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if_we_cant_do_more_lets_do_it_differently.pdf

`If we can't do more, let's do it differently!': using appreciative inquiry to promote innovative ideas for better health care work environments

MARIE-CLAIRE RICHER P h D , N 1, JUDITH RITCHIE P h D , N 2 and CAROLINE MARCHIONNI M S c A d m i n , M S c A , N

3

1Director, Transition Office, 2Associate Director for Nursing Research and 3Knowledge Broker, Transition Office, McGill University Health Centre, Montréal, QC, Canada

Introduction

Factors such as the shortage of health care personnel,

hospital closures and mergers, the ageing population

and the steady increase in the number of people living

with chronic disease have all added pressure to the

health care system. Inevitably, these pressures have had

a negative impact on current work environments and

Correspondence

Marie-Claire Richer

McGill University Health Centre

2155 Guy St., suite 790

Montréal, (QC)

Canada H3H 2R9

E-mail: [email protected]

mcgill.ca

R I C H E R M . - C . , R I T C H I E J . & M A R C H I O N N I C . (2009) Journal of Nursing Management 17,

947–955

`If we can't do more, let's do it differently!': using appreciative inquiry to promote innovative ideas for better health care work environments

Aim To examine the use of appreciative inquiry to promote the emergence of innovative ideas regarding the reorganization of health care services.

Background With persistent employee dissatisfaction with work environments,

experts are calling for radical changes in health care organizations. Appreciative

inquiry is a transformational change process based on the premise that nurses and

health care workers are accumulators and producers of knowledge who are agents

of change.

Methods A multiple embedded case study was conducted in two interdisciplinary

groups in outpatient cancer care to better understand the emergence and

implementation of innovative ideas.

Results The appreciative inquiry process and the diversity of the group promoted

the emergence and adoption of innovative ideas. Nurses mostly proposed new ideas

about work reorganization. Both groups adopted ideas related to interdisciplinary

networks and collaboration. A forum was created to examine health care quality

and efficiency issues in the delivery of cancer care.

Conclusion This study makes a contribution to the literature that examines micro

systems change processes and how ideas evolve in an interdisciplinary context.

Implications for nursing management The appreciative inquiry process created an

opportunity for team members to meet and share their successes while proposing

innovative ideas about care delivery. Managers need to support the implementation

of the proposed ideas to sustain the momentum engendered by the appreciative

inquiry process.

Keywords: appreciative inquiry, cancer care, innovation, teamwork, work environment

Accepted for publication: 27 April 2009

Journal of Nursing Management, 2009, 17, 947–955

DOI: 10.1111/j.1365-2834.2009.01022.x ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd 947

have resulted in a worldwide shortage of health care

personnel (International Council of Nurses 2006).

Despite calls to change health care organizations and

implement innovative measures to improve work envi-

ronments and the retention of health care personnel

(Gould 2006, Wagner 2006), few interventions have

been tested. Experts in the field of health care man-

agement are thus calling for radical changes in the way

in which health care services are delivered (Aiken et al.

2001, Shannon & French 2005).

Health care workers need opportunities to explore

the possibilities for change beyond the boundaries of the

problems they are experiencing. We propose apprecia-

tive inquiry (AI) as an approach to break through old

boundaries and promote the emergence of innovative

ideas (Marchionni & Richer 2007). This paper reports

one part of a study on the development of innovative

ideas relating to the organization of health services in a

large university-affiliated health care institution.

Literature review

Knowledge as a source of innovation and change

In knowledge-based environments, such as health

care, workers are not just participants in the labour

force, but also accumulators and producers of

knowledge who can be viewed as agents of change

(Banora & Revang 1993, Rycroft-Malone et al. 2002,

Aita et al. 2007). It has been several years since

Leonard-Barton (1992) first explored the strategic

importance of utilizing the organization�s distinctive �forces�, or human capabilities, in the development of innovation. Van de Ven et al. (1999) define the

innovation journey as �new ideas that are developed and implemented to achieve [a] desired outcome by

people who engage in relationships with others� (p. 7). This definition implies that knowledge is a source of

innovation and change that requires synergy between

individuals within a group.

Ackerman (1997) introduced the notion that people

are the promoters of transformational change in orga-

nizations. He explained that changes can be develop-

mental, when individuals enhance or correct aspects of

an organization; transitional, when planned changes

seek to achieve a known desired state that is different

from the existing one; and transformational, when

changes favour the emergence of a new state and imply

a shift in the assumptions that drive the organization

and its members in the process of change. Notably,

transformational changes parallel Senge�s (1990) gen- erative learning, which results in a shift in assumptions,

and imply that new knowledge emerges from social

interaction between the people within the system. These

notions are also supported by the works of Nonaka

(Nonaka 1994, Nonaka et al. 2000) and Brown and

Duguid (1991) who situate the notion of knowledge

creation in dynamic and iterative social processes

within organizations. This underscores the importance

of examining the interplay of the social context and the

creation of new knowledge as key components of

organizational change.

Theoretical framework

Based on this literature, a framework that draws on

organizational change and innovation theories was

developed. It situates AI as a transformational change

process and is based on two premises. The first

premise is that initiating organizational change in

professional settings requires the understanding that

organizations are socially constructed and generate

the contexts in which people act and interact to cre-

ate new realities through learning and innovation

(Argyris & Schön 1978, Cooperrider & Srivastva

1987, Van de Ven et al. 1999, Van de Ven & Poole

2000, Johannessen & Olsen 2003). The second pre-

mise is that, in order to initiate change, particular

attention should be paid to the process through which

change takes place. The change process, described as

complex and non-linear (Pettigrew et al. 1992, Van

de Ven & Poole 2000), often focuses on specific

problems to be solved. This is particularly true in the

health care sector because of the influence of the

medical model, which focuses on interventions for

specific medical problems.

In its pragmatic form, AI builds on learning and on

what works well in an organization at its best to effect

changes for the future (Whitney & Schau 1998).

According to its founders Cooperrider and Srivastva

(1987), AI is a complement to the more conventional

form of action research and is distinguished by its

ability to incite generative learning (Barrett 1995).

Because of AI�s positive stance, Cooperrider and Sri- vastva (1987) argue that this collaborative process has a

greater capacity to generate innovative change than the

traditional linear approach to problem solving. AI

considers the organization as a product of human

interaction and social constructions (Cooperrider et al.

1995). These are important tenets, because individuals� and groups� behaviour is influenced by their often- unquestioned beliefs and assumptions. Barrett (1995)

draws a parallel between the learning organization and

AI. With reference to Senge�s (1990) generative learning

M.-C. Richer et al.

948 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd, Journal of Nursing Management, 17, 947–955

concept, Barrett (1995) described AI as a systemic

process that promotes learning and thinking outside the

accepted limitations of a problem. This �appreciative approach� to learning in organizations is considered as a way to promote innovation (Barrett 1995) and foster

transformational change.

AI: a process to tap into the potential of innovative

ideas

Recognized as an approach that fosters innovative ideas

(Bushe 1998, Bushe & Kassam 2005), AI is a process in

which members of a team can exchange both tacit and

explicit knowledge to build a future for their team or

organization. AI involves the art and practice of asking

questions that strengthen a system�s ability to anticipate and build on its success and positive potential

(Cooperrider & Whitney 1998). Through its four-phase

process of Discovery, Dream, Design and Destiny, AI

helps individuals and groups to envision their future

and initiate change in the organization by concretely

doing more of what they do best (Cooperrider &

Srivastva 1987). See Table 1 for a description of the

four phases of AI.

Most AI applications have been reported by busi-

nesses, non-profit organizations and government or

community groups (Ludema et al. 2003). Despite

numerous calls for its use (Vitello-Cicciu 2003, Stange

2004, Gardner 2005, Marchionni & Richer 2007) there

have only been a limited number of published studies

evaluating AI as an organizational change method in

health care (e.g. Baker & Wright 2006, Richer 2007). In

this study, AI is used as a way to elicit innovative ideas

from the health care professional�s perspective regard- ing the organization of care and services. This paper

addresses the following question: How does an AI

change process lead to the development of innovative

ideas regarding the organization of health care services?

Method

Research strategy

A multiple embedded case study was conducted to

enhance the understanding of the multiple organiza-

tional, social and personal dimensions that influence the

emergence and implementation of innovative ideas in a

complex organization such as health care. Given these

multifaceted elements, the case study methodology con-

stituted an appropriate mode of inquiry that permitted

the use of multiple sources of evidence (Stake 1995, Yin

2003). Given the multifaceted elements involved, case

study methodology also permitted the use of multiple

sources of evidence (Stake 1995, Yin 2003). Two cases

were selected from the adult cancer care division of a

multi-site university-affiliated health care centre in a

metropolitan area in Quebec, Canada. In this study, two

cancer care clinics on separate sites constituted the

cases and the embedded units, subunits of the larger

cases, were the health care teams (within each clinic) and

the management team that oversaw both clinics.

Participants

Health care teams

All cancer care clinic personnel on each site, excluding

personnel on leave of absence, were eligible to partici-

pate in the study. The researcher met with a total of 65

health care personnel and volunteers; 47 agreed to

participate in the study, representing a 72.3% response

rate. Of the 47 participants, 28 were nurses and 19 were

volunteers, pharmacists, physicians, clerical staff and

attendants and are presented in Table 2.

Management team

Five middle and upper managers from medicine, nursing

and pharmacy, who had direct responsibilities in the

Table 1 Description of the appreciative inquiry (AI) process

Discovery Dream Design Destiny

Description Recognize and evoke the potential of a group through positive inquiry

Connect images from the past to possibilities for the

future of the group

Create a vision that represents the ideal for the group

Create and implement actions around the

group�s core strengths Objective Sharing of positive

past experiences, focus on what gives

life and energy to people

Envision the possibilities for change based on

common values

Articulate Provocative Propositions representing what

is best in the organization

Create and implement actions around the

Provocative Propositions

Activity Participants interview each other using a set of predetermined questions

The group identifies common themes and the central values

from the positive stories

Provocative propositions are formulated based on the group�s central values

An action plan is created Individuals or small groups

commit to its application

Compiled from Barrett (1995), Ludema et al. (2003) and Cooperrider and Srivastva (1987).

Appreciative inquiry to promote innovation

ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd, Journal of Nursing Management, 17, 947–955 949

organization and management of both cancer care clinics,

participated in the study.

Procedure

Appreciative Inquiry

The AI change process consisted of 11 sessions of

1 hour conducted with each health care team simulta-

neously over 9 months in 2004–5. The AI process led to

the development of an action plan for change that was

produced by each health care team and was presented

to the management team. In order to evaluate the

�innovativeness� of the ideas proposed by the teams, all ideas were listed and discussed by each team following

the �innovative idea grid� developed by the researcher and validated by experts in the field of innovation

research for the purpose of this study. Based on Van de

Ven et al.�s (1999) definition of innovation, the partic- ipants were each asked a series of questions to rate

whether the emerging ideas were perceived to be inno-

vative. The majority needed to concur before an idea

was classified as innovative. See tool in Appendix 1.

Sources of evidence

Yin (2003) suggests that the use of multiple sources of

evidence allows the researcher to address a broader

range of issues and helps to develop a converging line of

inquiry. The sources of evidence used in this study were

diverse and targeted specific concepts. They consisted of

participant observation, interviews, direct observation

and documentation.

Participant observation. As a source of evidence, partic-

ipant observation is described as a mode of observation in

which the researcher assumes a participating role regard-

ing the event that is being studied (Yin 2003). In this study,

the investigator conducted the AI process. To avoid

potential bias, all 22 1-hour sessions (11 in each case)

were tape-recorded and, after a field note guide, notes

were taken by an external observer who documented any

information related to the conduct and general content of

the sessions. Furthermore, the researcher started each AI

session with a summary of the previous session�s content ensuring further content validation.

Interviews. In addition to the AI process, targeted

interviews were conducted with the management team

to trace the organizational context throughout the study

and the organizational response for the implementation

of the action plan produced at the end of AI process.

Direct observation. Direct observation of management

meetings was also done to observe the organizational

responsiveness to the AI process and to determine the

extent to which the organization took actions based on

the proposed action plan. The researcher attended five

management meetings within nursing and pharmacy and

one leadership meeting that included physicians.

Documentation. For this study, sources of documenta-

tion included internal and external cancer care reports.

These reports were useful to situate the internal and

external context in which the study took place.

Analysis

Data consisted of verbatim transcripts of the AI ses-

sions, field notes, notes from interviews and meeting

observations and summaries of documentation. A

content analysis was done according to the method

proposed by Miles and Huberman (1994) consisting of

three concurrent flows of activity: data reduction, data

display and conclusion drawing and verification. The

analysis of the two cases was done sequentially using a

temporal bracketing strategy (Langley 1999, Van de

Ven & Poole 2000). This strategy involves breaking the

data into chronological sequences that could then be

compared in the analysis between cases. Data within

each case were analysed separately and then a cross-

case analysis was undertaken to identify convergent and

divergent trends between the cases (Van de Ven 1986,

Van de Ven & Poole 2000).

Ethical considerations

Ethical approval was obtained from the Research Ethics

Board of the institution. Careful consideration was

taken to ensure the confidentiality of the individual

participants� responses.

Table 2 Study participants

Nurses Volunteers Pharmacists Physicians Clerical

staff Patient

attendants Total

Case 1 14 3 2 1 3 0 23 Case 2 14 4 2 2 1 1 24

M.-C. Richer et al.

950 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd, Journal of Nursing Management, 17, 947–955

Results

Understanding the importance of the context

In the course of the AI process (see Table 1), members

of the health care team in both cases noted that the

political and social environment of cancer care greatly

influenced their work performance. At the beginning of

this project, the health centre in which the study was

done received confirmation that they would lead one of

four new provincial integrated health care networks,

covering over 60% of the geographical region. Inter-

views with the leadership team confirmed that this

political context exerted pressure on the organization

and was at the heart of their current concerns. They

noted that the shortage of family physicians in the

community was also an important factor that increased

ambulatory care visits and contributed to this increased

workload.

The emergence of innovative ideas

The process of going through the four phases of AI and

the diversity in the group composition promoted the

emergence and adoption of innovative ideas. As ideas

started to be formulated, the contributions of different

members of the health care team promoted their

refinement.

The emergence of ideas during the AI process

In general, the ideas evolved throughout the four phases

of AI in a succession of discussions that refined the

initial idea. For example in Team 1, the group first

raised the importance of collaboration and teamwork in

relationship to staffing, time efficiency and patient care.

The idea evolved and the group proposed that the

organization, that is, upper management, should create

a vision for cancer care. During the design phase, the

group took ownership of this idea and decided to pro-

pose a vision to all members of the interdisciplinary

team. By the destiny phase, a member of the team had

contacted members of other disciplines and a meeting

was organized to present the vision/goals that were

developed during the AI process.

Types of ideas

There were similarities in the types of ideas that the two

teams adopted and considered innovative. Out of the

eight ideas proposed by Team 1 and the seven proposed

by Team 2 in their final action plans, only one within

each case was considered non-innovative by the health

care team. The innovative ideas were more incremental

in nature (Van de Ven 1986, Gopalakrishnan &

Damanpour 1997) with the majority related to

processes for interdisciplinary collaboration and new

service delivery approaches.

As shown in Table 3, both teams adopted ideas

related to interdisciplinary networks and collaboration.

The idea to develop a unified vision and a structure for

interdisciplinary collaboration and decision-making

was proposed by both groups as a way to formalize

their vision for collaborative practice. This took the

form of an interdisciplinary forum/group in which

selected members from each discipline came together

and worked on health care quality and efficiency issues,

particularly on service co-ordination and delivery in

cancer care.

Initiators, refiners and adopters

In both cases, idea initiators were mostly nurses but the

ideas were developed with the participation of members

Table 3 Main ideas adopted by each health care team

Team 1 Team 2

1-Develop common goals/vision with the interdisciplinary team

1-Organize a cancer care retreat with the interdisciplinary team to develop a common vision and discuss issues related to clinic and patient services

2-Form an interdisciplinary forum with representation from each professional group

2-Create a interdisciplinary core group

3-Regular meetings to discuss issues to bring to interdisciplinary forum

3-Common room for staff to have lunch. Psycho-social support for staff

4-Integrated and seamless services with new model of care

4-Offer appropriate care 24/7 by having:

-Evidence-based telephone triage -Better collaboration with the palliative care unit

-Day hospital for medical emergency and cancer care emergency room

5-Separate clinic to deal with complications and treatment toxicity

5-Multidisciplinary teaching session for new patients

6-Separate clinic for non-malignant hematology population

6-Increase clinic efficiency by reducing wait time

7-In order to provide cutting edge evidence-based quality care, develop evidence-based standards for safe patient: health care professional ratio

Appreciative inquiry to promote innovation

ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd, Journal of Nursing Management, 17, 947–955 951

from all disciplines. Furthermore, the participation of

diverse members of the team was beneficial for the

refinement of the idea. Members of the diverse

disciplines shared their knowledge and perspective and

this shared learning gave form to the ideas that the group

considered innovative. For example, in Team 1, the idea

of an interdisciplinary forum started with a pharmacist

trying to find a way of improving communication within

the team. The idea of making interprofessional collabo-

ration more concrete was then brought up by a physician

and a volunteer proposed a format that could promote

the coming together of different team members. The

idea of initiating an interdisciplinary forum was then

formulated and refined by specifying the process of

functioning. These idea components evolved primarily

because they were related to the central values that the

group deemed important.

Idea evolution

The evolution of ideas followed different paths in each

case. Some of the ideas were first rejected before being

reconsidered and adopted. For example in Team 2, the

idea to propose an emergency room for cancer care

patients was rejected when it was first presented. The

group adopted the idea when it was reintroduced again

at a later time, and they also decided to think of short-

term alternatives. For example, a nurse proposed a

phone triage system to answer emergency needs, and a

physician suggested closer links with the palliative care

unit. Both of these ideas were adopted.

Organizational responsiveness and idea implementation

The process of implementing the adopted ideas presented

in the action plan mainly involved the mobilized actions

of individuals who participated in the AI process. The

organizational response to the ideas and their imple-

mentation was elicited through formal meetings between

management and the health care team, meetings within

various disciplines and the direct involvement of a nurse

manager. The management team, however, did not

respond to the health care teams� expectation to support the implementation of most ideas. During management

meetings, external context issues, and new emerging

internal pressures, took precedence over discussions of

ideas proposed in the action plan.

The analysis of the idea implementation shows that

the implementation of innovative ideas was facilitated

when the idea addressed the team�s values about patient care and when members from diverse disciplines

participated in the idea elaboration and implementation

process. The most critical elements for the implemen-

tation of innovative ideas was that one person or a

group of individuals took leadership with a member

from the management team showing direct support

during the implementation process.

Discussion

The emergence and implementation of innovative ideas

At a time when health care managers and researchers

are increasingly insistent on the need to engage

personnel in change efforts (Barney 2002, Lavoie-

Tremblay et al. 2005, Shannon & French 2005), the

results of this study suggest that AI not only provides a

way to involve health care professionals in change

processes but also creates the opportunity and some of

the conditions that promote the emergence and imple-

mentation of innovative ideas. The results of this study

suggest that the process of going through the four

phases of AI helped in the development of innovative

ideas. Throughout the AI process, discussions between

different members of the team permitted the refinement

and the evolution of the generated ideas. This process of

knowledge exchange and development is in line with

Nonaka�s (1991) proposition that the emergence of innovative ideas or new knowledge always begins with

individuals, is embedded in values and beliefs and is

created when tacit knowledge is made explicit and

transformed into something new. The different phases

of AI permitted this exchange and transformation of

knowledge into innovative ideas, supporting the pre-

mises of the theoretical framework.

The importance of social networks and interdisciplinary collaboration

This study contributes to the body of knowledge on the

emergence and adoption of innovative ideas in health

care and, in particular, the importance of social net-

works and interdisciplinary collaboration as necessary

conditions. The results of this study support the view of

Drazin and Schoonhoven (1996) and others (Hislop

et al. 2000) that equal attention should be given to

micro-level social structures for networking in the

production of innovation as well as to the larger

system�s perspective. The fact that, in both cases, innovative ideas got developed and refined through the

unique contribution of individuals from diverse back-

grounds is an important point to consider.

M.-C. Richer et al.

952 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Publishing Ltd, Journal of Nursing Management, 17, 947–955

As a process, AI is a means to encourage dialogue,

develop trust and create links not only between pro-

fessionals but also with other health care workers,

creating a �space� where knowledge can be developed and shared. This shared space, called �ba� (Nonaka & Konno 1998, Nonaka et al. 2000), encompasses any

virtual or physical area designed for the creation of

collective knowledge and the development of relation-

ships. Thus, the common context in which knowledge

was shared, created and utilized during the AI process

united physical and mental spaces, �ba�, that promoted the sharing of common goals and provided a platform

for innovation.

Organizational support: a key ingredient for idea implementation

Once ideas were generated, a key ingredient for idea

implementation was organizational support. The results

show that members of the health care team perceived

that organizational support was an imperative precur-

sor to the implementation of innovative ideas. As such,

one of the determinants of idea implementation is the

direct support from a member of the management team.

This confirms that the organization needs to be recep-

tive and support the implementation of these new ideas.

These ideas are the trigger for organizational improve-

ment and, in the views of Van de Ven (1986), an

organization can only survive when it pursues new

initiatives. In knowledge creation processes such as AI,

middle nursing managers are placed at the centre of the

knowledge management process because they are at the

core of the vertical and horizontal flow of information

within an organization, placing them in a �middle up down� management position (Nonaka & Takeutchi 1995).

Implications for nursing management

Nurse managers have an important role to play in cre-

ating a �space� where members of the interdisciplinary team can meet and share their successes and values

about care. However, the results of this study also show

that creating a �space� is not enough. Ideas cannot by themselves improve the organization without the

accompanying change, otherwise only the potential for

improvement exists. The major implication for man-

agers is the importance of following through on the

proposed ideas. For example, discussions, with mem-

bers of the health care team, about developing short-

term ideas or �quick successes�, would sustain the momentum engendered by the AI process. The study

implications also reiterated other reports that concluded

that organizational support is a key factor in changing

work environments and that multilevel interventions

are needed (Golden-Biddle et al. 2006).

Limitations and future research

A limitation of this study is that the observation period

following the end of the AI process was too short to

observe the full potential implementation of the inno-

vative ideas. In future studies, multilevel interventions

involving middle and upper nursing management

should be undertaken to better understand the factors

that influence the implementation of ideas and the key

role of management in this process.

Conclusion

Initiating a process that builds on positives such as AI in

an environment that is often depicted as complex and

fraught with problems may well be the first step

towards promoting the emergence of innovation in

health care. By bringing individuals and teams together

to uncover their strengths and successes, the AI process

inspired hope. The organization must then respond and

take action to support change. In the context of health

care, AI is a way to create organizational change by

building on its most important asset, its people.

Acknowledgements

M.-C.R. would like to thank the Centre for training and ex- pertise in nursing administration research (FERASI), the Fonds de la Recherche en Santé du Québec (FRSQ), ACEN and the research foundation of the McGill University Health Centre (THP Molson Award) for their financial support. The author would also like to thank Valerie Shannon, Ann Lynch, Margaret Graham and J.-L. Denis for their valuable feedback.

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Appendix 1

Evaluation of innovative ideas grid

An innovation is defined as new ideas that are developed to achieve a desired outcome by people who engage in relationships with others in changing institutional and organizational contexts. An innovative idea might be a combination of old ideas, a scheme that challenge the present order or a unique approach that is perceived as new by the people involved (Van de Ven et al. 1999).

This grid is to evaluate the innovativeness of the ideas that were developed during the AI intervention as well as their perceived value for implementation. Please indicate the proposition number under which the idea was developed. Complete a separate evaluation of innovative ideas grid for each idea.

Proposition # ________ Idea:__________________________________________

Idea Innovativeness 1- The idea can be considered as innovative because:

It is made of a combination of old ideas Yes No 2- The idea can be considered as innovative because:

It is new and represents a unique approach Yes No 3- This idea has been previously tried in the cancer care clinics

or implemented in this hospital Yes No

Perceived Implementation Value

Is this idea perceived as useful? Yes No Does it answer the needs of the organization? Yes No Is this idea readily applicable? Yes No Do you believe the idea will be implemented? Yes No

Comments: ________________________________________________________

A YES answer at item # 1 or 2 and a NO answer at item 3 classify the idea as innovative.

Appreciative inquiry to promote innovation

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