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.
I.2. Conclusion
The creation of a book is always the fruit of a long process. The present project began in 2019 when, in the vast majority of countries, the transformation of the health system was thought to be a long-term process, with uncertain results, and marked by a fiercely negotiated balance between “high” and “low”, between center and periphery, between institutional entrepreneurs and those more inclined to preserve so-called “assets”.
However, its manufacture concludes with a context that is completely new for many: the (global) health crisis of COVID-19 and the ways to combat it. Daily reports (TV, newspapers) recount the major difficulties faced by organizations and health professionals in informing, caring for and accompanying patients, users and caregivers: lack of personnel – and those who remain are exhausted – lack of masks and other protection, insufficient intensive care beds, etc. These are all the aspects of the healthcare system that are affected: hospitals, EHPAD, medical and social institutions providing support or accommodation for disabled children and adults, SAAD and SSIAD2, social services, “front-line” professionals, etc. This crisis will have been a powerful indicator of dysfunctions that have already been in place for a long time.
At the same time, many testimonies have revealed daily the determination of all professionals and other stakeholders (charitable workers and citizens) to continue to practice their “profession for the other”. In many countries, everyone seemed to be rallying for the “common good”, based on a principle of solidarity in capitalist societies (Tirole 2016). What a lot of tinkering! In the sense that, in a do-it-yourself approach, the stakeholder knows the aims of his or her actions, but at the same time, he or she must identify or locate the resources to achieve them (Levis-Strauss 1962; Garud & Karnoe 2003).
These do-it-yourself projects, as varied as they are ingenious and surprising, are all based on the different facets of action that we have just mentioned, all of which are based on the identification of boundaries and the conditions under which they are crossed. However, they reveal, with renewed acuity, three ingredients for a sustainable transformation of the health system: the autonomy of the stakeholders, enabling them to invent solutions; the benevolence of the supervisory authorities, with a view to mobilize methodological and support resources to assist these professionals and organizations; and the need for a sense of control and evaluation to ensure the sustainability of this inventiveness.
Finally, it emerges from most of the chapters of the book that this crisis is also a call to put an end to a culture of “the fairest”. The crisis has revealed what can be called a slack of solidarity, when individuals, companies, merchants, etc., spontaneously offer their help and service. The term slack refers to the surplus (time, resources) which we do not know a priori what it can be used for, except when it has to be used! Schulman (1993) identifies two types of slack: that of resources (surplus not strictly engaged in current activities) and that of control relative to the degree of freedom in organizational activities (i.e. a set of actions that are not framed by formal modes of power, and supervision). It is thanks to these that the crisis is overcome as quickly as possible. May this lesson be kept in mind, not only because some people predict the multiplication and complexity of future crises, but more generally because it is an important condition for any innovative organization, when individuals have time, outside of protocolized and routine activities, to imagine how to renew themselves in a different way.
