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2 Exclusive Summary... 1 Chapter 1 Introduction Introduction Outline of the Innovation Guidelines... 3 Chapter 2 Definition of key term and concepts Definition of Innovation Definition of co- creation Definition of culture PPI defines Innovation at Digital Innovation at OUH... 8 Chapter 3 Method Method applied in the Innovation Guidelines Focus group prototyping interview Informal conversations Combining qualitative interviews and desk research Background of the author Designing the interview guide about PPI challenges Interviews about PPI challenges Processing the interview about PPI challenges Designing the interview guide about co- creation Interview about co- creation processing the interviews about co- creation Designing the focus group prototyping interviews Processing the focus group prototyping interviews My role as an interviewer Chapter 4 Theory The Diamond of Innovation The co- creation process model The physical space framework... 22
3 4.4 Prototyping Chapter 5 Barriers and challenges in PPI Macro- level/political challenges Size and complexity Heritage and legacy Funding No Venture capital Administrative procedure The law, intellectual property right (IPR), and procurement rules Critical mass Politically driven organisation Summing Up Micro- level/project challenges Risk aversion Chapter 7 - Innovation guideline The preject period Knowing Analysing Synthersising Creating Balance between the communication and the knowledge dynamics Innovation roles The project period Implementation Chapter 8 Putting things into perspectice Putting things into perspective Recommendation to improve the innovation process in Digital Innovation Creative physical space Co- creation recommendation Ignorance recommendations Knowledge recommendation Concept recommendation Relations recommendation Project proposal
4 Appendix 1 Interview guide about PPI Appendix 2 Interviews data about PPI Appendix 3 Data about experience with PPI Appendix 4 Data about roles and responsibilities with PPI Appendix 5 Data about PPI goals and effects Appendix 6 Data about PPI process Appendix 7 Data about PPI relations Appendix 8 Interview guide about co- creation Appendix 9 Interviews about co- creation Appendix 10 Data about classical project management co- creation Appendix 11 Data about co- creation in the project phase Appendix 12 Data about prototyping Appendix 13 Data about co- creation and risk aversion Appendix 14 Data about co- creation and lack of courage Appendix 15 Data about co- creation and enthusiastic individuals Appendix 16 Data about co- creation and lack of experience Appendix 17 Data about co- creation and lack of clinical evidence Appendix 18 Data about co- creation and lack of patient involvment Appendix 19 Data about co- creation and artafacts Appendix 20 Data about co- creation and anti- innovation DNA Appendix 21 Data about co- creation and fear of divergence Appendix 22 Data about co- creation and implementation Appendix 23 Data about co- creation and scaling of outcome Appendix 24 Data about co- creation and error and failure Appendix 25 Data about co- creation and technical challenges
5 Appendix 26 Data about co- creation and slow decision- making Appendix 27 Data about co- creation and the culture gab Appendix 28 Data about supplier vs partner Appendix 29 Data about relations in a creative space Appendix 30 Data from informal talk Appendix 31 Data about a physical space for co- creation Appendix 32 Interview guide about prototyping Appendix 33 Data about prototyping Appendix 34 Data about geography / proximity Appendix 35 Data about layout Appendix 36 Data about design / decor Appendix 37 Physical, functional, and psychological framework Appendix 38 Pictures from prototyping interview A Appendix 39 Pictures from prototyping interview B Appendix 40 Pictures from prototyping interview c Appendix 41 Pictures from prototyping interview D Appendix 42 Pictures from prototyping interview E
6 The innovation guidelines provides insight into how challenges and barriers influence public- private innovation in Denmark with particular focus on the Odense University Hospital innovation department Digital Innovation, and how this department, Digital Innovation, can improve the innovation process in the project phase. The findings indicate three different categories of challenges and barriers in public- private innovation. The first category consists of macro- level challenges, such as the size and complexity of the public organisations, the heritage and legacy, the lack of public funding, lack of venture capital, administrative procedures, the law, intellectual property rights and procurement rules, and lack of critical mass. The second category relates to micro- level challenges like risk aversion, a lack of enthusiastic individuals, lack of experience and relations, clinical evidence, and lack of co- creation. The third category involves cultural challenges, which are an anti- innovation DNA, fear of divergence, scaling and implementation, courage, avoiding error and failure, technical barriers, and slow decision- making. Through process models and models of physical space, the findings and empirical data provide results indicating how Digital Innovation can improve the innovation process. The first result is that a higher degree of co- creation attracts more enthusiastic individuals, all voices become equal, breaking down the hierarchy, and, in the ignorance dimension, co- creation creates freedom which transcends the risk aversion barrier and engenders greater courage, with error and failure becoming easier to work with because mistakes are part of the co- creation process. In the knowledge dimension co- creation leads to a high degree of diversity in that we get to know each other, thereby reducing the culture gap. Sub- elements of the co- creation can become partial evidence applied in a methodical way. In the relational dimension, on entering co- creation, people become free by playing together, and, in the concept dimension, adding more prototyping aligns expectations and fosters creativity, and prototyping is fun and creates better outcomes, allowing visualisation of the product and opening the mindset.
7 The second result is that applying a physical space with a central geographical location provides proximity, and by providing a flexible layout, we create a fit between privacy and permission. In the ignorance dimension a physical space will attract more enthusiastic individuals, making it easier to involve more patients, do away with silo thinking, and stimulate greater courage. A creative physical space will make people more equal and reduce the culture gap. Relations in a physical space will be more interactive and you get a break from your daily business. The third result in the innovation guidelines is a chapter with a draft for an innovation model/set of innovation guidelines for Digital Innovation; a process model for both the project and the project phase. The innovation guidelines conclude with recommendations for improving the innovation set- up at Digital Innovation. 2
8 The last 10 years have seen an increasing demand for innovative change in the public sector, seeking to optimise flow, treatment, diagnostics and communication by means of public- private innovation (henceforward PPI). What started as a few hospitals setting up small innovation units is today a new industry; an industry considered by politicians as vital for creating new jobs in Denmark. The main purpose of PPI is to solve clinical challenges together with industry and thereby create new jobs through product growth. The primary focus within the healthcare sector is to develop new technologies. There has been input on a large scale, but the outcomes have not as yet been commensurate with the level of input. With a healthcare sector under extreme pressure, top- level management has realised that downsizing and cost- saving is no longer an option, as service levels are now at stake. With an increasing level of chronically ill patients, an increasingly ageing population that lives longer, and fewer hands to provide the service, PPI has finally gained the approval of top- level management in hospitals. In 10 years from now there will be five new super hospitals in Denmark, so we have a unique window in which to test, trial and implement new technologies. The co- creation process in the preject phase is so far negligible. By moving from classical project management to facilitating the innovative process in the preject phase, maybe we can move from an innovation process which is weak on innovation to one where we can facilitate innovation in a novel way? 3
9 The innovation guidelines is divided into 8 chapters. After an introduction in Chapter 1, the key terms and concepts are defined in Chapter 2, followed by Chapter 3 clarifying the method applied in the innovation guidelines. The theoretical frameworks are defined in Chapter 4, followed by the PPI challenges and barriers in Chapter 5. Chapter 6 is the analysis, where the barriers and challenges will be analysed together with the empirical data, and in Chapter 7 the innovation model for both the preject and the project phase is formed, and Chapter 8 the perspective is taken on recommendations, followed by a conclusion to end the Innovation Guidelines. 4
10 For the purposes of conceptual clarification, the key concepts that will be used throughout this project first need defining. There are many separate and distinct definitions of innovation. Darsø (2001) uses Joseph Schumpeter s definition from 1934 as quoted in Darsø (2001): Innovation is an effort of one or more individuals to create economic profit through qualitative change Darsø (2001, p.93) Darsø (2001) argues that innovation is the management of activities involved in the process of idea generation, development of technology, manufacturing and marketing new equipment (Darsø, 2001, pp.94-95), whereas Drucker (1985) believes that innovation is social or economic rather than technical, arguing for systematic innovation using organised search. Drucker (1985) suggests that systematic innovation includes the monitoring of seven sources for opportunity for innovation the unexpected, incongruities, innovation based on process need, changes in industry structure or market structure, demographic, change in perception, mood and meaning, and new knowledge (Drucker, 1985, p.32). Darsø (2003) propounds a distinction between radical inno- vation and incremental innovation, where incremental innovation consists in the recasting of existing technologies to form something new, and refers to minor innovations, whereas radical innovation often consists of bringing together technologies or concepts not previously connected (Darsø, 2003, p.2). Healthcare innovation is highly focused on technology, but also has elements of social innovation, because new technology forces new organisational changes upon us, as well as disruptive and incremental innovation. 5
11 Schumpeter equates innovation and economic profit, but Schumpeter s definition has its origins in the industrial age. Today, however, the outcomes created by the innovative efforts of one or more individuals are multi- dimensional and go beyond traditional economic parameters. Van de Ven et al. (1999) generate another approach, viewing innovation as random processes. In the view of the authors, innovation is not a simple linear sequence, but a more complex evolution of proceedings. Bason, C (2010) defines public innovation as the process of creating new ideas and turning them into value for society (Bason, 2010, p.34), and the author talks about the value of public sector innovation, pointing out that the public sector has four bottom lines: productivity, service experience, results, and democracy. Productivity consists in achieving a more favourable relationship between input and output; service experience is measured by how well citizens feel the public service delivers, and by experience of hospital stays; results are the output of the public sector s efforts which lead to outcomes; and democracy is citizen participation and empowerment, transparency, accountability and equality (Bason, 2010, pp.45 46). Miles and Røste (2005) distinguish between public and private innovation, taking the line that public organisations are typically the primary supplier of services. Thus the public sector is not competing in order to maximise profits, and the notion that the connection between a firm s behaviour and pecuniary reward is the central dynamic of economic rationale and the development of innovation has to be seen as too simplistic. The most observable distinction between the public and private sector is that the private sector is profit- driven (Miles and Røste, 2005), and the public sector has the four bottom lines (Bason, 2010). My analysis relates to co- creation at Digital Innovation at OUH. Of immediate relevance to this is identifying the different types of innovation within the public sector. Thenint (2010) discusses five different types of public innovation; service innovation, process innovation, administrative innovation, system innovation, and conceptual innovation. Thenint (2010) brings service and process innovation together under the umbrella concept of product innovation. 6
12 Bason (2010) argues that co- creation is an interrelated process of design- thinking, citizen involvement, the process of creating together and learning through measurements, going on to maintain that co- creation relates to how the solutions are designed. Bason (2010) also states that co- creation is about creating new solutions with people and not for people, whereas Prahald & Ramaswamy (2004) define co- creation as interactions of dialogue, access, risk- benefits and transparency. These authors argue that co- creation is about joint creation of value by the company and the customers, involving a joint problem- definition and problem- solving, and they go on to say that co- creation is about creating an experience environment where there can be active dialogue and the opportunity to co- construct personalised experiences. MacGregor & Torres- Coronas (2007) claim that co- creation is about virtual teams, and that the creation process is about both design and development of the product or service. Ind et al. (2012) take the view that co- creation is creativity developed with others, involving an interaction of individuals within a framework to evolve and re- define. At Digital Innovation, co- creation is about unleashing the creative energy of many people across the clinical domains with a range of partners from industry, universities, vocational schools, design schools, and institutes of technology. Morgan (2006) defines culture in the following way: When we talk about culture we are usually referring to the pattern of development reflected in a society s system of knowledge, ideology, laws, and day- to- day ritual (Morgan, 2006, p.116). Darsø (2012) refers to Edgar Schein s description of culture, claiming that when tasks or challenges appear, the words and the communication used describe the organisational culture. Ekvall (1991) says that culture refers to beliefs, values, and deep- rooted assumptions. I use culture in the Innovation Guidelines as the ideology within a clinical- evidence mindset, the day- to- day ritual in the clinical departments. I use the concept of culture to reflect a specific 7
13 pattern where different groups in the clinical departments react and behave towards clinicians specific to other groups or non- clinically educated employees. Weihe, G. et al. (2010) define public- private partnership (PPI) as a development process between public and private organisations with the aim of developing new solutions, and it is a co- creation where different core capabilities come into play (Weihe, et al. 2010). Bjerre & Hammer- Jakobsen (2010) list PPI in different categories: business- driven PPI, patent- and test driven PPI, vision- driven PPI, service- driven PPI, and demand- driven PPI (Bjerre & Hammer- Jakobsen, 2010, p.56) and finally Bason (2010) defines PPI as the process of creating new ideas and turning them into value for society the concept of innovation therefore places a laser- sharp focus on whether the organisation is able to generate and select the best possible ideas, implement them effectively and ensure they create value (Bason, 2010, p.34). What defines PPI at a practical level is that most projects are externally funded either by EU grants or private funds. Even though Digital Innovation have seen some projects that focus on services, in most projects the core activities are connected to technology, and the main catalyst behind PPI is to increase public value, thereby creating jobs. OUH has been working with innovation for eight years. Digital Innovation, which is my unit, with five innovation facilitators employed in Digital Innovation. The Adriansen & Krohn (2013, p.7) definition of a facilitator is appropriate as a description of our tasks: design and management of structures and processes that help a group do its work and minimize common problems people have working together. Digital Innovation is part of the IT department, focusing mainly on healthcare Apps and Serious Games. 8
14 The focus on healthcare Apps has exploded over the last two years, and more people have a smartphone and tablets, and by the end of 2014, all communication between the public sector and patients and citizens will take place electronically through the Danish e- boks system. Serious Games involves the transfer of gaming elements from the gaming industry to a clinical setting. Currently Digital Innovation is working on 10 EU- funded projects with 22 different technology pilots involving total funding of more than DKK 50 million, and all activities and wages for the five employees at Digital Innovation are 100% financed through EU funds. Thus we operate as a small firm within OUH, or as an enacting organisation constructing our own environment (Brown & Duguid, 1991). Facilitating innovation between the private and the public sectors, the process always represents a clinical challenge in association with at least one industrial partner, which has the appropriate competences. An EU application is then forwarded and once the funding commitment is made, Digital Innovation facilitates work in the preject and project phases between industry, the clinicians, and other stakeholders. In all facilitation processes there is a high degree of user involvement, involving patients, IT experts, and industry partners. Due to a history of bypassing organisational instructions, not having to seek permission, starting up projects without top- level managerial approval, Digital Innovation, I would argue, has over the years been given an informal wildcard to innovate. When we become aware of a clinical challenge we have the freedom to select and start up projects, and as soon as Digital Innovation has reached an agreement with a department s consulting doctor, we start the process. When projects reach a level of having something tangible, we approach director- level with presentations. This approach makes some employees uncomfortable, but by continually arguing for the freedom to operate, we manage to establish a kind of unwritten contract, and the directors tolerate our behaviour as long as the results follow. 9
15 I have used semi- structured qualitative interviews, focus group prototyping interviews, and informal conversations in groups. It was important to me to interview people who have experience working with PPI, so I have chosen a diverse group of people: clinicians, PhD students, innovation facilitators, and people from industry and the universities. They all have one thing in common: they have a connection to the EU project portfolio at Digital Innovation, and they have been working with innovation projects or innovative processes. Interviewing such a diverse group of people means that light can be shed on the subject from different angles. The use of the same respondents repeatedly throughout the process meant that they acquired a sense of ownership, because they know the findings and data come directly from them. All in all, I have used 20 different respondents, resulting in 19 interviews, some individual and some in focus groups. The starting point of the empirical case of the Innovation Guidelines is based on six semi- structured qualitative interviews. With a semi- structured approach (cf. interview guide in Appendix 1), I use a question guide, but the conversation could easily take off in any direction, as two- way communication. The inductive approach was used in the preparation as well as when conducting the interview in order to be able to examine practice within its own contexts rather than to form a predetermined theoretical basis. I decided to design the interviews about the PPI 10
16 challenges as semi- structured qualitative interviews because it was important to speak to the respondents individually to make sure I obtained all the different views from all respondents. The first six semi- structured qualitative interviews provided me with very little data about co- creation. The interview guide was very broad, only talking about innovation projects, and not creative processes, thus the conversation became wide- ranging, but it did provide some data on the PPI challenges, though no data about co- creation. Reflecting on the interview guide and the topic, it is obvious that the respondents never came across the topic in question because in talking about PPI challenges, the negative aspect of the topic prevents any in- depth discussion of possibilities relating to co- creation. The second part of the empirical case of the Innovation Guidelines is based on eight semi- structured qualitative interviews (cf. interview guide in Appendix 8). I used a question guide, but again the conversation could take off in any direction. The question guide was more direct, talking about co- creation, facilitating, prototyping, and the physical and mental space for innovation. The straightforwardness of the question guide might be taken to imply that I was manipulating the respondents, but, coming with very little data from the first six semi- structured qualitative interviews, it was a question of obtaining relevant data, and I wanted to make sure the respondents felt transparency with the core subject. Starting with the six semi- structured qualitative interviews about the PPI challenges, the findings provided me with new data for the questions about co- creation, where the questions build on my findings from the first six semi- structured qualitative interviews about PPI challenges. The findings from the co- creation semi- structured qualitative interviews provided me with new insights and findings about the need for physical space for co- creating. With all the respondents highlighting physical space as a key obstacle to co- creation, I use data from an earlier mini project from the 2nd semester at LAICS 1 (Lakman, 2013). I use the same data set, but here there is a change of perspective, because the physical space for innovation will be 1 LAICS Leadership & Innovation In Complex Systems 11
17 seen in a broader context as part of the overall co- creation process at Digital Innovation. I used a focus group prototyping interview approach (cf. interview guide in Appendix 31) with a question guide, but the conversation could take off in any direction while prototyping and building the creative physical space for Digital Innovation. I decided to conduct the focus group prototyping interview by prototyping in focus groups. When building creative physical spaces it is my contention that it would be most beneficial as a focus group where the respondents build on each other s ideas while prototyping. Thus I made up groups of two and three respondents to obtain the requisite group dynamics. The respondents prototyped the layout, design and décor of the physical space, using physical materials. With data about PPI challenges, co- creation, and physical space for innovation at my disposal, I undertook one final informal conversation with three respondents, all employed at Digital Innovation, where I submitted my findings. Talking about my findings in relation to PPI challenges, co- creation, and the physical space, I wanted the respondents to reflect on relations, concepts, knowledge and ignorance as a final opportunity for the respondents to comment on the findings or add something which our discussion in the previous interviews did not cover. Using the findings from earlier interviews with the respondents, I was able to make sure they became deeply involved. The process of writing the Innovation Guidlines involved working with the data from each interview as I finished the interviews and adjusting the interview guide where the respondents expressed confusion or had difficulties understanding the questions. My analysis is based on the findings from the qualitative interviews combined with desk research, and I use the desk research and the qualitative data to assess consistency, whether they are pointing in the same direction, or whether the qualitative interviews and the desk research conflict in some way. The desk research involves a combination of literature on the topic of PPI and literature on innovation. 12
18 I am a chief consultant and the leader of Digital Innovation. I am therefore biased, firstly because of my position as an insider (Adriansen & Madsen, 2009), and secondly because some of the respondents work for me. I always ask that they respond honestly in their role as interviewees, there is a chance they might want to impress me or provide me with a set of data pointing in a direction germane to my interest. However I have asked everyone to be completely frank and honest so that we may learn from the process and use the findings at Digital Innovation. I have been working with PPI at OUH for the past seven years. Over the last four years I have focused exclusively on Serious Games and healthcare Apps, with a large number of the technologies developed being implemented at OUH, and, in terms of healthcare Apps and Serious Games, all finished technologies have been implemented at OUH. Given my creative background as a cabinetmaker, a Master s degree in management and a Master s degree in leadership and innovation, all the respondents know about my drive for creativity and co- creation. The upshot of this is that I do have a bias due to my having a known interest. In designing the interview guide it was important to conceal the agenda, and I tried not to ask questions where the respondents could answer yes or no, making sure to use what do you think about, what, how, and asking the respondents to elaborate when they hit upon an interesting subject. Using the word challenges when discussing PPI might lead the respondents to overanalyse and come up with answers about challenges that do not exist, or where they might indulge in excessive analysis to impress me. To get more broad- based answers, I decided to undertake interviews with two innovation facilitators from Digital Innovation, two clinicians, and two people representing firms participating in PPI. 13
19 The interviews in Odense took place in a meeting room at Odense University Hospital we often use. There is therefore a certain pre- existing relationship between us and the meeting room. Even though the interviews were conducted based on a semi- structured qualitative interview guide allowing for conversation to take off in any direction, I unfortunately discovered the respondents wanted to stick to the questions, even though I tried to make the conversation more informal. An effort was made to accommodate each respondent in terms of time and place for the interviews. Prior to the interview, I also focused on creating a comfort zone in which the respondents would feel that they could speak openly and frankly. However, because in one case the interview/respondent relationship is also that of manager/employee, there is a risk that the respondents felt restricted in their answers, thus resulting in data that might not completely reflect their points of view. After the interviews the respondents elaborated on the level of the question guide, and they all declared the questions to be difficult and very broad in scope, implying that it was difficult for them to follow the direction I was taking. I have chosen not to transcribe the interviews in full, as this would have been very time- consuming. Instead, significant quotations from the various interview topics ( experience with PPI, roles and responsibilities, goals and effects, process, and relations ) have been assembled as an array of quotations. The various quotations have been processed and categorised by a common denominator in the Appendix. In the Appendix the questions are in Danish, but those transferred to the Innovation Guideline were translated into English. Subsequently the results of my desk research bore out the analysis, sustained by empirical data. Processing the data from the first six interviews, I realised that all the respondents articulate the innovation facilitator job as classic stage gate project management, whereas I look at it as facilitating an innovative process. How can the respondents talk about co- creation and creativity if the starting point is thinking in terms of stage gate project management? Thus I needed to conduct some interviews where the processes in and around the preject phase constituted the central focus of the interview. 14
20 Once again I tried not to construct questions where the respondents could only answer yes or no, making sure to use what do you think about, what, how, and asking the respondents to elaborate with examples. As a skilled cabinetmaker I always work with tangible artefacts to encourage conversation (Buur & Mitchell, 2011), and I would argue that, by moving from words to something visual and tangible, conversations will become more open. I therefore decided to bring in artefacts, such as paper, tape, glue, stickers, carton and other materials, just to set the mood (Wallace, 2012). I made different drawings describing the linear stage gate model (Drucker, 1985) and the non- linear models (Bason, 2010). I made seven different graphical drawings (cf. Appendix 9) of stage gates and innovation models. These involved Darsø s Diamond of Innovation framework (Darsø, 2001), drawings of the different stages of citizen involvement in the design process (Bason, 2010) together with pictures of prototyping, and a draft drawing of an innovation model for Digital Innovation. Having at my disposal an array of empirical data about political, project and cultural challenges, I decided to test my findings by asking the respondents about the relationship of and possibilities relating to co- creation when pitted against the various challenges: Can more co- creation solve some of the challenges identified in the earlier interviews? To ensure I got broad- based answers, I decided to carry out interviews with two innovation facilitators, two clinicians, two PhD students, and two people representing firms. In the following eight interviews I wanted to make sure the introduction was done correctly. Unfortunately I once again forgot to inform the respondents about this fact until after 10 minutes of conversation had elapsed. In addition, on subsequent listening to the tapes, I realise I said mini- structured interview and not semi- structured interview. The interviews in Odense took place in a meeting room at Odense University Hospital we often use. There is therefore a pre- existing relations between us and the meeting room. The interview with Eva Friis Kamelarczyk was conducted at a local cafe in Svendborg, because Eva Friis Kamelarczyk wanted the interview to be at a place other than the hospital. The interview with Palle Møldrup was also conducted at a local café in Odense which has a layout conducive to 15
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