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| 2. |
- Arrelöv, Britt, 1953-
(författare)
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Towards Understanding of Determinants of Physicians’ Sick-listing Practice and their Interrelations : A Population-based Epidemiological Study
- 2003
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Physicians are supposed to act as sick-listing experts and they possess a role as gate-keepers to the social insurance system. Earlier studies have demonstrated variation between physicians and physician categories regarding sick-listing practice. In addition to the patient's disease and its severity, a number of other factors may be expected to influence sick-listing practice. Most earlier studies have focused on the patient's disease and his or her work place as cause for sickness absence.The aims of this study were to analyse variation of sick-listing practice between physician categories and the influence of physician characteristics on sick-listing practice, the influence of structure, organisation and remuneration of health care on physician sick-listing practice, the influence of local structural factors in the community, and the influence of a legislative change on physician sick-listing practice.The study was conducted as a cross-sectional epidemiological study of 57563 doctors’ certificates for sickness absence, received by 28 local social insurance offices in eight Swedish counties, during four months in 1995 and two months in 1996.Patient age, sex, and diagnostic group, issuing physician category, presence of a hospital in the municipality, municipality population size and county were all significantly and independently correlated to number of net days of sick-listing. Physician characteristics, such as age, sex and degree of specialisation were all associated with number of net days of sick-listing. Physicians working in general practice issued significantly shorter periods of sick-listing than the other physician categories. Reimbursement of general practice and participation in financial co-operation with social insurance were significantly correlated to length of sickness episode issued by general practitioners. A legislative change performed during the study period was associated with small effects in sick-listing practice.In conclusion, a number of factors other than disease and disease severity and other patient and physician linked factors were found to influence the variation of sick-listing practice. It appears that the closer the influencing factor was to the place were the decision was taken, i.e., the patient-physician consultation, the higher the impact on the decision appeared to be.
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| 3. |
- Carlfjord, Siw, 1959-
(författare)
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The Challenge of Changing Practice : Applying Theory in the Implementation of an Innovation in Swedish Primary Health Care
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The translation of new knowledge, such as research findings, new tools or methods into health care practice has gained increased interest in recent years. Important factors that determine implementation outcome have been identified, and models and checklists to be followed in planning as well as in carrying out an implementation process have been produced. However, there are still knowledge gaps regarding what approach should be used in which setting and for which problems. Primary health care (PHC) in Sweden is an area where there is a paucity of research regarding implementation of new methods into practice. The aim of the thesis was to apply theory in the study of the implementation of an innovation in Swedish PHC, and identify factors that influenced outcome.Methods: The study was performed using a quasi-experimental design, and included six PHC units, two from each one of three county councils in the southeast part of Sweden. A computer-based lifestyle intervention tool (CLT) developed to facilitate addressing lifestyle issues, was introduced at the units. Two different strategies were used for the introduction, both aiming to facilitate the process: a theory-based explicit strategy and an implicit strategy requiring a minimum of effort. Data collection was performed at baseline, and after six, nine and 24 months. Questionnaires were distributed to staff and managers, and data was also collected from the CLT database and county council registers. Implementation outcome was defined as the proportion of eligible patients being referred to the CLT, and was also measured in terms of Reach, Effectiveness, Adoption, Implementation and Maintenance according to the RE-AIM framework. Interviews were performed in order to explore experiences of the implementation process as perceived by staff and managers.Results: A positive organizational climate seemed to promote implementation. Organizational changes or staff shortages coinciding with the implementation process had a negative influence on outcome. The explicit implementation strategy seemed to be more effective than the implicit strategy in the short term, but the differences levelled out over time. The adopters’ perceptions of the implementation seemed to be influenced by the existing professional sub-cultures. Successful implementation was associated with positive expectations, perceptions of the innovation being compatible with existing routines and perceptions of relative advantage.Conclusions: The general conclusion is that when theory was applied in the implementation of a lifestyle intervention tool in Swedish PHC, factors related to the adopters and to the innovation seemed to be more important over time than the strategy used. Staff expectations, perceptions of the innovation’s relative advantage and potential compatibility with existing routines were found to be positively associated with implementation outcome, and other major organizational changes concurrent with implementation seemed to affect the outcome in a negative way. Values, beliefs and behaviour associated with the existing sub-cultures in PHC appeared to influence how the implementation of an innovation was perceived by managers and the different professionals.
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| 4. |
- Choi, Soki, et al.
(författare)
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Executive Management in Radical Change – The Case of Karolinska University Hospital Merger
- 2011
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Ingår i: Scandinavian Journal of Management. - : Elsevier BV. - 0956-5221 .- 1873-3387. ; 27:1, s. 11-23
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Tidskriftsartikel (refereegranskat)abstract
- Based on the merger of two Swedish university hospitals, this paper examines top management's work in implementing radical change initiatives. Our case confirms the limitations of the classic top-down approach to radical change in professional organizations. We also identify an important paradox: contrary to contemporary change literature prescription, initial managerial success seems to impair the change process further down the organization. A key finding is that when mergers are used as tools to effect radical change in politically ambiguous environment, management appears to be limited to initiate change and to take the role of the scapegoat due to inherent factors in the change process. By elucidating management's difficult role vis-à-vis multiple stakeholders, this paper contributes to one aspect of managerial agency discourse that is rarely discussed in detail.
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| 5. |
- Choi, Soki, et al.
(författare)
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Managing clinical integration : a comparative study in a merged university hospital
- 2012
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Ingår i: Journal of Health Organization & Management. - : Emerald. - 1477-7266 .- 1758-7247. ; 26:4, s. 486-507
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Tidskriftsartikel (refereegranskat)abstract
- Purpose - This paper explores critical factors that may obstruct or advance integration efforts initiated by the clinical management following a hospital merger. The aim is to increase our understanding of why clinical integration succeeds or fails.Design/methodology/approach - We compare two cases of integration efforts following the Karolinska University Hospital merger in Sweden. Each case represents two merged departments of the same specialty from each hospital site. We conducted 53 interviews with individuals representing various staff categories and collected documents to check data consistency.Findings - The study identifies three critical factors that seem to be instrumental for the process and outcome of integration efforts – clinical management’s 1) interpretation of the mandate, 2) design of the management constellation and 3) approach to integration. Obstructive factors are: a sole focus on the formal assignment from the top; individual leadership; and the use of a classic, planned, top-down management approach. Supportive factors are: paying attention to multiple stakeholders; shared leadership; and the use of an emergent, bottom-up management approach within planned boundaries. These findings are basically consistent with the literature’s prescriptions for managing professional organisations.Practical implications - Managers need to understand that public healthcare organisations are based on multiple logics that need to be handled in a balanced way if clinical integration is to be achieved – especially the tension between managerialism and professionalism.Originality/value - By focusing on the merger consequences for clinical units, this paper addresses an important gap in the healthcare merger literature.
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| 6. |
- Granström, Emma, et al.
(författare)
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Digital tools as promoters for person-centered care practices in chronic care? : Healthcare professionals' experiences from rheumatology care
- 2020
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Ingår i: BMC Health Services Research. - : BioMed Central. - 1472-6963. ; 20:1
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Person-centered care (PCC) emphasize the importance of supporting individuals' involvement in care provided and self-care. PCC has become more important in chronic care as the number of people living with chronic conditions is increasing due to the demographic changes. Digital tools have potential to support interaction between patients and healthcare providers, but empirical examples of how to achieve PCC in chronic care and the role of digital tools in this process is limited. The aim of this study was to investigate strategies to achieve PCC used by the healthcare professionals at an outpatient Rheumatology clinic (RC), the strategies' relation to digital tools, and the perceived impact of the strategies on healthcare professionals and patients.METHODS: A single case study design was used. The qualitative data consisted of 14 semi-structured interviews and staff meeting minutes, covering the time period 2017-2019. The data were analyzed using conventional content analysis, complemented with document analyses.RESULTS: Ten strategies on two levels to operationalize PCC, and three categories of perceived impact were identified. On the individual patient level strategies involved several digital tools focusing on flexible access to care, mutual information sharing and the distribution of initiatives, tasks, and responsibilities from provider to patients. On the unit level, strategies concerned involving patient representatives and individual patients in development of digital services and work practices. The roles of both professionals and patients were affected and the importance of behavioral and cultural change became clear.CONCLUSIONS: By providing an empirical example from chronic care the study contributes to the knowledge on strategies for achieving PCC, how digital tools and work practices interact, and how they can affect healthcare staff, patients and the unit. A conclusion is that the use of the digital tools, spanning over different dimensions of engagement, facilitated the healthcare professionals' interaction with patients and the patients' involvement in their own care. Digital tools complemented, rather than replaced, care practices.
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| 7. |
- Granström, Emma, et al.
(författare)
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Enhancing policy implementation to improve healthcare practices : The role and strategies of hybrid national-local support structures
- 2018
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Ingår i: International Journal of Health Planning and Management. - : John Wiley & Sons. - 0749-6753 .- 1099-1751. ; 33:4, s. E1262-E1278
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Tidskriftsartikel (refereegranskat)abstract
- Background In this study, we followed a national initiative to enhance the use of quality indicators gathered in national quality registries (NQRs) for improvement of clinical practices in Swedish healthcare, more specifically by investigating the support strategies of regional support centers with national and local missions. The aim was to increase knowledge on the role, challenges, and strategies of support structures with mixed and complex missions in the healthcare system. Methods Documents and 25 semistructured interviews with staff at 6 regional support centers, ie, quality registry centers, formed this multiple case study. Data were analyzed using conventional content analysis. Results The centers' strategies varied from developing the NQRs to become more suitable for improvement to supporting healthcare's use of NQRs, from the use of task to process-oriented support strategies, and from taking on national responsibilities to responding to local initiatives. All quality registry centers engaged in initiatives inspired by the Breakthrough Series approach. Some used preexisting change concepts or collaborated with local development units. A main challenge was to overcome a lack of formal mandate to act in the healthcare organizations they served. Conclusions Support functions with mixed and complex missions have to use a variation of strategies to reach relevant actors and achieve changes. This study provides valuable input for policy and decision-makers on the support strategies used and challenges of support functions with complex missions situated in-between national and local levels of the healthcare system, here denoted hybrid national-local support structures.
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| 8. |
- Mazzocato, Pamela, et al.
(författare)
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Complexity complicates lean: lessons from seven emergency services
- 2014
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Ingår i: Journal of Health Organization & Management. - : Emerald Group Publishing Limited. - 1477-7266 .- 1758-7247. ; 28:2, s. 266-288
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Tidskriftsartikel (refereegranskat)abstract
- Purpose – The purpose of this paper is to explain how different emergency services adopt and adapt the same hospital-wide lean-inspired intervention and how this is reflected in hospital process performance data.Design/methodology/approach – A multiple case study based on a realistic evaluation approach to identify mechanisms for how lean impacts process performance and services’ capability to learn and continually improve. Four years of process performance data were collected from seven emergency services at a Swedish University Hospital: ear, nose and throat (ENT) (two), pediatrics (two), gynecology, internal medicine, and surgery. Performance patterns were linked with qualitative data collected through realist interviews.Findings – The complexity of the care process influenced how improvement in access to care was achieved. For less complex care processes (ENT and gynecology), large and sustained improvement was mainly the result of a better match between capacity and demand. For medicine, surgery, and pediatrics, which exhibit greater care process complexity, sustainable, or continual improvement were constrained because the changes implemented were insufficient in addressing the higher degree of complexity.Originality/value – The variation in process performance and sustainability of results indicate that lean efforts should be carefully adapted to the complexity of the care process and to the educational commitment of healthcare organizations. Ultimately, the ability to adapt lean to a particular context of application depends on the development of routines that effectively support learning from daily practices.
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| 9. |
- Mazzocato, Pamela, et al.
(författare)
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How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren Childrens hospital, Stockholm, Sweden
- 2012
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Ingår i: BMC Health Services Research. - : BioMed Central. - 1472-6963. ; 12:28
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Tidskriftsartikel (refereegranskat)abstract
- Background: There is growing interest in applying lean thinking in healthcare, yet, there is still limited knowledge of how and why lean interventions succeed (or fail). To address this gap, this in-depth case study examines a lean-inspired intervention in a Swedish pediatric Accident and Emergency department. less thanbrgreater than less thanbrgreater thanMethods: We used a mixed methods explanatory single case study design. Hospital performance data were analyzed using analysis of variance (ANOVA) and statistical process control techniques to assess changes in performance one year before and two years after the intervention. We collected qualitative data through non-participant observations, semi-structured interviews, and internal documents to describe the process and content of the lean intervention. We then analyzed empirical findings using four theoretical lean principles (Spear and Bowen 1999) to understand how and why the intervention worked in its local context as well as to identify its strengths and weaknesses. less thanbrgreater than less thanbrgreater thanResults: Improvements in waiting and lead times (19-24%) were achieved and sustained in the two years following lean-inspired changes to employee roles, staffing and scheduling, communication and coordination, expertise, workspace layout, and problem solving. These changes resulted in improvement because they: (a) standardized work and reduced ambiguity, (b) connected people who were dependent on one another, (c) enhanced seamless, uninterrupted flow through the process, and (d) empowered staff to investigate problems and to develop countermeasures using a "scientific method". Contextual factors that may explain why not even greater improvement was achieved included: a mismatch between job tasks, licensing constraints, and competence; a perception of being monitored, and discomfort with inter-professional collaboration. less thanbrgreater than less thanbrgreater thanConclusions: Drawing on Spear and Bowens theoretical propositions, this study explains how a package of lean-like changes translated into better care process management. It adds new knowledge regarding how lean principles can be beneficially applied in healthcare and identifies changes to professional roles as a potential challenge when introducing lean thinking there. This knowledge may enable health care organizations and managers in other settings to configure their own lean program and to better understand the reasons behind leans success (or failure).
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| 10. |
- Mazzocato, Pamela, et al.
(författare)
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Lean thinking in healthcare: a realist review of the literature
- 2010
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Ingår i: Quality and Safety in Healthcare. - : BMJ Publishing Group. - 1475-3898 .- 1470-7934 .- 1475-3901. ; 19:5, s. 376-382
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Tidskriftsartikel (refereegranskat)abstract
- Objective To understand how lean thinking has been put into practice in healthcare and how it has worked. Design A realist literature review. Data sources The authors systematically searched for articles in Pub Med, Web of Science and Business Source Premier (January 1998 to February 2008) and then added articles through a snowball approach. Review methods The authors included empirical studies of lean thinking applications in healthcare and excluded those articles that did not influence patient care, or reported hybrid approaches. The authors conducted a thematic analysis based on data collected using an original abstraction form. Based on this, they articulated interactions between context, lean interventions, mechanisms and outcomes. Results The authors reviewed 33 articles and found a wide range of lean applications. The articles describe initial implementation stages and emphasise technical aspects. All articles report positive results. The authors found common contextual aspects which interact with different components of the lean interventions and trigger four different change mechanisms: understand processes to generate shared understanding; organise and design for effectiveness and efficiency; improve error detection to increase awareness and process reliability; and collaborate to systematically solve problems to enhance continual improvement. Conclusions Lean thinking has been applied successfully in a wide variety of healthcare settings. While lean theory emphasises a holistic view, most cases report narrower technical applications with limited organisational reach. To better realise the potential benefits, healthcare organisations need to directly involve senior management, work across functional divides, pursue value creation for patients and other customers, and nurture a long-term view of continual improvement.
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