Strategic Health Service Redesign Through Community Engagement and Systems Thinking: A Study of Hospital Redevelopment Projects

Abstract

The challenge for healthcare policy makers, managers and practitioners is finding ways to effectively collaborate with patients and community to plan, deliver and evaluate services. The study examined how managers engage the community with the strategic redesign of health services. The study focused on four large scale redevelopment projects, valued at A$2.8B, occurring within a health district in New South Wales, Australia. The study employed a multiple qualitative methods design comprising semi-structured interviews and focus groups. Participants were professionals (n = 24) involved in the strategic planning of health facility redevelopment. Thematic analysis was used to identify, analyse and report findings. Three issues emerged as significant factors influencing engagement, including the following: establishing a new mindset to service planning and delivery; future proofing service delivery; and management of stakeholder expectations. The unique contribution of the research is the identification of three interwoven strategies with 30 actions proposed to assess, understand and respond to external factors: 1. Foster an environment that allows for flexible and adaptable thinking and discussion; 2. Develop systems, structures and processes that facilitate engagement; 3. Encourage systems thinking for effective continuous service provision and redevelopment. Large scale redevelopment projects provide a platform for the strategic redesign of health services. When doing so, engaging the community with strategic planning, implementation and evaluation of healthcare services can lead to improved care outcomes.

1. Introduction

Effective planning for diverse community needs is built upon flexible community and staff engagement approaches, adapted to local contexts [1,2]. The challenge for policy makers, practitioners and researchers of health organisations is integrating different expectations into how services are redesigned, how new facilities are built and how staff deliver services in new spaces [3,4,5]. Hence, there is increased recognition among policy makers and practitioners to find ways to collaborate with patients, the broader community and professionals to plan, deliver and evaluate healthcare services [6,7]. Knowing how to redevelop public hospitals is an important undertaking. Public–private partnerships were viewed as a key strategy; however, recent difficulties associated with politics, financing and scope are limiting their implementation [8]. In NSW Australia, A$10.8 billion over four years has been invested into public healthcare facility redevelopment [9]. The large-scale redevelopment of public healthcare facilities presents the opportunity to do this [10], providing a vehicle to overcome the seemingly incongruent requirements of diverse stakeholders [5,7].

Healthcare policy makers and practitioners know that engaging with frontline professionals is critical for effective service redesign [11]. An increasing insight to achieve transformative healthcare services, requires engaging with the community [12], which, additionally and positively, also enhances care outcomes for the community [11]. Significantly, effective community engagement can improve health outcomes amongst disadvantaged populations [13]. Community engagement, in this context, is “a process of developing relationships that enable stakeholders to work together to address health-related issues and promote well-being to achieve positive health impact and outcomes” [14]. Community and patient participation in co-designing care leads to changes in organisational culture and quality of care outcomes [15]. Moreover, engaging with the community leads to better health outcomes across multiple health issues, including cardiovascular disease, obesity, smoking and substance cessation, antenatal care and health promotion [16].

Collaboration with diverse populations and interest groups leads to the development of more holistic, creative models of care and interventions [17]. Co-design is one approach to achieving collaboration where consumers and healthcare professionals work collectively to enhance health services [18]. Hence, community engagement is being conducted in multiple ways, transforming how health services conceptualise, organise and deliver care, including through the community participating in long term care and strategic planning [3,5,19]. However, for collaboration to be effective and non-tokenistic, organisational processes must: allow decision making by communities, drawn from the populations across schools, local government and business; and, be achieved through the creation of inclusive leadership and educational opportunities [20]. When doing so, managers and researchers are utilising flexible, open engagement strategies, facilitating an increase in community-based participatory research or participatory health research endeavours [21,22]. This development is welcomed as for effective health service planning to occur, it is imperative to understand how political, economic and social environments shape community engagement and planning, to build or undermine trust with the community [3,4,5,23]. Additionally, diverse stakeholder engagement and consultation for service reconceptualization is critical to achieve positive outcomes [2].

Previously, the nature of the collaboration research has tended to be evaluative, measuring the experience of service users such as patients [24], rather than strategic, planning for how healthcare could be reconceptualised and redesigned. Additionally, knowing how to effectively work with patients in service improvements is not well understood [23,24] with advice from studies differing in focus and approaches [15,25]. This focus and approach have led to a significant gap in knowledge [26], which this research sought to address. The study aim was to examine how health managers engage the community with the strategic redesign of health services. We provide three strategies and a set of associated actions for engaging stakeholders in large scale redesign of health services.

2. Materials and Methods

The study employed a multiple qualitative methods [27] design comprising semi-structured interviews and focus groups.

2.1. Study Setting and Design

The study setting is a large health district [referred to as the “District”] in New South Wales, Australia. The District services a population of approximately 800,000 people through six acute facilities and community, oral, drug and mental health services delivered across rural and urban locations. The study focused on four large scale redevelopment projects, with a total value at A$2.8 billion, occurring within the District. Redevelopment of healthcare facilities can be referred to in various ways. Reflective of this, we use the terms redevelopment projects, rebuilds, and strategic redesign interchangeably.

The four areas of focus, and the associated areas for discussion covered are as follows: redevelopment process and outcomes; engagement; evidence, monitoring performance and evaluation; and, sustainability, vision and transformation (

Table 1. Guiding topics for interview and focus group discussion.

Focus	Areas for Discussion
Redevelopment process and outcomes	Outline redevelopment occurring and processes
	Role in the development process
	Redevelopment used to achieve organisation strategic vision
Engagement	Involvement of the staff, patients, community and other stakeholders including LGAs, schools/ education providers and business
	Staff engagement to problem solve operational delivery
Evidence, monitoring performance and evaluation	Scientific and other evidence used to guide the redevelopment
	Performance measures to ensure alignment of activities to achieve redevelopment goals
	Redevelopment success
	Impact of redevelopment on current and future service provision
	Monitoring and evaluation of the redevelopment
Sustainability, vision and transformation	Reflections on approaching future redevelopments
	Teaching peers about experiences
	Redevelopment to build momentum for further change and improvement

). In developing the areas for discussion, the research team were guided by literature focused on contextual redevelopment issues [2] (transformational healthcare organisational change at the system level [28]), evaluation and monitoring [29], and sustainability [30]. Reflexivity was used throughout the data collection process from framing the guiding topics for discussion, to reviewing the manuscripts to generate codes and to the final write up of themes. Reflexivity was used to keep an audit trail and help reduce researcher biases. This included reflexive writing through field notes and recorded reflections after interviews and collaborative reflexivity between the diverse research team to ask questions about assumptions and decisions [31].

2.2. Recruitment of Participants and Data Collection

Ethics approval was obtained (2019/ETH13124), with data collected over a three-month period. Participants were healthcare professionals (n = 24) involved in the strategic planning of health facility redevelopment. Recruitment occurred through purposeful snowball sampling [32]. Participants signed a consent sheet and completed a demographic form (

Table 2. Participant demographics.

Participant Category	Role	Time in Healthcare Organisations and Redevelopment Role (Years)	Experience: Clinical, Corporate or Both
Executive (n = 6)	General Manager	24–2.5	Both
	General Manager	31–6	Both
	Other Executive	36–6	Both
	General Manager	24–1.5	Both
	Other Executive	40–6	Both
	Manager, Planning	18–3	Corporate
Redevelopment team members (n = 18)	Redevelopment Director	24–1	Both
	Change Manager	11–1.5	Corporate
	Senior Planner	13–2	Both
	Information Technology Officer	5–2	Corporate
	Operations Manager	21–0.8	Both
	Project Officer	5–1	Corporate
	Facilities Planner	36–1.7	Both
	Communications and Engagement Officer	1–1	Corporate
	Deputy Manager, Planning	7–2.5	Corporate
	Redevelopment Director	12–1.5	Corporate
	Communication and Engagement Manager	0.25–0.25	Corporate
	Redevelopment Administrator	7–1.5	Corporate
	Project Officer	15–0.7	Both
	Senior Planner	23–7	Both
	Senior Planner	15–0.5	Both
	Senior Project Officer	4.5–1.5	Corporate
	Project Officer	15–1.1	Corporate
	Senior Planning Analyst	27–2	Both

).

Healthcare executives and facility managers (n = 6), responsible for the strategic direction/strategy of the redevelopments, were invited to participate in a semi-structured interview, which lasted approximately one hour. Project planners, managers and officers, involved in planning and operationalising the redevelopment direction/strategy, were invited to participate in a focus group. An email invitation was sent to the redevelopment leads, who then forwarded invitations to redevelopment projects team members. Participants (n = 18) engaged in a focus group discussion (n = 3), lasting approximately 1.5 h. To the best of the team’s knowledge, all those invited participated in the study.

2.3. Data Analysis

Interviews and focus groups were transcribed verbatim, and the transcripts were placed in NVivo to assist with the coding process. An interpretive lens with Braun and Clarke’s six-step thematic analysis approach was used to identify, analyse and report [33] common responses. This enabled us to consider the contextual factors within the study setting, accounting for diversity of views and roles, and identifying the themes in the data. We strove to achieve the criteria of dependability, credibility, confirmability and transferability [34], that is dependability via two researchers assessing the data independently (KE and DG); credibility via data triangulation across collection techniques and subjects; confirmability via a third industry researcher reviewing and endorsing the analysis (AD); and, transferability through a clear description of the study context. Familiarisation with the interview content occurred, with two members of the research team (KE and DG) meeting to analyse transcripts. They generated an initial list of codes and then reviewed one transcript together to confirm the application of the codes, and, where necessary, to refine the code set for improved use. Each transcript was reviewed applying the codes, with ongoing meetings to audit and negotiate minor queries as required. Throughout, discussion with the entire research team about the process, code set and emerging analysis occurred. When all transcripts were analysed, the codes and identified material were evaluated and developed into themes and sub-themes. Underpinning these steps was a reflexive approach between team members to consistently question assumptions and decisions [31].

3. Results

Three themes were identified as being key to understanding how to effectively engage the community to strategically reconceptualise and redesign health services (

Table 3. Themes and sub-themes.

Themes	Sub Themes
1. Establish a new mindset to service planning and delivery	Holistic governance thinking and strategies for organisational alignment
	Tangible community input
	Conduit for cultural change to siloed service provision
2. Future proofing service delivery	Community involvement at the centre of redevelopment builds
	Integrating services for improved continuity
	Understanding how infrastructure can be harnessed
3. Management of stakeholder expectations	Setting the direction
	Mediation and communication
	Adapting to external factors

). The themes are as follows: 1. Establish a new mindset to service planning and delivery; 2. Future proofing service delivery; 3. Management of stakeholder expectations.

3.1. Establish a New Mindset to Service Planning and Delivery

The first key theme is the importance of establishing a new mindset to service delivery. The health professionals emphasised the need to re-think, and the re-action of, how they approached service and care planning and delivery across the District. Changes in one reinforce changes in the other to engage the community and transform service and care delivery. Such re-thinking and re-action are required to ensure that the multiple rebuilds across the District are anchored by the same strategic vision. A new mindset is established through three activities: holistic governance thinking and strategies for organisational alignment; tangible community input; and a conduit for cultural change to siloed service provision.

3.1.1. Holistic Governance Thinking and Strategies for Organisational Alignment

Participants discussed the importance of holistic governance thinking for organisational alignment across facilities throughout the District. They identified the need for executive support and shared responsibility across, not just their responsibilities for individual facilities.

Where multiple large scale redevelopment projects were occurring simultaneously, the participants advocated that holistic governance thinking and strategies driven from the executive were important. They argued the District’s executive organisational wide leadership was crucial for the successful outcomes:

… and effectively, the District are the ones that need to deliver the outcome, it becomes then very complicated to deliver the full vision that is wanted and desired, when there’s physically no processes, no support structures.

(Health Manager/Officer 14)

Participants viewed the redevelopment as an opportunity to “deliver the full vision”, that is, that services were to be available to patients within the District, so that they did not have to travel elsewhere. The redevelopment of multiple facilities was a generational opportunity for reviewing and renewing service delivery at a District level, not just at individual facilities, as one participant explained:

… the vision has always been to build up [Facility 1] capacity to deal with, and to prevent people from having to seek care outside of the region, and to alleviate that external burden on [Facility 2], for them to provide their quaternary based service.

(Health Executive 1)

However, creating and maintaining a new mindset was a significant challenge. There was the understanding from participants that realising the District’s vision for redevelopment projects was different to the ongoing daily management of a facility. They clearly emphasised the importance of the governance processes, including detailed documentation, to be followed to ensure that plans could be tracked, monitored and implemented in a consistent, coherent manner. For most participants, they faced a similar challenge, as reflected below:

I came from a facility background. Things in Facility operate a lot different than a project does. We require the documentation. We require all that kind of stuff. Whereas in Facility, you see a problem, you go fix it.

(Health Manager/Officer 15)

Rigorous structures and processes were viewed as important by participants to enable the implementation of a new mindset promoting a holistic district and community perspective and resolving of differences. An unexpected insight was knowing when to escalate an issue was discussed by managers and planners an important factor in determining solutions:

We have a solid governance structure if there are any issues that arise, we push them through our governance process, and it’s worked quite well. Up ‘til now, we’ve been able to resolve a number of issues that would’ve just dragged the project down and slowed it down if we didn’t have that process in place.

(Health Manager/Officer 8)

The development of a ‘big picture’ or systems view of the organisation was important for success. A new governance mindset that considered the individual parts and the whole organisation was advocated for.

3.1.2. Tangible Community Input

Re-thinking required the health professionals finding ways to tangibly encourage and commemorate involvement with, and across, different groups in the community; this was noted as a key success factor for those driving the redevelopment projects. Linking with the community encouraged the coordinated approach to service delivery required across multiple builds. Additionally, the redevelopment projects were viewed by participants as an opportunity to build better community engagement and connectedness.

Participants explained that integration of diverse community, not just health, stakeholder needs and interests was a goal for the redevelopment projects. They acknowledge that this required a re-thinking of the silos they viewed in the world. Integration was attained by ensuring that connected service industries, such as education providers, local government and transport services, were consulted throughout the rebuilds; not a normal activity for many health professionals in any project. An executive member reported their approach in these terms:

… we’re talking to a lot of stakeholders around sort of the big elements of, you know, where the new hospital is going to be sited, and talking to universities and Council and transport and education and whatnot, even the airport around sort of those kinds of decisions [needs, interests and future expectations] and how we’re going to sort of integrate those into the urban landscape.

(Health Executive 5)

Respondents observed a further dimension to the task was recognising the “community” was not homogenous but made up of many different cultural sub-communities or groups. Different sub-communities previously and currently have different levels of engagement. Finding ways to encourage the sub-communities less engaged, to have further involvement, was variable across settings. An unexpected insight from one manager was as follows:

So when we’ve gone to communities and asked them for feedback, we don’t get a lot of engagement. Whereas the other projects, especially in [Facility 4] and [Facility 1] have been able to really easily engage with their community, because it seems to be a very different type of community, because they’re in different locations.

(Health Manager/Officer 10)

Keeping the mindset to ensure the whole community was connected to the redevelopment builds, throughout various stages of the process, was important to participants. An explanation of how this continuous engagement was encouraged, through tangible signs that could be visually displayed, is as follows:

Anyone that we’ve engaged along the way, we are letting them know that this is what you’ve helped us create or do and keeping them engaged in the process through that closing of the loop. Plaques on walls or things that commemorate who was involved, or handprints in, you know, the first bit concrete. Things that people can refer to into the future and know that they were a part of it. Because that sort of then progresses through the generations and keep people connected to the project.

(Health Manager/Officer 10)

Re-thinking enabled strengthening old and finding new ways to build better community engagement and connectedness with, and across, different groups in the community. Tangible community inclusion was noted as a key success factor.

3.1.3. Conduit for Cultural Change to Siloed Service Provision

Redevelopment was viewed as a vehicle for new, sustainable, affordable and alternative ways of working, arising from reconceptualising service provision. Respondents with significant planning responsibilities, that is, executives and other senior managers, continually questioned how the redevelopment could be used as a catalyst to change healthcare delivery. Specifically, if traditional methods of healthcare delivery were best or if alternative methods could be used in the new spaces:

What I really think we really need to do is make sure people get their care in the right place and that shouldn’t be hospital a lot of the time… this sort of allows you to say well actually this care is not best delivered in you know a major tertiary acute hospital, it is actually better delivered in this setting and actually hardwiring that by making sure that you build or don’t build the infrastructure to enable that to happen. So I’d like to think in the future we will see a lot of the care delivered virtually.

(Health Executive 5)

Participants saw the redevelopment as a conduit for cultural change in how service provision could occur, helping to remove the soiled approach to service delivery within health. When planning such large-scale changes to service delivery, respondents identified the need for different health stakeholders to imagine how service provision could be improved through coordinated approaches to service delivery.

The redevelopment provided an opportunity for planning to occur between groups of health stakeholders that would not previously have come together. Where difficult issues would have previously caused tension, the respondents reported that the redevelopment projects were a mechanism to facilitate difficult conversations with the view of generating workable solutions. As explained by one manager:

We’re bringing services from the same stream or even different streams together? If we all go away to our offices and write our own models of care, we’re just going to perpetuate the same siloed approach; like we need to be talking to each other. So there’s definitely an awareness of it, it’s just how to organise and facilitate those sorts of conversations. And they’re hard conversations.

(Health Manager/Officer 1)

Meeting and talking together was on opportunity to confront, in a positive manner, the issues to find common ground. One manager stated succinctly:

So their clinical reference groups come and present in the common approaches meeting.

(Health Manager/Officer 3)

The unexpected insight being voiced was the understanding that cultural change was required to facilitate better service provision beyond the physical build. Participants pointed out the need for real change to occur beyond the new buildings in how people behaved. Hence, targeted change management addressing behaviour was necessary:

… bricks and mortar I think are possibly the easier thing to work on. I think the harder thing to work on is, what will be done differently and how will, how will we do things differently in a new building, and how do we bring people, one along with the information, and two along with the change management piece.

(Health Executive 2)

Change could be achieved when redevelopment was approached with a new mindset. This involved stakeholders collaborating across silos to look for new, sustainable, affordable and alternative ways of working.

3.2. Future Proofing Service Delivery

The second key theme is the need to future proof service delivery. Health professionals highlighted the requirement to create services that delivered care based on the current needs of the population as well providing capacity for future demands. Future proofing service delivery is achieved through three activities: community involvement at the centre of redevelopment builds; integrating services to reduce the gaps; and understanding how infrastructure can be harnessed.

3.2.1. Community Involvement at the Centre of Redevelopment Builds

Participants discussed that the community should be at the centre of any redevelopment projects planning activities. They recognised community involvement was required to ensure success.

Those facilitating the redevelopment projects had to find ways of engaging the many user groups. The respondents explained the need to drive participation processes so that all user groups would be represented in the design phase:

But people always just think of the staff, well no, the patients go to there as well, the visitors go there. So we actually include community participations and users in our user groups, for instance, we run ads in the paper to say we’ve got this project, we want people to come and help us design the hospital, here is the list of user groups we’ve got, contact us if you want to be part of that.

(Health Executive 3)

This invitation reflects the health professional’s orientation to work with the community, a process they viewed as important but challenging. The respondents recognised that the community were entering into the realm of health where the content and language used was foreign. Such an unfamiliar environment meant it was difficult to place the community at the centre of planning for future service provision; one manger discussed the point in these terms:

… community also being involved but obviously with some models of care it’s a bit harder to have that involvement of the community because of the meetings, how they’re run and also subject matter discussed.

(Health Manager/Officer 5)

Nevertheless, participants understood community engagement is a two-way process. The respondents interviewed knew that they had to be reaching out and engage the community. At the same time, participants knew the community had to want to be engaged with them. Both were required for a successful redevelopment. A project officer explained, if users within the community were committed, then involving them in the planning of care delivery for the redevelopment projects became easier:

I’m finding that—yeah, in terms of engaging with communities, there’s either a really invested community, or they’re not.

(Health Manager/Officer 11)

The task of community engagement was a challenging and ongoing one. However, stakeholders recognised that when the community is placed at the centre of the redevelopment projects planning activities, the action promoted the future proofing of service delivery.

3.2.2. Integrating Services for Improved Continuity

Respondents viewed the redevelopment projects as an opportunity to incorporate disparate services more fully for enhanced continuity. Rebuilding and expanding the capacity of the services provided for similar presentations enabled continuity across service transitions. From the perspective of participants, such an integration across services would then reduce the likelihood of gaps in service provision:

… one of the pieces of work we are doing is how do you support transition. Transition for young people, particularly with complex needs from paediatric services into an adult world… trying to match the models of care so that you don’t have paediatrics over here doing one thing, adult services over here doing another, and then when the time comes to pass, when the young person has hit their early twenties and needs to go to adult services, there is no gap between the two.

(Health Executive 2)

Respondents reflected on the disparate service provision provided by the different providers, in different settings, ranging from acute to community. Manager, planners and clinicians all viewed the redevelopment as an opportunity to reconceptualise how models of care for the same conditions could be better managed, regardless of which service was providing the care:

There is a section in the models of care to talk about community services associated with those service. There’s often not a lot of detail in there. The model of care is focused on the service within the acute facility, but there is a whole lot of community work going on that should really connect with that acute facility model of care. And we met with community last week to talk about how that might work. And moving forward there, are going to provide documentation on the model of cares … that they have for the community and rather than being separate community models of care, they should really interlink with the acute service models.

(Health Manager/Officer 1)

The health professionals interviewed, particularly at the executive level, advocated the redevelopment build was an opportunity for diverse ideas, unimpeded by previous constraints. Those tasked with developing the strategy for planning of future provision had two simultaneous objectives. The first was to encourage end-users to consider how to develop services in the current state, and the second was to encourage forward thinking about how future service provision could occur. Respondents saw these combined objectives as being necessary but challenging. They explained the task of asking staff to set aside conventional, tried and tested decision making heuristics for more creative, utopian ideas that might not eventuate:

I think they’re being challenged now because we’re asking them to work a different way and that’s really hard for them. However, if you said to them, what’s your model of care? This is what it is now, you know, if you imagined … did a bit of blue sky thinking and said, you know, in five years’ time if money wasn’t an object, what would you want it to be?… if you get them thinking around that, I think that’s what really helps.

(Health Executive 4)

Such progressive dual thinking was encouraged with foundation in the District’s broader strategic plan, forums and platforms. Participants spoke about the need for the District’s internal structures and processes to maintain changes and new care models in future service provision. The insight one executive offered was as follows:

We then need to ensure that we have internal processes that support the things that come out of the development, that they are ongoing, so they don’t have a life, and don’t kind of get to the end of the development and it’s like, oh well we’ve done that, you know. And look, the way that the organisation is set up with kind of opportunities for innovation, research and whatever, there are platforms that allow that to continue.

(Health Executive 2)

Stakeholders were advocating future proofing service delivery required incorporating disparate services for enhanced continuity. In this way, it would promote integration across services, further strengthening community support for the changes.

3.2.3. Understanding How Infrastructure Can Be Harnessed

While alignment and cohesion with internal structures and processes was necessary for the success of new service delivery in the future, respondents viewed infrastructure innovations as a way of reinforcing the plans. Participants discussed how improvements to infrastructure and technology could be viewed as both risks and opportunities in creating flexibility for the uplifting of the facilities. Bringing in external expertise was required to help build that flexibility into the new facilities:

You need to get a good concept of how you’re doing the planning first but you definitely need to engage internal and external stakeholders early and if it’s a state significant project like [Facility 3] which is A$1.3 billion, places like the Ministry and Telehealth should get involved early and it’s really difficult to think about the future and so, that’s a different skills set from models of care. So you need to get help on your futurist thinking which is different from that model of care and the technology thinking because it’s really easy to build a hospital and open it on day one and it’s out of date.

(Health Executive 6)

Infrastructure and technology advances were seen as an opportunity to further improve the design of workspaces. Specifically, respondents discussed how such advances led to the updating of workspaces, and how this modernising could encourage different work behaviour:

There’s been a lot of work around not just the physical design, but how people work and we’ve got a lot of information out of that… So I think it is a delicate change piece, not just in that we know we’re creating these nice Admin Hubs that are touch down spaces and less office space, more, I guess, activity based open plan; but changing the flexibility in the way people work, identifying who has the ability to work offsite, trying to put the infrastructure into place which, at the moment, I know our ICT Consultants do a lot of work and identify a lot of areas that [District] needs to fix from a District perspective.

(Health Manager/Officer 9)

Events, including the COVID-19 pandemic, further created an impetus for introducing changes to traditional care delivery and behaviours in facilities. Some participants reported that the disruptor of the pandemic propelled planning efforts for more strategic resource utilisation:

The pandemic response has actually assisted in pushing some of that change process… it really has pushed that need for engagement of virtual care and other strategies around social distancing and in some ways, that has assisted us.

(Health Manager/Officer 18)

Thinking about ways to use co-use underutilised assets with stakeholder groups outside of health was seen as being beneficial. The explanation presented by an executive was:

When I look the current auditorium at [Facility 2]… it has about a 40 percent utilisation rate, right, so we do need it because we use it quite frequently, but it doesn’t get utilised well. So, if we build one and it’s shared between a couple of universities, us, anybody that wants to use it, [Institute], then it becomes a more valuable asset.

(Health Executive 3)

Infrastructure innovations were the practical, tangible actions that turned words and plans into future proofing service delivery. Spaces became new places for integration of services from within the organisation and, significantly, groups traditionally on the outside.

3.3. Management of Stakeholder Expectations

The third key theme is the need to manage stakeholder expectations. Respondents highlighted that effective engagement of stakeholders required negotiating the often-diverse expectations and finding middle ground between groups to prioritise resource allocation. Managing stakeholder expectations is achieved through three activities: setting the direction; mediation and communication; and adapting to external factors.

3.3.1. Setting the Direction

Respondents highlighted the need to establish a clear direction to generate an agreed upon agenda from all stakeholders. Setting a clear agenda, with tangible plans aligned to it, progressed the rebuilding of facilities, demonstrated listening to stakeholders and communicated leadership capability; all of which were key drivers for engagement. Developing and adhering to plans ensured a systematic approach to stakeholder involvement across multiple settings and levels. It was explained as follows:

So we have an engagement plan, we have a communication plan that calls out all the stakeholders from a political level, to a local level, to those that have an influence that if you didn’t know about, could come back and bite you.

(Health Executive 2)

Communicating strategy was by senior leadership, as the process of reconciling multiple stakeholder expectations was challenging. Managers discussed how they learnt from previous redevelopment projects the importance of systematically communicating a clear direction. The insight offered from one manager was as follows:

There really should have been some conversations at the District level, at the top level, to say, “Well, this is the direction that our hospitals are going. Let’s start at the District base and see what we need from that backbone, and then filter the information down”, rather than down, as they’ve said, “We’ve kind of been the pilot site and we’re filtering that information up”.

(Health Manager/Officer 13)

When doing so, participants note the task was to provide the right level and amount of information to different stakeholders. This balancing act necessitated understanding the expertise levels of each stakeholder group. One manager explained the task in the following terms:

I’m dealing with people who have no knowledge of ICT to people who are experts with a much higher level of technical ability than myself. So I need to be very aware of who I’m going to, and what information they actually need driven out of the meeting or the presentations that I’m giving them.

(Health Manager/Officer 18)

When issues became contentious or there were conflicting expectations, respondents used the organisational governance processes, and the need to stay within budget, as mediating mechanisms to move the conversation forward. The managers in these positions noted the challenges in this manner:

But we still have issues where there’s gaps and that, and we have to take it sometimes through governance… when we’re talking to stakeholders, I make sure it’s really clear, unless I have a document that’s saying that I can provide them that, at this moment, I can’t provide it. And that’s not to say that can’t happen, but there’s some governance that needs to be followed in order to bring that effectively into what’s called, “scope,” to enable it to have a budget allocation and be implemented.

(Health Manager/Officer 14)

Managing stakeholder expectations was achieved through collaborative leadership that listened to and established an agreed agenda, with tangible transformational plans aligned to it. All actions were key drivers for community engagement and required a new mindset to approach the task.

3.3.2. Mediation and Communication

Mediation, incorporating evidence and negotiation, were used to shape the outcome. When approaching conversations that required staff to reconsider traditional methods to working, participants used peer reviewed evidence to generate agreement on the agenda. The task, as they saw it, was to be persuasive about the need to change:

The project team wants to go in one direction and our Pharmacy user group wants to go in another, and the problem is, do we want to be left behind at the end of the day? And this is what governance is going to have to decide, because we’re going to be the only redevelopment in Sydney and also interstate, in metro areas that are not implementing a pharmacy robot. So I’ve used articles [evidence] to back my case.

(Health Manager/Officer 8)

In addition to using evidence, respondents spoke about the conciliatory role they performed. Participants discussed how the redevelopment teams mediated stakeholders views across construction and health fields to integrate differing preferences in the projects:

Some of my early learnings were being able to push back to the construction side, to say, “No. That degree of flexibility is just not going to work and it’s not going to win us any friends in the clinical realm if we can’t get things running a little bit more closely”… I mean, if we want sustained buy in from clinicians and it’s vital to make sure that we can deliver a really good outcome, we have to deliver what we say we’re going to.

(Health Manager/Officer 16)

A strategy to mediate stakeholder needs was “communicating the middle ground” to different audiences. Respondents stated communication was a key factor to achieve engagement and success. The participants explained the task of delivering redevelopment outcomes using processes within processes. Forming smaller working groups was an effective strategy to progress conversations to reach common understanding in a timely manner. The insight was reported in the following terms:

If you’ve got the time to continue to meet with the group and kind of work them through from, you know, this siloed view to a combined view, then that’s such a luxury. I think we can often find is that, you know, the kind of middle ground is that approach of having a smaller group that can meet more frequently and then speak for the broader group in terms of a decision-making process.

(Health Manager/Officer 2)

Managing stakeholder expectations required interpersonal skills integrated with evidence. The task was to facilitate open discussions about new uses of spaces and different service connections. Engagement, collaboration, and persuasion were utilised to mediate new mindsets and future proof services.

3.3.3. Adapting to External Factors

A significant challenge managers and planners faced was formulating strategies that adapted to external factors, such as political priorities, environmental and social factors and financing. Plans and implementation of strategies were diverted by factors external to the organisation. A manger explained the point:

There is, in theory, the way the process should run is that you have a clinical services plan which involves models of care that then informs infrastructure requirements that then informs funding. But, the way that it works because we don’t operate this kind of process in a vacuum.

(Health Manager/Officer 2)

Participants discussed how external drivers were important, but often unpredictable, and projects required flexibility to respond. For example, the political drivers of funding, combined with the expectations of service delivery, contributed to the way the rebuilds were planned and reassessed for further changes. As the manager went on to report the following:

There’s political cycles that need to play their part. We often end up with the funding and then it’s a matter of working out how much of the clinical services plan we can fulfil and also then thinking through a plan, particularly in these processes thinking through what models of care do we need to change or overhaul significantly in order to provide service for the next 20 or 30 years.

(Health Manager/Officer 2)

Additionally, there were political considerations that were driven by the community and including local business. The participants involved in planning and executing the redevelopment projects recognised the potential economic impact and contribution to the local economy by local business and contractors:

At some stage soon we’re expecting to have 400 contractors onsite, building, and so the expectation is that contributes to the local economic sort of development of [Facility 1], not just pulling people in from different areas of Sydney, but it impacts locally.

(Health Executive 1)

Additionally, another manager’s explanation reinforced the point. Local communities’ businesses were directly involved, thereby multiplying the impact—financial and engagement in the redevelopment:

We’ve tried to, in regards to involving local communities, in particular businesses, we’ve tried to actually target where we can, local businesses for procurement. Right, so in other words, the bricks in [Facility 4] have come from [Local] Brickworks.

(Health Executive 3)

Responding, constructively and creatively, to unpredictability from external factors was an ongoing requirement. Doing so enabled ongoing stakeholder engagement, a commitment to plans and facilitated the mediative processes.

4. Discussion

This study highlights how those tasked with large scale redevelopment can effectively engage the community to strategically reconceptualise and redesign health services. Three issues emerged as significant factors including: establishing a new mindset to service planning and delivery; future proofing service delivery; and management of stakeholder expectations. These findings reflect policy makers and practitioners experience that meaningful community engagement provides a platform to reconceptualise traditional approaches to planning, delivering, and evaluating healthcare service provision. Collaborating with diverse populations introduces more ideas driving creative approaches to developing models of care and questioning about what other interventions can occur [17]. Moreover, the benefits then extend further beyond the building process as engaging with the community leads to better health outcomes [11,12,15] across multiple health issues that significantly impact individuals, populations and the healthcare system [16].

Specifying tangible actions for collaborating with stakeholders in the strategic redesign of health service delivery. These actions include acquiring a new mindset to service planning and delivery and think differently to obtain a different outcome. Establishing governance structures that encourage shared decision making and shared resource allocation across facilities and services are essential components to this [35]. Second, future proofing service delivery is achieved through integrated service delivery. Redevelopment opportunities provide a landscape for more integrated efforts to planning, implementation and evaluation of health system improvement efforts [2,10]. Third, productive redevelopment projects are grounded in community engagement which manage and incorporate stakeholder expectations. There is significant value in engaging the broader community and co-developing initiatives that are reflective of local contexts [1]. Understanding healthcare organisations as complex adaptive systems [36] reinforces the need for the three interrelated insights discussed. Change is challenging but can be achieved through: addressing structural and process elements; reinforcing existing and creating new interrelationships; and focusing on the whole and individual parts simultaneously [36].

In addition to these three key contributions, an area of silence within the study highlights a further opportunity for improving the evidence base. There was little discussion about including the community in evaluating redevelopment projects. Community-based participatory research or participatory health research strategies can be used to assess the effectiveness of planning processes, the physical results, experiences of engagement, and whether new models of care emerged and where sustained [21,22]. Given the resources committed to redevelopment projects—nearly A$3 billion locally [10] and A$10.8 billion over four years in NSW alone [9]—evaluating their impact seems a prudent action, and involving the community when doing so is necessary for improved outcomes.

Effective service planning occurs by understanding how external factors, such as political, economic, and social environments, shape engagement and build trust [3,4,5,23]. Using the complex adaptive systems lens [36] to extrapolate from the three key study insights, three interwoven strategies with 30 actions are proposed to assess, understand and respond to external factors (Figure 1;

Table 4. Strategies for redevelopment engagement.

Themes	Sub Themes	Action
	Strategy One: Foster an environment that allows for flexible and adaptable planning/thinking
Establish a new mindset to service planning and delivery	Holistic governance thinking and strategies for organisational alignment	1. Identify key clinical leads who can work closely with redevelopment executive to develop/ form governance structures 2. Establish regular communication channels to facilitate problem solving, celebrate positive outcomes and overcome issues that arise 3. Seek opportunities to engage diverse stakeholders at a broader organisational level 4. Construct formal structures to govern programs and projects 5. Provide opportunities for different stakeholders to engage all aspects of the projects 6. Ensure regular communication and site visits to track progress
	Tangible community input	7. Provide the community with tangible opportunities to engage in planning through committees, user groups and arts projects 8. Provide feedback about changes that have occurred as a result of community contribution
	Conduit for cultural change to siloed service provision	9. Give permission to staff to make small changes in workflow to encourage a culture of continuous improvement 10. Lead by example, with the executive team demonstrating innovative thinking and action regarding governance and associated processes 11. Develop consultation groups and committees where the members are also those that will ensure the change works in practice 12. Structure consultation groups and committees so that they are multidisciplinary, multiservice and where relevant, multi-agency 13. Ensure the governance group provides strong oversight through clear, practical agenda setting
	Strategy Two: Develop systems, structures and processes that facilitate engagement
Future proofing service delivery	Community involvement at the centre of redevelopment builds	14. Identify existing methods of engaging with internal and external stakeholders to build upon relationships 15. Avoid tokenism by starting the redevelopment process with community involvement as a key pillar 16. Recognise that staff are part of the community, and therefore dual stakeholder as service provider and user
	Integrating services for improved continuity	17. Develop models of care structures or templates that require teams to plan for integrative service provision 18. Provide evidence that meaningful community input has occurred through the involvement of key community partners 19. Develop structures that are inclusive and demonstrate a broad range of perspectives from within the organisation 20. Include leaders from outside of the organisation to encourage the development of new ideas through challenging the status quo 21. Set agendas that allow the team to have open discussion by encouraging a culture that allows questioning of conventional practice
	Understanding how infrastructure can be harnessed	22. Encourage teams to challenge traditional approaches to building and working within environments 23. Review different industries to assess opportunities to work differently
	Strategy Three: Encourage systems thinking for effective continuous service provision and redevelopment
Management of stakeholder expectations	Setting the direction	24. Consistently communicate the vision of what the redevelopment needs to achieve at every opportunity 25. Engage the leadership team in the vision and direction. Ensure that the team is communicating this to their teams 26. Ensure practical agendas and communications plans mirror the vision and direction
	Mediation and communication	27. Engage with clinical, corporate, community and academic experts in throughout the using formal and informal touch points 28. Engage with clinical/community/health experts who will be able to ‘broker’ expectations and ‘trouble shoot’ problems
	Adapting to external factors	29. Set a clear communications plan, ensuring that there is consistency of messaging throughout the program 30. Acknowledge when required that there has been a change brought on by external factors

). The three strategies are as follows: strategy one—foster an environment that allows for flexible and adaptable thinking and discussion; strategy two—develop systems, structures and processes that facilitate engagement; and strategy three—encourage systems thinking for effective continuous service provision and redevelopment.

This study included healthcare professionals such as executives, managers, planners and project officers involved in the strategic planning of health facility redevelopment. There is an opportunity to quantify the findings using a survey questionnaire to examine a larger and broader stakeholder perception of how the engagement process has been managed. Additionally, a further next step is to speak with frontline clinicians and corporate staff, patients, consumers and external partners, including local government, builders, education partners and infrastructure providers. Participatory research [37] or organisational participatory research [38] provide evaluation approaches to investigate the inclusion and impact of community members to the redevelopment process. Doing so would promote capacity building, reinforce an increased sense of ownership of the new facilities and meet the community desire to be involved in research [39].

The study took place at four facilities within one local health district, hence the need to investigate the experience in other settings. The strategies and actions proposed provide others involved in large scale redevelopment tangible steps to implement and evaluate the strategies used within other contexts. For example, this can include examining policy, organisational and clinical data to examine improvements for the health of the community.

5. Conclusions

Large scale redevelopment projects provide a platform for the strategic redesign of health services. When doing so, engaging the community with strategic planning, implementation and evaluation of healthcare services can lead to improved care outcomes. We present strategies and actions for those tasked with managing large scale redesign and building new facilities. This study, to our knowledge, has been the first to examine this critical issue. The findings are important as they provide tangible approaches for engaging the broader community beyond measuring patient experience. Community engagement with a forward-thinking lens fosters an environment that allows flexible, strategic planning. Additionally, strategic community engagement provides opportunities for codeveloped systems, structures and processes that facilitate ongoing engagement.