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Thinking of innovation from a perspective of “altering frontiers” invites us, on the contrary, to invest in that which forms a boundary. Indeed, a boundary makes it possible to name, identify, make tangible or visible what is distinctive between what is inside or outside a “space” (Lamont & Molnar 2002). There are thus multiple dimensions (Zietsma & Lawrence 2010; Bucher & Langley 2016): social, relational, cognitive, symbolic, geographical, temporal, material, institutional, etc. (Zietsma & Lawrence 2010; Bucher & Langley 2016). From this perspective, innovation becomes opportune when crossing boundaries, and makes it possible.

Let us consider, for example, the new methods of intervention with the elderly that are currently emerging in France or in other countries and that are described by the still imprecise expression: EHPAD hors les murs (EHPAD¹ outside the walls). For such an establishment, it is a question of intervening in the homes of these people by relocating expertise there. The depth of the innovation is measured in terms of the different boundaries crossed: institutional boundaries between the establishment and the home or professional boundaries between the professions of the EHPAD and the home, for example. Some of the contributions in this book shed light on these crossed boundaries that are necessary to support innovation in the field of healthcare: with the emergence of a new “profession”, that of advanced practice nurses which, according to Philippe Mossé (Chapter 2), attempts to create a new, autonomous professional space between the nurse and the general practitioner; with entry into the domain of the common stakeholders of care or support, of volunteers who, according to Bertrand Pauget (Chapter 3), seek to make the most of their expertise, which is neither professional nor completely lay.

Another way of rethinking boundaries is to design new spaces conducive to innovation (Grenier & Denis 2017), taking the form of original structural reorganizations, which may be internal and/or external, and bringing together stakeholders from different services or structures. This is the case, for example, of teams reshaping their relationships and knowledge when, according to Delphine Wannenmacher (Chapter 4), they use a new technology (surgical robot) to deliver care differently. In this chapter, the author shows in particular how much, with respect to this robot, visual communication (and associated skills) is reduced and the usual partitions (with regard to time and division of work) are no longer effective. In the same way, the creation of service clusters within hospitals constitutes, for Christelle Havard (Chapter 5), a potential for transformation provided that the stakeholders can carry out cooperative work, at three levels: structural (at the level of the hospital as a whole, to divide and coordinate work), operational (at the level of a department, to organize care tasks around the patient) and trajectorial (around the patient to design and implement a care plan). Finally, we can cite the example of the PTA (plateforme territoriale d’appui, territorial support platform), which organizes in an original way the coordination between so-called “front-line” professionals to provide a coordinated response to patients in complex situations. For Matthieu Sibé, Sandrine Cueille and Tamara Roberts (Chapter 7), this organizational innovation will reach its full capacity to provide individualized solutions in the monitoring of trajectories if the stakeholders reinvent their relationships and governance according to the adhocracy model (Mintzberg 1993). This form reflects flexible organizations, combining multidisciplinary and crossdisciplinary skills, capable of adapting to the needs and constraints of the tasks to be accomplished. In this way, another lesson from the various contributions in this book is that the managerial and organizational innovation that accompanies the adoption of new intervention models, new tools or processes only produces its effects if the paradigms relating to modes of governance and decision-making are also transformed (Moore & Hartley 2008).

This calls for a look at a second point to think about innovation, enabled by the boundary concept: creating new networks of knowledge, insights and experience. One way is to introduce new stakeholders who will renew the cognitive reserve of those typically present. With reference to charitable workers working with older people in Sweden, Bertrand Pauget (Chapter 3) examines the interest in encouraging the creation of communities of practice, henceforth called “managed communities” (Bootz 2015), to enable these stakeholders to exchange their experiences in order to improve or even transform them. Focusing on patients, Luigi Flora (Chapter 1) relates the original experience of the “UniverCité” of patients, based in the south of France (Nice). The latter is inspired by similar Quebec models, and brings together health professionals, patients, caregivers, users and civil society to develop experiential knowledge about care, particularly about chronic diseases. It is a double innovation that is thus introduced: the recognition of patients’ knowledge and the recognition of experiential knowledge.

Following the example of this type of university, a community of practice forms spaces conducive to building new knowledge, beyond the diversity of stakeholders, and could generate misunderstandings if it is not accompanied in this way. This misunderstanding is of three kinds (Carlile 2004): syntactic, when the misunderstanding concerns words or acronyms; semantic, when it stems from different representations or values; and pragmatic, when it calls into question the re-articulation of interests and areas of power.

These spaces are favorable to the co-construction of knowledge and discursive elements when they have certain characteristics. Thus, Delphine Wannenmacher (Chapter 4) draws our attention to the importance of establishing interactive and reflexive spaces of dialog, in which the stakeholders will define their language and acquire new skills together. Similarly, Boiteau and Baret (2017), studying a working group on new HR practices in a public hospital, show the conditions under which this group was able to support this innovation: by being a “translation center” within which problematization and enlistment made it possible to “tackle subjects considered until then as taboos” by transforming misunderstandings or disinterest around certain questions into controversies that allow stakeholders to express themselves and develop acceptable proposals. It is here that the quality of the controversy enables innovation (Grenier & Denis 2017).

More broadly, we can understand the significance of new stakeholders in the health field, known by the generic term “intermediary organizations”, “boundary partners” (Chesbrough & Haas 2016) or “brokers” (Hargadon 1997), whose role (political, cognitive and symbolic) is to bring together professionals who are not accustomed to working together or interacting, in order to build new cognitive and discursive resources together. However, following the example of what is generally observed in third places such as FabLabs, do specific methodological resources (such as those provided by Design Thinking; Grenier et al. 2020) still need to be developed to allow stakeholders to cross the boundaries of their institutional embeddedness?

If innovation takes place “at the boundaries”, by putting stakeholders in a position to collaborate despite their different cultural or professional spheres, they must also be able to absorb this “novelty” that is made available. Corinne Grenier and

Christine Dutrieux (Chapter 9) question the extent to which organizations can absorb, and thus bring within their boundaries, ideas, models and practices “from elsewhere”. Absorptive capacity is understood as a set of organizational routines and processes by which the organization acquires and mobilizes external knowledge to produce dynamic organizational capacity (Todorova & Durisin 2007; Imbert & Chauvet 2012). This capacity is based on four processes (or four stages):

1 1) acquisition, referring to the organization’s ability to recognize, value and acquire external knowledge and ideas;

2 2) assimilation, referring to the organization’s ability to understand, analyze and interpret this knowledge and ideas;

3 3) transformation, consisting of the organization’s ability to develop new routines to facilitate the combination of the old and the new;

4 4) exploitation, aimed at deploying this renewed stock of knowledge and ideas into new projects, activities and processes.

Entering this process means that some distance is necessary in the exploration of new ideas and knowledge from the acquired stock (to avoid absorbing only those with which individuals and organizations are already familiar). This distance is created a priori in the specific places we mentioned above (third places), which host both established operators and start-ups, professionals or entrepreneurs, and very often from various sectors. It is up to Hugo Bertillot (Chapter 10) to offer us an original view on this ability to distance ourselves from habits. He focuses on the comparative management indicators developed since the end of the 2000s, integrated into the certification procedure for public hospitals in France and made public at the national level. They are instruments for regulation, decision support for contractualization and internal drivers for improvement. However, the power of indicators to transform hospitals is far from self-evident. Everything will depend on the ability of the stakeholders to “open the black box” of these indicators, to detect, or even build in, room for maneuver in relation to their habits of doing and thinking.

Finally, this book questions the boundary from a temporal and spatial view by questioning the diffusion of innovation. Many currents are mobilized by the literature investigating the field of health, such as: the adoption of what is new (de Vaujany 2005); a network of stakeholders to advance innovation, by operations of problematization, translation and irreversibility mechanism (Callon 1986), or more recently, by networks of practices (Agterberg et al. 2010, 2011) consisting of organizing the circulation of practices and ideas from one place to another. Healthcare innovation has a high degree of contextualization, stemming from in particular the territorialization of the stakeholders’ intervention; the question is then approached in terms not of adoption but of adaptation (Sahlin & Wedlin 2008).

This adaptation process requires specific methodologies to capture what has been experimented with in order to disseminate it, and in particular everything that is “invisible”, tacit or informal and too often cannot be reduced to “experience capitalization guides”. Thus, for Jessica Gheller, Christian Bourret and Gérard Mick (Chapter 8), dissemination appears to be a “journey” reinforced by an exciting, meaningful communication, making it possible to identify the experiences acquired during an expedition, then continuing with the deployment of a living “memory” that will be enriched as innovations are disseminated in other places. This living memory forms a knowledge base that can be subject to questioning and reflexivity for professionals wishing to adopt experiences already developed in other spaces. It promotes learning, an essential element identified by Frédéric Gilbert (Chapter 6) in his study on the dissemination of the family doctor group model in Quebec. In this experience, it is then, a contrario, the downside of an evaluative approach that prevents this learning and limits the journey from place to place of this original front-line organizational form.