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Quality Improvement in Healthcare: Experiences from a Swedish County Council Initiative
Linköping University, Department of Management and Engineering, Quality Technology and Management. Linköping University, The Institute of Technology.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Kvalitetsutveckling och förbättringsarbete i hälso- och sjukvården : Erfarenheter från ett svenskt landsting (Swedish)
Abstract [en]

Quality improvement (QI) has become an important issue in healthcare settings. A central question for many healthcare systems is how to manage improvement initiatives adequately. All county councils and regions managing healthcare in Sweden have started to work with QI at an organizational system level, to varied extents. The Kalmar county council improvement initiative constitutes the empirical basis of this thesis. The aim of the thesis is to provide knowledge about different aspects of a county-wide improvement initiative, and a broader understanding of factors and strategies that affect participation, management and outcomes. The overall study design is based on a case study.

The first two studies illuminate the practice-based (micro level), bottom-up perspective. Inductively five different areas (categories) were identified. Factors influencing participation in improvement initiatives provided the basis for the next study. The result showed that different staff categories were attracted by different initiatives. The next two studies illuminate the top-down (macro/meso) management perspective. Managers’ views of how patients can participate were investigated and a content analysis of the written answers was made. Four main areas (categories) were identified. A survey study investigated all of the county council managers’ experiences of the whole improvement initiative. Overall the managers thought that the improvement work was worth the effort. To evaluate the Breakthrough Collaborative program, a survey was developed and tested. This survey was used to investigate process and outcome of the BC program. The majority of the respondents were satisfied with their work, but wanted more time for teams to meet and work. To find out if an improvement program can affect outcome and contribute to sustainable changes, interviews were made with project applicants (n=202). Almost half (48%) of the projects were funded, and of those 51% were sustained. Of the rejected (not funded) projects, 28% were accomplished and sustained anyway. The results in this thesis cannot show that the “golden mean” exists, or that a single best way to manage changes and improvements in a healthcare organization has been found, but the way QI initiatives are organized does affect participation and outcomes. The intention, from the management topdown system level, encouraging staff and units and letting practice-based ideas develop at all system levels, can stimulate and facilitate improvement work.

Abstract [sv]

Kvalitetsutveckling och förbättringsarbete har blivit en viktig del av hälso- och sjukvården. En viktig fråga för landsting och regioner är hur kvalitetsutveckling skall drivas och styras. Syftet med detta arbete är att bidra till ökad kunskap om kvalitetsarbete i en hälso- och sjukvårdsorganisation, hur förbättringsinitiativ kan bedrivas och ledas, samt vilka faktorer som bidrar till ett framgångsrikt förbättringsarbete. Arbetet utgår empiriskt från en satsning på kvalitet och förbättringsarbete i landstinget i Kalmar län och är genomförd som en fallstudie (case).

Resultatet speglar vad ett landstings satsning på förbättringsarbete utifrån mikro-, macro- och mesonivå kan ge. De första två delstudierna speglar det praktikbaserade förbättringsarbetet utifrån ett praktikbaserat perspektiv. En innehållsanalys av projekten som ansökt om ekonomisk ersättning gjordes. Fem kategorier utformades, och projekten betonade områden som patientsäkerhet, förbättrad tillgänglighet och effektivitet. Studie II kartlade deltagande i förbättringsarbete utifrån två olika initiativ. Resultatet visade att de olika initiativen attraherade olika personalkategorier, men kunde samtidigt utesluta andra grupper. Chefernas åsikter om och erfarenheter av landstingets satsning undersöktes i studie III och IV. Cheferna var överlag positiva och nöjda med arbetet. Förbättringsprogrammen följdes med frågeformuläret Swedish Improvement Measurement Questionnaire (SIMQ) som testats och utvärderats. Resultatet visade att deltagarna är nöjda med arbetet med sin förbättringsidé, men att metodiken kan upplevas som svår. Dessutom efterlyste deltagarna mer tid för förbättringsarbete i vardagen. Till sist analyserades de projekt som sökt pengar för att driva förbättringsarbete. Nästan hälften av alla projekt (48%) hade fått ekonomisk ersättning, och av dessa hade fler än hälften (51%) uppnått sitt mål och infört en bestående förbättring. Den här avhandlingen påvisar vikten av att ledningen uppmärksammar, möjliggör och stimulerar förbättringsarbete. Genom att erbjuda flera olika sätt att bedriva förbättringsarbete ökar möjligheten för allas medverkan.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2013. , 115 p.
Series
Linköping Studies in Science and Technology. Dissertations, ISSN 0345-7524 ; 1505
Keyword [en]
Improvement work, Swedish healthcare organizations, Quality of Healthcare, Quality Management
Keyword [sv]
Förbättringsarbete, Kvalitetsutveckling, Svensk hälso- och sjukvårdsorganisation
National Category
Social Sciences Interdisciplinary
Identifiers
URN: urn:nbn:se:liu:diva-91255ISBN: 978-91-7519-664-0 (print)OAI: oai:DiVA.org:liu-91255DiVA: diva2:616665
Public defence
2013-05-23, Tem21, Hus T, Campus Valla, Linköpings universitet, Linköping, 10:15 (Swedish)
Opponent
Supervisors
Available from: 2013-04-18 Created: 2013-04-18 Last updated: 2013-04-18Bibliographically approved
List of papers
1. Five Types of Practice-Based ImprovementIdeas in Health Care Services: An EmpiricallyDefined Typology
Open this publication in new window or tab >>Five Types of Practice-Based ImprovementIdeas in Health Care Services: An EmpiricallyDefined Typology
2011 (English)In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 20, no 2, 122-130 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study is to empirically identify and present different kinds of practice-based improvement ideas developed in health care services. 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 health care sector. This study is based on a Swedish county council improvement program. Health care departments and primary health care centers in the Kalmar County Council were invited to apply for money to accomplish improvement projects. A qualitative content analysis was done of 183 proposed applications from various health care departments and primary health care centers. The following 5 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. These projects point to the various problems and experiences health care professionals encounter in their day-to-day work. To generalize beyond this improvement program and to validate the typology, we applied it to all articles found when searching for quality improvement projects in the journal Quality Management in Health Care during the last 2 years and found that all of them could be fitted into at least 1 of those 5 categories. This article provides valuable insights into the current state of improvemen  work in Swedish health care, and will serve as a foundation for further investigations in this quality improvement program.

Keyword
health care settings, improvement projects, quality improvement initiatives, Hälso- och sjukvård, Förbättringsarbete, Kvalitet
National Category
Social Sciences Interdisciplinary
Identifiers
urn:nbn:se:liu:diva-68073 (URN)10.1097/QMH.0b013e3182134b3c (DOI)
Available from: 2011-05-10 Created: 2011-05-10 Last updated: 2017-12-11
2. Improvement Strategies: Forms and Consequences for Participation in Healthcare Improvement Projects
Open this publication in new window or tab >>Improvement Strategies: Forms and Consequences for Participation in Healthcare Improvement Projects
2013 (English)Manuscript (preprint) (Other academic)
Abstract [en]

From a management point of view there are many different approaches from which to choose in how to engage staff in initiatives to improve performance. The present study investigates how two different types of improvement strategies stimulate and encourage involvement of different professional groups in healthcare organizations. The first type, Designed Improvement Processes, is constituted of a methodologically guided collaborative program. The second type, Intrapreneurship Projects, is characterized by an “intrapreneur” working with an improvement project in a rather free manner. The data analysis was carried out through classifying the participants´ profession, position, gender and the organizational administration of which they were a part. The result showed that nurses were the largest group participating in both improvement initiatives. Physicians were also well represented, although they seemed to prefer the less structured Intrapreneurship Projects approach. Assistant nurses, being the second largest staff group, were poorly represented in both initiatives. This indicates that the benefits and support for one group may push another group aside. Managers need to give prerequisites and incentives for staff who do not participate to do so.

Keyword
Gender, Healthcare settings, Nursing staff professions, Participation, Quality Improvement, Quality Management
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-91250 (URN)
Available from: 2013-04-18 Created: 2013-04-18 Last updated: 2013-04-18Bibliographically approved
3. Patient participation in quality improvement: managers’ opinions of patients as resources
Open this publication in new window or tab >>Patient participation in quality improvement: managers’ opinions of patients as resources
2012 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 21, no 23-24, 3590-3593 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to investigate managers’ opinions of how to take advantage of patients as resources in quality improvement work in the Swedish healthcare sector.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2012
National Category
Reliability and Maintenance
Identifiers
urn:nbn:se:liu:diva-85638 (URN)10.1111/j.1365-2702.2012.04254.x (DOI)000310978000030 ()
Available from: 2012-11-26 Created: 2012-11-26 Last updated: 2017-12-07Bibliographically approved
4. Managers’ Views and Experiences of a Large-Scale County Council Improvement Program: Limitations and Opportunities
Open this publication in new window or tab >>Managers’ Views and Experiences of a Large-Scale County Council Improvement Program: Limitations and Opportunities
2013 (English)In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 22, no 2, 152-160 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to explore and evaluate managers’ views of a large-scale improvement program, including their experiences and opinions about improvement initiatives and drivers for change. The study is based on a survey used in 2 nationwide mappings of improvement initiatives and developmental trends in Swedish health care. The participants were all managers in a county council in Sweden. Data were analyzed descriptively, and statements were ranked in order of preferences. A majority of the respondents stated that they had worked with improvements since the county council improvement program started. The managers sometimes found it difficult to find data and measurements that supported the improvements, yet a majority considered that it was worth the effort and that the improvement work yielded results. The top-ranked driving forces were ideas from personnel and problems in the daily work. Staff satisfaction was ranked highest of the improvement potentials, but issues about patients’ experiences of their care and patient safety came second and third. The managers stated that no or only a few patients had been involved in their improvement initiatives. Large-scale county council improvement initiatives can illuminate quality problems and lead to increased interest in improvement initiatives in the health care sector.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2013
National Category
Social Sciences Interdisciplinary
Identifiers
urn:nbn:se:liu:diva-91251 (URN)10.1097/QMH.0b013e31828bc276 (DOI)000209317100009 ()
Available from: 2013-04-18 Created: 2013-04-18 Last updated: 2017-12-06Bibliographically approved
5. Evaluating a questionnaire to measure improvement initiatives in Swedish healthcare
Open this publication in new window or tab >>Evaluating a questionnaire to measure improvement initiatives in Swedish healthcare
2013 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 13, no 48Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

Quality improvement initiatives have expanded recently within the healthcare sector. Studies have shown that less than 40% of these initiatives are successful, indicating the need for an instrument that can measure the progress and results of quality improvement initiatives and answer questions about how quality initiatives are conducted. The aim of the present study was to develop and test an instrument to measure improvement process and outcome in Swedish healthcare.

METHODS:

A questionnaire, founded on the Minnesota Innovation Survey (MIS), was developed in several steps. Items were merged and answer alternatives were revised. Employees participating in a county council improvement program received the web-based questionnaire. Data was analysed by descriptive statistics and correlation analysis. The questionnaire psychometric properties were investigated and an exploratory factor analysis was conducted.

RESULTS:

The Swedish Improvement Measurement Questionnaire consists of 27 items. The Improvement Effectiveness Outcome dimension consists of three items and has a Cronbach's alpha coefficient of 0.67. The Internal Improvement Processes dimension consists of eight sub-dimensions with a total of 24 items. Cronbach's alpha coefficient for the complete dimension was 0.72. Three significant item correlations were found. A large involvement in the improvement initiative was shown and the majority of the respondents were satisfied with their work.

CONCLUSIONS:

The psychometric property tests suggest initial support for the questionnaire to study and evaluate quality improvement initiatives in Swedish healthcare settings. The overall satisfaction with the quality improvement initiative correlates positively to the awareness of individual responsibilities.

Place, publisher, year, edition, pages
BioMed Central, 2013
National Category
Other Engineering and Technologies not elsewhere specified
Identifiers
urn:nbn:se:liu:diva-89620 (URN)10.1186/1472-6963-13-48 (DOI)000315037600001 ()
Available from: 2013-02-28 Created: 2013-02-28 Last updated: 2017-12-06
6. Evaluating a Breakthrough Series Collaborative in a Swedish healthcare context
Open this publication in new window or tab >>Evaluating a Breakthrough Series Collaborative in a Swedish healthcare context
2013 (English)Manuscript (preprint) (Other academic)
Abstract [en]

Since the mid-1990s, increased attention has been placed on quality improvement and patient safety within the healthcare context. This study aims to evaluate the use of the Breakthrough Series Collaborative methodology in a Swedish county council improvement program, comparing measurements at the beginning and after six months. A questionnaire was used, and improvement processes and outcomes were analysed. The results showed an overall large engagement in improvements, although the methodology and the facilitators were seen as only moderately supportive. Nursing educators have highlighted the importance of improvement education amongst healthcare professions, and nurses could play an active role in improving healthcare practices and patient safety.

Keyword
Breakthrough Series Collaborative, Nursing, Quality Improvement, Questionnaire, Swedish healthcare
National Category
Social Sciences Interdisciplinary
Identifiers
urn:nbn:se:liu:diva-91252 (URN)
Available from: 2013-04-18 Created: 2013-04-18 Last updated: 2013-04-18Bibliographically approved
7. Sustainable Outcomes of an Improvement Program: Do Financial Incentives Matter?
Open this publication in new window or tab >>Sustainable Outcomes of an Improvement Program: Do Financial Incentives Matter?
2013 (English)Manuscript (preprint) (Other academic)
Abstract [en]

The purpose of this study was to evaluate whether an improvement program can contribute to positive sustainable improvements in an organization, and whether financial incentives are driving forces for improvements. The material was all projects (n=232) that applied for funding in a county council improvement program between 2007 and 2010. The projects were analyzed as to whether they received funding (n=98) or were rejected (n=95). In addition, a categorization of the projects’ intentions was analyzed. Some projects were still ongoing, but 50 projects were implemented and sustained two or more years after being finalized. Implemented improvements were on different levels, from (micro level) units up to the entire (macro level) organization. In addition, 27 rejected projects were finalized without funding. Eighteen of those 27 were sustainably implemented. This study indicates that there are incentives other than financial at work if an improvement program will contribute to sustainable improvements in the organization. To encourage practice-based improvements is one way of incentivizing the intention and effort to become and perform better.

Keyword
Quality improvement, healthcare settings, improvement program, sustainable improvement, financial incentives
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-91254 (URN)
Available from: 2013-04-18 Created: 2013-04-18 Last updated: 2013-04-18Bibliographically approved

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