The theme of the November research partners meeting was ‘Boundary strategies for quality improvement’. Catherine French, Lead for the Collaborative Learning and Partnerships Theme at CLAHRC NWL, provided an overview of how boundaries are studied in the social sciences describing typologies and characteristics of boundaries. Boundary strategies as a theoretical lens may be applied to the work of translating research evidence into practice – often seen a task of mobilising research knowledge created by academics into the clinical practice of healthcare professionals – crossing the boundary between the two domains.
Research into different types of boundaries has been of interest in many academic disciplines and Lamont and Molnar (2002) offer a summary of some of this work. Boundaries in many of these studies has been described as a divisions between class, ethnicity, gender, knowledge, profession and organisations.
These last three form the basis for ways of understanding boundaries that may be useful to quality improvement and health services research. Epistemic (knowledge) boundaries are those which define not just different types of knowledge but also the culture associated with the creation, sharing and use of this knowledge. This is often explicitly linked to professional boundaries, which delineate jurisdiction and expertise in a particular field of practice. Both are often linked to organisational boundaries, which usually define the remit of an organisation, but may also include silos or boundaries within organisations that may be explicitly related to professional or epistemic boundaries.
After establishing boundary typologies Catherine went on to describe how different aspects of boundaries might be related and the types of people, activities or objects that work across them).
One way in which boundaries can be crossed is through individuals who may represent two or more professional groups or different organisations. This type of ‘boundary spanner’ might include academics who are also clinicians, for example (Williams, 2002).
Events or activities may offer an opportunity for individuals from different professional groups, organisations or academic disciplines to come together and discuss issues. These so-called ‘boundary interactions’ might include events such as the collaborative learning events organised by CLAHRC.
Finally, artefacts or objects may also play an explicit role in bringing different groups of people or organisations together(Star and Griesemer 1989). . These artefacts act as ‘boundary objects’, which is a common term in social science literature. Nicolini et al (2012) theorise the different roles objects can take in cross disciplinary collaboration. In their view, primary objects drive and motivate innovation and collaboration. Secondary objects are used by various groups of individuals but for different purposes. Tertiary objects offer a simple but often essential function as part of the infrastructure of collaboration. Examples of each of these include a primary object which might be a research funding grant to look at a particular health problem; whereas a secondary object might include a prescription that provides different information and meaning to different professionals; whilst a tertiary object might be an email distribution list.
How objects can be used in health services to facilitate interaction and collaboration between different communities of practices, professional groups, disciplines and organisations is of great interest to CLAHRC researchers.
Professor Mitch Blair, from the CLAHRC NWL Early Years theme, presented his reflections and experience on the use of the Action Effect Diagram (AED), a quality improvement method developed at CLAHRC Northwest London. The purpose of the AED is to support discussion and consensus on the development of a project aim and identify activities that could help achieve this. Additionally, the AED allows stakeholders to articulate their assumptions about the links between these activities and the overall aim, or highlight evidence for these links.
Mitch used the example of an Action Effect Diagram that was created to identify the different functions and activities within the Child Health GP hubs in northwest London. These hubs relied heavily on the interaction between a huge number of stakeholders and required vertical and horizontal integrations to ensure that children received the care they needed.
The construction and creation of the AED provided an opportunity to engage with more than 90 different stakeholders and ensure that everyone’s voice was heard, and creating a shared aim among them. The AED was also used to identify different metrics that could be used to assess the delivery and success of different elements of the hub. Moreover, the AED facilitation provided an opportunity to engage and navigate a complex system by ‘connecting the dots’.
Sophia Hashmy, from the Atrial Fibrillation (AF) project, went on to describe the central role of a hand-held ECG device that has been used in a project in Hounslow to improve the detection of AF, a rhythm disorder of the heart that can often lead to stroke. The project is collaboration between local GPs and cardiologists to improve early detection and treatment of those with AF. Sophia and Dr Sadia Khan, the clinical lead for the project, further highlighted the central role the Alivecor device, not only through its function as a medical device, but also as an object that brought together different stakeholders.
This summary of theoretical perspectives of boundaries and boundary strategies alongside some examples of objects within projects that could be seen to act as ‘boundary objects’ stimulated much debate and discussion about the value of this work in understanding how we support future collaborative efforts. The discussion went on to further highlight many other examples of boundary objects and their value to support collaboration between different professionals or organisations. We look forward to hearing more about this work in due course.