Author: Ruth Alison Stewart
Stewart, Ruth Alison, 2011 Lessons From The Development Of A Maternity Managed Clinical Network In A Low Volume Rural Context, Flinders University, School of Medicine
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This thesis describes the rise and fall of a small rural maternity managed clinical network: the Corangamite Managed Clinical Network (CMCN). Although the context of the CMCN is a rural maternity service, the network themes are relevant to health care everywhere because of the lessons that can be drawn. The managed clinical network model addresses three important contemporary rural health issues: the struggles of small health services to enact quality assurance, to provide continuing professional development and to attract clinicians. Over the past twenty years, there has been a sharp decline in the number of rural maternity services in Australia. Maternity service models that are sustainable in the current health service environment are required. The successes of Corangamite Managed Clinical Network (CMCN) show what can be achieved in a low volume, rural maternity service. The failures of the CMCN are a cautionary tale for those interested in network development. The thesis comprises four studies that used quantitative and qualitative methods to examine the development of the CMCN. The researcher adopted a relativist ontology and subjectivist epistemology and used naturalistic research methodologies. She performed literature reviews to build an historical case; interviews and grounded theory to assess what the actors believed about the maternity services and network; participant observation and narrative inquiry to describe what happened and how, and finally a quantitative clinical audit to provide a different perspective of clinical and educational activity within the CMCN. In this way a comprehensive picture of the CMCN is painted. The depiction enables detailed analysis of the CMCN to occur. This thesis measures the CMCN against four theoretical models that have been used to qualitatively evaluate health services: systems thinking, the learning organisation, the diffusion of innovation within organisations and criteria for receptivity to innovation within them, organisational culture and service performance. Using these models this thesis finds that the CMCN performed as a clinical microsystem in an unsupportive macrosystem. It was a learning organisation under command of a less reflective organisation. It was receptive to innovation and its diffusion within a context that did not support innovation and finally, the CMCN displayed health service cultural characteristics that have been associated with high performing health services and the regional health service culture did not. It is noteworthy that these contradistinctions occurred in the rural context. The CMCN achieved its aims to provide maternity services using a patient-centred model, to share expertise and resources between the hospitals, to deliver a quality assurance program, to facilitate local team-based multidisciplinary professional development and to develop a sustainable workforce model. The CMCN was internally strong with a good management structure and committed clinicians. Yet despite these strengths, it collapsed. The tragic flaw of the CMCN that spelt its end was that it did not fully engage with a culturally dissonant regional health service management.
Keywords: Managed Clinical Network,Clinical Network,Maternity,Rural,Learning Organisation,Diffusion of Innovation,Systems thinking,organisational culture,clinical microsystem,clinical macrosystem,patient centred model of care
Subject: Medicine thesis
Thesis type: Doctor of Philosophy
School: School of Medicine
Supervisor: Professor James Dunbar