Necessary but Not Sufficient ... Comment on “ Knowledge Mobilization in Healthcare Organizations : A View From the Resource-Based View of the Firm ”

The challenge of mobilizing knowledge to improve patient care, population health and ensure effective use of resources is an enduring one in healthcare systems across the world. This commentary reflects on an earlier paper by Ferlie and colleagues that proposes the resource-based view (RBV) of the firm as a useful theoretical lens through which to study knowledge mobilization in healthcare. Specifically, the commentary considers 3 areas that need to be addressed in relation to the proposed application of RBV: the definition of competitive advantage in healthcare; the contribution of macro level theory to understanding knowledge mobilization in healthcare; and the need to embrace and align multiple theories at the micro, meso, and macro levels of implementation.

1. How we define 'competitive advantage' in healthcare; 2. The contribution of macro level theory to our understanding of knowledge mobilization; 3. The need to embrace and align theory across the micro, meso, and macro levels of implementation.

What Do Mean by 'Competitive Advantage' in Healthcare?
One of the common objections to importing private sector theories to inform thinking in healthcare is the view that healthcare organizations are fundamentally different as they are not subject to the same conditions or drivers as the private sector, namely a need to be profitable and to achieve competitive advantage over their rivals in order to survive.However, public sector healthcare organizations are universally subject to economic constraints and many are operating within market or quasi-market conditions as a result of various policy reforms.Whilst the relative advantage of introducing a market economy in healthcare is debated, 5 one could conclude that there are enough similarities between the private and public sectors to suggest that theory transfer is relevant. 6,7Notwithstanding the likely transferability of RBV theory to healthcare, that still leaves us with the thorny issue of how we define competitive advantage.Is it about delivering the highest quality care at a population level?Or is it about providing the best possible experience of care at an individual patient level?Or alternatively, is it concerned with the efficient management of limited resources?Or indeed, all of these together -and if that is the case, is it feasible or possible to deliver on patientcentred, clinically effective and cost efficient healthcare simultaneously?Contemporary evidence from international health systems suggests it is very difficult to balance priorities  9 One of the key recommendations of the Francis Inquiry was a need to focus on compassionate caring in health systems, a point reinforced by the current interest in understanding and promoting the fundamentals of patient care. 10,11An immediate challenge from an RBV perspective would be around how healthcare organizations can embrace patientcentred fundamental care as a strategic aim that aligns with their values, motivation and operational goals. 12eturning to our starting question of how we define competitive advantage in healthcare, it is clear that this is far from straightforward.Certainly it is concerned with maintaining and improving quality, but quality is a multidimensional concept and can mean different things to different people. 13This, in turn, has implications that need to be considered when we think about applying RBV to the study of knowledge mobilization of healthcare.First and foremost, we need to be clear about the knowledge we are aiming to mobilize and for what purpose -what is the advantage we are seeking to gain?In addressing this question, organizations need to think carefully about the different priorities that they need to deliver on and how to keep these in balance, with the patient and patient-centred care remaining centre stage throughout.

The Contribution of Macro Level Theory to Our Understanding of Knowledge Mobilization
A second consideration is the role that a macro level theory such as RBV can contribute to our understanding of effective knowledge mobilization in healthcare.Ferlie and colleagues 1 make the point that many analyses of implementing evidence-based knowledge into healthcare practice have focused on barriers or obstacles at the micro level of individuals and teams.They argue that this needs to be complemented by attention at the macro system level to ensure that organizations have the core competences needed to support and facilitate effective and timely knowledge mobilization.From the experiences of knowledge mobilization in healthcare to date, what is the evidence to support this claim?One source of evidence is the findings emerging from the first wave of Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) in the English NHS.5][16][17][18] Whilst these evaluations demonstrate achievements in terms of mobilizing knowledge at the local project level, questions remain as to whether CLAHRCs in the organizational form of a knowledge mobilizing network deliver added value. 17his is due to the complex inter-relationship of a number of wider system-level factors such as the past history of partnership working amongst CLAHRC stakeholders, the influence of senior leaders and epistemic differences between partners in the network. 14,16,19This supports the need to draw on theory at a wider contextual level when planning, initiating and coordinating knowledge mobilization at an organizational or health system level.RBV and related theories of dynamic capabilities, absorptive capacity and organizational ambidexterity could provide useful insights to those involved in developing or evaluating knowledge mobilization at this wider system level.Equally, researchers concerned with studying knowledge mobilization in healthcare more generally are increasingly recognizing the need to look at both internal and external contextual influences on implementation, as reflected in conceptual frameworks and models for knowledge mobilization. 20,21[24] The Need to Align Theory Across the Micro, Meso, and Macro Levels Our final observation focuses on the need to adopt an eclectic yet aligned approach to knowledge mobilization in healthcare.
Given the recognized complexity of knowledge mobilization and the influence of multiple factors relating to the evidence to be implemented, the context in which implementation takes place and the strategies and processes that are used to support implementation, 25,26 there is potential for a range of different theories to be applied to guide knowledge mobilization efforts.This is an area that we have recently been studying as part of revisiting and revising the Promoting Action of Research Implementation in Health Services (PARIHS) framework.Originally published as a conceptual framework in 1998, 25 PARIHS proposed that successful implementation resulted from the interplay between evidence, context and the processes of facilitating implementation.The framework was subsequently tested and refined over the following 10 years 26,27 ; more recently one of the issues that we have been focusing on is identifying the theories that underpin PARIHS as a conceptual framework.This, in turn, has led to a further revision of the framework to produce the integrated or i-PARIHS framework, which more explicitly integrates theories informing knowledge mobilization at a micro, meso, and macro level of implementation. 21s a conceptual framework, i-PARIHS proposes that successful implementation results from the facilitation of an innovation with the recipients of the innovation in their local, organizational and health system context.Within the revised framework, evidence is incorporated within the broader concept of innovation to reflect the dynamic and iterative way in which knowledge to inform practice is generated and applied.Recipients at an individual and collective level are included as a new construct, acknowledging the central role of human agency in defining and shaping the process of mobilizing knowledge, and context is more clearly differentiated as spanning from a micro (local) level to meso and macro levels of implementation.Figure provides a visual representation of the i-PARIHS framework, illustrating the multiplicity of factors that influence knowledge mobilization.
In order to assess and respond to these inter-related factors, i-PARIHS proposes that facilitation -comprising an individual (or individuals) in facilitator roles applying facilitation methods and processes -is essential as the active ingredient of implementation.
Corresponding theories to inform thinking about the dimensions of innovation, recipients, levels of context and facilitation have been identified, as illustrated in Table .As the Table illustrates, absorptive capacity is specifically referenced as a theory that is relevant to understanding wider contextual influences; equally RBV as the parent theory would be pertinent to consider here.However, an important point to make is that in planning, conducting and evaluating knowledge mobilization, there are likely to be multiple theories that are appropriate and important to draw upon at any one time.This reflects the multifaceted and dynamic nature of knowledge mobilization in practice.It also suggests a need for a level of theoretical understanding and expertise amongst those who are responsible for leading or researching knowledge mobilization in healthcare.Furthermore, it is important to ensure that theories are applied that are consistent with underlying world-views about knowledge and knowledge mobilization.In the case of PARIHS and now i-PARIHS, we start from a position that knowledge mobilization is dynamic, iterative and multifaceted (as opposed to rational and linear), hence evidence has to be negotiated and adapted to context, which requires active facilitation by a facilitator employing enabling (as opposed to persuasive, coercive or telling) strategies.Consequently, the theories that we have listed as aligning with our beliefs about implementation and knowledge mobilization reflect the importance of situated, experiential learning, distributed leadership, humanistic approaches to learning and change and complex adaptive systems.We suggest that RBV and absorptive capacity theory is consistent with this worldview of knowledge mobilization as it acknowledges the contingent and dynamic way in which organizations seek, assimilate and apply knowledge to improve performance. 23However, it needs to be complemented by theories that more specifically focus on micro and meso level issues relating to the nature of the innovation, the key actors involved and their immediate work culture and organisational environment.

Conclusion
In this commentary we have reflected on the contribution of RBV theory to our understanding of knowledge mobilization in healthcare and come to the conclusion that it has a useful -but on its own -insufficient role to play.As a macro level theory, RBV could usefully align with more micro and meso level theories that recognise the multidimensional and contextually situated nature of knowledge mobilization.However, in adopting RBV, we suggest that a central concern has to be on articulating and debating what competitive advantage actually means in healthcare and, importantly, how healthcare organizations make sense of and manage the competing priorities that face them.Patients and patientcentred, compassionate care must feature at the heart of what healthcare organizations are attempting to achieve through effective knowledge mobilization.
8uch as individual patient experience, population health gain and cost containment, as the recent evaluation of the Triple Aim initiative instigated by the Institute for Health Improvement in the US demonstrates.8Whilsta small number of the 141 participating organizations succeeded in the Triple Aim goals of improving individual experience of care, improving population health and reducing per capita costs, the majority were unable to pursue all 3 elements at the same time.