Nature of the inquiry: My research inquiry investigated how qualities of personal interaction shape and affect the promotion of research utilisation for quality improvement in the US healthcare sector. The research investigated my own professional practice of consulting, teaching, and research regarding the improvement of healthcare practices and outcomes. Efforts to improve the quality of healthcare services are often difficult to realise and sustain. The quality improvement movement in the USA and elsewhere has not conducted much self-examination of its own processes for sources of these perennially problematic results. Relevance: The quality of healthcare services can be readily understood as having consequences of life or death, wellness or suffering. Healthcare expenditures in the USA are estimated at 16% of GDP and over 9% in the UK. Improving healthcare quality improvement efforts is a matter of profound human and social significance. Approach: The DMan research methodology is a reflexively aware process conducted as a cohort and as small learning groups of researchers during the three-year programme. The research inquiry used the complex responsive process of relating theory of learning as emergent changes of meaning or, equivalently, knowledge. As a social science of qualities, it uses the qualities of human interaction as the unit of analysis. The research utilised an interdisciplinary approach drawing upon: healthcare quality improvement literature; organizational discourse studies; research on strategy as practice; performance management; communications theories; the theory of mindful learning; interpersonal neurobiology; figurational sociology; and American pragmatist philosophy. The methodology employs a mindful reflexivity research strategy related to concepts from mindful learning and social neuroscience literature. Central methods included iterative peer and supervisor debriefing and iterative reflexive narrative practice. Findings: A contribution is made to the healthcare literature by describing how ordinary qualities of social coordination dynamics affect the promoters of healthcare research, not just potential users of research. A contribution is made to professional practice by providing a new perspective from which to analyse the sources of performance challenges prevalent in healthcare quality improvement efforts. The research findings indicate how applications of substantial organisational and social resources to promote research utilisation in the US health sector can be co-opted and dissipated away from ostensive substantive objectives. This occurs by research promoters‟ organizational discourse efforts to favourably shape power relating and other qualities of interaction of improvement initiatives. These efforts restrict the emergence of learning about the promoted changes.

The thesis seeks to interrogate historically the relationship between multinational healthcare service companies and states in the pursuit of market-oriented reforms for healthcare. It constitutes a critical reading of the idea of globalisation as a concept with substantive explanatory value to analyse the causal role of multinational service firms in a commercial transformation in national healthcare service sectors. It analyses the development and expansion of commercial (for-profit) healthcare service provision and financing in the healthcare systems of OECD countries. The hospital and health insurance sectors in the US and UK are analysed as case studies towards developing this critical reading from a more specific national setting. The thesis contributes to developing a framework for analysing the emergence of an international market for trade in healthcare services, which is a recently emerging area of research in the social sciences. As such, it uses an interdisciplinary approach, utilising insights from health policy and international political economy. The research entails a longitudinal study of secondary and primary sources of qualitative data broadly covering the period 1975-2005. I have also made extensive use of quantitative data to illustrate key economic trends that are relevant to the changes in the particular healthcare services sectors analysed. The research finds a substantive shift in the mixed economy of healthcare in which commercial healthcare service provision and financing are increasing. However, while the internationalisation of healthcare service firms is a key element in helping to drive some of this change, the changes are ultimately highly dependent on state-level decision making and regulation. In this context, the thesis argues that globalisation presents an inadequate and potentially misleading conceptual framework for analysing these changes without a historical grounding in the particular developments of national and international markets for healthcare services.