Implementing NASSS-CAT
Research type
Research Study
Full title
Implementing NASSS-CAT (Non-adoption, and Challenges to Scale up, Spread and Sustainability - Complexity Assessment Tool): an action research study
IRAS ID
258679
Contact name
Trish Greenhalgh
Contact email
Sponsor organisation
University of Oxford / Clinical Trials and Research Governance
Duration of Study in the UK
1 years, 2 months, 30 days
Research summary
Summary of Research
Failure rates of technology-supported change projects in health and social care are high, usually because they are ambitious and complex. Using a detailed systematic literature review and a three-year empirical study of a range of technology implementation case studies, we developed the NASSS (non-adoption, abandonment, scale-up, spread, sustainability) framework to explain the varied (and often poor) fortunes of technology projects in health and care.The NASSS framework allows researchers to surface and explain the multiple forms and manifestations of complexity in technology-supported change projects. It consists of seven domains: the condition or illness, the technology, the value proposition, the adopter system (intended users), the organisation(s), the wider system (especially regulatory, legal and policy issues) and emergence over time. Each domain may be simple (few components, predictable), complicated (many components but still largely predictable) or complex (many components interacting in a dynamic and unpredictable way).
NASSS has proved useful in academic analysis and we have been approached by local, national and international policymakers to help them apply it to real-world technology implementation.
This project will involve using NASSS to support the implementation and evaluation of technology-supported change across different healthcare organisations. This will include piloting and refining our NASSS complexity assessment tool (CAT), designed to guide such service developments.
We will undertake four contrasting implementation studies, selected to provide maximum variety in conditions, technologies, care settings, scope and scale, and policy drivers. The data sources and methods we will use in each of the cases have been selected to enable us to build a rich and evolving picture of the context, challenges and events influencing the introduction of the technology and associated service change. This will include semi-structured interviews with stakeholders, staff and patients, self-assessment survey (NASSS-CAT), observation of meetings, and qualitative and quantitative analysis of the technology use and service outcomes.
Summary of Results
This study applied the NASSS-CAT (Non-adoption, abandonment and challenges to Scale-up, Spread and Sustainability – Complexity Assessment Tool), in order to study and develop theory on complex change in healthcare systems.NASSS CAT in an implementation framework to continually inform service change. It consists of six key domains to consider: the condition or illness, the technology, the value proposition, the adopter system (intended users), the organisation(s), the wider system (especially regulatory, legal and policy issues), and a seventh cross-cutting domain of emergence over time.
This study focused on the implementation and scale up of remote video consultations within the NHS. The project commenced prior to COVID-19, and was extended to continue working within the case sites during the pandemic.
Overall, the study involved 11 health boards in Scotland and four Trusts in England. The data consisted of qualitative data (‘NASSS CAT interview’, focus groups and observations) and quantitative data provided by participating organisations (e.g. appointment activity data, surveys). In total, 200 participants were recruited. This included clinicians (e.g. nurses, doctors, and allied health professionals), non-clinical staff (e.g. managers, IT support, and administrators), patients, carers, and national stakeholders.
Using the NASSS domains, the project provided insight into the multiple challenges to introducing and mainstreaming the use of video in different NHS settings. Cross-case comparisons revealed common challenges, as well as organisational factors that facilitated use and scale up.
Before COVID-19, actual use of video across services was relatively low, with many clinicians describing their use as ‘ad hoc’ rather than business as usual. There were complex challenges to embedding video within routine practice. This included the need to develop new ways of organising clinical and administrative work.
But when the COVID-19 outbreak reached the UK, the roll out of video was accelerated, in order to avoid direct patient-clinician interaction. The pandemic helped bring about a more conducive set of organisational conditions for the use of video, including a positive narrative about the technology (to minimise risk of infection), slack (available) resources (redirecting staff/equipment) and senior management and clinician buy-in (with national directives and reporting mechanisms).
Cross-case comparisons highlighted that scale up was most extensive in settings where much groundwork for implementation had been done prior to the pandemic. These organisations were characterised by a significant presence of 'clinical champions' (people who believed in the innovation and sought to persuade others of its benefits) and pre-existing technical and material infrastructure to support the technology. At national level (England and Scotland), the analysis revealed the importance of establishing a national strategic vision for video consultations, alongside a well-resourced quality improvement model to enhance shared learning and collaboration.
The case studies illustrate how the NASSS domains can help inform and evaluate the multiple interacting factors that have a bearing on the success of technology-supported change in healthcare, including clinical, social, logistical, organisational and technical issues.
The findings informed organisational change within participating sites (before and during the pandemic), national policy, and the development of NHS guidance on the use remote consultations in different care settings.
REC name
London - Camberwell St Giles Research Ethics Committee
REC reference
19/LO/0550
Date of REC Opinion
10 Jun 2019
REC opinion
Further Information Favourable Opinion