Frontline Service Delivery Research Articles

Networks and evidence-based advocacy: influencing a policy subsystem

Background: Timely access to relevant and trustworthy research findings is an important facilitator of research use. But the relational aspects of evidence generation, mobilisation and use have been insufficiently explored. Aims and objectives: Our aim is to describe the strategic communicative and relational work of two intermediary organisations playing thought leadership roles within a large, heterogeneous and loosely configured network comprised of individuals and organisations from the following sectors: academia, frontline service delivery, philanthropic funding, advocacy organisations and government. Methods: The data for this project were generated as part of a study of the ways social science research influences policy, practice and systems-change processes. Proceeding from the standpoints of people who generate and/or engage with research in an effort to address homelessness in Canada, this article focuses on the intersections of research, strategic communication and policy making. Findings: Our findings suggest that strategic communication and knowledge exchange play integral roles in efforts to create evidence-based policy change. These communicative activities take the form of public-facing political and/or media engagement strategies, traditional knowledge mobilisation activities and continuous informal and timely exchanges of information between trusted allies. Discussion and conclusions: Our study reveals the importance of a heterogeneous network structure, with formal and informal alliances between individuals and organisations, as well as key intermediary organisations through which knowledge can be strategically mobilised within the network to serve policy change aims. Furthermore, our study suggests that interest in evidence-led governance is shifting the boundaries between research, advocacy and government action.

How can we improve patient-centered care of motor neuron disease?

This perspectives paper discusses patient-centered care for people living with motor neuron disease. We identify challenges and offer solutions from the patient-centered care literature for this population in frontline care, service delivery, research and health system organization. Examples from Australian and international motor neuron disease care are used to illustrate interrelated issues for practice and policy.

Why Medical Residents Do (and Don't) Speak Up About Organizational Barriers and Opportunities to Improve the Quality of Care.

Medical residents are valuable sources of information about the quality of frontline service delivery, but if they do not speak up, their ideas, opinions, and suggestions for improving their work practices cannot be considered. However, speaking up can be difficult for residents. Therefore, the authors have explored both what helps residents speak up about organizational barriers and opportunities to improve the quality of their work and what hinders them from doing so. The authors conducted an exploratory qualitative interview study with 27 Dutch medical residents in the Netherlands in 2016. They used the critical incident technique for data collection and the constant comparison method of the Qualitative Analysis Guide of Leuven for data analysis. Three types of incidents in which residents considered speaking up are described. The authors identified 2 main considerations that influenced residents' decisions about speaking up: Is it safe to speak up, and is speaking up likely to be effective? Residents' decisions were influenced by personal, team, and organizational aspects of their situations, such as supervisors' open attitudes, hierarchy, duration of clinical rotations, organization size, and experiences (either vicarious or their own). Findings from this study indicate that residents tend to be silent when they encounter organizational barriers or opportunities to improve the quality of their work. Perceived effectiveness and safety are important forces that drive and constrain speaking up. The authors provide important starting points to empower medical residents to speak up about their suggestions for change.

Epistemologies of bordering: Domestic violence advocacy with marriage migrants in the shadow of deportation

Abstract Drawing on interviews with service providers and legal advocates in Canada, this article explores how bordering practices shape front-line service delivery with immigrant women seeking safety from domestic violence. Our research examines the implementation of ‘conditional permanent residence’ (conditional PR) between 2012 and 2017. Conditional PR applied to some newly sponsored spouses and partners who were required to cohabit with their sponsoring spouse/partner for two years following their arrival in Canada in order to retain their permanent resident status. We illustrate how conditional PR exacerbated the vulnerabilities already facing spousal immigrants by linking deportation to the failure to cohabit with their spouse. In particular, we examine the implementation of an ‘exception for abuse and neglect’, whereby victims of domestic violence could apply to remove the condition on their permanent resident status. We argue that when service providers mobilized their ‘ways of knowing’ about domestic violence to verify a sponsored spouse’s claims of abuse, they inadvertently took part in regulating ‘deserving’ versus deportable immigrants. This research develops a gendered analysis of deportability towards theorizing how bordering practices operate through the shadow state to regulate racialized immigrant women.

Changing the narrative: the role of frontline worker attitudes and beliefs in shaping dementia-friendly services in England

Applying the main principles of the social model of disability as a guide, this article argues that the attitudes and beliefs of staff and volunteers employed in frontline service delivery can play an important role in the achievement of dementia-friendly communities, particularly through influencing the types of services offered. This position is supported by findings from an evaluation of an awareness-raising intervention run by Age UK, aimed at organisations which provide services for people living with dementia in England. The article contributes to an understanding of the cultural climate within frontline service delivery, which is often neglected in favour of discussions around meeting more immediate care and support needs. More specifically, the article reflects on whether there is a need for an additional conceptualisation within the discourse around dementia-friendly communities which ensures inclusion of the cultural environment.

Relational Dynamics Supporting Client Orientation: Perspectives from the Front Lines of Service Delivery

This study explored how identification processes among front-line workers influence client orientation. We interviewed 15 front-line workers from two sport/leisure organizations. Thematic analyses of interview results suggest how identification and relational processes can foster client orientation. Front-line workers may identify with co-workers, the organization (mission was particularly important), the client, and even the activity for which they are responsible. Identification with these targets offers insight into how to treat clients. For example, several of those interviewed noted the importance of mission statements in setting the tone for a client orientation. Two conditions seemed important. First, the mission statement must offer clarity into the role of client orientation in the service delivery model. It should focus directly on serving the client. Second, it must be crafted in a way that encourages identification by staff members. They must see their own value system within the mission statement. These identification processes became critical when other identification targets (in this case, other staff) offered direction that was incompatible with client orientation. We found, for example, that at times co-workers’ values and behaviours could be inconsistent with client orientation. On such occasions, though, those with already high client orientation tendencies failed to identify with, or at least model, the behaviours of their co-workers. Instead they looked to vision for service laid out by the organization. These findings also highlight the importance of staff-participant and staff-activity identification. Observers believed that staff members sharing a sense of similarity and familiarity with program participants, often possessed a client orientation. Particularly striking in our interviews was the notion of a shared passion for the activity (e.g., special event or sport) in developing client orientation. Most leisure service staff described here had a background in the activity they facilitated. As a result, they had a strong passion for that activity. When they interacted with participants who also demonstrated a passion for the activity, identification processes were enhanced. This identification seemed to aid in client orientation. Finally, participants described how job descriptions often failed to capture the nuances of client orientation and instead focused on core tasks. It is perhaps unsurprising then, that client orientation was described as being a lower priority among staff who focused on tasks (as laid out in their job descriptions or in policy). Subscribe to JPRA

Lean implementation in a service factory: views from the front-line

The deployment of Lean methods in service work is increasingly viewed as a legitimate response more efficient front-line service delivery. However, there are mixed results with process efficiency gains frequently marginalised by losses in employee satisfaction and customer focus. It is suggested that these sub-optimal outcomes result from partial adoptions of Lean with emphasis on process efficiency neglecting employee and customer outcomes. Utilising Action Research this paper investigates a Lean implementation within a UK call centre. This research finds that Lean when implemented properly can lead to improved process efficiency, a better customer experience and increased employee satisfaction. It suggests that to achieve these optimum outcomes Lean implementations must as a priority be focused on creating customer satisfaction and be customised to fit with particular contingencies in the organisational context such as the nature of the interface between the front-line worker and the customer.

Social accountability in frontline service delivery: Citizen engagement and provider response in four Indonesian districts

AbstractSocial accountability (SA) tools engage citizens in improving frontline service delivery. Contextual factors are increasingly recognized as key to the effectiveness and sustainability of SA. This article identifies micro‐level factors associated with attitudes and continued commitment to SA, drawing on 60 interviews with providers, clients and local officials at 15 primary health centres in four Indonesian districts. We found that healthcare providers and local governments demonstrated responsiveness to citizens not only in conducive contexts, but also in less favourable ones. State actors’ perceptions of the appropriate role of citizens varied. We conclude that long‐term sustainability of citizen engagement in accountability relationships will depend upon alignment of providers’ and citizens’ expectations, along with supportive institutional incentives.

Exploring how different modes of governance act across health system levels to influence primary healthcare facility managers\u2019 use of information in decision-making: experience from Cape Town, South Africa

BackgroundGovernance, which includes decision-making at all levels of the health system, and information have been identified as key, interacting levers of health system strengthening. However there is an extensive literature detailing the challenges of supporting health managers to use formal information from health information systems (HISs) in their decision-making. While health information needs differ across levels of the health system there has been surprisingly little empirical work considering what information is actually used by primary healthcare facility managers in managing, and making decisions about, service delivery. This paper, therefore, specifically examines experience from Cape Town, South Africa, asking the question: How is primary healthcare facility managers’ use of information for decision-making influenced by governance across levels of the health system? The research is novel in that it both explores what information these facility managers actually use in decision-making, and considers how wider governance processes influence this information use.MethodsAn academic researcher and four facility managers worked as co-researchers in a multi-case study in which three areas of management were served as the cases. There were iterative cycles of data collection and collaborative analysis with individual and peer reflective learning over a period of three years.ResultsCentral governance shaped what information and knowledge was valued – and, therefore, generated and used at lower system levels. The central level valued formal health information generated in the district-based HIS which therefore attracted management attention across the levels of the health system in terms of design, funding and implementation. This information was useful in the top-down practices of planning and management of the public health system. However, in facilities at the frontline of service delivery, there was a strong requirement for local, disaggregated information and experiential knowledge to make locally-appropriate and responsive decisions, and to perform the people management tasks required. Despite central level influences, modes of governance operating at the subdistrict level had influence over what information was valued, generated and used locally.ConclusionsStrengthening local level managers’ ability to create enabling environments is an important leverage point in supporting informed local decision-making, and, in turn, translating national policies and priorities, including equity goals, into appropriate service delivery practices.

Raising the bar: Professionalism and service delivery standards within New Zealand’s contract private security industry

The remarkable growth of private security has re-shaped New Zealand’s policing landscape. However, despite its growth, little is known about its professional standards and service delivery or indeed the licencing system designed to ‘police’ and improve them. Notwithstanding the burgeoning security governance literature, there is a limited amount of research that captures practitioner perceptions of their own industry. This article makes an important contribution to that limited research by presenting the findings of two New Zealand-focused studies that together throw much needed light onto an industry on which so many New Zealanders now rely. Drawing on the perceptions and practical experience of those at the front-line of service delivery, the first provides a first-hand ‘insider’ view of industry standards and professionalism. The second examined industry standards through an analysis of all 2011 security licence applications and approvals. In combination the studies highlight the challenges faced by the new regulatory framework in raising standards and reducing risk.

Future bus transport contracts under a mobility as a service (MaaS) regime in the digital age: Are they likely to change?

The digital age has opened up new opportunities to improve the customer experience in using public transport. Specifically, we see the role of smart technology in the hands of customers as the new rubric to deliver services that are individualised to the needs and preferences of current and future public transport users. This frontline of service delivery has become known as mobility as a service (MaaS) whereby an individual can book a service delivered through a range of possible modes of transport. At one extreme we have point-to-point car based services such as Uber, Lyft, BlaBlaCar and RydHero (for children), with futuristic suggestions of these gravitating to driverless vehicles (cars and buses). Variations around this future are bus-based options that include smart bookable ‘point-via-point-to-point’ services that offer up options on travel times and fares (with the extreme converting to the point-to-point car service, possibly also operated by a bus business); as well as the continuation of conventional bus services (with larger buses) where the market for smart MaaS is difficult or inappropriate to provide (e.g., contracted (often free) school bus services). This paper, as a think piece, presents a number of positions that could potentially represent future contexts in which bus services might be offered, recognising that a hybrid multi-modal state of affairs may be the most appealing new contract setting, enabling the design of contracts to be driven by the mode-neutral customer experience, and the growing opportunity to focus on MaaS. We suggest that the adrenal rush for mobility services, however, may not deliver the full solution that supporters are suggesting.

Homeless Liaisons' Perceptions of McKinney-Vento Act Implementation: Examining Geographical Trends and Differences

The number of children experiencing homelessness continues to rise at alarming rates. Schools are on the front lines of service delivery and face numerous barriers in an attempt to meet the educational and psychosocial needs of these children. This study explored the perceptions of homeless liaisons in three states about the implementation of the McKinney Vento Act within the school districts. While no differences were found across the states, significant differences were found between rural and urban geographic densities in the perceived implementation of the federal legislation. The significant differences relate to collaboration within the community and resonate with the lack of resources available to the families experiencing homelessness in rural areas.

Snap shots from a photo competition: what does it reveal about close-to-community providers, gender and power in health systems?

In this commentary, we discuss a photography competition, launched during the summer of 2014, to explore the everyday stories of how gender plays out within health systems around the world. While no submission fees were charged nor financial awards involved, the winning entries were exhibited at the Global Symposium on Health Systems Research in Cape Town, South Africa, in October 2014, with credits to the photographers involved. Anyone who had an experience of, or interest in, gender and health systems was invited to participate. Underlying the aims of the photo competition was a recognition of the importance of participation of community members, health workers and other non-academics in our research engagement and in venues where their perspectives are often missing. The competition elicited participation from a range of stakeholders engaged in health systems: professional photographers, project managers, donors, researchers, activists and community members. In total, 54 photos were submitted by 29 participants from 15 different nationalities and country locations. We unpack what the photos suggest about gender and health systems and the pivotal role of community-level systems that support health, including that of close-to-community health providers. Three themes emerged: women active on the frontlines of service delivery and as primary unpaid carers, the visibility of men in gender and health systems and the inter-sectoral nature and intra-household dynamics of community health that embed close-to-community health providers. The question of who has the right to take and display images, under what contexts and for what purpose also permeated the photo competition. We reflect on how photos can be valuable representations of the worlds that we, health workers and health systems are embedded in. Photographs broaden our horizons by capturing and connecting us to subjects from afar in seemingly unmediated ways but also reflect the politics, values and subjectivities of the photographer. They represent stereotypes, but also showcase alternate realities of people and health systems, and thereby can engender further reflection and change. We conclude with thoughts about the place of photography in health systems research and practice in highlighting and potentially transforming how we look at and address close-to-community providers.

Welfare reform and the street level bureaucrat in homelessness services

Purpose – Lipsky’s street level bureaucrat conceptual framework is employed to assist in understanding the ways in which statutory frontline homelessness practitioners are engaging with the current welfare reform agenda. The paper aims to discuss these issues. Design/methodology/approach – Draws the street level bureaucrat framework. A national baseline survey of homelessness practitioners was followed by targeted qualitative interviews involving 12 local authorities in England. Findings – Homelessness practitioners are facing a twofold crisis due to an increase in service users and corresponding decrease in feasible housing options or resources to tackle this. It was reported that effective service provision for all who required it was becoming increasingly difficult, which in turn fostered an environment in which unlawful gatekeeping practices could thrive. Further, it was found that a service user’s position may be additionally weakened due to the new powers conferred in the Localism Act. Research limitations/implications – Qualitative data were limited to North East Authorities due to limited research resources. Social implications – The current austere climate is negatively impacting upon the delivery of statutory homelessness provision. Differing implementation of the Localism Act will lead to inequitable service outcomes. Originality/value – Application of the street level bureaucrat implementation framework to English homelessness services, a national survey of English frontline service delivery in an austere climate.

Engaging frontline health providers in improving the quality of health care using facility-based improvement collaboratives in Afghanistan: case study

BackgroundAccess to health services in Afghanistan has expanded in the last decade; however, gaps in care quality and outcomes of care remain a challenge. Recognizing these gaps, in 2009 the USAID Health Care Improvement Project (HCI) began assisting the Ministry of Public Health (MoPH) in Afghanistan to improve the quality of health services. Though eventually scaled up to nine provinces, in 2009 the MoPH and HCI began developing and testing a facility-based, scalable model of maternal and newborn interventions in health facilities in Kunduz and Balkh provinces and in several large public and private hospitals in Kabul.Case descriptionTo address these issues, the MoPH and HCI applied the collaborative improvement approach, which links the efforts of multiple teams focused on making improvements in the same area of care to achieve the same aims. As demonstration sites, two provincial level quality improvement teams (QITs) were established in Kunduz and Balkh provinces that, in turn, supported 25 facility-level QITs chosen by purposive sampling. In addition, three government maternity hospitals and three private hospitals in Kabul were selected by the MoPH to participate in a demonstration hospital collaborative. Measurable gains were achieved in these demonstration sites for use of the partograph, compliance with antenatal care counseling, vaginal births for which all three elements of active management of the third stage of labor were performed, and compliance with newborn and postnatal care standards.Discussion and evaluationQuality of care can be significantly improved by engaging teams of frontline workers to identify problems and find local solutions for those problems. Based on the results achieved in Kunduz, Balkh, and Kabul, the collaborative improvement work was expanded from 2010–2012 to seven more provinces. The results achieved on the ground also led the MoPH to establish a unit for quality and a national health care quality improvement strategy for Afghanistan.ConclusionsAfghanistan demonstrates that even in fragile states, measurable improvements in actual patient care at the frontlines of service delivery can be achieved while systematically building capacity at all levels of the health system through national leadership and policy making.

Integrating people with dementia and their carers into service design

Purpose – The purpose of this paper is to reflect upon the method of using a participatory action research (PAR) approach and offer some insight into the processes of integrated working with service users and carers. The Public Bodies (Joint Working) (Scotland) Bill, 2013 (The Scottish Government, 2013) is focused on integrated and partnership working within the systems of health and social care. The author begins with a person-centred approach and explore the value of placing service user engagement for successful integrated practice. Through these reflections on PAR, the author offers some new lessons about what integration means to practitioners at the front line of service delivery. Design/methodology/approach – This paper offers insights from a practitioner-research project which the author conducted within the author ' s own practice. It is a reflection on the process of using PAR with five people with dementia and their carers in a research project on the use of music to increase wellbeing for both...

Opportunities and challenges for intersectoral convergence in the delivery of nutrition interventions in India (632.16)

Background: In India, delivery of interventions to improve child nutrition requires active IC between the Ministries of Health and Family Welfare (MOHFW) and Women and Child Development (MWCD). This in turn requires linked actions in policy formulation, implementation, and monitoring & evaluation (M&E), but little is known about IC or how to optimize it.Objectives: To identify opportunities and challenges to achieving IC in policy, implementation and M&E for nutrition at the national level and in 2 states.Methods: Content analysis of policy & program documents, stakeholder interviews (n=38 national; 26 state).Results: Policy: Some shared objectives, an articulated need for IC, and diverse task forces support convergence in policy. Nutrition interventions are part of MOHFW programs, but nutrition is not a core objective. Implementation: Operational designs recognize need for coordinated frontline service delivery; delivery structures provide IC opportunities. However, personal relationships and shared understanding of work needs, rather than formal mechanisms facilitated IC. At state & district levels, facilitators were political commitment, will and leadership. M&E: Lack of common indicators and monitoring systems limit IC.Conclusions: There is potential to optimize IC but strong leadership, explicit roles and linked M&E systems could facilitate better IC for nutrition impact in India.Grant Funding Source: Supported by: Bill & Melinda Gates Foundation, through POSHAN , led by IFPRI

Repositioning Electronic Information Systems in Human Service Organizations

The electronic information systems (IS) that have been implemented in human service organizations have been heavily criticized, in particular that they have undermined frontline service delivery. Attention has turned to how they might be better designed for the future but understanding why IS have not performed as intended remains important to avoid past mistakes. Drawing from research that aims to improve future designs of IS, the reasons why positioning IS as a panacea for organizations is problematic are explored in relation to the tasks IS can be realistically expected to support within a human services organization.

When More Is Less: Contradictions of Nonprofit Work

This study uses an employee-centric approach to investigate working conditions in nonprofit social service organizations in Memphis, Tennessee. Many entities exert control over the nonprofit labor process, muddling decision making and contributing to the overall opacity of governance. Oftentimes, nonprofits' structures appoint executive directors as the gatekeeper between employees and boards of directors, complicating paths to expressing grievances. Nonprofits' reliance on external funding to operate also imbues funders with enormous influence over daily operations. In turn, many granting agencies impose fiscal accountability systems that force nonprofits to quantify the qualitative work that they do. This relationship pits categories of employees against one another: high-ranking “administrative” staff must track and report program information to funders; “programming” staff are responsible for implementing these systems. This dynamic widens the communication gap between the former, who are removed from direct contact with the clients and are low ranking, and the latter, who are responsible for and possess the greatest knowledge of front-line service delivery. Furthermore, programming employees and clients often forge deep caring relationships, which collapse their options for self-advocacy. Yet individual employees, especially at lower levels, strive daily to provide high-quality care and bring about social change within the confines of a hierarchical and increasingly corporatized structure. In addition to these structural conditions, the nonprofit labor process co-opts broader ideologies about gender and race that reinforce this hierarchy of power, pay, and prestige. By privileging the perspectives of employees at all levels, this study shows that program outcomes are linked to donor satisfaction rather than to client satisfaction, suggesting that nonprofits have many “uses” besides their stated missions and that striving to meet the “needs” of outside groups often comes at the cost of service delivery to clients and employee satisfaction.

Servitization of manufacture

Purpose – This “research note” sets out to fuel the debate around the practices and technologies within operations that are critical to success with servitization. It presents a study of four companies which are delivering advanced services and reports on the organisation and skill-sets of people within these. Design/methodology/approach – This has been case-based research at four manufacturers leading in their delivery of services. Findings – It describes the desirable behaviour of people in the front-line of service delivery, identifies the supporting skill-sets, how these people are organised, and explains why all these factors are so important. Originality/value – This paper contributes to the understanding of the servitization process and, in particular, the implications to broader operations of the firm.