1.
Lim, E. L. P., et al.
(författare)
How the Esther Network model for coproduction of person-centred health and social care was adopted and adapted in Singapore : a realist evaluation
2022
Ingår i: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 12:12
Tidskriftsartikel (refereegranskat) abstract
OBJECTIVES: The Esther Network (EN) model, a person-centred care innovation in Sweden, was adopted in Singapore to promote person-centredness and improve integration between health and social care practitioners. This realist evaluation aimed to explain its adoption and adaptation in Singapore. DESIGN: An organisational case study using a realist evaluation approach drawing on Greenhalgh et al (2004)'s Diffusion of Innovations in Service Organisations to guide data collection and analysis. Data collection included interviews with seven individuals and three focus groups (including stakeholders from the macrosystem, mesosystem and microsystem levels) about their experiences of EN in Singapore, and field notes from participant observations of EN activities. SETTING: SingHealth, a healthcare cluster serving a population of 1.37 million residents in Eastern Singapore. PARTICIPANTS: Policy makers (n=4), EN programme implementers (n=3), practitioners (n=6) and service users (n=7) participated in individual interviews or focus group discussions. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcome data from healthcare institutions (n=13) and community agencies (n=59) were included in document analysis. RESULTS: Singapore's ageing population and need to transition from a hospital-based model to a more sustainable community-based model provided an opportunity for change. The personalised nature and logic of the EN model resonated with leaders and led to collective adoption. Embedded cultural influences such as the need for order and hierarchical structures were both barriers to, and facilitators of, change. Coproduction between service users and practitioners in making care improvements deepened the relationships and commitments that held the network together. CONCLUSIONS: The enabling role of leaders (macrosystem level), the bridging role of practitioners (mesosystem level) and the unifying role of service users (microsystem level) all contributed to EN's success in Singapore. Understanding these roles helps us understand how staff at various levels can contribute to the adoption and adaptation of EN and similar complex innovations systemwide.
2.
Gremyr, Andreas, et al.
(författare)
Using Complexity Assessment to Inform the Development and Deployment of a Digital Dashboard for Schizophrenia Care: Case Study
2020
Ingår i: Journal of Medical Internet Research. - : JMIR Publications Inc.. - 1438-8871. ; 22:4
Tidskriftsartikel (refereegranskat) abstract
Background: Health care is becoming more complex. For an increasing number of individuals, interacting with health care means addressing more than just one illness or disorder, engaging in more than one treatment, and interacting with more than one care provider. Individuals with severe mental illnesses such as schizophrenia are disproportionately affected by this complexity. Characteristic symptoms can make it harder to establish and maintain relationships. Treatment failure is common even where there is access to effective treatments, increasing suicide risk. Knowledge of complex adaptive systems has been increasingly recognized as useful in understanding and developing health care. A complex adaptive system is a collection of interconnected agents with the freedom to act based on their own internalized rules, affecting each other. In a complex health care system, relevant feedback is crucial in enabling continuous learning and improvement on all levels. New technology has potential, but the failure rate of technology projects in health care is high, arguably due to complexity. The Nonadoption, Abandonment, and challenges to Scale-up, Spread, and Sustainability (NASSS) framework and complexity assessment tool (NASSS-CAT) have been developed specifically to help identify and manage complexity in technology-related development projects in health care. Objective: This study aimed to use a pilot version of the NASSS-CAT instrument to inform the development and deployment of a point-of-care dashboard supporting schizophrenia care in west Sweden. Specifically, we report on the complexity profile of the project, stakeholders' experiences with using NASSS-CAT, and practical implications. Methods: We used complexity assessment to structure data collection and feedback sessions with stakeholders, thereby informing an emergent approach to the development and deployment of the point-of-care dashboard. We also performed a thematic analysis, drawing on observations and documents related to stakeholders' use of the NASSS-CAT to describe their views on its usefulness. Results: Application of the NASSS framework revealed different types of complexity across multiple domains, including the condition, technology, value proposition, organizational tasks and pathways, and wider system. Stakeholders perceived the NASSS-CAT tool as useful in gaining perspective and new insights, covering areas that might otherwise have been neglected. Practical implications derived from feedback sessions with managers and developers are described. Conclusions: This case study shows how stakeholders can identify and plan to address complexities during the introduction of a technological solution. Our findings suggest that NASSS-CAT can bring participants a greater understanding of complexities in digitalization projects in general.
3.
Bergerum, Carolina, 1967-
(författare)
Patient and public involvement in hospital quality improvement interventions : the mechanisms, monitoring and management
2022
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
This dissertation focuses on the mechanisms, monitoring and management of patient and public involvement in hospital quality improvement (QI) interventions. Findings from a literature review generated an initial programme theory (PT) on active patient involvement in healthcare QI interventions (Paper 1). Empirical studies were also undertaken in order to describe what was actually happening in the hospital QI teams and what patients and professionals experience influence their joint involvement (Paper 2), and to compare hospital leaders’ and managers’ experiences of managing QI interventions involving patients and the public (Paper 3). Finally, it was studied how patient-reported measures stimulate patient involvement in QI interventions in practice (Paper 4). The research had a qualitative design. The approach was descriptive and comparative, and the studies were carried out prospectively. Data were collected in two hospital organisations in Sweden and in one hospital organisation in the Netherlands. Data collection methods were a literature search (Paper 1), interviews and field observations (Paper 2 and 3) and data collection meetings (Paper 4). Altogether, 93 team meetings and meetings between the team leaders and management were attended and a total of 20 days of study visits with different forms of meetings were made. Twelve patients, 12 healthcare professionals and 17 and 8 hospital leaders and managers, respectively, participated in the interviews and data collection meetings. Realist synthesis was used to formulate the initial PT (Paper 1). Constructivist grounded theory was used to analyse and describe what was happening in the QI teams and how it was experienced by the team members (Paper 2). To compare hospital leaders’ and managers’ different, contextual meanings in Sweden and the Netherlands, the reflexive thematic analysis informed by critical realism was used (Paper 3). To order, manage and map data from 31 examples of local QI interventions associated to patient-reported measures, the framework method was used (Paper 4). The results formulate a generic PT on the mechanisms, monitoring and management perspectives of co-produced QI interventions in hospital services where patients and the public are involved. The PT provides a hypothesis on the various mechanisms at play and outcomes obtained at the different levels of hospital organisations in the process. It is argued that focus should be on experiences, interaction, relationships and dialogue, integration of context, and the matching of hospital resources to patient and public demands and needs. Subsequently, the outcome will be the resources and reasoning interplay resulting in actions and processes, experiences and knowledge, ‘product’ benefits, emotions, judgements and motivations. Monitoring constitutes an important feedback loop to enable such learnings. The PT aligns the perspectives of the clinical microsystem, improvement science and the service-dominant logic, and has a potential to explain how patient and public involvement in QI interventions might work.
4.
Ulhassan, Waqar, et al.
(författare)
Does lean implementation interact with group functioning?
2014
Ingår i: Journal of Health Organization & Management. - : Emerald Group Publishing Ltd.. - 1477-7266 .- 1758-7247. ; 28:2, s. 196-213
Tidskriftsartikel (refereegranskat) abstract
PURPOSE: As healthcare often is studied in relation to operational rather than socio-technical aspects of Lean such as teamwork, the purpose of this paper is to explore how a Swedish hospital Lean intervention was related to changes in teamwork over time.DESIGN/METHODOLOGY/APPROACH: Teamwork was measured with the Group Development Questionnaire (GDQ) employee survey during Lean implementation at three units, in 2010 (n = 133) and 2011 (n = 130). Qualitative data including interviews, observations and document analysis were used to characterize the Lean implementation and context. The expected teamwork change patterns were compared with GDQ data through linear regression analysis.FINDINGS: At Ward-I, Lean implementation was successful and teamwork improved. At Ward-II, Lean was partially implemented and teamwork improved slightly, while both Lean and teamwork deteriorated at the emergency department (ED). The regression analysis was significant at ED (p = 0.02) and the Ward-II (p = 0.04), but not at Ward-I (p = 0.11).RESEARCH LIMITATIONS/IMPLICATIONS: Expected changes in teamwork informed by theory and qualitative data may make it possible to detect the results of a complex change.PRACTICAL IMPLICATIONS: Overall, Lean may have some impact on teamwork, if properly implemented. However, this impact may be more prominent in relation to structural and productivity issues of teamwork than group members' relational issues. Practitioners should note that, with groups struggling with initial stages of group functioning, Lean may be very challenging.ORIGINALITY/VALUE: This study focussed specifically on implications of Lean for nurse teamwork in a hospital setting using both qualitative and quantitative data. Importantly, the group functioning at the time when Lean is initiated may affect the implementation of Lean.
5.
Gremyr, Andreas, et al.
(författare)
The role of co-production in Learning Health Systems
2021
Ingår i: International Journal for Quality in Health Care. - : Oxford University Press. - 1353-4505 .- 1464-3677. ; 33:Supplement 2, s. ii26-ii32
Tidskriftsartikel (refereegranskat) abstract
BACKGROUND: Co-production of health is defined as 'the interdependent work of users and professionals who are creating, designing, producing, delivering, assessing, and evaluating the relationships and actions that contribute to the health of individuals and populations'. It can assume many forms and include multiple stakeholders in pursuit of continuous improvement, as in Learning Health Systems (LHSs). There is increasing interest in how the LHS concept allows integration of different knowledge domains to support and achieve better health. Even if definitions of LHSs include engaging users and their family as active participants in aspects of enabling better health for individuals and populations, LHS descriptions emphasize technological solutions, such as the use of information systems. Fewer LHS texts address how interpersonal interactions contribute to the design and improvement of healthcare services.OBJECTIVE: We examined the literature on LHS to clarify the role and contributions of co-production in LHS conceptualizations and applications.METHOD: First, we undertook a scoping review of LHS conceptualizations. Second, we compared those conceptualizations to the characteristics of LHSs first described by the US Institute of Medicine. Third, we examined the LHS conceptualizations to assess how they bring four types of value co-creation in public services into play: co-production, co-design, co-construction and co-innovation. These were used to describe core ideas, as principles, to guide development.RESULT: Among 17 identified LHS conceptualizations, 3 qualified as most comprehensive regarding fidelity to LHS characteristics and their use in multiple settings: (i) the Cincinnati Collaborative LHS Model, (ii) the Dartmouth Coproduction LHS Model and (iii) the Michigan Learning Cycle Model. These conceptualizations exhibit all four types of value co-creation, provide examples of how LHSs can harness co-production and are used to identify principles that can enhance value co-creation: (i) use a shared aim, (ii) navigate towards improved outcomes, (iii) tailor feedback with and for users, (iv) distribute leadership, (v) facilitate interactions, (vi) co-design services and (vii) support self-organization.CONCLUSIONS: The LHS conceptualizations have common features and harness co-production to generate value for individual patients as well as for health systems. They facilitate learning and improvement by integrating supportive technologies into the sociotechnical systems that make up healthcare. Further research on LHS applications in real-world complex settings is needed to unpack how LHSs are grown through coproduction and other types of value co-creation.
6.
7.
Ulhassan, W., et al.
(författare)
Antecedents and characteristics of lean thinking implementation in a swedish hospital : A case study
2013
Ingår i: Quality Management in Health Care. - 1063-8628 .- 1550-5154. ; 22:1, s. 48-61
Tidskriftsartikel (refereegranskat) abstract
Despite the reported success of Lean in health care settings, it is unclear why and how organizations adopt Lean and how Lean transforms work design and, in turn, affects employees' work. This study investigated a cardiology department's journey to adopt and adapt Lean. The investigation was focused on the rationale and evolution of the Lean adoption to illuminate how a department with a long quality improvement history arrived at the decision to introduce Lean, and how Lean influenced employees' daily work. This is an explanatory single case study based on semistructured interviews, nonparticipant observations, and document studies. Guided by a Lean model, we undertook manifest content analysis of the data. We found that previous improvement efforts may facilitate the introduction of Lean but may be less important when forecasting whether Lean will be sustained over time. Contextual factors seemed to influence both what Lean tools were implemented and how well the changes were sustained. For example, adoption of Lean varied with the degree to which staff saw a need for change. Work redesign and teamwork were found helpful to improve patient care whereas problem solving was found helpful in keeping the staff engaged and sustaining the results over time.
8.
Staines, Anthony, et al.
(författare)
Sustaining improvement? The 20-year Jönköping Quality Improvement program revisited
2015
Ingår i: Quality Management in Health Care. - 1063-8628 .- 1550-5154. ; 24:1, s. 21-37
Tidskriftsartikel (refereegranskat) abstract
Background: There is scarce evidence of organization-wide and sustained impact of quality improvement (QI) programsin health care. For 20 years, the Jönköping County Council’s (Sweden) ambitious program has attracted attention from practitioners and researchers alike. Methods: This is a follow-up case of a 2006 study of Jönköping’s improvement program, triangulating data from 20 semi-structured interviews, observation and secondary analysis of internal performance data. Results: In 2010, clinical outcomes had clearly improved in 2 departments (pediatrics, intensive care), while process improvements were evident in many departments. In an overall index of the 20 Swedish county councils’ performance, Jönköping had improved its ranking since 2006 to lead in 2010. Five key issues shaped Jönköping’s improvement program since 2006: a rigorously managed succession of chief executive officer; adept management of a changing external context; clear strategic direction relating to integration; a broadened conceptualization of “quality” (incorporating clinical effectiveness, patient safety, and patient experience); and continuing investment in QI education and research. Physician involvement in formal QI initiatives had increased since 2006 but remained a challenge in 2010. A new clinical information system was being deployed but had not yet met expectations. Conclusions: This study suggests that ambitious approaches can carry health care organizations beyond the sustainability threshold.
9.
Bergerum, Carolina, 1967-, et al.
(författare)
Organising and managing patient and public involvement to enhance quality improvement—Comparing a Swedish and a Dutch hospital
2022
Ingår i: Health Policy. - : Elsevier. - 0168-8510 .- 1872-6054. ; 126:7, s. 603-612
Tidskriftsartikel (refereegranskat) abstract
As co-production approaches to quality improvement (QI) gain importance in healthcare, hospital leaders and managers are expected to organise and support such efforts. Yet, patient and public involvement (PPI) can be challenging. Hospital organisations, emphasising knowledge and evidence domains, are characterised by operational-professional rather than patient-preference led management. Thus, PPI adds aspects of influence and responsibility that are not clearly defined or understood, with limited knowledge about how it can be orchestrated. This study, therefore, aimed to explore hospital leaders’ and managers’ contextualised experiences of managing QI efforts involving patients, by comparing two European hospitals.The study draws on field observations and qualitative interviews with a total of 21 QI team leaders and hospital managers in a Swedish and a Dutch hospital organisation. The data were subjected to thematic analysis with a critical realist approach.Results define seven themes, or areas, in which mechanisms are at play: (1) patient involvement in hospital QI, and (2) improving outcomes for patients, originating from the strategic view of achieving the hospital vision. Furthermore, (3) societal influence, (4) knowledge and evidence, (5) complexity, (6) individual resources, and (7) cooperation are areas in which mechanisms operate in the process. These areas are equally relevant for both hospitals, yet the mechanisms involved play out differently depending on contextual structure and local means of action.
10.
Holmqvist, Malin
(författare)
Together towards safer medication treatment for older persons
2023
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
This thesis focuses on promoting patient safety in older persons using medications. Given that medications can unintentionally harm patients, the World Health Organisation emphasises “Medication without harm” as a global patient safety challenge. Older persons are more likely to experience harm, and harm tends to occur when prescribing or monitoring medications. Co-production of healthcare with patients may reduce the risk of adverse events and can serve as a resource to promote safety in healthcare. Accordingly, this thesis aims to increase knowledge of how older persons and healthcare professionals can co-produce a solution for improved medication evaluation and thereby promote patient safety.Co-design is an approach that emphasises patient involvement in improvements of healthcare services. Therefore, the thesis was guided by the four phases of the Double Diamond framework for co-design. In the Discover phase experiences of medication evaluations were collected. Older persons were interviewed and data were analysed using qualitative inductive content analysis (Paper I). Critical Incident Technique was used to collect and analyse data from interviews with healthcare professionals in primary care (Paper II). In the Define and Develop phases, a case study design was used to explore older persons’, nurses’ and physicians’ design choices for a medication and their experiences of a remote co-design approach. Collected data were analysed using descriptive statistics along with directed content analysis (Paper III) and thematic analysis (Paper IV). In the Deliver phase, the feasibility of applying a medication plan in primary care, as well as the study methods used were examined. Data were analysed using descriptive statistics and inductive content analysis (Paper V).The findings showed that older persons reported having a responsibility to engage in their medication evaluations, even if some felt unable to do so or considered themselves unconcerned. Continuity of care and participation facilitate evaluations, but a comprehensive medication evaluation was lacking (Paper I). Healthcare professionals experienced that medication evaluations for older persons were influenced by working conditions and working in partnership. Actions taken to manage medication evaluations were carried out through working with a plan and collaborative problem-solving (Paper II). A medication plan, linked to the medication list, had to provide an added everyday value related to safety, effort and engagement, and support communication, continuity and interaction. Important functional requirements were to provide instant access, automation and attention, and content requirements were detailed information about the medication treatment (Paper III). Remote co-design can complement or substitute for face-to-face co-design sessions. The approach allowed an accessible environment, and sharing everyday life experiences created learning and awareness of possible risks and strategies that could promote patient safety (Paper IV). The feasibility of applying a medication plan, assessed as usability, varied and the participants’ experiences of usability concerned a de-prioritised medication plan, functionalities, individualisation and resources. The participants’ perceptions of patient safety addressed awareness and information, challenges beyond the medication plan and patient involvement (Paper V).Healthcare services could promote patient safety by involving older persons in medication evaluations and in co-designing patient safety solutions. However, implementing a medication plan in clinical practice is complex and requires continuous co-produced improvements at different levels within the healthcare system.
