophylaxis was about 15 per cent. League tables pushed that up to about 50 per cent, and the nurse education  up to 70-75 per cent. In two years the trust has halved secondary VTEs and mortality has decreased. (Health Service Journal, August 26, 2010).  2. Colorectal screening. The Health Council in the Netherlands has recommended adding screening for colorectal cancer to the national health  program. Fecal occult blood test (FOBT) can be introduced in the general screenings program, or a more innovative technique such as virtual  colonoscopy can be adopted.  These screening techniques differ strongly in the impact they have on patients. Impacts include associated risks, social stigma and diagnostic  effectiveness. Moreover, the widespread adoption of one of these techniques is likely to be dependent upon the efficient organization of care. In  other countries, the uptake of Colorectal Cancer Screening remains poor.  Fiscal- managerial innovations  3. Patient’s sojourn time. In many hospitals there is a long waiting period for diagnostic services. However, when a diagnosis has been made,  follow-up care is promptly identified and executed. To eliminate access / waiting time, diagnostics can be organized on a walk-in basis. Walk-in  diagnostics, by definition, eliminate access / waiting time, and heavily impact the lead-time of the patient’s care pathway. Many hospitals are,  however, hesitant to implement this innovative concept.  4. The Manchester Triage System (MTS) allows a fast and structured assessment of patients’ status in an emergency unit. The MTS provides  guidelines on who is in need of immediate treatment and separates them from those who require less immediate attention. Assessment is  performed by qualified and trained nurses, rather than doctors. Thus, MTS supports patient care by a standardised system of prioritisation and is  meant to reduce the workload of all staff involved. The MTS proved controversial on its introduction into German hospitals.  Strategic innovations  5. Infrastructure design. There is much clinical evidence that the “healing environment” can affect the speed of a patient’s recovery. The healing  environment of buildings has two components: the interior (referring to the furnishing and interior styling of a building) and the architectural  design (referring to the structural design aspects). Recent developments in both areas (Dijkstra, Pieterse & Pruyn, 2006) have demonstrated  impact on quality of care, employee outcomes, and productivity.  6. Patient case-management system. Under the patient-case management system an in-hospital case manager coordinates the diagnosis, care  and discharge of a patient to ensure that the patient progresses through the care pathway. The in-hospital case manager plans the patient’s  discharge to a community-based case manager (located in a “Pflegestützpunkt” – care station) who continues to coordinate treatment and  provides support and advice to the family. Case-management systems affect the role of the doctor since they have to devolve responsibility and  decision making authority to other staff groups.  7. House for Health. Houses of health are public centres for health and social well-being, supported by local community organizations. Their  objective is to promote the unity and integration of primary care and social services through spatial proximity. The centres facilitate ambulatory  outpatient care and the tailoring of general and specialist medicine for a specific portion of the population.  Methodology and associated work plan  The research will combine the perspectives of three key stakeholder groups (multi actor); the nature and extent of innovation implementation  across individual, organisational and societal levels (multi level) and different research methods (multi method). The methods to be adopted  include 1. preliminary scoping interviews, 2. multi-criteria decision analyses (AHP); and 3. a survey. In the first stage of the research, preliminary  scoping interviews with the three stakeholder groups will be conducted. These will support contextual understanding and accurate instrument  construction via the identification of salient hard and soft decision criteria. Prioritization of these criteria will then be conducted by panels of  patients, employees and managers.  The measurement of the performance of the innovations regarding the ‘hard’ criteria will be based on the outcomes of logistical modelling. The  measurement of the performance of the innovations regarding the ‘soft’ criteria will be based on the judgements of the patients, employees and  management. A weighted average of the performance of the innovations and their implementation on the prioritized performance criteria will  reflects the overall performance of the innovations and, as a consequence, the estimated rate of the adoption. This data will also be utilised to  provide insight into the relative weight of stakeholder perspectives on adoption decisions. Saaty’s mathematical model, the analytic hierarchy  process (AHP), will be applied to assess the perceived impact of the different innovations on the quality of labour, the quality of care and the  efficiency of care (key stakeholder concerns). Prior research (e.g. Dolan et al (1991) and Hummel et al (2000)) has shown that the AHP is  particularly valuable for evaluating the implementation of health care innovations.  In the second stage of the research, the findings will be validated in ‘real life’. In each country surveys of patients, employees and managers will  be conducted. The surveys will utilise validated and reliable scales to  assess the relative impact of the stakeholders and the behavioural change of employees and patients, with regard to the innovation. The patient  surveys will include questions regarding lifestyles and life skills, empowerment and self-management of condition. The employee and  management survey will include questions regarding innovative behaviour, organisation commitment, willingness to change, resistance to  change and engagement. Data from these studies will be analysed by means of multi level modelling techniques.  Workplan: In year one the collective and in-country research teams will conduct a comprehensive literature review in the project domains. In  addition, particular attention will be afforded to cross-national contextual familiarisation, with the collective research team becoming familiar with  the problems related to the specific innovations in the different European countries. In year 2 the execution of the AHP will be completed in each  country. The preliminary findings will be reported through the writing of at least one conference paper, to be presented at an international  conference, and the generation of at least one article.  After finalisation of the AHP, the survey validation instrument will be prepared. In year 3 the data collection will be completed, data will be  analyzed, and validated. The research team will begin to disseminate the research findings through conference paper and article write-up. An  international conference will be attended. Cross-national discussions regarding further grant applications emanating from the research will take  place. 2. Impact 2.1 Expected impacts listed in the work programme  This research programme will support the adoption of cost-effective healthcare innovations and interventions, which are a strategic imperative for  most developed countries. According to the World Health Organization (WHO, 2008), there are growing inequities between countries. Cost  effective healthcare innovations can help combat such inequity, by increasing care provided within available resources. This can help address  common challenges, including 1. greater workloads, often among fewer clinicians, associated with higher patient acuity (Hogan, et al., 2007). 2.  increased care requirements associated with aging populations, including the healthcare workforce (Hogan, et al., 2007); 3. challenges with  patient safety; and 4. rapidly evolving technology.  Internationally, the common policy shift from care provision to public health reflects an effort to reduce the rapidly rising healthcare costs  attributed to various types of lifestyle (Thaler & Cass, 2010). Cost effective innovations are another method of approaching the issue of  escalating costs. Overall, a surge in interest in quality management has been evident internationally. However, the fact that most improvement  work is undertaken by front-line healthcare professionals with service delivery responsibilities ‘has slowedimprovement of the improvement  process’ (Davidoff & Batalden, 2005: 322). Hence, our multi-stakeholder study of innovation implementation will make an important contribution  to the understanding of healthcare innovation processes. Our adoption of a systemic approach recognises the need to move attention away from  individual errors and incidents and towards concern with the overarching social and organisational systems necessary to support innovations  that can improve quality, safety and efficiency. The globalized nature of healthcare in developed nations offers the opportunity to share  knowledge about why and how different innovations in some nations work while this is not the case in other.  The most important outcome of this research program will be the identification of the enablers of, and barriers to, the adoption and  implementation of healthcare innovations. The added value of the international dimension of the research programme will be knowledge of how  factors at different levels   (societal, organisational, community and individual) operate and offer insight into the factors that facilitate or impede the implementation of  innovations in different national and organisational contexts.  The research will include ongoing (bi-annual) stakeholder liaison throughout the project. In addition, we will incorporate focus groups to identify  the ‘actionable implications’ of our findings, for keystakeholders and policy makers. We will undertake strong practitioner as well as academic  dissemination, producing executive practitioner reports and briefing papers that will be disseminated through bodies like theEuropean Public  Health Alliance and the European healthcare consortium ‘DETERMINE’, as well asthrough a dedicated project website. Comprehensive  academic dissemination of the research findings through conference attendance and article write-up are also included in the project plan.  References  Berwick, D. M. 2003. Improvement, trust and the healthcare workforce. Quality and Safety in Health Care,  12: 2-6.  Berwick, D. M. 2004. The improvement horse race: bet on the UK. Quality and Safety in Health Care, 13:  407-409.  Bate, P., & Robert, G. 2006. Experience-based design: from redesigning the system around the patient to codesigning  services with the patient. Quality and Safety in Health Care, 15: 307-310.  Bhaga, R., Harvesto, P. and Triandis, H. (2002). 'Cultural variations in the cross border transfer of  organizational knowledge: an integrative framework', Academy of Management Review, 27, 204-221,  Cross, R. Parker, A. Prusak, L. & Borgatti, S.P. 2001 Knowing what we know: Supporting Knowledge Creating and Sharing in Social Networks. Organizational Dynamics, 30, 100-120.  Crossan, M.M., & Apaydin, M. 2010 A Multi Dimensional Framework of Organizational Innovation: A  Systematic Review of Literature. Journal of Management Studies, 47, 1154-1191.  Dopson S. 1994 Management: The One Disease Consultants Did Not Think Existed. Journal of Management  in Medicine, 8(5): 25-36.  Dijkstra, K., Pieterse. M. & Pruyn, A. 2006 Physical environmental stimuli that turn healthcare facilities into healing environments through psychologically mediated effects. Journal of Advanced Nursing, 56 (2),  166-181.  Ferlie, E., Fitzgerald, L., Wood, M., & Hawkins, C. 2005. The non spread of Innovations: The mediating role  of professionals. Academy of Management Journal, 48, 117-134.  Greer, A.L. (1984). Medical technology and professional dominance theory. Social Science & Medicine, 18,  809-817.  Hummel, J.M., Rossum, W. van, Verkerke, G.J. Rakhorst, G. 2000, Assessing medical technologies in development: a new method of constructive technology assessment, International Journal of  Technology Assessment in Health Care, 16, 1214-1219;  McNulty, T. & Ferlie, E. 2002. Reengineering health care: The complexities of organizational  transformation. Oxford, England.  Pettigrew, A.M., Ferlie, E., & McKee, L. 1992. Shaping strategic change – Making change in large organizations: The case of the NHS. London: Sage.  Shipton, H., West, M., Dawson, J., Patterson, M. & Birdi, K. (2006). Human resource management as a predictor of innovation. Human Resource Management Journal, 16, (1) pp. 3- 27.  West, M. A. & Farr, J. L. (1990). Innovation at work. In M.A. West & J. L. Farr (Eds.), Innovation and Creativity at Work: 3-13. Chichester, UK: John Wiley & Sons. World Health Organization 2008. Closing the gap in a generation: Health equity through action on the social  determinants of health. Final Report: Executive Summary.