| 1. |
- Eldh, Ann Catrine, 1965-, et al.
(författare)
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Depicting the interplay between organisational tiers in the use of a national quality registry to develop quality of care in Sweden
- 2015
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Ingår i: BMC Health Services Research. - : Springer Science and Business Media LLC. - 1472-6963. ; 15:1
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: With a pending need to identify potential means to improved quality of care, national quality registries (NQRs) are identified as a promising route. Yet, there is limited evidence with regards to what hinders and facilitates the NQR innovation, what signifies the contexts in which NQRs are applied and drive quality improvement. Supposedly, barriers and facilitators to NQR-driven quality improvement may be found in the healthcare context, in the politico-administrative context, as well as with an NQR itself. In this study, we investigated the potential variation with regards to if and how an NQR was applied by decision-makers and users in regions and clinical settings. The aim was to depict the interplay between the clinical and the politico-administrative tiers in the use of NQRs to develop quality of care, examining an established registry on stroke care as a case study.METHODS: We interviewed 44 individuals representing the clinical and the politico-administrative settings of 4 out of 21 regions strategically chosen for including stroke units representing a variety of outcomes in the NQR on stroke (Riksstroke) and a variety of settings. The transcribed interviews were analysed by applying The Consolidated Framework for Implementation Research (CFIR).RESULTS: In two regions, decision-makers and/or administrators had initiated healthcare process projects for stroke, engaging the health professionals in the local stroke units who contributed with, for example, local data from Riksstroke. The Riksstroke data was used for identifying improvement issues, for setting goals, and asserting that the stroke units achieved an equivalent standard of care and a certain level of quality of stroke care. Meanwhile, one region had more recently initiated such a project and the fourth region had no similar collaboration across tiers. Apart from these projects, there was limited joint communication across tiers and none that included all individuals and functions engaged in quality improvement with regards to stroke care.CONCLUSIONS: If NQRs are to provide for quality improvement and learning opportunities, advances must be made in the links between the structures and processes across all organisational tiers, including decision-makers, administrators and health professionals engaged in a particular healthcare process.
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| 2. |
- Eldh, Ann Catrine, et al.
(författare)
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Facilitators and barriers to applying a national quality registry for quality improvement in stroke care
- 2014
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Ingår i: BMC Health Services Research. - : Springer Science and Business Media LLC. - 1472-6963. ; 14, s. 354-
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Tidskriftsartikel (refereegranskat)abstract
- Background: National quality registries (NQRs) purportedly facilitate quality improvement, while neither the extent nor the mechanisms of such a relationship are fully known. The aim of this case study is to describe the experiences of local stakeholders to determine those elements that facilitate and hinder clinical quality improvement in relation to participation in a well-known and established NQR on stroke in Sweden. Methods: A strategic sample was drawn of 8 hospitals in 4 county councils, representing a variety of settings and outcomes according to the NQR's criteria. Semi-structured telephone interviews were conducted with 25 managers, physicians in charge of the Riks-Stroke, and registered nurses registering local data at the hospitals. Interviews, including aspects of barriers and facilitators within the NQR and the local context, were analysed with content analysis. Results: An NQR can provide vital aspects for facilitating evidence-based practice, for example, local data drawn from national guidelines which can be used for comparisons over time within the organisation or with other hospitals. Major effort is required to ensure that data entries are accurate and valid, and thus the trustworthiness of local data output competes with resources needed for everyday clinical stroke care and quality improvement initiatives. Local stakeholders with knowledge of and interest in both the medical area (in this case stroke) and quality improvement can apply the NQR data to effectively initiate, carry out, and evaluate quality improvement, if supported by managers and co-workers, a common stroke care process and an operational management system that embraces and engages with the NQR data. Conclusion: While quality registries are assumed to support adherence to evidence-based guidelines around the world, this study proposes that a NQR can facilitate improvement of care but neither the registry itself nor the reporting of data initiates quality improvement. Rather, the local and general evidence provided by the NQR must be considered relevant and must be applied in the local context. Further, the quality improvement process needs to be facilitated by stakeholders collaborating within and outside the context, who know how to initiate, perform, and evaluate quality improvement, and who have the resources to do so.
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| 3. |
- Eldh, Ann Catrine, 1965-, et al.
(författare)
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Factors facilitating a national quality registry to aid clinical quality improvement : findings of a national survey
- 2016
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Ingår i: BMJ Open. - : BMJ. - 2044-6055. ; 6:11
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Tidskriftsartikel (refereegranskat)abstract
- Objectives: While national quality registries (NQRs) are suggested to provide opportunities for systematic follow-up and learning opportunities, and thus clinical improvements, features in registries and contexts triggering such processes are not fully known. This study focuses on one of the world's largest stroke registries, the Swedish NQR Riksstroke, investigating what aspects of the registry and healthcare organisations facilitate or hinder the use of registry data in clinical quality improvement.Methods: Following particular qualitative studies, we performed a quantitative survey in an exploratory sequential design. The survey, including 50 items on context, processes and the registry, was sent to managers, physicians and nurses engaged in Riksstroke in all 72 Swedish stroke units. Altogether, 242 individuals were presented with the survey; 163 responded, representing all but two units. Data were analysed descriptively and through multiple linear regression.Results: A majority (88%) considered Riksstroke data to facilitate detection of stroke care improvement needs and acknowledged that their data motivated quality improvements (78%). The use of Riksstroke for quality improvement initiatives was associated (R2=0.76) with ‘Colleagues’ call for local results’ (p=<0.001), ‘Management Request of Registry data’ (p=<0.001), and it was said to be ‘Simple to explain the results to colleagues’ (p=0.02). Using stepwise regression, ‘Colleagues’ call for local results’ was identified as the most influential factor. Yet, while 73% reported that managers request registry data, only 39% reported that their colleagues call for the unit's Riksstroke results.Conclusions: While an NQR like Riksstroke demonstrates improvement needs and motivates stakeholders to make progress, local stroke care staff and managers need to engage to keep the momentum going in terms of applying registry data when planning, performing and evaluating quality initiatives.
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| 4. |
- Fredriksson, Mio, 1976-, et al.
(författare)
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A New Way of Thinking and Talking About Economy : Clinic Managers' Perspectives on the Sustainable Implementation of a Decommissioning Programme in Sweden
- 2023
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Ingår i: HEALTH SERVICES INSIGHTS. - : SAGE Publications. - 1178-6329. ; 16
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Tidskriftsartikel (refereegranskat)abstract
- Healthcare systems may run into economic problems that may require 'active' decommissioning by policy-makers and managers. The aim of this study was to investigate, from a sustainability perspective, the implementation of an extensive decommissioning programme in one of the Swedish regions. Interviews were performed with 26 clinic managers 3 years after initial implementation. Those were analysed inductively, and then discussed based on a model of potential influences on sustainability. Although the programme was only 'partly sustained', the result point to a sustained attention to the health system's poor economy, visible in a great effort by the clinics to maintain their budgets. The most important influences were intervention fit and modifications made at the clinic level (i. innovation characteristics), clinic and health system leadership (ii. context), champions (iii. capacity) and shared decision-making and relationship building (iv. processes and interactions). When implementing decommissioning, it is particularly important to engage managers responsible for the care of patients and clinic budgets from an early stage and to allow them to design approaches based on the staff's and managers' detailed knowledge of the situation at their clinics and of the disease area, that is, to achieve fit at the clinics. In this way, the decommissioning approaches can more likely get the character of quality improvement efforts, which increases sustainability and may lead to positive quality outcomes. Despite being unpopular, the study suggests that decommissioning can have positive effects as well, such as creating opportunities to make difficult but necessary changes and fostering increased collegial support during the centralisation of services.
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| 5. |
- Fredriksson, Mio, 1976-, et al.
(författare)
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Are data from national quality registries used in quality improvement at Swedish hospital clinics?
- 2017
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Ingår i: International Journal for Quality in Health Care. - : Oxford University Press (OUP). - 1353-4505 .- 1464-3677. ; 29:7, s. 909-915
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Tidskriftsartikel (refereegranskat)abstract
- To investigate the use of data from national quality registries (NQRs) in local quality improvement as well as purported key factors for effective clinical use in Sweden. Comparative descriptive: a web survey of all Swedish hospitals participating in three NQRs with different levels of development (certification level). Heads of the clinics and physician(s) at clinics participating in the Swedish Stroke Register (Riksstroke), the Swedish National Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) and the Swedish Lung Cancer Registry (NLCR). Individual and unit level use of NQRs in local quality improvement, and perceptions on data quality, organizational conditions and user motivation. Riksstroke data were reported as most extensively used at individual and unit levels ((x) over bar 17.97 of 24 and (x) over bar 27.06 of 35). Data quality and usefulness was considered high for the two most developed NQRs ((x) over bar 19.86 for Riksstroke and (x) over bar 19.89 for GallRiks of 25). Organizational conditions were estimated at the same level for Riksstroke and GallRiks ((x) over bar 12.90 and (x) over bar 13.28 of 20) while the least developed registry, the NLCR, had lower estimates (x 10.32). In Riksstroke, the managers requested registry data more often ((x) over bar 15.17 of 20). While there were significant differences between registries in key factors such as management interest, use of NQR data in local quality improvement seems rather prevalent, at least for Riksstroke. The link between the registry's level of development and factors important for routinization of innovations such as NQRs needs investigation.
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| 6. |
- Fredriksson, Mio, 1976-, et al.
(författare)
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Awareness and opinions on healthcare decommissioning in a Swedish region
- 2020
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Ingår i: Health Policy. - : Elsevier BV. - 0168-8510 .- 1872-6054. ; 124:9, s. 991-997
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Tidskriftsartikel (refereegranskat)abstract
- Decision-makers may have to decommission services as a response to budget deficits. The aim of this study was to investigate a case of decommissioning with regard to the public's awareness and opinions. The analysis of a survey in a Swedish region that begun the implementation of an extensive decommissioning programme in 2015 shows that the majority of respondents were well or very well informed about the programme (68 %). A large proportion of the respondents thought the decision-makers to a low or very low degree had adopted appropriate measures to solve the economic problems (43 %), but together more respondents were either indifferent (39.5 %) or positive (17.5 %). Regarding the level of satisfaction with the region's healthcare system, compared to prior to the decommissioning period, 30 % were less satisfied while together more were either indifferent (48 %) or had become more satisfied (22 %). The large share of indifferent responses opens up for various interpretations or framings of the programme outcomes. Trust in the regions' healthcare system nevertheless increased during the same period. Furthermore, self-assessed health as well as age and utilization seem to be associated with healthcare system satisfaction during decommissioning. This illustrates heterogeneity in the public's responses to decommissioning, which calls for further investigation.
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| 7. |
- Fredriksson, Mio, 1976-
(författare)
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Between Equity and Local Autonomy : A Governance Dilemma in Swedish Healthcare
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Both national equity in healthcare and the county councils’ local autonomy are important values supported by Swedish law. Politically it is a balancing act; how much freedom should the county councils have and to what extent should healthcare be equal throughout the country? The general aim of this dissertation, concerning political governance in Swedish healthcare, is to investigate the tensional values of national equity and local autonomy in the light of current trends in healthcare governance in Sweden. How is this tension manifested? Four studies are included in the dissertation. These studies show that the Swedish state is becoming more active in governing and regulating healthcare, for example by the use of informative governance and legislation, which increasingly rely on monitoring and evaluation of results that are made public. The findings show that the tension between national equity and local autonomy is manifested in increasing emphasis on national equity – or rather national equivalence – which is interpreted in terms of Swedish healthcare being recentralized. Delivery and financing of healthcare are still the responsibilities of the county councils. Planning and arranging – the setting of the regulatory framework – is increasingly taken over by the central state. Although power seems to be transferred from local level to central level, the county councils’ autonomy is only partially restricted, which means Swedish healthcare is still decentralized. However, if the recentralization process proceeds further, the county councils´ autonomy may be seriously challenged. Another challenge is to maintain or strengthen the procedures for democratic legitimacy through citizen participation at the local level. When local autonomy looses ground, it becomes more difficult to tailor healthcare according to local needs and conditions in the county councils, and decisions are taken at greater distance from the citizens.
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| 8. |
- Fredriksson, Mio, et al.
(författare)
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Caesarean section on maternal request : a qualitative study of conflicts related to shared decision-making and person-centred care in Sweden
- 2024
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Ingår i: Reproductive Health. - : BioMed Central (BMC). - 1742-4755. ; 21:1
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundToday, person-centred care is seen as a cornerstone of health policy and practice, but accommodating individual patient preferences can be challenging, for example involving caesarean section on maternal request (CSMR). The aim of this study was to explore Swedish health professionals' perspectives on CSMR and analyse them with regard to potential conflicts that may arise from person-centred care, specifically in relation to shared decision-making.MethodsA qualitative study using both inductive and deductive content analysis was conducted based on semi-structured interviews. It was based on a purposeful sampling of 12 health professionals: seven obstetricians, three midwives and two neonatologists working at different hospitals in southern and central Sweden. The interviews were recorded either in a telephone call or in a video conference call, and audio files were deleted after transcription.ResultsIn the interviews, twelve types of expressions (sub-categories) of five types of conflicts (categories) between shared decision-making and CSMR emerged. Most health professionals agreed in principle that women have the right to decide over their own body, but did not believe this included the right to choose surgery without medical indications (patient autonomy). The health professionals also expressed that they had to consider not only the woman's current preferences and health but also her future health, which could be negatively impacted by a CSMR (treatment quality and patient safety). Furthermore, the health professionals did not consider costs in the individual decision, but thought CSMR might lead to crowding-out effects (avoiding treatments that harm others). Although the health professionals emphasised that every CSMR request was addressed individually, they referred to different strategies for avoiding arbitrariness (equality and non-discrimination). Lastly, they described that CSMR entailed a multifaceted decision being individual yet collective, and the use of birth contracts in order to increase a woman's sense of security (an uncomplicated decision-making process).ConclusionsThe complex landscape for handling CSMR in Sweden, arising from a restrictive approach centred on collective and standardised solutions alongside a simultaneous shift towards person-centred care and individual decision-making, was evident in the health professionals' reasoning. Although most health professionals emphasised that the mode of delivery is ultimately a professional decision, they still strived towards shared decision-making through information and support. Given the different views on CSMR, it is of utmost importance for healthcare professionals and women to reach a consensus on how to address this issue and to discuss what patient autonomy and shared decision-making mean in this specific context. Person-centered care is today a widespread approach, but accommodating individual patient preferences can be challenging, for example involving caesarean section on maternal request (CSMR). This study examines Swedish health professionals' views on CSMR. Interviews with 12 health professionals reveal conflicts between CSMR and key aspects of person-centered care, in particular shared decision-making. While professionals acknowledge women's autonomy, they question CSMR without medical need. Concerns include for example treatment quality and patient safety, and avoiding treatments that harm others. The Swedish context, balancing collective solutions with individualized care, complicates decision-making. Unlike countries with more private healthcare, where CSMR support might be higher, Swedish health professionals emphasize shared decision-making despite viewing the mode of delivery as primarily a professional decision. This study sheds light on the challenges in integrating CSMR into person-centered care frameworks.
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| 9. |
- Fredriksson, Mio, et al.
(författare)
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Conflict and Compliance in Swedish Health Care Governance : Soft Law in the ‘Shadow of Hierarchy’
- 2012
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Ingår i: Scandinavian Political Studies. - : Wiley. - 0080-6757 .- 1467-9477. ; 35:1, s. 48-70
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Tidskriftsartikel (refereegranskat)abstract
- Soft law, or non-legislative modes of policy making, is becoming increasingly common today. The Nordic countries have a long tradition soft law, not least in central–local relations, where non-binding agreements are frequently used to coordinate policies. A key question springing from soft law theory is that of compliance. Why do independent actors comply if they are not formally obliged to do so, and what happens if they do not comply? This article addresses the question of how compliance can be achieved during policy conflict between actors at different governing levels by investigating a case of health care reform in Sweden. An important finding in the study is that compliance was reached ‘in the shadow of hierarchy’. The central government resorted to the threat of regular legislation to force the county councils to comply. This finding points to the fact that sanctions and the presence of a hierarchical order may play an important role even in soft law governance. The study also shows that an additional important reason that the voluntary agreement between the county councils and central government was honoured in the end by both parties can be attributed to the efforts of a mediating actor: the organization representing the county councils in their negotiations with the government. Finally, the study also illustrates how various forms of informal social pressures such as shaming, peer pressure and moral responsibility can help enforce local compliance in a case of open policy conflict. Arguably, all these compliance mechanisms also have relevance outside the Nordic setting.
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| 10. |
- Fredriksson, Mio, et al.
(författare)
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Consequences of a decentralized healthcare governance model : measuring regional authority support for patient choice in Sweden
- 2008
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Ingår i: Social Science and Medicine. - : Elsevier BV. - 0277-9536 .- 1873-5347. ; 67:2, s. 271-279
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Tidskriftsartikel (refereegranskat)abstract
- What are the implications of a decentralized model of healthcare governance? This case study on patient choice in Sweden is an attempt to shed light on this issue. Due to decentralization and constitutional rights of self-determination, the regional authorities in Sweden, called County Councils (CCs), have far-reaching rights to manage the healthcare sector. The fact that patient choice is considered to be a soft law or a soft governance regulation, opens it up to regional variation. To examine the CCs level of support of patient choice, an index is presented. The Patient Choice Index (PCI) shows that there is extensive variation among the CCs. To explain the causes of these variations, a number of hypotheses are tested. The analyses imply that ideology and economy, and more specifically the CCs' governing majorities and running net profits, are major explanations for the level of support. A number of conclusions can be drawn from the results of this study. In short, the CCs appear to act according to a local point of view, which means that there is no functioning national patient choice standard, and thus patients do not have equal access to healthcare and patients' rights are unevenly distributed. Furthermore, the CCs' financial conditions and governing majorities seem to undermine equivalent reform realization in a national context. In summary, the results of this study emphasize the conflict between regional self-governance and national equality, which is particularly visible in the decentralized Swedish healthcare model.
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