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Practice-based Improvements in Healthcare
Linköping University, Department of Management and Engineering, Quality Technology and Management . Linköping University, The Institute of Technology.
2010 (English)Licentiate thesis, comprehensive summary (Other academic)
Abstract [en]

A central problem for the healthcare sector today is how to manage change and improvements. In recent decades the county councils in Sweden have started various improvement initiatives and programs in order to improve their healthcare services. The improvement program of the Kalmar county council, which constitutes the empirical context for this thesis, is one of those initiatives.

The purpose of this thesis is to contribute to a broader understanding of large-scale improvement program in a healthcare setting. This is done by analyzing practitioner’s improvement ideas, describing participants in the improvement projects, revising and testing a survey to measure the development of improvement ideas and describing the improvement program from a theoretical perspective. The theoretical change model used looks at change from two opposing directions in six dimensions; Goals, Leadership, Focus, Process, Reward system and Use of consultants.

The aims of the county council improvement program are to become a learning organization, disseminate improvement methodologies and implement continuous quality improvements in the organization. All healthcare administrations and departments in the county council were invited to apply for funds to accomplish improvement projects. Another initiative invited staff teams to work with improvement ideas in a program with support from facilitators, using the breakthrough methodology. Now almost all ongoing developments, improvements, patient safety projects, manager and leader development initiatives are put together under the county council improvement program umbrella.

In the appended papers both qualitative and quantitative research approach were used. The first study (paper I) analyzed which types of improvement projects practitioners are engaged in using qualitative content analysis. Five main categories were identified: Organizational Process; Evidence and Quality; Competence Development; Process Technology; and Proactive Patient Work. Most common was a focus on organizational changes and process, while least frequent was proactive patient work. Besides these areas of focus, almost all aimed to increase patient safety and increase effectiveness and availability.

Paper II described the participants in two of the initiatives, the categorized improvement projects in paper I and the team members in the methodology guided improvement programs. Strong professions like physicians and nurses were well represented, but other staff groups were not as active. Managers were responsible for a majority of the projects. The gender perspective reflected the overall mix of employees in the county council.

Paper III described a revision and test of a Minnesota Innovation Survey (MIS) that will be used to follow and measure how quality improvement ideas develop and improve over time. Descriptive statistics were presented. The respondents were satisfied with their work and what they had accomplished. The most common comment was about time, not having enough time to work with the improvement idea and the difficulty of finding time because of regular tasks. This was the first test of the revised survey and the high use of the answer alternative “Do not know” showed that the survey did not fit the context very well in its present version.

Trying to connect the county council improvement program and the initiatives studied in papers I and II with the change model gave rise to some considerations. The county council improvement program has an effort to combine organizational changes and a culture that encourages continuous improvements. Top-down and bottom-up management approaches are used, through setting out strategies from above and at the same time encouraging practitioners to improve their day-to-day work. Whether this will be a successful way to implement and achieve a continuous improvement culture in the whole organization is one of the main issues remaining to find out in further studies.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2010. , 58 p.
Series
Linköping Studies in Science and Technology. Thesis, ISSN 0280-7971 ; 1455
National Category
Engineering and Technology
Identifiers
URN: urn:nbn:se:liu:diva-63717Local ID: LiU-TEK-Lic 2010:26ISBN: 978-91-7393-275-2 (print)OAI: oai:DiVA.org:liu-63717DiVA: diva2:382397
Presentation
2010-12-02, Arcas, Campus Valla, Linköpings universitet, Linköping, 10:00 (Swedish)
Opponent
Supervisors
Available from: 2010-12-30 Created: 2010-12-30 Last updated: 2011-01-03Bibliographically approved
List of papers
1. Practice-based improvement ideas in healthcare services
Open this publication in new window or tab >>Practice-based improvement ideas in healthcare services
2010 (English)Conference paper, Published paper (Other academic)
Abstract [en]

Objective. The present study will contribute to knowledge of how practitioners in a healthcare region engage in quality improvement initiatives. The focus is on individual placement needs, problems/issues and the ability to organize work on the development, implementation and institutionalization of ideas for the healthcare sector.

Design and settings. This study is based on the Kalmar county council Improvement Program. Healthcare departments and primary healthcare centers in the county council were invited to apply for money to accomplish improvement projects. The aim is to empirically identify and present the different kinds of practice-based improvement ideas developed in healthcare services. The 202 applications received from various healthcare departments and primary healthcare centers are analyzed using qualitative content analysis.

Outcome and Results. Five types of improvement projects were identified: Organizational Process; Evidence and Quality; Competence Development; Process Technology; and Proactive Patient Work. This illustrates the range of strategies that encourage letting individual units define their own improvement needs. In addition, a common characteristic among the studied project applications is to increase patient safety, effectiveness and availability of care, and education/training. Those intentions are found in many of the applications and therefore give the impression of being most important to caregivers today.

Conclusions. These projects point to the various problems and experiences healthcare professionals encounter in their day-to-day work. This paper provides valuable insights into the current state of improvement work in Swedish healthcare, and will serve as a foundation for further investigations in this quality program.

Keyword
Quality improvement initiatives, healthcare settings, improvement projects
National Category
Engineering and Technology
Identifiers
urn:nbn:se:liu:diva-63714 (URN)
Conference
12th International QMOD and Toulon-Verona Conference on Quality and Service Sciences (ICQSS) 27-29 August 2009, Verona, Italy
Available from: 2010-12-30 Created: 2010-12-30 Last updated: 2010-12-30
2. Who conducts quality improvement initiatives in healthcare services? An evaluation of an improvement program in acounty council in Sweden
Open this publication in new window or tab >>Who conducts quality improvement initiatives in healthcare services? An evaluation of an improvement program in acounty council in Sweden
2010 (English)Conference paper, Published paper (Other academic)
Abstract [en]

Purpose – The aim of this paper is to contribute to the knowledge of who engages in quality improvement initiatives and to describe whether staff professions or gender are relevant variables.

Design/methodology/approach – This paper contains an evaluation of the participants in a specific defined strategic improvement initiative program in one county council in southeast Sweden. The improvement program was initiated by county council politicians to encourage improvement initiatives and to spread improvement skills and knowledge in the organization. The program is driven both “top down” (teaching/convincing line managers to demand improvements) and “bottom up” through improvement programs using methodology to help teams identify, plan and adopt improvements in their daily work. Data was collected from special applications (called Free Applications, FA) and from participants in the education program (called Improvement Program, IP), both of which include information about profession and 2 gender. A content analysis was made. After the first categorization of which types of improvement projects practitioners engage in, further analysis of staff disciplines, professions (hierarchy) and gender was done. The results were compared to the overall structure of staff presence in the county council.

Findings – Changes in participation occurred over time. The FA (Free Applications) part (n=202) shows a higher share of leaders and managers (35%), but their participation in the IP (Improvement Program) (n=477) fluctuated (8-26%). Physicians were more represented in the FA than in the IP. The largest single group was nurses. Overall the gender perspective reflects the conditions of the county council, but in FA the representation of women was lower. Five types of improvement projects were identified: 1) Organizational process focus; 2) Evidence and quality; 3) Competence development; 4) Process Technology; and 5) Proactive patient work. Managers were most represented in the category “Organizational process”. The largest difference was seen in the category “Proactive patient work” with the highest occurrence among women (86%) and less among men (17%) and managers (21%). The patient as a contributor taking active part was not found in either the FA or the IP.

Research limitations/implications – This study shows differences in participation between free applications and methodology-guided programs when it comes to professions and gender in the country council improvement drive. It may be useful for further research regarding how to successfully work for and implement improvements and change in healthcare environments.

Practical implications – The study will discuss and contribute to further knowledge of whether profession, hierarchy and gender have an impact (obstructive or as an asset) in performing improvement work in healthcare settings.

Originality/value - Not much has been written about who is accomplishing quality improvements in terms of profession and gender. This paper provides some valuable insights into the differences between staff categories (professions) and gender in the improvement work in Swedish healthcare.

Keyword
quality improvement, improvement work, healthcare settings, nursing staff professions, gender
National Category
Engineering and Technology
Identifiers
urn:nbn:se:liu:diva-63715 (URN)
Conference
13th International QMOD Conference, August 30 - September 01, Cottbus, Germany
Available from: 2010-12-30 Created: 2010-12-30 Last updated: 2010-12-30
3. Adapting a survey to evaluate quality improvements in Swedish healthcare
Open this publication in new window or tab >>Adapting a survey to evaluate quality improvements in Swedish healthcare
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Quality improvement initiatives, a concept with origins in the manufacturing sector, have increased within the Swedish healthcare sector in recent decades. These efforts to improve quality can be seen as a response to demands for more cost-effectiveness and better medical results. However, studies have shown that less than 40% of these initiatives are successful (Olsson et al. 2007). The reason why specific improvement initiatives in healthcare fail or succeed is, therefore, a central question in studies of change. To be able to manage, improve and implement quality initiatives and improvements it is necessary to observe, measure and evaluate. Batalden and Davidoff (2007) point out that if there are no mechanisms to measure the changes, there is no way to know whether they actually lead to improvements. A more severe consequence, as stated by Sorian (2006), is that we sometimes accept an organizational system that not only fails to reward or encourage quality improvements but also sometimes punishes those who prioritize quality over cost-effectiveness. The need for more evidence about how to organize and manage new quality initiatives is identified as an important task within studies of healthcare improvement (Walshe 2009, Olsson et al. 2007).

National Category
Engineering and Technology
Identifiers
urn:nbn:se:liu:diva-63716 (URN)
Available from: 2010-12-30 Created: 2010-12-30 Last updated: 2010-12-30

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