| 1. |
- Wang, Zhaoming, et al.
(författare)
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Imputation and subset-based association analysis across different cancer types identifies multiple independent risk loci in the TERT-CLPTM1L region on chromosome 5p15.33
- 2014
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Ingår i: Human Molecular Genetics. - : Oxford University Press (OUP). - 0964-6906 .- 1460-2083. ; 23:24, s. 6616-6633
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Tidskriftsartikel (refereegranskat)abstract
- Genome-wide association studies (GWAS) have mapped risk alleles for at least 10 distinct cancers to a small region of 63 000 bp on chromosome 5p15.33. This region harbors the TERT and CLPTM1L genes; the former encodes the catalytic subunit of telomerase reverse transcriptase and the latter may play a role in apoptosis. To investigate further the genetic architecture of common susceptibility alleles in this region, we conducted an agnostic subset-based meta-analysis (association analysis based on subsets) across six distinct cancers in 34 248 cases and 45 036 controls. Based on sequential conditional analysis, we identified as many as six independent risk loci marked by common single-nucleotide polymorphisms: five in the TERT gene (Region 1: rs7726159, P = 2.10 × 10(-39); Region 3: rs2853677, P = 3.30 × 10(-36) and PConditional = 2.36 × 10(-8); Region 4: rs2736098, P = 3.87 × 10(-12) and PConditional = 5.19 × 10(-6), Region 5: rs13172201, P = 0.041 and PConditional = 2.04 × 10(-6); and Region 6: rs10069690, P = 7.49 × 10(-15) and PConditional = 5.35 × 10(-7)) and one in the neighboring CLPTM1L gene (Region 2: rs451360; P = 1.90 × 10(-18) and PConditional = 7.06 × 10(-16)). Between three and five cancers mapped to each independent locus with both risk-enhancing and protective effects. Allele-specific effects on DNA methylation were seen for a subset of risk loci, indicating that methylation and subsequent effects on gene expression may contribute to the biology of risk variants on 5p15.33. Our results provide strong support for extensive pleiotropy across this region of 5p15.33, to an extent not previously observed in other cancer susceptibility loci.
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| 2. |
- Sampson, Joshua N., et al.
(författare)
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Analysis of Heritability and Shared Heritability Based on Genome-Wide Association Studies for 13 Cancer Types
- 2015
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Ingår i: Journal of the National Cancer Institute. - : Oxford University Press (OUP). - 0027-8874 .- 1460-2105. ; 107:12
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Tidskriftsartikel (refereegranskat)abstract
- Background: Studies of related individuals have consistently demonstrated notable familial aggregation of cancer. We aim to estimate the heritability and genetic correlation attributable to the additive effects of common single-nucleotide polymorphisms (SNPs) for cancer at 13 anatomical sites. Methods: Between 2007 and 2014, the US National Cancer Institute has generated data from genome-wide association studies (GWAS) for 49 492 cancer case patients and 34 131 control patients. We apply novel mixed model methodology (GCTA) to this GWAS data to estimate the heritability of individual cancers, as well as the proportion of heritability attributable to cigarette smoking in smoking-related cancers, and the genetic correlation between pairs of cancers. Results: GWAS heritability was statistically significant at nearly all sites, with the estimates of array-based heritability, h(l)(2), on the liability threshold (LT) scale ranging from 0.05 to 0.38. Estimating the combined heritability of multiple smoking characteristics, we calculate that at least 24% (95% confidence interval [CI] = 14% to 37%) and 7% (95% CI = 4% to 11%) of the heritability for lung and bladder cancer, respectively, can be attributed to genetic determinants of smoking. Most pairs of cancers studied did not show evidence of strong genetic correlation. We found only four pairs of cancers with marginally statistically significant correlations, specifically kidney and testes (rho = 0.73, SE = 0.28), diffuse large B-cell lymphoma (DLBCL) and pediatric osteosarcoma (rho = 0.53, SE = 0.21), DLBCL and chronic lymphocytic leukemia (CLL) (rho = 0.51, SE = 0.18), and bladder and lung (rho = 0.35, SE = 0.14). Correlation analysis also indicates that the genetic architecture of lung cancer differs between a smoking population of European ancestry and a nonsmoking Asian population, allowing for the possibility that the genetic etiology for the same disease can vary by population and environmental exposures. Conclusion: Our results provide important insights into the genetic architecture of cancers and suggest new avenues for investigation.
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| 3. |
- Jacobs, Kevin B, et al.
(författare)
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Detectable clonal mosaicism and its relationship to aging and cancer.
- 2012
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Ingår i: Nature Genetics. - New York : Nature Publishing Group. - 1061-4036 .- 1546-1718. ; 44:6, s. 651-658
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Tidskriftsartikel (refereegranskat)abstract
- In an analysis of 31,717 cancer cases and 26,136 cancer-free controls from 13 genome-wide association studies, we observed large chromosomal abnormalities in a subset of clones in DNA obtained from blood or buccal samples. We observed mosaic abnormalities, either aneuploidy or copy-neutral loss of heterozygosity, of >2 Mb in size in autosomes of 517 individuals (0.89%), with abnormal cell proportions of between 7% and 95%. In cancer-free individuals, frequency increased with age, from 0.23% under 50 years to 1.91% between 75 and 79 years (P = 4.8 × 10(-8)). Mosaic abnormalities were more frequent in individuals with solid tumors (0.97% versus 0.74% in cancer-free individuals; odds ratio (OR) = 1.25; P = 0.016), with stronger association with cases who had DNA collected before diagnosis or treatment (OR = 1.45; P = 0.0005). Detectable mosaicism was also more common in individuals for whom DNA was collected at least 1 year before diagnosis with leukemia compared to cancer-free individuals (OR = 35.4; P = 3.8 × 10(-11)). These findings underscore the time-dependent nature of somatic events in the etiology of cancer and potentially other late-onset diseases.
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| 4. |
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| 5. |
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| 6. |
- Algurén, Beatrix, 1977, et al.
(författare)
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Quality indicators and their regular use in clinical practice: results from a survey among users of two cardiovascular National Registries in Sweden
- 2018
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Ingår i: International Journal for Quality in Health Care. - : Oxford University Press (OUP). - 1353-4505 .- 1464-3677. ; 30:10, s. 786-792
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Tidskriftsartikel (refereegranskat)abstract
- Objective To examine the regular use of quality indicators from Swedish cardiovascular National Quality Registries (NQRs) by clinical staff; particularly differences in use between the two NQRs and between nurses and physicians. Design Cross-sectional online survey study. Setting Two Swedish cardiovascular NQRs: (a) Swedish Heart Failure Registry and (b) Swedeheart. Participants Clinicians (n =185; 70% nurses, 26% physicians) via the NQRs’ email networks. Main Outcome Measures Frequency of NQR use for (a) producing healthcare activity statistics; (b) comparing results between similar departments; (c) sharing results with colleagues; (d) identifying areas for quality improvement (QI); (e) surveilling the impact of QI efforts; (f) monitoring effects of implementation of new treatment methods; (g) doing research and (h) educating and informing healthcare professionals and patients. Results Median use of NQRs was 10 times a year (25th and 75th percentiles range: 3–23 times/year). Quality indicators from the NQRs were used mainly for producing healthcare activity statistics. Median use of Swedeheart was six times greater than Swedish Heart Failure Registry (SwedeHF; P < 0.000). Physicians used the NQRs more than twice as often as nurses (18 vs. 7.5 times/year; P < 0.000) and perceived NQR work more often as meaningful. Around twice as many Swedeheart users had the role to participate in data analysis and in QI efforts compared to SwedeHF users. Conclusions Most respondents used quality indicators from the two cardiovascular NQRs infrequently (<3 times/year). The results indicate that linking registration of quality indicators to using them for QI activities increases their routine use and makes them meaningful tools for professionals.
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| 7. |
- Andersson, Ann-Christine, et al.
(författare)
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Challenges to Improve Inter-Professional Care and Service Collaboration for People Living With Psychiatric Disabilities in Ordinary Housing.
- 2016
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Ingår i: Quality Management in Health Care. - : Lippincott Williams and Wilkins Ltd.. - 1063-8628 .- 1550-5154. ; 25:1, s. 44-52
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Tidskriftsartikel (refereegranskat)abstract
- The aim of this study was to describe health care- and social service professionals' experiences of a quality-improvement program implemented in the south of Sweden. The focus of the program was to develop inter-professional collaboration to improve care and service to people with psychiatric disabilities in ordinary housing. Focus group interviews and a thematic analysis were used. The result was captured as themes along steps in process. (I) Entering the quality-improvement program: Lack of information about the program, The challenge of getting started, and Approaching the resources reluctantly. (II) Doing the practice-based improvement work: Facing unprepared workplaces, and Doing twice the work. (III) Looking back-evaluation over 1 year: Balancing theoretical knowledge with practical training, and Considering profound knowledge as an integral part of work. The improvement process in clinical practice was found to be both time and energy consuming, yet worth the effort. The findings also indicate that collaboration across organizational boundaries was broadened, and the care and service delivery were improved.
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| 8. |
- Andersson, Ann-Christine, et al.
(författare)
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Erfarenheter från lärandeseminarier : Barn som anhöriga: Reflektioner från följeforskning
- 2016
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Rapport (övrigt vetenskapligt/konstnärligt)abstract
- Under 2015 genomfördes nationella lärandeseminarier för att stärka implementeringen av den lag som ger barn rätt till information, råd och stöd när en förälder plötsligt avlider, är svårt sjuk eller skadad (HSL 2g §). Satsningen var ett förbättringsarbete som omfattade sex landsting som med hjälp av en projektledning träffades vid fyra tillfällen från januari till september. Två av träffarna skedde i Stockholm och två var digitala. Under våren 2015 knöts följeforskning till arbetet med frågeställningar om vilka resultat förbättringsarbetet gav och hur deltagarna upplevde arbetssättet. Syftet var att lyfta fram vad satsningen gav samt att lära inför framtida satsningar – är lärandeseminarier ett användbart arbetssätt för nationella implementeringssatsningar?Rapporten visar att lärandeseminarier tycks vara en användbar form. Teamen kan redovisa att de uppnått många av de mål som de föresatte sig under projekttiden. Det handlade om kartläggning av kunskapsläge och strukturer, kompetensutveckling samt utveckling av rutiner och material. Teamen uppskattade också att få delta i ett nationellt sammanhang som gav inspiration. Samtidigt framkom det önskemål om fortsatt och ännu mer handfast stöd i fortsatt implementering i klinisk verksamhet.
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| 9. |
- Andersson, Ann-Christine, 1968-, et al.
(författare)
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Identification of children as relatives with a systematic approach: a prerequisite in order to offer advice and support
- 2018
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Ingår i: Quality Management in Health Care. - : Wolters Kluwer. - 1063-8628 .- 1550-5154. ; 27:3, s. 172-177
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Tidskriftsartikel (refereegranskat)abstract
- The purpose of this study was to elucidate conditions at all system levels in a specific health care service to develop practices for identification of children as relatives. An interactive research approach with the intention to create mutual learning between practice and research was used. The participating health care service cared for both clinic in- and outpatients with psychiatric disorders. Health care professionals from different system levels (micro, meso, macro) participated, representing different professions. At the first project meeting, it was obvious that there was no systematic approach to identify children as relatives. At the micro level, activities such as a pilot survey and an open house activity were carried out. At the meso level, it was discussed how to better support collaboration between units. At the management (macro) level, it was decided that all units should appoint at least one child agent, with the aim to increase collaboration throughout the whole health care service. To change focus, in this case from only parents to inclusion of children, is an important challenge faced by health care services when forced to incorporate new policies and regulations. The new regulations contribute to increased complexity in already complex organizations. This study highlights that such challenges are underestimated.
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| 10. |
- Andersson, Ann-Christine, 1968-, et al.
(författare)
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Learning through networking in healthcare and welfare : The use of a breakthrough collaborative in the Swedish context
- 2020
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Ingår i: International Journal of Healthcare Management. - : Maney Publishing. - 2047-9700 .- 2047-9719. ; 13:3, s. 236-244
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Tidskriftsartikel (refereegranskat)abstract
- Breakthrough Collaborative (BC) aims at learning through networking, mainly at micro level, and is used as a tool to improve care and welfare organizations. The aim of this study was to explore and illuminate the challenges when applying BC model at meso and macro level. In 2010, the Swedish Health and Medical Services Act stated the responsibility of healthcare professionals to consider children’s needs as relatives. This study uses an interactive collaborative research model. To support healthcare organizations in the implementation of the regulation, county councils/regions in Sweden were invited to take part in a BC during 2015. Six teams from different county councils/regions participated. Team members were interviewed several times during the project time. Data were analyzed with an explorative and descriptive qualitative content analysis. The result illuminates the challenges faced when applying BC at meso and macro level. Most challenges concern preparation, support structures and system connections. There are similarities with the challenges met at micro level when BC is used at meso and macro level. But it seems even more important to consider how the team is constituted at meso and macro level to make use of the learnings and achieve long-term impact in the home organization.
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| 11. |
- Andersson, Ann-Christine, 1968-, et al.
(författare)
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Rapport om utvärdering av IVO:s lärande tillsyn
- 2018
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Rapport (övrigt vetenskapligt/konstnärligt)abstract
- Inspektionen för vård och omsorg (IVO) har i sin tillsynspolicy lagt fokus på att främja lärande för att stödja utvecklingen av god kvalitet och säkerhet i vård och omsorg. Under 2017 har IVO givit Jönköping Academy for Improvement of Health and Welfare vid Jönköping University i uppdrag att utvärdera tillämpning av lärande tillsyn. Syftet med denna studie var att belysa om, och om möjligt hur, IVO:s tillsyn kan stödja verksamhetsutveckling och förbättring i de tillsynade verksamheter. Det finns många teoribildningar kring lärande och kvalitetsutveckling. Denna rapport tar utgångspunkt i teorier om organisatoriskt lärande, samskapande och förbättringskunskap och belyser vad som kan bidra, och i så fall hur, till en ömsesidig tillit som leder till ett fördjupat lärande som grund för förbättring.Studien omfattar två tillsyner, där deltagarna bestod av personal från de berörda verksamheterna, samt IVO-inspektörer från de regionala IVO avdelningar. Det empiriska materialet samlades in genom intervjuer och en observation. En dokumentgenomgång av relevanta IVO dokument skapade underlag för utvecklandet av studiens intervjuguider. Intervjuerna bandades, transkriberades och analyserades med en metod inspirerad av tematisk analys, som utmynnade i fem teman: (I) Förberedelse inför tillsyn; (II) Genomförande i verksamheten; (III) Resultat i verksamheten; (IV) Förutsättningar för lärande; och (V) Önskemål för ökat lärande. Samtliga teman innehåller både förhållanden som stödjer (främjar) och som försvårar (hindrar) lärande:Förberedelsearbetet ansågs inte bidra till en ökad tillit som förutsättning för lärande. Det uttrycktes en önskan om mer samskapande i förberedelsearbetet redan innan tillsynstillfälletDet framkom önskemål om att lärandet, som ett av målen med tillsynen, skulle lyftas tydligare i dialogen vid tillsynstillfället.Det uppfattades som svårt att peka på reella resultat i verksamheterna som direkt berodde på tillsynen, men det beskrevs ändå som viktigt att tillsynen fanns.Det fanns olika uppfattningar om hur IVO:s roll som tillsynsmyndighet påverkade lärandet. Ett större fokus på gemensam uppföljning skulle vara ett sätt att optimera lärandet både i verksamheterna och hos IVO:s inspektörer.Ett lärande skulle gynnas av en tydlig gemensam problembeskrivning, samt fortlöpande uppföljningar och delad kunskap, exempelvis genom goda exempel och dialogkonferenser.Generellt fanns en stor samstämmighet mellan IVO:s inspektörer och de verksamhetsföreträdare som intervjuats, men vissa skillnader framkom också. Rapporten avslutas med några avslutande reflektioner.
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| 12. |
- Andersson, Ann-Christine, et al.
(författare)
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Using quality improvement methods to implement guidelines to decrease the proportion of urinary retention in orthopaedic care
- 2017
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Ingår i: International Archives of Nursing and Health Care. - : ClinMed International Library. - 2469-5823. ; 3:1
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Tidskriftsartikel (refereegranskat)abstract
- In patients treated with indwelling urethral catheter (IUC), complications such as catheter associated urinary tract infections are common, while underuse of IUC may cause harmful urinary retention (UR). A quality improvement (QI) program called ‘Indwelling urethral catheter (IUC) - only when needed’ was developed in Jönköping County Council, Sweden, aiming at creating a new approach: hospital staff should be able to identify and manage patients with risk of UR, prevent UR or treat UR without delay, and only use urinary IUCs on appropriate indications. The aim of this study was to describe the process of application of the quality improvement program. The Model for Improvement was used, and process coaches were appointed in the participating units. Their training was based on clinical issues and facts about UR, IUCs, guidelines, QI methods and measurements. Data were collected through prospective and retrospective patient record reviews, and differences were analyzed by inferential statistics.Before the intervention, only two patients out of 296 were cared for following the guidelines perfectly. During the intervention, adherence to guidelines showed a rising trend, and reached a new stable level, with an average of 67% adherence to guidelines. A systematic improvement program supported by coaches and improvement tools can increase the adherence to new guidelines and incorporate them into local practice. This study also shows that adherence to guidelines can improve patient safety, in this case a decreased risk for and incidence of UR in an orthopaedic patient population.
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| 13. |
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| 14. |
- Gremyr, Andreas, et al.
(författare)
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How a Point-of-Care Dashboard Facilitates Co-production of Health Care and Health for and with Individuals with Psychotic Disorders : A Mixed-methods Case Study
- 2022
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Ingår i: BMC Health Services Research. - : BioMed Central (BMC). - 1472-6963. ; 22
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundIndividuals with psychotic disorders experience widespread treatment failures and risk early death. Sweden’s largest department specializing in psychotic disorders sought to improve patients’ health by developing a point-of-care dashboard to support joint planning and co-production of care. The dashboard was tested for 18 months and included more than 400 patients at two outpatient clinics.MethodsThis study evaluates the dashboard by addressing two questions:Can differences in health-related outcome measures be attributed to the use of the dashboard?How did the case managers experience the accessibility, use, and usefulness of the dashboard for co-producing care with individuals with psychotic disorders? This mixed-method case study used both Patient-Reported Outcome Measures (PROM) and data from a focus group interview with case managers. Data collection and analysis were framed by the Clinical Adoption Meta Model (CAMM) phases: i) accessibility, ii) system use, iii) behavior, and iv) clinical outcomes. The PROM used was the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0), which assesses functional impairment and disability. Patients at clinics using the dashboard were matched with patients at clinics not using the dashboard. PROM data were compared using non-parametric statistics due to skewness in distribution. The focus group included five case managers who had experience using the dashboard with patients.ResultsCompared to patients from clinics that did not use the dashboard, patients from clinics that did use the dashboard improved significantly overall (p = 0.045) and in the domain self-care (p = 0.041). Focus group participants reported that the dashboard supported data feedback-informed care and a proactive stance related to changes in patients’ health. The dashboard helped users identify critical changes and enabled joint planning and evaluation.ConclusionDashboard use was related to better patient health (WHODAS scores) when compared with matched patients from clinics that did not use the dashboard. In addition, case managers had a positive experience using the dashboard. Dashboard use might have lowered the risk for missing critical changes in patients’ health while increasing the ability to proactively address needs. Future studies should investigate how to enhance patient co-production through use of supportive technologies.
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| 15. |
- Gremyr, Andreas
(författare)
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Improving health with and for individuals with schizophrenia using a learning health system approach : From idea to daily practice
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Psychotic disorders like schizophrenia have a typical onset in early adulthood with symptoms of hallucinations and disturbances of thought. Despite knowledge on what constitutes effective schizophrenia care, more than 70% of treatment attempts fail in Sweden, sometimes leading to early death. An appraisal of schizophrenia care shows a lack of ways to jointly plan and evaluate care, and an absence of a trustworthy theory-of-change. The Learning Health System (LHS) is a vision that has been translated into theories and models associated with improved outcomes for patients with other chronic conditions. The aim of this thesis is to enhance the understanding of the applicability of the LHS vision in the context of schizophrenia care, from the perspectives of both individuals and the health system in enabling coproduction of better health by addressing two research questions:i) How can improvement of health for individuals with schizophrenia and improvement of system performance be supported by coproduction in an LHS model?ii) Can an LHS-based intervention, i.e. the use of a point of care dashboard, contribute to better health for individuals with schizophrenia?Studying the existing published knowledge of LHS show that the concept has not yet been applied in mental healthcare settings but has potential to increase patient coproduction, continuous improvement and better health. Different forms of coproduction are supported in the most comprehensive LHS models and applications, ranging from dashboards at point of care to platforms that can help facilitate improvement initiatives.A case study, focused on studying the use and usefulness of a point-of-care dashboard at patient visits in outpatient care at the Department of Schizophrenia Spectrum Disorders at Sahlgrenska University Hospital in western Sweden. Use of the dashboard is associated with improved communication and health for patients. Assessment of the dashboard-project’s complexity using the Non-adoption, abandonment, scale-up, spread and sustainability complexity assessment tool (NASSS-CAT) was perceived as helpful in evaluating challenges and provided insight that can guide future development. An LHS model, that builds on both the reviewing of the literature and practical testing, is proposed.Further research is proposed in two areas, exploration of how dashboard initiatives can support coproduction and better health for individuals with complex chronic conditions and further development of LHS models by studying different LHS initiatives regarding system properties, forms of coproduction at play and effects on health outcomes for individuals and populations.
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| 16. |
- Gremyr, Andreas, et al.
(författare)
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The role of co-production in Learning Health Systems
- 2021
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Ingår i: International Journal for Quality in Health Care. - : Oxford University Press. - 1353-4505 .- 1464-3677. ; 33:Supplement 2, s. ii26-ii32
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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.
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| 17. |
- Gremyr, Andreas, et al.
(författare)
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Using Complexity Assessment to Inform the Development and Deployment of a Digital Dashboard for Schizophrenia Care: Case Study
- 2020
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Ingår i: Journal of Medical Internet Research. - : JMIR Publications Inc.. - 1438-8871. ; 22:4
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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.
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| 18. |
- Gäre, Klas, 1948-, et al.
(författare)
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Evidence informed healthcare improvement : Design and evaluation
- 2023
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Rapport (övrigt vetenskapligt/konstnärligt)abstract
- Healthcare is in constant change with fast development in knowledge, new technology and varying needs and expectations from patients, citizens, management, and politicians. There is a challenge in balancing the involved actors´ focus, needs, preferences, and resources for healthcare improvement. Improvement of healthcare is an ongoing activity, sometimes managed and controlled, often not. A key ingredient for success is competence where the need for competence varies with perspectives of the improving actors. Actors in healthcare improvement are professionals, patients, politicians, management, citizens, researchers, research foundations and others. In this report a review of frameworks in healthcare improvement are presented together with management myths and questions around needs for healthcare improvement competence and capabilities currently on the agenda.Most improvement initiatives of some size have substantial parts of IT and have had so for a considerable time. This rather long experience of more and less successful IT implementation and use is transparent and useful in all kinds of healthcare improvement. One important issue in this report is what has real impact is the actual understanding and use of innovations and artefacts by healthcare actors in a broad sense for healthcare improvement (e.g., new clinical evidence, clinical guidelines, process changes, information systems and more). The aim in this report is to review frameworks which can be useful in healthcare improvement as well as in the study of healthcare improvement.Conclusions concern what is found to be important to study and understand healthcare improvement, considering the presented frameworks. Improvement of healthcare is present in all the frameworks but in different ways and what is emphasized concerning scope and focus. Improving healthcare take place in the interaction of at least two parts, one of which is healthcare professionals, and another is the patient/next-of-kin. Professionals and patient populations interact in processes of social networks and structures. Actors and context are useful concepts for understanding action (use) and its social contexts. The actual use of innovations is best understood in terms of integration into clinical activities and processes – actors’ interaction, coordination and communication activities and processes.Theoretical implications are that there is a need for more research concerning meso and macro perspectives on methods for healthcare improvement, and the interplay of perspectives regarding the understanding of improvement in healthcare. Of course, a challenge is that the objects of improvement are complex adaptive systems of healthcare is not easily to catch in simple rules. They are genuinely difficult both to change and evaluate changes. Practical implications of the report support design and contents of education programs in improvement of healthcare, in better understanding usefulness, practice, use, and experience base. To help the understanding of the need and usefulness of integrating different perspectives for successful healthcare improvement, e.g., micro, meso, and macro perspectives, use of mixed methods and more.
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| 19. |
- Janlöv, Ann-Christin, et al.
(författare)
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An improvement program as a way to intensify inter-professional collaboration in the community for people with mental disabilities : a follow-up
- 2016
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Ingår i: Issues in Mental Health Nursing. - : Taylor & Francis. - 0161-2840 .- 1096-4673. ; 37:12, s. 885-893
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Tidskriftsartikel (refereegranskat)abstract
- The aim of the study was to follow up inter-professional experiences of improvement work one year after a completed CII improvement program aiming at improve health care and social services for people with mental disabilities living in ordinary housing. This study was performed with a qualitative descriptive approach which employed six focus group interviews followed by a thematic analysis. The results revealed four themes; Self-awareness and insights; Behavior and actions in daily practice; Organizational cultures and subcultures; and Organizational practices, using Ken Wilbers' integral theory of four quadrants of realities as a holistic frame in the discussion.
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| 20. |
- Janlöv, Ann-Christin, et al.
(författare)
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An improvement program as a way to intensify inter-professional collaboration in the community for people with mental disabilities : a follow-up
- 2016
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Ingår i: Issues in Mental Health Nursing. - : Informa Healthcare. - 0161-2840 .- 1096-4673. ; 37:12, s. 885-893
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Tidskriftsartikel (refereegranskat)abstract
- The aim of the study was to follow up inter-professional experiences of improvement work one year after a completed CII improvement program aiming at improve health care and social services for people with mental disabilities living in ordinary housing. This study was performed with a qualitative descriptive approach which employed six focus group interviews followed by a thematic analysis. The results revealed four themes; Self-awareness and insights; Behavior and actions in daily practice; Organizational cultures and subcultures; and Organizational practices, using Ken Wilbers' integral theory of four quadrants of realities as a holistic frame in the discussion.
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| 21. |
- Kjellström, Sofia, 1970-, et al.
(författare)
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Exploring, measuring and enhancing the coproduction of health and well-being at the national, regional and local levels through comparative case studies in Sweden and England : the 'Samskapa' research programme protocol
- 2019
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Ingår i: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 9:7
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Tidskriftsartikel (refereegranskat)abstract
- INTRODUCTION:Cocreation, coproduction and codesign are advocated as effective ways of involving citizens in the design, management, provision and evaluation of health and social care services. Although numerous case studies describe the nature and level of coproduction in individual projects, there remain three significant gaps in the evidence base: (1) measures of coproduction processes and their outcomes, (2) mechanisms that enable inclusivity and reciprocity and (3) management systems and styles. By focusing on these issues, we aim to explore, enhance and measure the value of coproduction for improving the health and well-being of citizens.METHODS AND ANALYSIS:Nine ongoing coproduction projects form the core of an interactive research programme ('Samskapa') during a 6-year period (2019-2024). Six of these will take place in Sweden and three will be undertaken in England to enable knowledge exchange and cross-cultural comparison. The programme has a longitudinal case study design using both qualitative and quantitative methods. Cross-case analysis and a sensemaking process will generate relevant lessons both for those participating in the projects and researchers. Based on the findings, we will develop explanatory models and other outputs to increase the sustained value (and values) of future coproduction initiatives in these sectors.ETHICS AND DISSEMINATION:All necessary ethical approvals will be obtained from the regional Ethical Board in Sweden and from relevant authorities in England. All data and personal data will be handled in accordance with General Data Protection Regulations. Given the interactive nature of the research programme, knowledge dissemination to participants and stakeholders in the nine projects will be ongoing throughout the 6 years. External workshops-facilitated in collaboration with participating case studies and citizens-both during and at the end of the programme will provide an additional dissemination mechanism and involve health and social care practitioners, policymakers and third-sector organisations.
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| 22. |
- Nordin, Annika, et al.
(författare)
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Emergent programme theories of a national quality register - a longitudinal study in Swedish elderly care
- 2017
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Ingår i: Journal of Evaluation In Clinical Practice. - : John Wiley & Sons. - 1356-1294 .- 1365-2753. ; 23:6, s. 1329-1335
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Tidskriftsartikel (refereegranskat)abstract
- Rationale, aim, and objective: This study aimed to explore programme theories of a national quality register. A programme theory is a bundle of assumptions underpinning how and why an improvement initiative functions. The purpose was to examine and establish programme theories of a national quality register widely used in Sweden: Senior alert. The paper reports on how programme theories among change recipients emerge in relation to the established programme theory of the initiator.Methods: A qualitative approach and a longitudinal research design were used. To develop programme theories among change recipients, individual semistructured interviews were conducted. Three sets of interviews were conducted in the period of 2011 to 2013, totalling 22 interviews. In addition, 4 participant observations were made. To develop the initiator's programme theory, an iterative multistage collaboration process between the researchers and the initiator was used. A directed content analysis was used to analyse data.Findings: The initiator and change recipients described similar programme logics, but differing programme theories. With time, change recipients' programme theories emerged. Their programme theories converged and became more like the programme theory of the initiator.Conclusions: This study has demonstrated the importance of making both the initiator's and change recipients' programme theories explicit. To learn about conditions for improvement initiatives, comparisons between their programme theories are valuable. Differences in programme theories provide information on how initiators can customize support for their improvement initiatives. Similar programme logics can be underpinned by different programme theories, which can be deceptive. Programme theories emerge over time and need to be understood as dynamic phenomena.
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| 23. |
- Nordin, Annika
(författare)
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Expressions of shared interpretations - Intangible outcomes of continuous quality improvement efforts in health- and elderly care
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This thesis is anchored in improvement science, the research field of improvement. Improvement science describes and explores improvement in real-life contexts and “system of profound knowledge” (Deming, 2000) is a cornerstone. Performance measures, including their variation over time, are fundamental in the research and evaluation of outcomes of continuous quality improvement efforts (CQI efforts). However, the strong emphasis on operationalisations and measurements risks overshadowing other kinds of outcomes to which CQI efforts can lead.Research has shown that it is advantageous that those performing change have some kind of “sharedness”, e.g. shared cognitions, understanding, knowledge, interpretations or frame of reference. Despite the diversity of concepts and scientific studies, “sharedness” is mainly described as a prerequisite for change.This thesis addresses the call to broaden the scientific approach in improvement science and to take advantage of knowledge developed since Deming's time. It has a point of departure in the presumption that CQI efforts also lead to intangible outcomes; qualitative effects that are not easily captured with traditional performance measures. The concept “Expressions of shared interpretations” is used to study “sharedness” as intangible outcomes.The overall aim with this thesis is to explore Expressions of shared interpretations as intangible outcomes of CQI efforts from the perspective of clinical microsystems and healthcare professionals. The specific aims are to examine and establish how Expressions of shared interpretations develop, influence CQI efforts and change over time.Using a qualitative approach, this thesis comprises four papers, based on three studies. The empirical context is healthcare and welfare organizations providing care: hospital clinics in county councils/regions and nursing homes in municipalities. The studies include time periods from one to three and a half years, totalling six years. Expressions of shared interpretations inherently mean that the methods for data analysis need to be based on commonalities or patterns in the data. In this thesis three methods are used: qualitative content analysis, thematic analysis and directed content analysis. To examine time-related changes, year-to-year comparative analyses of themes and categories are done.To explore Expressions of shared interpretations, different theoretical frameworks are used: team cognitions (Paper 1), sensemaking theory (Paper 2), cognitive shifts (Paper 3) and programme theories (Paper 4).A directed content analysis is applied in a meta-analysis of the results presented in the four papers. The results indicate that Expressions of shared interpretations develop as intangible outcomes of CQI efforts and a general programme theory of CQI efforts in health- and elderly care is developed, illuminating how Expressions of shared interpretations change and influence CQI efforts. The general programme theory incorporates the PDSA cycle and describes the complex, interconnected and continuous development of Expressions of shared interpretations. It also illuminates how Expressions of shared interpretations provide change performers with momentum to engage in forthcoming PDSA cycles and how sensemaking is a central activity.CQI efforts in health- and elderly care are characterised by a “just get on with it” attitude, while in this thesis, thoughtfulness is emphasized. Existing improvement tools support collaboration, creativity and analysis of critical aspects of the operations, yet none of the improvement tools help change performers gain understanding of the CQI effort as such. To address this, this thesis suggests that change performers complement the use of improvement tools with an inquiring mind, that they collaborate in thoughtful dialogues and that leaders function as inquirers. To support this posture, the widely used Model for improvement is complemented with a fourth question: What are our assumptions? The question pinpoints the need to be thoughtful in every step of the CQI effort, not just in the analysis of the problem at hand.
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| 24. |
- Nordin, Annika, et al.
(författare)
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Prospective sensemaking of a national quality register in health care and elderly care
- 2018
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Ingår i: Leadership in Health Services. - : Emerald Group Publishing Limited. - 1751-1879 .- 1751-1887. ; 31:4, s. 398-408
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Tidskriftsartikel (refereegranskat)abstract
- PurposeThe purpose of this paper is to examine how external change agents (ECAs) engaged to disseminate a national quality register (NQR) called Senior alert nationwide in the Swedish health care and elderly care sectors interpret their work. To study this, sensemaking theories are used.Design/methodology/approachThis is a qualitative inductive interview study including eight ECAs. To analyze the data, a thematic analysis is carried out.FindingsWell-disseminated NQRs support health care organizations’ possibility to work with quality improvement and to improve care for patient groups. NQRs function as artifacts that can influence how health care professionals make sense of their work. In this paper, a typology depicting how the ECAs make sense of their dissemination work has been developed. The ECAs are engaged in prospective sensemaking. They describe their work as being about creating future good results, both for patients and affiliated organizations, and they can balance different quality aspects.Originality/valueThe number of NQRs increased markedly in Sweden and elsewhere, but there are few reports on how health care professionals working with the registers interpret their work. The use of ECAs to disseminate NQRs is a novel approach. This paper describes how the ECAs are engaged in prospective sensemaking – an under-researched perspective of the sensemaking theory.
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| 25. |
- Nordin, Annika, et al.
(författare)
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Sensemaking and cognitive shifts – learning from dissemination of a National Quality Register in health care and elderly care
- 2018
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Ingår i: Leadership in Health Services. - : Emerald Group Publishing Limited. - 1751-1879 .- 1751-1887. ; 31:4, s. 371-383
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Tidskriftsartikel (refereegranskat)abstract
- PurposeThe purpose of this study is to examine and establish how sensemaking develops among a group of external change agents (ECAs) engaged to disseminate a national quality register nationwide in Swedish health care and elderly care. To study the emergent sensemaking, the theoretical concept of cognitive shift has been used.Design/methodology/approachThe data collection method included individual semi-structured interviews, and two sets of interviews (initial sensemaking and renewed sensemaking) have been conducted. Based on a typology describing how ECAs interpret their work, structural analyses and comparisons of initial and renewed sensemaking are made and illuminated in spider diagrams. The data are then analyzed to search for cognitive shifts.FindingsThe ECAs’ sensemaking develops. Three cognitive shifts are identified, and a new kind of issue-related cognitive shift, the outcome-related cognitive shift, is suggested. For the ECAs to customize their work, they need to be aware of how they interpret their own work and how these interpretations develop over time.Originality/valueThe study takes a novel view of the interrelated concepts of sensemaking and sensegivers and points out the cognitive shifts as a helpful theoretical concept to study how sensemaking develops.
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