Navigating the Future of Organisational Health Services Research in Germany and beyond: a Position Paper

Abstract

Background Recent analyses have shown that in health services research in Germany, healthcare organisations are often considered primarily as a study setting, without fully taking their complex organisational nature into account, neither theoretically nor methodologically. Therefore, an initiative was launched to analyse the state of Organisational Health Services Research (OHSR) in Germany and to develop a strategic framework and road map to guide future efforts in the field. This paper summarizes positions that have been jointly developed by consulting experts from the interdisciplinary and international scientific community.

Methods In July 2023, a scoping workshop over the course of three days was held with 32 (inter)national experts from different research fields centred around OHSR topics using interactive workshop methods. Participants discussed their perspectives on OHSR, analysed current challenges in OHSR in Germany and developed key positions for the field’s development.

Results The seven agreed-upon key positions addressed conceptual and strategic aspects. There was consensus that the field required the development of a research agenda that can guide future efforts. On a conceptual level, the need to address challenges in terms of interdisciplinarity, terminology, organisation(s) as research subjects, international comparative research and utilisation of organisational theory was recognized. On a strategic level, requirements with regard to teaching, promotion of interdisciplinary and international collaboration, suitable funding opportunities and participatory research were identified.

Conclusions This position paper seeks to serve as a framework to support further development of OHSR in Germany and as a guide for researchers and funding organisations on how to move OHSR forward. Some of the challenges discussed for German OHSR are equally present in other countries. Thus, this position paper can be used to initiate fruitful discussions in other countries.

Keywords

Healthcare organisations - organisational behaviour - organisational research - health services research - interdisciplinary - international network

Background

Healthcare organisations are a building block of healthcare systems, providing a variety of healthcare services spanning from prevention to palliative care. They range from small office-based practices to large-scale hospitals and play a vital role in shaping the way healthcare is delivered to patients. Healthcare organisations can be defined as organisations that provide personal services in interaction with patients with the aim of prevention and health promotion, curation, rehabilitation, palliation or nursing care [1] . While healthcare services are predominantly provided by healthcare organisations, they are also offered in companies and institutions outside of the healthcare sector (e. g. in occupational health).

Understanding the organisation and delivery of healthcare services, as well as the functioning of healthcare organisations, is a central task of health services research (HSR). HSR is a crucial research field that investigates the organisation, management, financing, professional arrangement and delivery of healthcare services to patients and the population. It aims to identify effective and efficient approaches to enhance patient-centred care and patient safety, as well as the conditions under which safe patient-centred healthcare can be delivered [2] . HSR places the complexity of healthcare systems, organisations and institutions at the centre of its investigation, thereby acknowledging the critical role of interrelations between micro-, meso- and macro level factors. These factors include individuals and teams, organisations, and health care systems and their institutions (e. g. regulations and governing bodies).

In Germany, HSR has emerged as a rapidly growing interdisciplinary field, first established as a subfield within the broader health sciences in the late 1990s. Over the past decade, HSR has increasingly gained recognition as a critical pillar of health research in Germany, striving to enhance the understanding and improvement of routine healthcare practices. The significance of organisations in HSR was acknowledged early on in the fieldʼs development in Germany. The working group ‘Organisational Health Services Research’ was established as one of the first working groups within the German Network Health Services Research (DNVF). In 2009, the working group published the first consensus paper (‘Memorandum’) on the conceptual and methodological foundations of organisational health services research (OHSR) [3] . A more elaborated consensus paper, comprising three parts, was published ten years later in 2019 [1] [4] [5] . To further promote OHSR in Germany, a scientific network initiative entitled ‘Network on Organisational Behaviour in Healthcare’ was funded by the German Research Foundation (DFG) between 2014 and 2018. In the resulting book publication, researchers from Germany contributed 15 chapters with original work covering various OHSR themes, such as work organisation, leadership and patient safety, interprofessional teamwork, promotion of hand hygiene in hospitals and integrated care networks [6] . The origins of the network can be traced back to the ‘Health Services Research’ working group founded in 2004 within the German Society of Medical Sociology (DGMS).

The experience of the aforementioned two working groups suggests that HSR in Germany often perceives healthcare organisations merely as empirical study settings [7] [8] . This perspective overlooks the theoretical and methodological importance of treating the ‘organisation’ as a distinct entity in its own right, including the activities and practices conducted within the entity as well as the collective agency. In order to rectify this omission, the two working groups jointly organised an online symposium in September 2021 to discuss the current state and future perspectives of OHSR with national and international experts. The participants concluded that the following objectives are necessary for the future development of OHSR in Germany: refinement of the concept, the inclusion of related scientific disciplines, and international collaboration. Due to its origins in HSR, OHSR in Germany operates somewhat detached rather than synergistically with its parent disciplines [9] , e. g., organisational sociology and psychology, economics and management, and sociology of health and medicine. At the same time, organisational research in healthcare is conducted in disciplinary silos within these parent disciplines as well, and this runs the risk of preventing the exchange of knowledge and interaction with the HSR community. A scoping review was conducted to capture the range and scope of OHSR within the HSR community in Germany [7] [8] . An analysis of the abstracts submitted to the annual conference on HSR in Germany in 2020 revealed that many studies engage with both teams and individuals in organisations as well as with organisational behaviour. However, explicitly formulated research questions dealing specifically with the organisation as a research object, as well as in reference to relevant organisational theory, were rare.

The observations described above imply that healthcare organisations are generally regarded as a marginal phenomenon in HSR in Germany, despite the fact that they are fundamental to HSR. They serve as a context for healthcare rather than a constitutive element of healthcare to be analysed [10] . Against this background, the idea for a scoping workshop was born in order to develop the field of OHSR in a systematic and targeted way.

Aims

In order to navigate the direction of future research activities and increase the attractiveness of the discipline for (early-career) researchers, a sustainable establishment and consolidation of OHSR in Germany is crucial. However, there are several challenges for OHSR in Germany. Firstly, a research agenda that pinpoints relevant research questions in the field is missing. Furthermore, there is a need to address the lack of theoretical underpinning and application of existing organisational theory. Similarly, the application and adaptation of the broad range of methodologies for OHSR is limited, and truly interdisciplinary and international collaboration is rare. The aim of the scoping workshop was therefore to address these gaps and create a conceptual foundation via an interdisciplinary scientific community. In this position paper, insights from the scoping workshop are summarized and integrated. These insights were revealed through the involvement of experts from the interdisciplinary and international scientific community. The aim of this paper is to present a strategic framework and road map for German OHSR to guide future efforts in the field. This position paper is addressed to researchers and funding organisations connected to OHSR and its parent disciplines.

Methods of the scoping workshop

The scoping workshop was funded by the Volkswagen Foundation and took place at Schloss Herrenhausen, Hanover, Germany, in July 2023. Over the course of three days, 32 (inter)national experts discussed the current state of OHSR in Germany and its potential for development. To build bridges to neighboring and parent disciplines, experts from various research fields were invited in addition to health services researchers (e. g., sociology of health and medicine, implementation science, nursing science, occupational health, public health, organisational sociology, psychology, economics and management, health policy). In addition to participants from Germany, experts from Australia, Norway, UK, Austria and the Netherlands attended the workshop. [Table 1] displays the topics and interactive formats applied in the workshop.

Table 1 Overview of the scoping workshop topics and formats

Workshop days	Topics and formats
Day 1: Where are we at?	Living statistics: Getting to know each other Four Pitches: Development of Organisational Research in Healthcare from various disciplines and countries World Café: What is needed for interdisciplinary collaboration in the field of OHSR?
Day 2: What are the main challenges?	Group discussions: How to move Organisational Research in Healthcare forward? Four Pitches: Key challenges for healthcare organisations within different healthcare systems: Different Country – Same Challenge? Panel discussion: International collaboration – Why and How? Presentation: funding opportunities for international collaboration from the DFG and Volkswagen-Foundation
Day 3: Where do we go from here?	Group discussions: How can we strengthen the field of OHSR in Germany? Nominal Group Technique: Developing Positions

The interactive workshop concluded on Day 3 with an interactive summarising session, where participants aimed to formulate positions based on discussion results from Days 1 and 2. Participants were asked to state what is needed to strengthen the field of OHSR in Germany and beyond. Following the workshop, these central positions were condensed, prioritised, and approved by the participants.

Results

In the following, key positions derived from the scoping workshop are presented (see [Fig. 1] ). These positions and their arguments should not be seen as independent from each other but rather as highly intertwined.

Fig. 1 Central positions that can guide the development of German OHSR.

1. Developing a research agenda

Many discussions within the workshop hinted towards one central requirement: a systematically developed research agenda for OHSR in Germany and beyond is necessary. A research agenda can guide future research efforts by highlighting relevant research questions and suitable theory and methods. Additionally, a research agenda can be used to monitor OHSR’s achievements in subsequent years. Previous reviews of OHSR in Germany [3] [8] [11] indicate that a large share of research work engages with healthcare organisations solely as study settings, without fully appreciating the fundamental organisational nature of many behaviours and phenomena in healthcare. Additionally, current OHSR research efforts focus mostly on the hospital acute care setting, neglecting many other relevant settings and adjacent fields in the realm [11] such as outpatient care, prevention, occupational health and rehabilitation. Moreover, many OHSR studies in Germany lack a theoretical underpinning (see position 4), which in turn limits their explanatory power. Current efforts leading to this scoping workshop also indicate that the German OHSR field requires conceptual sharpening. These central shortcomings need to be informed by a comprehensive research agenda. The following positions are closely linked to a research agenda but emphasize specific shortcomings related to content and strategy.

2. Clarifying the interdisciplinary field of OHSR and its terminology

Due to our finding that the organisational nature of many HSR studies is being disregarded, it is crucial to clarify what organisational research in healthcare entails, what it contributes to HSR, and which (inter)disciplinary theoretical and methodological perspectives are most interesting, relevant, useful and feasible. First of all, there is a need to reconsider terminology in communicating OHSR research. A consensus is needed on what to call our field (our suggestion: OHSR) within the German research landscape and internationally, in order to be able to use clear and consistent language, promote the field, and gain visibility. Research results and publications should be labelled accordingly.

A clarification is needed of which disciplines or research fields beyond HSR should actively be included in order to foster interdisciplinary research and mutual inspiration (as an illustration see [12] ). In order to turn the interdisciplinary character of OHSR research to advantage, research efforts need be oriented towards the research problem under study, rather than being limited by disciplinary boundaries and academic traditions. In the context of interdisciplinarity, questions arise regarding the self-conception and role of researchers in the field of OHSR. A discussion is pending about whether researchers in OHSR should aim to (1) understand and explain organisational phenomena from an observer perspective to gain basic knowledge and/or, going further (2) to contribute and facilitate change (e. g., in intervention studies). It will be important to strike an adequate balance between the two aims and shape the translation from basic to applied research (and back). A consensus in the understanding of science and the role of researchers in OHSR is not central to that discussion; however, achieving clarity about the different disciplinary self-conceptions will help to reduce barriers in interdisciplinary cooperation.

3. Putting organisation at the centre of our research and making use of international comparative studies

Currently, organisational aspects in German HSR are often studied as a side project or sub-question within larger HSR studies and thus tend to be reduced to a “nice-to-have” add-on. This practice fails to acknowledge the clear relevance that organisational characteristics have in shaping and delivering healthcare. Although these add-on projects, which are often of an applied nature, can still produce relevant knowledge for OHSR, researchers should put organisational phenomena at the centre of their studies and develop convincing, theory-informed and relevant research questions. Drawing from the international character of the scoping workshop, comparative research between different countries and healthcare systems as well as jointly coordinated research projects could contribute greatly to developing such research questions. To date, researchers in German HSR have tended to focus on national collaboration and are less visible to potential international partners. Since strengthening internationalisation is of central importance for HSR, the OHSR field could strive to become a leading example.

4. Utilising the range of organisational theories and promoting theory development

To increase the explanatory power and reach of the knowledge produced from OHSR studies, OHSR researchers need to become better in using organisational theory. Theory application should become a crucial part of OHSR studies and should help direct and inform research questions, study design(s) and interpretation of results, particularly in regard to complex organisational phenomena. Current organisation and management theory, for example, offers a broad spectrum of well-tested approaches - such as New Institutionalism [13] , the Behavioural Theory of the Firm [14] , Network Theory [15] or Systems Theory [16] . Among other things, these theories help unpack hidden agendas of collective action underlying a given healthcare arrangement, such as barriers to effective collaboration of physicians and nurses or hospitals and general physician practices. At the same time, empirical research results can inform theory refinement and theory development in OHSR and thereby contribute to knowledge building that goes beyond single specific research questions and healthcare settings.

5. Institutionalising the teaching of OHSR

Since many studies in German HSR do not acknowledge the organisational character of their research or underestimate its relevance, it is particularly important to integrate organisational theory and research into existing study programs that qualify for OHSR. Several recently-developed master-level programs in HSR in Germany do incorporate the respective content; however, this remains the exception rather than the norm [17] [18] . Developing learning goals, central competencies and a curriculum on OHSR that can be integrated into existing curricula could strengthen the field and attract future OHSR researchers. The integration of such curricula could be equally beneficial for study programmes in medicine, nursing, management, health policy etc. Teaching healthcare professionals and managers about the functioning of healthcare organisations and about the difficulties and opportunities of stimulating change in organisations could contribute to professional development, interdisciplinary collaboration and innovation in healthcare. In order to deal with these specific competencies, an orientation, such as the set of core competencies in HSR published by Burgess et al. [19] or on implementation science could be valuable [20] .

6. Promoting international and interdisciplinary exchange and cooperation

International and interdisciplinary exchange and cooperation in OHSR is beneficial for the development of the field and for individual academic careers. Therefore, the research community as well as the academic system need to promote and incentivise international as well as interdisciplinary research. Since OHSR is a highly interdisciplinary field, funding opportunities for interdisciplinary research projects and an openness towards interdisciplinary approaches are needed. Furthermore, committees that determine academic promotion should be encouraged to value research outputs that are grounded in interdisciplinary collaboration rather than focus on disciplinary rankings. In terms of international collaboration, instruments such as international honorary professorships and research visits can be established. This would enable the building of long-term collaborative relationships and would attract renowned academics and researchers from other countries to collaborate with research institutions in Germany. In addition, opportunities for international mobility are essential for early-career researchers. Once long-term international networks are established, the prospects for acquiring funding from the EU and other international funding organisations will grow. Besides the demand for suitable funding opportunities, researchers should make use of existing funding opportunities and promote them among colleagues.

7. Tailoring research funding for OHSR and strengthening participatory research approaches

In Germany, the Federal Ministry of Education and Research (BMBF), the Federal Ministry of Health (BMG) – including the Innovation Fund - and the German Research Foundation (DFG) are the main funding institutions that HSR can exploit. Although funding opportunities for HSR in Germany have clearly increased over the last decade, it is oftentimes challenging to acquire funding for OHSR research that is not necessarily of a highly applied nature. Fundamental OHSR is essential to better understand the complexities and realities of healthcare organisations. It follows that explicit funding calls for OHSR are desired, particularly funding opportunities that go beyond the three-year corridor, as this timeframe is largely insufficient when trying to understand complex organisational change processes [5] . Besides funding opportunities for individual OHSR projects, funding programmes bringing together interdisciplinary and international networks as well as connecting researchers from traditional universities and universities of applied sciences (such as the scoping workshop format by Volkswagen Foundation) can be highly effective formats that fields such as OHSR require for fruitful development. Funding formats like these have the potential to build capacity for larger joint applications on OHSR with an interdisciplinary and international character. As indicated above, it is vital that funding institutions become more open to truly interdisciplinary research, since, in our experience, a highly interdisciplinary project idea often has a lower chance of approval due to widespread mono-disciplinary thinking and reviewing. Furthermore, to promote academic careers in OHSR, funding formats for early-career researchers are crucial. Public and patient involvement (PPI) and particularly co-design of complex interventions is essential in many OHSR studies [21] [22] [23] . Funding institutions increasingly expect applicants to include strategies for PPI. Besides the involvement of patients, relatives and the public, OHSR often requires the involvement of other stakeholders in healthcare organisations (e. g., healthcare professionals, managers), especially when research deals with organisational change. Thus, funding institutions should broaden their definition of PPI. OHSR researchers should also make use of the potential of PPI by systematically planning and conducting PPI when it is relevant for the research aim.

Conclusions

The position paper has two main claims: First, a research agenda placing organisations and their core activities at the centre of OHSR is needed. This requires conceptual sharpening and clarifying the OHSR field and its interdisciplinary nature. Questions on the potential and methods of PPI and on the application of organisational theory are closely linked to this claim. Second, research communities and funding institutions need to work on conditions that are conducive to developing OHSR in Germany. This entails educating the next generation of researchers by teaching OHSR in study programs, but also valuing, enabling, and making use of opportunities for international mobility as well as international and interdisciplinary collaboration.

The workshop revealed that some of the challenges discussed for German OHSR are equally present in other countries. Thus, we hope that this position paper can initiate fruitful discussions in those countries as well and possibly within international academic societies such as the Society for Studies in Organizing Healthcare (SHOC).

This position paper seeks to serve as a guide for researchers and funding organisations on how to bring OHSR forward. In addition, the scoping workshop contributed to forging international networks and to expanding disciplinary boundaries. The ultimate goal is to further cultivate and develop the newly-formed network.

This article is part of the DNVF supplement “Health Care Research and Implementation”

Hinweis

Dieser Artikel wurde gemäß des Erratums vom 19.08.2024 geändert.

Erratum

Im oben genannten Artikel wurde der deutsche Titel korrigiert. Korrekt ist: Die Zukunft der organisationsbezogenen Versorgungsforschung in Deutschland und darüber hinaus – ein Positionspapier.

Interessenkonflikt

LA ist Vorstandsmitglied der DGMS und des DNVF. Sie ist Mitglied des Editorial Boards des Journal of Health Care Services and Implementation. JB erhält Fördermittel für mehrere OVF-Projekte in Australien und Europa. ME ist Vorsitzender der Society for Studies in Organizing Healthcare (SHOC). Die Arbeit des Instituts für Arbeitsmedizin, Sozialmedizin und Versorgungsforschung, Universitätsklinikum Tübingen, wird durch einen zweckungebundenen Zuschuss des Arbeitgeberverbands der Metall- und Elektroindustrie Baden-Württemberg (Südwestmetall) unterstützt. Die übrigen Autor*innen erklären, dass keine Interessenkonflikte bestehen.

Acknowledgements

The position paper is a result of a longstanding cooperation of the DGMS and the DNVF. We are grateful to Malin Plüschke, Theresa Hensel and Marvin Schmitt for their support in preparing and hosting the workshop. Many thanks to Susan Lee for English language editing.

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Publikationsverlauf

Artikel online veröffentlicht:
22. Juli 2024