An apocryphal (but probably not wildly out) statistic suggests that 80% of technology-supported change projects in health and social care fail. We all know that’s because they’re complex. It’s time to unpack what that complexity is all about – because failed technology projects are costly, wasteful and potentially harmful at both human and system level.
Many promising technologies are not adopted at all (for example, because of clinician “resistance”) – or they are adopted but quickly abandoned (for example, when it becomes clear that using them creates problems somewhere else in the system). Technologies that are successfully adopted on a small scale (for example, in proof-of-concept demonstration projects – perhaps as part of a randomised controlled trial) may prove difficult or impossible to scale up locally beyond the initial team of enthusiasts, and/or impossible to spread elsewhere (even when the settings appear comparable). Finally, few technology projects are sustained over time in a way that adapts and evolves with a changing context. These five challenges (Non-adoption, Abandonment, and failure of Scale-up, Spread and Sustainability) inspired the development and testing of a framework (NASSS) to explain such phenomena. NASSS is based on the most extensive systematic review ever published on technology adoption in healthcare, plus a large and diverse sample of organisational case studies followed for up to three years. It considers seven domains – the illness or condition, the technology, the value proposition, individual adopters (patients, staff), the adopting organisation(s), the wider system and time. Each domain may be simple (that is, few components, clear categories and predictable), complicated (multiple components and issues), or complex (dynamic, ambiguous, unpredictable).
Complexity in multiple NASSS domains appears strongly predictive of programme failure. Proactive attention to reducing complexity in the different NASSS domains early in the planning stages may reduce the risk of failure (though that hypothesis remains to be tested empirically). The NASSS framework was published in November 2017 and quickly became one of the most downloaded papers ever published in the Journal of Medical Internet Research. Various researchers, design companies, consultancies and policymakers have begun to use it to guide, support and/or evaluate the development, adoption, implementation and scale-up of technology-supported programmes.
This lecture will introduce the NASSS framework, give examples of its application and invite discussion on how it might be used and refined in the future.