Facilitating the learning and adaptation process of regional initiatives that transform towards health and wellbeing systems.

Introduction: Health-systems in western countries are under pressure due to increasing costs, changing health care demands, and a growing shortage of staff. Therefore, regional initiatives are searching for ways to integrate and reorganize services across domains. This is a complex process and requires an incremental approach based on reflection and adaptation. However, regional initiatives are still searching how to construct these processes. This study aimed to gain more understanding of how the reflection and adaptation process in regional initiatives could be facilitated. Methods and analysis: This study included an action research within a Dutch regional initiative, including the program managers, involved municipalities, province, health care insurer and the public health services. The partners reflected on transformation themes, identified in previous evaluation studies, by scoring them in questionnaires and discussing them in interviews. Finally, two reflection meetings were facilitated with representation of all partners, respectively on management and board level. The program manager was interviewed about the experiences with this action research. Notes of this interview and observations of the reflection sessions were analyzed inductively. To broaden the experiences within this one initiative, the experiences with the reflection process were reflected upon in semi-structured interviews with program managers from other regional initiatives (n = 11). The semi-structured interviews were coded and clustered inductively. Results: Based on the scoring in questionnaires and interviews a radar chart was shown in the reflection meetings. This highlighted that especially two themes (accountability and citizen participation) would need adaptation. Partners especially recognized the problems regarding accountability and agreed that further elaboration was needed. One of the aims of the reflection process was to create a collective feeling of ownership. Results show that external facilitation of the reflection process, which was objective and knowledge-based, helped to enhance the collective conversation. Reflecting with the program managers of the other initiatives learned that not all initiatives invested in a regional reflection and adaptation process. Lack of this investment was related to partners not prioritizing this process. Some program managers expected the knowledge-based reflection to be helpful in creating a common ground among the partners. The use of scoring, like in the questionnaires, or having actionable options after scoring the themes was expected to be helpful to be able to act upon the reflection. Lessons learned and next steps: This study described the experiences with facilitating reflection and adaptation processes of regional initiatives. It showed that knowledge-based reflection by an external facilitator was valued to enhance the collective conversation and common ground about transformation. Further research is needed to learn how this common ground could eventually result in adaptation of the initiatives and thus aid their transformation. This research identified the importance of creating a collective process amongst partners for learning and adaptation, though found that not all initiatives invested in this process due to other priorities. More awareness among partners of the initiatives is needed about the importance of this process for transformation and their role in this collective process.