• an evidence-based conceptual model delineating the process by which innovation is transferred in health service organizations
• a "robust" and replicable methodology for the systematic review of policy and management
• the identification of gaps, in theory and in research, which indicate a need for further analyses and study. 

[Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations. Milbank Quarterly, 82(4), 581-629.]

The team led by Greenhalgh, Robert, MacFarlane, Bate and Kyriakidou, culled over 6,000 papers, titles, books, and abstracts, and focus on 495 pieces of literature, both empirical and non-empirical.  Their complete literature review has been published as a 315-page book, "Diffusion of Innovations in Health Service Organisations: A Systematic Literature Review" (2005).

To establish a common language for their review, key terms in innovation transfer are defined by the authors:

• diffusion - - the passive spread of innovation in an organization
• dissemination - -active and planned efforts to specific groups in order to adopt innovation
• implementation - - actions and efforts undertaken to spread innovation within an organization
• sustainability - -  the shift during which an innovation becomes "routine" until that innovation  is no longer needed

As the scope of their review widened, Greenhalgh et al. developed a unique methodology which they coin meta-narrative. It involved tracing the evolution of theory, methodology and concepts in various research traditions pertaining to innovation diffusion via the identification and analysis of seminal literature, research studies and theoretical models put forth by reputed experts in the field.

Research Traditions

The authors identified, categorized and evaluated 13 research traditions delineated as "early diffusion research," emerging models, and organization/management literature.  "Early diffusion research" concepts or theories include:

1. Rural sociology (Rogers 1995) - - the spread of innovative individual practice in rural areas, such as farming methods;
2. Medical sociology (Coleman, Katz, and Menzel 1966; Burt 1973) - - network analysis of innovation in a systematic study of "who knows whom" and "who copies whom" among physicians in clinical settings;
3. Communication studies (Rogers and Kincaid 1981) - - new information and ideas spread by either mass media or interpersonal communication;
4. Marketing (Bass 1969) - - a market analysis of products and/or services measured by weighing costs and benefits and the development of mathematical formula by which to ascertain the likelihood of innovation adoption.

These early studies were found deficient on a number of fronts including that they relied on individuals and individual innovations as the only germane units of analysis, and that it was thought that the innovation could be universally transferable to other contexts.

Those in emerging research traditions include:

5. Development studies (Bourdenave 1976) --  expanding research to include technological,  ideological and political aspects of the innovation and its dissemination;
6. Health promotion (Potvin, Haddad and Frohlich 2001) - advice and good ideas promoting healthy living via targeted social marketing;
7. Evidence-based medicine (Granados et al 1997; Grimshaw et al 2004; Ferlie et al 2001) - in general, technologies and practices within the medical field that are supported by viable research evidence.

The balance of these research traditions are classified as organization/management literature:

8. Studies of the structural determinants of organizational innovativeness (Damanpour 1991, 1992, 1996) - innovation viewed as a process likely to make the entity more profitable;
9. Studies of organizational culture, process and context (Kanter 1988; Van de Ven et  al 1999)  -- soft, mainly qualitative practices that adopt, assimilate and normalize an innovation;
10. Interorganizational studies (Granovetter and Soong 1983; Abrahamson 1991; Abrahamson and Fairchild 1999) -- influences of outside organizations, communication, collaboration, competition and normative values on innovation    (i.e. the role of networking and "fads and fashions" as agents of change);
11. Knowledge-based approaches (Nonaka and Takeuchi 1999; Zahra and George  2002) -- an organization's absorptive capacity for assimilating and distributing new knowledge and information;
12. Narrative organizational studies (Czarniawska 1998; Gabriel 2000; Buckler and Zein 1996; Bate 2004) - - innovative organization as the ability to generate, capture and circulate new ideas as "shared stories" within a "community of   practice";
13. Complexity studies (Fonseca 2001; Plsek 2003) - - deduced from reciprocal, organic, dynamic, and adaptive relationships between innovations and organizations with minimal influence from external change agents.

Their meta-narrative review involved five phases:

• Planning - assembling a multidisciplinary research team with relevant subject matter backgrounds.
• Search - conducting a progressive search beginning with informal networking to track the variance of perspectives; identifying and evaluating seminal conceptual papers in established research traditions; and targeting empirical research articles via electronic subscription databases, manual searches of noted journals, and snowballing (tracking references of references).
• Mapping - identifying the key elements (concept, theory, methodology, tools) and people, events and language associated with each research tradition.
• Appraising - evaluating the validity and applicability of key studies, and categorizing them according to relevant "critical appraisal" methods.
• Synthesis - define key contributions and conflicting findings per research tradition.   

Conceptual Model 

The empirical results from this extensive review were formulated into a conceptual model for considering the process and content of innovation, diffusion, dissemination, and implementation."  The key attributes of successful innovation indicated in their model involve:

• Relative Advantage - clear benefits and cost-effectiveness are apparent;
• Compatibility - in sync with adopters' values and perceived needs;
• Low Complexity --  perceived simplicity of use bodes well for adoption;
• Trialability - ability for trial experimentation;
• Observability --  benefits need to be easily discernible by adopters;
• Reinvention - ease of modification, adaptation makes adoption easier;
• Fuzzy Boundaries - similar to reinvention in that a softer periphery (as opposed to a "hard core" with more strict components as seen in more complex innovations of service groups) often promises more adaptiveness;
• Risk - less risk or uncertainty of outcome favor more certainty of adoption;
• Task Issues - clear potential for work-performance improvement;
• Knowledge Requirements - ease of knowledge transfer within various contexts;
• Augmentation/Support - additional support components (i.e., training and support staff) favor ease of adoption. 

The reviewers consider the assimilation of innovation as more than simple imitation, but  a more complex, organic, and "often messy" process with fluid stages of initiation, development, and implementation often beset by "setbacks" and surprises.  Other influential factors that are critical in the adoption process within the organizational framework, according to the authors, include:  network structures; homophily (i.e., similarities in values, background); opinion leaders; harnessing the opinion leader's influence; champions; boundary spanners; and formal dissemination programs.

Greenhalgh et al. list a number of potential determinants of innovation within the structure of organizations.  Through this literature review, those determinants found to have a positive (negative) significant association with organization innovativeness were:  administrative intensity; centralization (negative correlation); complexity;  external communication; functional differentiation; internal communication; managerial attitudes towards change; professionalism; adequate resources; specialization; and technical capacity.  Two additional determinants were noted as prerequisites to the transfer of innovation imbedded outside the structural organization - - the absorptive capacity for new knowledge and a receptive context for change.

A system's readiness for innovation is, according to the authors, dependent on the following:  tension for change; innovation-system fit; assessment of implications; support and advocacy; dedicated time and resources; and capacity to evaluate the innovation.  Influences supporting innovation outside the system/organization include: informal interorganizational networks; intentional spread strategies or formal networks; the wider environment; and political directives or mandates.

The successful implementation and routinization of innovations is nonlinear in process.  Variables include:  organizational structure; leadership and management; human resource issues; funding; intraorganizational communications; intraorganizational networks; feedback; and the ability to adapt or reinvent an innovation.  Strong evidence among the research reviewed indicates the following: a necessity for linkage at the development stage; a positive and supportive role of the change agency; and effective external change agents possessing credibility, providing support and training, encouraging communication of varying needs and perspectives and the ability to empower the users of the innovations.

The authors suggest future research on diffusion of innovation should focus on: 

• Theory driven research
• Process rather than "package"
• Ecological analyses
• A common language, measures, and tools
• Collaboration and coordination
• Multidisciplinary and multimethods research
• Meticulous details
• Participation between practitioners and researchers. 
  

Tools/Knowledge Objects/Resources/Contacts/Etc:

• Abrahamson, E. (1991). Managerial Fads and Fashions: The Diffusion and Rejection of Innovation. California Management Review, 16, 586-612. 
• Abrahamson, E., & Fairchild, G. (1999). Management Fashion: Lifecycles, Triggers, and Collective Learning Processes. Administrative Science Quarterly, 44(4), 708-740.
• Bass, F. M. (1969). A New Product Growth Model for Consumer Durables. Management Science, 13(5), 215-227.
• Bourdenave, J. D. (1976). Communication of Agricultural Innovations in Latin America:  The Need for New Models. Communication  Research  3(2), 135-154.
• Burt, R. S. (1973). The  Differential Impact of  Social Integration on Participation in the Diffusion of Innovations. Social Science Research 2(2), 125-144.
• Coleman, J. S., Katz, E. & Menzel, H. (1966).  Medical Innovations: A Diffusion Study. New York: Bobbs-Merrill.
• Damanpour, F. (1991). Organisational Innovations:  A Meta-Analysis of Effects of Determinants and Moderators. Academy of Management Journal, 34, 555-590.
• Damanpour, F. (1992). Organizational Size and Innovation. Organization Studies (Walter de Gruyter GmbH & Co. KG.), 13(3), 375-402.
• Damanpour, F. (1996). Organizational Complexity and Innovations: Developing and Testing Multiple Contingency Models. Management Science, 42, 693-716. 
• Ferlie, E.,  J. Gabbay, L. Fitzgerald, L. Locock & S. Dopson (2001). Evidence-Based Medicine and Organisational Change: An Overview of Some Recent Qualitative Research. In Organisational Behaviour and Organisational Studies in Health Care: Reflections on the Future, Ashburner, L. ed. Basingstoke: Palgrave.
• Fonseca, J. (2001). Complexity and Innovation in Organisations. London. Routledge.
• Granados, A., Jonsson, E., Banta, H. D., Bero, L., Bonair, A., Cochet, C., et al. (1997). EUR-ASSESS Project Subgroup Report on Dissemination and Impact. International Journal of Technology Assessment in Health Care, 13(2), 220-286.
• Granovetter, M., & Soong, R. (1983). Threshold Models of diffusion and Collective Behavior. Journal of Mathematical Sociology, 9, 165-179.
• Greenhalgh, T., G. Robert, P. Bate, O. Kyrakidou, F. Macfarlane, and R. Peacock     (2005). Diffusion of Innovations in Health Service Organisations: A Systematic Literature Review. Oxford: Blackwell Publishing.
• Greenhalgh, T., G. Robert, F. Macfarlane, P. Bate, O. Kyriakidou, and R. Peacock. (2005b). Storylines of Research: A Meta-Narrative Perspective on Systematic Review. Social Science & Medicine 61(2), 417-430.
• Kanter, R. M. (1988). When a Thousand Flowers Bloom: Structural, Collective and Social Conditions for Innovation in Organisation. In B. M. Staw & L. L. Cummings (Eds.), Research in Organisational Behaviour. Greenwich: JAI Press.
• Potvin, L., Haddad, S., & Frohlich, K. L. (2001). Beyond Process and Outcome Evaluation: A Comprehensive Approach for Evaluating Health Promotion Programmes. WHO Regional Publications, European Series, 92, 45-62.
• Rogers, E. M. (1995). Diffusion of Innovations. New York: Free Press.
• Van de Ven, A. H., Polley, D. E., Garud, R., & Venkataraman, S. (1999). The Innovation Journey. Oxford: Oxford University Press.
• Zahra, A. S., George, G. (2002). Absorptive Capacity: A Review, Reconceptualization and Extension. Academy of Management Review. 27(2). 185-203.