Adopting and adapting foreign innovations in health service delivery: a case study in elderly care in Suzhou, China

Abstract

Background

One of the shared challenges faced by societies worldwide is aging, which started in high-income countries and has gradually been prevalent in middle- and low-income countries. International exchange of innovations has been encouraged to address global challenges. However, transferring innovations in service delivery across different health systems has been found challenging and influenced by various factors. There remains a shortage of empirical studies that focus on how the adoption and adaption of innovations originating from high-income Western countries in low- and middle-income contexts such as China have taken place.

Methods

To deepen the understanding of the process of international transfer of innovations an exploratory case study was conducted at Suzhou Social Welfare Institution, located in Suzhou City, Jiangsu Province, China, July 2022 -January 2023. This case study focuses on the organization’s journey of adopting and adapting innovations in elderly care from the Netherlands over 20 years. With a qualitative design, we conducted 5 one-to-one semi-structured interviews with Dutch respondents and 3 group interviews, each comprising 8 Chinese respondents. Additionally, we analyzed 10 documents.

Results

Four key characteristics were identified which influence the processes of adopting and adapting Dutch innovations in elderly care in the Chinese context. First, the fact that the Chinese government uses governmental-designated pilot organizations like SSWI to support the diffusion of innovations in elderly care. Second, the hybrid top-down and bottom-up approach used in Chinese organizations to manage innovations. Third, the differences between the values of the Chinese context and the values embedded in the innovation. Fourth, the trust and informal relationships build with foreign experts based on long-term cooperation.

Conclusion

It may take considerable time to adopt and adapt innovations in health service delivery, especially when there are discrepancies between values embedded in innovations and the contextual values. To facilitate the process, taking an incremental approach and establishing a long-term collaboration between experts involved in the countries of origin and implementation may be beneficial. This message may shed a light for other middle- and low-income countries to transfer innovations in service delivery from high-income countries.

Introduction

Population ageing is a global challenge. It is estimated that 1 in 6 people will be aged 60 years or over by 2030 [1]. High-income countries, such as Japan and Netherlands were the first to be confronted with the challenges of population aging. Recently, aging has started to advance profoundly in low- and middle- income countries as well [1]. By 2050, two-thirds of the world’s population over 60 years is expected to live in low- and middle-income countries [1].

International exchange of innovations has been viewed an efficient approach to overcome global challenges faced by human societies [2]. By learning from others’ successful innovations and adapting them to local contexts, challenges can be addressed faster and more efficiently [3]. While the potential benefits of international exchange of innovations are widely recognized, there is also much evidence of the challenges associated with transferring service delivery innovations from one context to another (e.g., between health systems) [4, 5]. Context-specific elements such as society, culture, politics and economy present opportunities and/or obstacles for transferring service innovations. When deciding how to adopt and adapt innovations, those elements need to be identified and addressed [6]. Greenhalgh et al. [4] present a model with key factors influencing the effectiveness of the spread of innovations. Among these factors are, for instance, characteristics of the innovation itself (e.g., complexity), system readiness for change (e.g., system-innovation fit), the innovation journey (e.g., the implementation process), and the outer context. Current scientific models explaining the effectiveness of health service innovation exchange between contexts, including Greenhalgh’s model [4], are almost exclusively based on evidence from health systems in Western, high- income countries [7]. Evidence on the adoption of health service innovations from Western, high -income countries to non-Western and low- and middle-income contexts such as the Chinese health system remains scarce. The scarce evidence that is available shows that most Western innovations poorly transfer to non-Western contexts such as low- and middle-income countries [8, 9]. Challenges arise due to several factors, including differences in healthcare infrastructure, socioeconomic conditions, cultural factors, and health system structures. These challenges especially relate to health service innovations because they often require the alignment of multiple systems; technical, social, economic, and organizational, to be effectively implemented.

China is increasingly involved in global health, and its potential for population and economic impact is gigantic [10]. As one of the largest developing countries, China is expected to have 402 million people (28% total population) aged over 60 by 2040 [11]. The demographic shift will bring challenges to China’s health and social systems. China has therefore actively pursued to learn from successful innovations to address the challenges associated with aging from high income countries which experienced these developments earlier. Therefore, it is urgent to deepen our understanding of context-specific factors influencing the adoption and adaptation of elderly care innovations transferred in the Chinese context. That may shed a light on transferring innovations from those high-income countries to low- and middle-income countries other than China.

Among others, China has recognized Dutch innovations in elderly care to provide valuable best practices for learning [12]. The Dutch health system has often been ranked (among the) highest in assessments such as the Euro Health Consumer Index and the Global AgeWatch Index [13, 14]. The Netherlands also ranks high for quality of life among elderly [15]. The Netherlands has actively been exchanging knowledge and embracing international cooperation especially in elderly care since the 1990s [16]. As early as 1996, the Ministry of Health, Welfare and Sports of the Kingdom of the Netherlands signed a Memorandum of Understanding (MoU) of cooperation in the field of health and elderly care, with the China National Planning Commission (presently known as National Development and Reform Commission). This memorandum has been the first in a long series, of which the latest bilateral cooperation achievement is the “MoU on Elderly Care Cooperation” signed in May 2019. These cooperation mechanisms aim to promote the exchange of knowledge, professional expertise, and innovative practices, and to mutually improve healthcare and services for the elderly [17].

As additionally shown in previous studies, structural and cultural differences between the country of origin of the innovation and the country of adoption can also affect the adoption and adaptation of foreign innovations [4, 6, 18, 19]. For elderly care in particular, cultural and professional norms and values may act as barriers for introducing Western innovations in China. These values also show in the decision-making processes and professional roles during the adoption and implementation, and subsequently when practicing the Western innovations. While the differences in factors influencing adoption and implementation of Western elderly care innovations in China are starting to be recognized, primary empirical research on how and why these factors together influence adoption and implementation of foreign elderly care innovations in China still appears scarce.

Given the magnitude and importance of China’s challenge to develop high quality elderly care services and the selected approach to learn from successful innovations from other contexts, we aim to deepen understanding of the adoption and implementation of Western elderly care innovations to the Chinese context and particularly how and why adaptations to this new context have taken place. To this purpose, we conducted a case study at Suzhou Social Welfare Institution (SSWI), which is especially designated by the Chinese government to act as a pilot organization for new innovations in care, also those from abroad. It has a rich history of adopting and adapting Dutch health services innovations in China (as further elaborated below) [20, 21] and therefore has in-depth knowledge of the challenges faced and of the type of adaptations required to fit innovations from abroad into the Chinese context. Their long experience also allows us to learn about how adaptations develop over time. Our case study was guided by the following research question: How and why have Dutch innovations in elderly care been adopted and adapted in the Chinese context?

Suzhou social welfare institution background

Established in 1710, SSWI is a social welfare organization located in Suzhou, China. It consists of four centers: the Elderly Welfare Center, Children’s Welfare Center, Psychiatric Welfare Center, and Disabled Welfare Center. This government supported center provides comprehensive social welfare services for vulnerable individuals who are homeless, helpless and without means of livelihood, including elderly, disabled children and mentally challenged persons. SSWI has been supported by national, provincial, and municipal government (e.g., Ministry of Civil Affairs, and Provincial Department of Civil Affairs) to lead innovations that improve the quality of care services [22]. SSWI has been nationally recognized with the titles of “Place of Longevity”, “Premium Service Brand” and “National Standardization Demonstration Unit” [22]. It serves as a national pilot institution for elderly care and holds the distinction of being the first in Jiangsu province to receive a five-star rating, a designation awarded to facilities meeting the highest standards in quality of care, amenities, and services provided to residents. SSWI serves as the context of this case study because of its more than 20 years of history in exchanging innovations under the long-term cooperation with the Netherlands that started with the aforementioned 1996 MoU. The institute has adopted and adapted various innovations such as the provisioning of person-centered care for the elderly, working in social worker lead multidisciplinary care teams, and practicing the Plan-Do-Act-Check (PDCA) for continuous improvement and evaluation. The cooperation has resulted in a collaboration network involving multiple Dutch entities including the government (e.g., North Brabant Province), health organizations (e.g., GGZ Delfland, Reinier de Graaf Hospital), universities (e.g., The Hague University) and consultancy companies.

Methods

Research design

A case study is well suited to develop understanding of complex phenomena such as the process of cross-border innovation exchange [23]. This study has adopted a qualitative design [24, 25], because it allows the in-depth exploration of answers to the “how” and “why” questions. The method of case study also allows to collect data from several sources to answer the research questions [20]. This case study used semi-structured interviews of individuals, semi-structured group interviews, as well as document analysis [25, 26].

We employed a systematic approach to select three innovations to investigate the adoption and adaptation process. For the innovation selection process, we first asked SSWI to provide a list of innovations it has adopted from the Netherlands and were considered most relevant. Second, we asked Dutch experts with knowledge of elderly care and the cooperation with SSWI to review the list and identify innovations they considered as most relevant from the Dutch perspective (for instance because of their Dutch origin or elaboration). Subsequently, we selected the innovations mutually recognized and acknowledged. This resulted in three selected innovations;1) person-centered for the elderly, 2) multidisciplinary care team led by social workers, and 3) the Plan-Do-Check-Act (PDCA) cycle. Additional file 1 describes the innovations which have been adopted and adapted by SSWI.

Participants, data collection

Since 1996, many stakeholders from both sides have been involved in the Dutch-Sino cooperation in health care in general and in the adoption, implementation and adaptation of Dutch innovations in elderly care by SSWI in particular. We thus included Chinese and Dutch respondents in our data collection process. Chinese respondents may better understand the actual adoption and adaption in SSWI. Dutch respondents may have a deeper understanding of the original innovation and reveal processes which are difficult to observe by Chinese respondents. We only included respondents who have been actively involved in the innovation projects. We started from a set of original key players in the collaboration and used the snow-balling technique to recruit subsequent respondents.

We intended to conduct one-to-one interviews with all respondents. We conducted 5 one-to-one interviews with Dutch respondents. A sixth Dutch respondent passed away during the pandemic. Due to human resource constraints and regulations implemented during the Covid-19 pandemic, SSWI faced limitations in participating in research, and had to limit the further interviewing to three group interviews, each consisting of 8 individuals per group. The group compositions followed the selection criteria specified by the authors. Group 1 included nurses and their management, Group 2 consisted of social workers and their management, and Group 3 involved management and employees from various support departments, among which the departments of human resources, and information technology. An additional file (see Additional file 2) shows the list of participants and their professional background.

The interview protocol was developed for this study based on Greenhalgh’s conceptual model which considers multiple determinants for diffusion, dissemination, and implementation of innovations in health service delivery and organization [4, 7] and on findings from our earlier systematic literature review and explorative qualitative studies [7]. The model by Greenhalgh provides a general holistic perspective on factors that influence the diffusion of innovation. The findings from the systematic literature search provided more specific factors related to the Chinese context [7]. An Additional file shows the interview questionnaires (see Additional file 3). The questionnaire consisted of open-ended questions to probe for in-depth information, such as “How has the innovation of person-centered care for the elderly been adapted?” What are the similarities, if any, compared to original innovations in the Netherlands? What are differences, if any? ”

All participant contributions were systematically recorded, with the interviewer actively monitoring participation by marking each individual’s input to ensure balanced engagement. All participants were required to wear masks (due to Covid-19), which limited facial expression cues. Furthermore, a structured interview protocol was used to prevent hierarchal tensions and foster a more open dialogue.

For reasons of infection prevention, all interviews but one were conducted online using WeChat calls and Zoom meetings, in the period from September 2022 to February 2023. The duration of the interviews ranged from 58 to 78 min, with an average duration of 60 min. To ensure accuracy and thoroughness, the first author personally audio-recorded and transcribed all interviews. The Chinese interview transcripts were subsequently translated into English for joint analysis and interpretation.

In addition to interviews, we asked our respondents to send any documents related to the selected innovation projects. Ten documents from both sides were collected and reviewed using content analysis to acquire relevant information on innovations, organizational practices, and policy contexts (see for these documents Additional file 4). Among these documents are a historical review on the cooperation between SSWI and the Netherlands, policy documents, evaluation reports on innovations, service brochures, and newspapers/magazine articles.

Data analysis

A thematic content analysis was conducted in Atlas.ti 9 software to identify and generate patterns [24, 27]. The content analysis employed a systematic, inductive approach that allowed themes to naturally emerge from the data [27, 28] to capture the unique characteristics of the Chinese context. First, the initial coding process was independently conducted by the first and second authors, who analyzed transcripts and documents using a bottom-up method and identified initial codes and patterns, such as “hospital culture” and “top-down and bottom-up,” which began to reveal patterns within the data.

Then, related codes were discussed and combined to develop more comprehensive themes. For example, the initial code “hospital culture” was re-evaluated and revised to “clinical orientation” after discussion, capturing a more precise depiction of the emphasis on hospital-based practices. Additionally, codes and patterns related to “cultural values embedded within innovations” (such as “holistic approach”, “emotional support”) were combined with those related to “contextual culture” (such as “clinical orientation”, “medical technology”) to develop the theme of “differences between contextual values and values embedded in the innovations”. This theme highlights how the discrepancy in culture can influence the innovation process.

Meanwhile, data from different sources were compared to identify converging and diverging themes. The findings from interviews and documents analysis were triangulated to validate the consistency of themes across different data sources [28]. Also, supporting literature was consulted to better capture the contextual conditions related to the interventions. The credibility and reliability were assured by consensus review and appraisal of themes among all authors.

Results

Descriptions of the three selected innovations from the Netherlands that have been adopted and adapted in SSWI are presented in an additional text box file (see Additional file 1). The analysis revealed four key characteristics that have impacted the processes of adoption and adaption over time and which we identify as: Being a governmental-designated pilot organization, Taking a hybrid top-down and bottom-up approach, Differences between contextual values and values embedded in the innovations, and building trust and informal relationships with foreign experts.

Being a governmental-designated pilot organization

Suzhou Social Welfare Institute (SSWI), has been designated by the Chinese government as a pioneer organization with the objective to explore cooperation with the Netherlands to overcome challenges of an aging society [16, 22]. This approach in which the central government carefully chooses and promulgates local experiments (known as pilots) to address national issues is regularly practiced in China [29]. Over time, SSWI has been elevated pilot organization to model organization, and to serve as a template for other health institutions to follow. Pilot and model organizations receive support from the Chinese government and have to meet the expectations that come with this special status [30].

The governmental support included funding and access to foreign contacts with the Dutch government, which enabled to visit the Netherlands, participate in professional training programs in The Netherlands, and invite Dutch professionals to assist in innovation implementation at SSWI.

“For nearly 24 years, our institution has sent nearly 50 professionals to study in the Netherlands. The money comes from the government of Suzhou.” (Chinese).

Especially sponsored visits in the Netherlands have initially enabled SSWI to observe Dutch innovations in elderly care and then bring those innovations back to their institution. For instance, during a visit to the nursing home “Vrederust” in The Hague, The Netherlands, SSWI noticed the architectural design of a central courtyard surrounded by rooms in a large, circular building. This layout feature enables care providers to have a panoramic view of the surroundings as they walk inside and promotes a sense of social connectedness among the elderly. This design also aimed to reduce feeling of social isolation by the inhabitants, as experienced in traditional hospital-based designs with long corridors and small, cramped rooms on both sides. Inspired by the innovative design concept, SSWI took several photos, and 2 years later, Dutch visitors encountered a Chinese version of the design at SSWI. They noticed that there was much resemblance with the Dutch design, but some features had been adapted.

“This is a copy of a Dutch nursing home, with some Chinese elements inside.” (Dutch).

The original design in the Netherlands intentionally avoids any resemblances with hospitals, to promote that the nursing home feels like “home” to its residents. However, SSWI choose to combine the design of a Dutch nursing home with some features of a Chinese hospital, like a nursing station.

“A framework of a nursing home plus a hospital.” (Dutch).

“The nursing station is placed at the head, and the physical therapist’s clinic is at the tail for medical operations. The nursing station is a place for doctors and nurses to work, and the other end is a rehabilitation place.” (Dutch).

This adaptation can be attributed to expectations from the government, according to our Chinese respondents. As a pilot organization, SSWI is not only supported but also expected to align its practices with national policy and regulations. The 14th 5-year plan [31] emphasizes the national policy of integrating medical and elderly care. That signals to health organizations to combine medical and elderly care instead of choosing between them.

“The references of all aspects in the entire care process are equally important, compliance with various implementation standards issued by the national policy, service standards of nursing homes, and relevant professional standards and guidance of care.”(Chinese).

Another example of how the role of being a pilot organization and later a model organization, impacted adaptation regards the compliance to the regulation that care professionals must wear uniforms. During a visit in 2007, Dutch professionals saw all care providers in SSWI wear white uniforms, and then suggested to change this practice to make the nursing home less hospital like. In Dutch elderly care organizations, professionals don’t wear uniforms, as these may create a sense of distance and impersonality.

“Before this international exchange, we all wore white working uniforms, which gave a feeling of being cold in hospitals. It was very obvious that employees are employees, and the elderly are the elderly.”(Chinese).

In the following years, SSWI adopted the practice of not wearing uniforms as much as possible. However, Chinese regulations mandated that professionals in health organizations wear uniforms. Within the limits of these regulations, SSWI then offered a variety of colors and styles for the uniforms.

“Our nurses’ uniforms were originally white, but now they have changed to blue. Caregivers’ uniforms were also white, but now in pink and red. Also, different styles are available to choose from.”(Chinese).

“Now it is like in a foreign institution, you can wear your own clothing. However, professionals, such as doctors and nurses, must wear uniforms in China to indicate that they are doctors and nurses. This improvement of ours is the biggest change since the China-Dutch exchange.”(Chinese).

A hybrid top-down and bottom-up approach

Some earlier studies [9] have shown a typical Chinese approach to innovation which combines top-down procedures to stimulate adoption and bottom-up adaptations to tailor innovations in the local context. In our study, we observed a similar hybrid approach.

The first step in this process is what is called; top structuring [32]. Leaders at SSWI, inspired by innovations they witnessed during international visits to various Dutch organizations, selected innovations that they expect will fit their aims and their local context. After filtering out innovations or elements that seemed to be incompatible with their local context or required uncontrollable radical changes, leaders selected and combined different elements of various innovations from different organizations. These new configurations were then seen as ready to be implemented.

“As mentioned in the Three Kingdoms Chronicle, a Chinese classic work, if you can draw on wisdom in different forms, from different sources, then you are invincible.”(Chinese).

“In fact, we adopted some management methods or applied some technologies, because the context allows it to happen.”(Chinese).

Top structuring for example played a role in SSWI’s introduction of person-centered care for the elderly. SSWI leaders visited over 5 health organizations in the Netherlands where they witnessed a variety of innovative practices. Then, leaders selected various elements from different Dutch organizations. For instance, they drew inspiration from GGZingeest, a mental health hospital in Amsterdam, for the practice of making individualized care plans. Additionally, the idea of building an interactive experience room (explained in quotation below) was inspired by a nursing home in Goeree Overflakkee. The use of Plan-Do-Check-Act (PDCA) as an instrumental tool was influenced by online webinars involving multiple Dutch health organizations. These practices were combined into an innovation package consisting of individualized care plans, specialized facilities (e.g., interactive experience room), supported by PDCA for quality assessment and improvement.

“The nursing home provides elderly residents with a multi-sensory interactive boat house. In this interactive experience boat house, the elderly can simulate sailing on the sea and there are multimedia sounds, simulating the sound of the boat, waves, and seagulls. Many of the elderly on the island (in the Netherlands) had work experience at seaports when they were young, and later developed dementia symptoms. The interactive boat house can further enhance their sensory experience and also help them recall their past lives.”(Chinese).

“In fact, this idea is similar to our institution’s interactive experience room. Our organization also has an interactive experience device which enables the elderly to engage in virtual driving experiences within the famous landmark of Suzhou-Guancheng Street.”(Chinese).

Upon the creation of the innovation package, institution leaders established explicit goals for its implementation. Although top structuring initially filters out some innovations that may not fit the local context, the implementation of the innovative package may still encounter contextual challenges which may require further adaptations during the implementation. This therefore initiates the second stage: bottom-up adaptions, where the employees on the working floor strive to make necessary changes to innovations and find solutions to collaboratively achieve pre-determined goals.

“.There are still some difficulties in the implementation process.”(Chinese).

“When the goal of the leadership is clear, then social workers can communicate with other departments and work together to make this work. The leadership’s support gives us confidence.” (Chinese).

The pre-determined goals often are open-ended and leave room for interpretation. Employees are thus often expected to comprehend and interpret implicit intensions and create solutions to translate the blueprint into reality. For instance, one of the pre-determined goals was to incorporate a PDCA cycle from a Dutch audit framework to evaluate the quality of healthcare and the organization of healthcare while meeting ‘corresponding requirements’. During the bottom-up adaption, ‘meeting corresponding requirements’ was interpreted as aligning with Health Commission’s examination requirements centering on human performance evaluation. With the pre-determined top down goals in mind, the adaptation led to partial adoption of the 12 component Dutch audit system, focusing on human resource management components (as stated in the document of the Symposium of China-Japan-Netherlands Elders’ Nursing Home Management; see Additional file 4).

“The leader’ goal of utilizing PDCA is to identify and resolve problems, establishing a closed-loop quality management approach, and meeting the examination requirements set by the Health Commission.” (Chinese).

“The inspection contents revolve around performance evaluation requirements. This is also consistent with the ultimate goal of our management.’ (Chinese).

Differences between contextual values and values embedded in the innovations

According to our respondents, some innovations introduced by SSWI are based on values that may not inherently align with the clinical orientation for organizing care, commonly encountered in the context of Chinese nursing homes such as SSWI [33].

The clinical orientation encompasses values concerning care, skills and professional roles. At the care level, the clinical orientation emphasizes physical health and needs of the elderly rather than mental, psychological and social wellbeing [33]. This disease-centered approach contrasts with a person-centeredness approach that value a holistic perspective on the demands of the elderly [34, 35]. The clinical orientation thus implied values that differed from the values embedded in person-centered care that SSWI intended to introduce.

“The service may tend to focus more on the basic physical needs of the elderly, and not pay enough attention to the deeper psychological and social needs, leading to declined experience for the elderly and a lack of depth in nursing services.” (Chinese).

At the same time different forms of care in China are more focused on groups then on individuals.

“Previously, their plans were for groups, not for individuals. All people with dementia and psychiatric problems are treated in the same way. They have to get up at the same time, they have to eat at the same time. When they came back, already sitting there waiting for their medicines. They had to directly take the medicine. And then they all went for lunch, and they all wear the same shoes. They went to sleep at the same time.”(Dutch).

To adopt person-centered care for the elderly, a fundamental transition in values of good care thus appeared essential. It involved recognizing the elderly as whole individuals with multidimensional demands. Furthermore, it involved engaging the elderly as active participants in the care provisioning, empowering them to be “co-designer” and “joint-decision maker” rather than viewing them as passive “service recipients” [34, 35].

At the skill level, a clinical orientation may lead to emphasizing hard skills such as medical treatment and technology over soft skills such as communication and empathy. According to our respondents, the (originally less developed) communication skills indeed appeared essential for the successful implementation of person-centered care.

“We find it is difficult to talk with our service recipients, especially with psychiatric patients. Sometimes it is just hard to grasp.” (Chinese).

“If you don’t ask the elderly what the problems and demands are, then you cannot make anything individual care.” (Dutch).

The clinical orientation also shows through valuing and appreciating care providers with hard skills (e.g., doctors and nurses) more than care professionals with soft skills (e.g., caregivers and social workers). Professionals with soft skills experienced lower status, as manifested through lower payment and heavier workloads.

“They must feed these people well in half an hour, what can you do?” (Dutch).

“Those caregivers often work hard for money to support their family, but they receive the least payment within the entire organization.” (Dutch).

“They spend the most time with the elderly, so their opinions on how things can be improved should have been asked. They don’t get used to being asked about and sharing their professional opinions.” (Dutch).

Therefore, the original decision making and care provision dynamics within care teams in which care professionals with various skills collaborate was dominated by doctors. These dynamics consequently presented challenges to the introduction of multidisciplinary care team led by social workers which aimed to promote person centered care. The difficulty experienced by social workers to assume team leadership has been especially challenging.

“Doctors have always been regarded as ‘primary leaders’. The first thing that you need is to respect each other’s profession. It is about equality, seeing each other’s profession and knowledge. You know something and I know something, both very necessary. You both have some skills. This is the first step.” (Dutch).

While being supported by continuous organization wide training and education programs, the shift away from the clinical orientation took longer than expected. The process of joint comprehension of the importance of a holistic approach and committing to this approach advanced gradually.

“Some staff may not have a complete understanding of the person-centered care philosophy. We may still be influenced by traditional ideas and practices. Nursing work is highly practical, so our staff may focus more on technical operation rather than humanistic care.” (Chinese).

The gradual, step-by-step approach eventually taken by SSWI started with introducing the role of social workers in elderly care in 2001. This first step aimed to address insufficiency of attention for the elderly residents’ social and emotional demands. Social workers then started to play a role in identifying the elderly residents’ demands, intensifying communicating, providing companionship, and designing social activities for the elderly. They also managed the involvement of the support network of the elderly, such as their families, to develop individual care plans and to help providing emotional support for the elderly.

Some rehabilitation and entertainment activities will be arranged, such as taking a walk and making Chinese knots.” (Chinese).

“He was very upset without any appetite, and his daughter was abroad and international travel was too difficult during that time (due to pandemic). So we arranged video calls for him with his daughter to make him feel better.” (Chinese).

A decade after the first step of introducing social workers, SSWI extended the role of social workers to coordinating the care provided by professionals from various disciplines in function of the personal demands of the elderly. As a result, in 2012, SSWI took the second step, to completely adopt the innovation of social worker led multidisciplinary care teams [34]. This innovation has remained the standard practice since.

Building trust and informal relationships with foreign experts

The foreign expert network, established through a three-year governmental agreement in 1996 has expanded over more than 2 decades. This network operates through the active engagement of Dutch experts for longer term collaborations. The strength of the relationships that develop over this longer term appears to play a crucial role in navigating the complexities of adopting and adapting Dutch innovations in elderly care in the Chinese context.

Initially, invited Dutch experts shared their expertise while supporting SSWI in the process of adoption and implementation of Dutch innovations in elderly care. Many Dutch respondents were impressed by the Chinese hospitality and interest, which helped to develop a relationship of mutual trust.

“Once we arrived, there were all staff outside to welcome us, and then it was a big dinner welcome. The director clears all his agenda, and everything is for us. I can learn from this….” (Dutch).

Gradually, the interactions extended beyond formal meetings to relatively informal settings such as shared dinners and conversations over tea and coffee. Over time, the Dutch experts became trusted allies in the innovation processes of SSWI and some became to be considered as friends, committed to helping SSWI adopt and implement innovations.

“You have coffee at 10 pm after dinner, some people gone, and suddenly you have the real talk. At the second half the dinner, you often had real talks too.” (Dutch).

“You see their passion, compassion, commitment, really helps.”(Chinese).

The trust built within the long-term network, has enabled opportunities for collaborations beyond Dutch health organizations. SSWI has then expanded its partnerships to include Dutch universities and health enterprises since 2010.

“What also helps, is to create more organizations involved in that, and then it becomes stronger.”(Dutch)_.

“Over the past 20 years, we have witnessed the growth of collaboration and the development of Sino-Dutch friendship.” (Chinese).

The longstanding relationships facilitated the iterative processes of adoption and adaption and developed into a continuous knowledge exchange between Suzhou and the Netherlands. It enabled SSWI to continuously learn new innovations and further familiarize themselves with adopted innovations and improve throughout the different stages of the implementation process.

“…We have exchanged a lot about innovations, individualized care, working with social workers, care for patients with dementia patients’ rights, etc. Whenever the opportunity arises, we invite experts from various fields to teach in our institution or sent our staff to the Netherlands. ”(Chinese).

“They later, continuously asked a lot of questions about social workers.”(Dutch).

By interacting with Dutch experts, SSWI received technical support and according to our respondents developed a better understanding of the values embedded in the selected innovations. Such deeper understanding may be crucial for complex innovations like person-centered care for the elderly [36].

In 2010, for instance, the practice of making individualized care plans for the elderly was introduced in SSWI. Initially, SSWI faced challenges in implementing this practice, due to a lack of understanding of “individuality” and unfamiliarity with tailored care provider-the elderly communication techniques, as discussed in the previous section.

Recognizing the need for professional support and guidance, some of our Dutch respondents were invited to help for a three-month period at SSWI. Their expertise in making individualized nursing plans and their understanding of the importance of respecting the elderly’s individuality and effective communication was according to our respondents beneficial. The Dutch experts conducted training sessions especially for nurses who encountered difficulties in communicating with the elderly with mental issues. Those trainings focused both on how to ask questions, fostering meaningful interactions with the elderly, and on periodic evaluation of care plans.

“I showed them how to make a plan in the three months. I found they didn’t evaluate the plan regularly. One thing I told nurses is that if you want to make the plans that you need to make a conversation with the patients regularly to see if this plan works.” (Dutch).

“You have to understand, two people who both have diabetes can have totally different care plans. Although they both need insulin, they are different as individuals with different habits, preferences, beliefs…” (Dutch).

“Regarding personalized renovation, we now have different rooms in Chinese, European, and South Asian styles, with a focus on green plants and landscape design, eliminating labeling. You can also make your room decoration, put something made by yourself. They can decorate their own rooms based on personal preferences.”(Chinese).

“The elderly can place an order, and our chef will make the dish.”(Chinese).

In 2019, SSWI explored a next level in person-centered care, expanding the scope of individual decision-making beyond matters such as clothing, food and room decoration. This involved shared decision making on clinical matters and possible advancements in patient rights. There have been ongoing exchanges regarding patient rights, especially for those with dementia, which continued as online webinars during the pandemic. The long-term relationships thus seemed to provide a valuable platform for dialogue in support of continued gradual changes, including conversations about values of care embedded in the selected innovations.

“A topic that has also been talked a lot about is patients’ right. How the law works in the country, and people are not able to decide for themselves… psychiatric patients, the elderly with dementia. Here in the Netherlands, what you can do is really based on the law of patients’ rights. If the patient says no, then you cannot do anything…”(Dutch).

During the implementation and adaption, Dutch experts and professionals have also acted as intermediator between the SSWI leaders and employees, leveraging the built trust to assist the top-down and bottom-up dialogues. For instance, Dutch professionals would observe and hear about implementation challenges from the nurses at SSWI and bring them to the attention of the leaders.

“She (one Dutch respondent), sought feedback from nurses in SSWI, and then told the leader ‘they worked so hard, like one nurse has to manage 20 different patients. So probably the goals should be set lower, bi-weekly evaluation, instead of weekly evaluation. ”(Dutch).

“We also changed our scheduling, more flexible, for nurses.”(Chinese).

As the relationships and trust developed over time, the foreign experts thus also functioned to resolve some of the challenges left unaddressed by the traditional Chinese feedback practices which prioritize relaying positive feedback to the top management.

Discussion

The purpose of this case study was to explore the processes of adoption and adaptation of Dutch innovations in elderly care in the Chinese context. We identified four key characteristics that influenced adoption and adaptation: Being a governmental-designated pilot organization, a hybrid top-down and bottom-up approach, differences between contextual values and values embedded in the innovations, building trust and informal relationships with foreign experts.

The governmental pilot designation has played an important role in shaping SSWI’s approach to innovation adoption and adaptation, by providing targeted policy guidance, financial resources, and infrastructural support. Our findings suggest that this status not only facilitates innovation adoption but also influences other key components and processes identified in this study. For instance, the norm of “clinical orientation” was shaped by the national priorities tied to the pilot designation, as SSWI aligned its practices to meet the broader healthcare objectives set at the policy level [30]. Additionally, the theme of " Building trust and informal relationships with foreign experts " is closely linked to the pilot designation, as the collaboration with Dutch organizations was initiated under a formal agreement tied to this status [16, 17]. This designation created a structured framework for cross-national collaboration and resource exchange.

Previous studies have shown that top-down adoption and implementation of innovations often begins with local experimentation (also known as piloting) in a small number of settings, before making systematic efforts to replicate the innovations on a larger scale [37, 38]. Our findings show following this approach has also influenced the innovation processes at SSWI, which acted as government designated pilot organization to introduce innovations in elderly care from the Netherlands.

Most Western evidence suggests a negative association with top-down adoption and successful implementation and sustainability, because a top-down approach may not align well with the local needs [4, 5]. However, our findings indicate that a top-down approach may also positively influence the innovation implementation. This may be attributed to leaders’ active engagement in structuring innovations from the top, prior to the implementation, and their resulting up front support for the innovation. Leaders can filter innovations that may not fit the local context and modify and design innovation components to better fit the local setting.

In the Chinese context, modifications primarily consider requirements and constraints imposed by governmental policies and regulations, which aims to better meet governmental expectations on a designated organization. Given the importance of keeping alignment with governmental policies in the Chinese context, top structuring may increase the likelihood of successful implementation, as it adapts innovations to be in line with relevant policies before the actual implementation. This is for instance illustrated by the example of introducing uniforms of various colors and styles rather than eliminating their use, to ensure compliance with government regulations that mandate uniforms for health professionals while creating a more personal and home-like environment for the elderly.

Although adoption is primarily top-down, adaptation in the Chinese context often also involves a bottom-up approach [9]. In the adaptation process middle level leaders play a vital role as they are responsible for the iterations necessary for successful implementation. At the same time, they manage two communication loops: one where they report positively on progress to top level leaders, and the other where they coordinate the adaptive problem solving down to the work floor.

Interestingly, the Dutch experts played a closely related role in the bottom-up adaptation phase. They provided support when they considered it necessary for successful implementation and also coordinated communication upwards and downwards. They complemented the traditional positive feedback loop and often communicated with the leaders about challenges and barriers. As a result, such issues were more likely to be exposed and addressed in a timely manner, facilitating the success of innovation adoption and adaptation.

Western literature and evidence often focus on bottom-up adaptations to the innovation itself [37]. Our results reveal how the innovation processes have additionally triggered tangible and intangible adaptations to the context, for instance regarding values of care. The intangible adaptations often involve changes in professional roles and responsibilities which appeared challenging because they required changes in deeply held values and norms [37]. Therefore, it may take considerable time to achieve the transition. SSWI took 10 years to transition from doctor-led care delivery to social worker-led care delivery in multidisciplinary care team.

As recognized in international literature, cultural values and norms play a significant role in the adoption and adaptation at the macro, meso, and micro level. Values and norms may vary across regions, stakeholders and sectors [4, 18, 19]. However, few studies focus on values embedded in innovations and on the potential conflict that may arise especially when the contextual culture clashes with the values embedded in the innovations. The greater the discrepancy between the two, the more challenging it may become to adopt and adapt the innovations, especially those requiring behavioral changes [4, 37]. Our findings suggest that values and norms inherent in innovations in service delivery appear to constitute an integral and unalterable part of the innovation, often referred to as “hard core”. An innovation in service can be viewed as having: a “hard core” (irreducible elements intrinsic to the innovation); and a “soft periphery” (the organizational structures and systems required for full implementation of the innovation) [4].

Under this circumstance, it appears necessary to adapt values and norms within the local context to maintain the fidelity of the service innovation by ensuring the alignment with the “hard core” of the innovation. Our findings indicate that shifting values and norms within the local context typically demands long-term commitment and dedication. Taking a series of incremental, intermediate, steps has helped to address an urgently felt need to innovate together with a long-term change in values and norms.

Partnerships and connections with outer entities (known as cosmopolite: interpersonal influence from outside) can be beneficial to effectively acquiring knowledge and promoting learning in health service innovation [4, 39]. Our findings suggest that the long-term nature of the collaboration and the trust that was built over time became important enablers of the innovation exchange. Long-term collaboration continuously provided access to expertise and to up-to-date knowledge (both value-related and technical) needed for adopting and adapting innovations along the journey [4, 37]. Trust has facilitated the adoption and adaption of the Dutch innovations in the Chinese context, confirming that trustworthiness of the source of innovations can function as an important implementation determinant [40]. Moreover, mutual trust facilitates open, transparent, and constructive dialogues in knowledge sharing and feedback provisioning during the implementation and adaptation. This is particularly visible through the trust in Dutch experts to occasionally form an additional communication channel between higher management and professionals.

To tackle global health challenges it is important to diffuse innovations. However, research suggests that especially innovations between Western and non-Western contexts such as low- and middle-income countries transfer poorly [8, 9]. Challenges arise due to several factors including differences in healthcare infrastructure, socioeconomic conditions, cultural factors, and health system structures. Our study shows how specifically governmental regulations, differences in how innovations are managed within organizations (top-down-versus bottom up) and differences between contextual values and values embedded in the innovations may potentially threaten adoption and adaptation of such innovations. However, our study also provides important suggestions on how to deal with such challenges. First, the introduction of governmental designated pilot sights which are provided with policy guidance, financial resources, and infrastructural may support diffusion of innovation between Western and low- and middle-income countries. Second, fostering long-term collaborations can build mutual trust and understanding, helping to bridge cultural gaps. Third, adopting incremental approaches allows organizations to integrate innovations gradually, aligning them with current care demands while facilitating a long-term cultural shift. Finally, capacity-building initiatives, such as targeted training and knowledge exchange programs, can equip staff with the skills needed to adapt and sustain innovations effectively. These interventions may reflect the value of context-specific, stepwise strategies in overcoming barriers and facilitating successful adoption and adaptation in similar cases.

Limitations

Several limitations exist in this study. First, due to lock-down policies during covid-19 pandemic, we were not able to visit SSWI in person during the study and conduct on-site observations. Consequently, this study may have missed some implicit organizational dynamics and contextual details relevant to understanding the processes of adoption and adaptation. Second, we were only able to conduct group interviews involving both managers and caregivers rather than separate group interviews with managers and caregivers or one-to-one interviews. This method was shaped by external constraints including organizational preference, policy restrictions, and capacity issues due to the COVID-19 pandemic. This may consequently limit the divergence of viewpoints, as the hierarchical relations and group dynamics may have influenced employees’ responses during the interviews. On the positive side, the group dynamics may have generated advancement of perspectives that are difficult to achieve in one-to-one interviews. Efforts to manage power dynamics included a structured interview protocol and asking caregivers explicitly to voice their opinions during the group interviews Third, we adhered to COVID-19 safety protocols meaning that respondents wore facemasks. This may have restricted the participants and the researchers to use and observe non-verbal cues and may have decreased spontaneity. Fourth, SSWI has a well-established support structure and extensive experience in international collaboration (e.g., formal partnership agreements). While this setting allows us to tap into a lot of experience with adoption and adaption, the findings may have limited transferability to less-experienced organizations that lack similar resources and support networks, which could result in different challenges in implementing such innovations. Finally, the limitations in the number of interviews may have prevented saturation, even while being complemented with Chinese and Dutch documents.

Conclusion

This case study identified four key characteristics that shape the processes of adopting and adapting Dutch innovations in elderly care in SSWI, the Chinese context. Being a governmental designated organization, SSWI’s adoption of Dutch innovations takes a top-down approach. The initial stages involve structuring innovation modules by top management before actual implementation to ensure alignment with governmental polices and regulations. Adaptation often follows a bottom-up approach, during which Dutch experts play an important role in communication upwards and downwards. Adaptations made can be both tangible and intangible. The reference for making those changes include not only governmental policies and regulations, but also cultural barriers when the values embedded in the innovations are not fully compatible with the contextual values. Taking an incremental approach with intermediate steps has facilitated gradual implementation. The resulting longer-term process benefits from long-term collaboration between experts involved in the countries of origin and implementation.