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The issue of organizational innovation in health is not new, but it is nonetheless topical. All health systems in high-income countries face significant challenges when adapting their health systems to changing demands, knowledge and preferences, economic circumstances or technologies (Denis et al. 2018). The current COVID-19 pandemic highlights the need for organizational innovation to better respond to the unexpected and ensure an adequate and accountable response. These organizational innovations are multifaceted and refer to a reconfiguration of the professional, clinical, managerial and civic logics, to name but a few, that structure the functioning of a healthcare system (Thornton & Ocasio 2008). The healthcare system has long been characterized by a significant gap between technical innovation and organizational or institutional innovation. While such a gap is not unique to the healthcare sector, it is surprisingly acute in this sector. Technical innovation in the broadest sense of the term is a powerful driver of change in the healthcare sector. New drugs and diagnostic and therapeutic technologies are penetrating the healthcare system and organizations at a speed that makes them difficult to master. What is looming in terms of cell therapies is described as a tsunami that could sweep away the healthcare system, or at least revive it without being able to escape the difficult question of costs and what should or should not be offered by our social welfare systems. Digital innovation and artificial intelligence will also bring about organizational and institutional transformations (Hinings et al. 2018).

Organizational innovation, which can be more broadly described as immaterial innovation, is difficult to bring about, or at least to such a degree that it would allow better control of so-called technical innovations. One need only think of the experience of healthcare systems in the face of the deinstitutionalization of care made possible (in principle) by the arrival of laparoscopic technologies in the 1990s. The development of ambulatory care has been slower than otherwise, and clinical or organizational environments have had difficulty capitalizing on this opportunity.

This is certainly a reflection of reasonable caution, since innovation must make it possible to produce quality care in complete safety. There is also the imprint left by professional, organizational or political rigidities that make this capitalization uncertain or late.

Healthcare is not alone in this fight for innovation. Other sectors of activity, including that of economically oriented companies, have long stressed the difficulty of renewing social relations of production in favor of greater adaptation to a constantly changing environment (Osty et al. 2007). In the healthcare sector, organizational innovations, which I would call “basic”, are also slow to materialize. Take, for example, the difficulty in linking the designation of responsibility for care, the establishment of incentives to take on this responsibility and the optimization of the use of clinical resources. The interest in France and elsewhere in the implementation of new organizational forms such as Accountable Care Organizations (ACOs) is a major challenge in terms of innovation (Lemaire 2019). More broadly, we could also highlight the difficulty for several healthcare systems to also refocus their mission toward emerging priorities (mental health, frailty, etc.). Obviously, this is not only a question of organizational innovation, but also of innovations in terms of mentalities and social relations between stakeholders. So what does this book offer us? Without claiming to do it justice in a few lines, it serves to better understand the strategies likely to promote and capitalize on organizational innovation. The interest of such a book lies not in its diagnostic scope – the problem is fairly well known – but in the avenues of response it proposes to the tricky issue of the cumbersomeness or inadequacy of organizational innovation in health. I will limit myself to some remarks on the three main theses that make up the three parts of the book. These three themes are partly overlapping and I will come back to them in conclusion.

The first theme of this book, dealt with in Part 1 entitled “Innovations as Seen by Stakeholders”, raises the question of the agility of health innovation processes. In this case, innovation means developing a greater scope for the thought and action of stakeholders on the usual channels of power, whether they are professionals or patients. Organizational innovation here involves the ability to generate counter-powers in order to increase the legitimacy of new knowledge, modes of intervention and representations. These counter-powers (Light 2010) are the source of innovation insofar as they are and will be powerful enough to move away from the reproduction of the logics that dictate the current functioning of organizations and the health system. Behind this staging of new stakeholders is a real political project in the sense that organizational innovation consists of fundamentally renewing the social relationships between stakeholders in the healthcare sector (Hallett & Ventresca 2006). Under this topic, a greater or at least more explicit place could be given to stakeholders who live on the limits of the health system but who call for its renewal. I am referring here to people in social situations described as marginal and militant organizations for whom the social and healthcare issues overlap and are confused.

The second topic, dealt with in Part 2 entitled “Innovations on the Collective Side”, explores innovation as the product of new agencies. These spaces or collectives of all kinds, communities of practice and innovation laboratories among others, are themselves innovations from the point of view of organizations and the health system. Their establishment questions current practices and expresses a form of productive resistance in organizations and the healthcare system (Courpasson et al. 2012). The hypothesis here sees innovation as the product of a protective zone that allows stakeholders to freely engage in exploration and experimentation. The vitality of such spaces depends on the fact that the organization accepts the temporary suspension of environmental discipline to allow innovation to emerge (Zietsma & Lawrence 2010). These spaces testify to the importance of creativity and detachment in rethinking ways of doing things. They also enable the bringing together of stakeholders who usually operate in parallel or separate universes. They will bring innovation insofar as what they produce is taken up and accepted by stakeholders who can influence the decisions made within the organization.

This is the challenge of sustainability and scaling up of healthcare innovations where, too often, successful local experiences fail to be brought to light and institutionalized. Here, the authors do not deal only with innovative spaces but also with innovations in the design of organizations (structuring into clusters, for example) or in public policies (territorialization of policies, for example). It can be hypothesized that innovative design and new spaces of innovation complement each other, perhaps offering the prospect of an institutionalization of innovation. Innovations in organizational design in a sense absorb the logic of the living laboratory by formalizing new frameworks for interaction. They must be accompanied by change and boldness of ideas and mindsets in order for organizational innovations and new practices to emerge. Finally, technologies are called upon to play an increasingly important role in bringing together and creating tension between various stakeholders in search of innovation. Each of the chapters presented in this section could consider the potential of new technologies to create collective spaces that accelerate organizational innovation (Ansell & Gash 2018).

The third topic, dealt with in Part 3 entitled “Reflective Insights on Organizational Innovations in Healthcare”, gives way for the systematic analysis of experiences to contemplate change and innovation, whether through research or through evaluation in context. This part highlights, through the various contributions that compose it, the importance of the knowledge-power nexus in understanding and shaping innovations (Ferlie & McGivern 2014). Organizational innovation emerges from a rather deliberate process and does not easily reveal all its subtlety. Systematic processes must be put in place in order to learn from experience and produce knowledge that can accompany and propel innovations. The idea is to produce, by means of a reflexive analysis, knowledge about the conditions for transforming an organization or a health system. The analysis of public healthcare policy offers an opportunity to learn in real time from initiatives aimed at bringing about large-scale transformations and generalizing organizational innovations.

The next challenge is to make this knowledge effective, i.e. to create the conditions for stakeholders to take an interest in it in order to act in favor of innovation. Management tools and policy instruments play a key role here, since they put into circulation representations of activities, behaviors and changes they can induce that were previously less or little known. Ideally, they make it possible to open up new objects to governance, whether it be the state of health of a population, quality of life or healthy living with illness (Jarzabkowski & Kaplan 2015). In all innovation processes, it is important to pay attention to the resource allocation channels that weigh in favor of or against organizational innovation. It is not enough to want to renew primary care or encourage the so-called grassroots innovation; an organization must be able to dedicate the resources that will enable these stakeholders to materialize their projects. These resources are not necessarily new, underlining the importance of being able to reallocate resources to emerging priorities or representations in the healthcare system.

The three parts that structure this book on organizational innovation in healthcare complement one another. Fostering innovation requires stakeholders with the capacity to influence, spaces to create and experiment, and knowledge about processes that can support and accelerate the challenging of the status quo and the implementation of new organizational modes or practices. One of the essential conditions for the governance of innovation in healthcare systems is the question of alignment and coherence between public policies and the dynamics and needs found in organizations and clinical settings. This book provides us with the pieces to tackle the puzzle of organizational innovation with seriousness and relevance. It will benefit from being complemented by a reflection on the political and social conditions that enable health systems to adapt better than others to the major contemporary challenges of health and thus to capitalize on innovation on a large scale, whether organizational or not.

Jean-Louis DENIS

CR-CHUM

Université de Montréal

March 2021