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  • 1.
    Elg, Mattias
    et al.
    Linköping University, Department of Management and Engineering, Logistics & Quality Management. Linköping University, Faculty of Science & Engineering. Linköping University, HELIX Vinn Excellence Centre.
    Lindmark, Jan
    CIO Axfood AB.
    Wiger, Malin
    Linköping University, Department of Management and Engineering, Logistics & Quality Management. Linköping University, Faculty of Science & Engineering.
    Wihlborg, Elin
    Linköping University, Department of Management and Engineering, Political Science. Linköping University, Faculty of Arts and Sciences.
    Översättning av riktlinjer: Fallstudier av sjukdomsförebyggande metoders genomslag2016Report (Other academic)
    Abstract [en]

    The National Board of Health and Welfare decided in November 2011 on the national guidelines for methods of preventing disease. The guidelines focus on four areas: tobacco use; hazardous use of alcohol; insufficient physical activity; and unhealthy eating habits. Health care systems in Sweden, ie, county councils and municipalities, have since the introduction of the guidelines established effort for the implementation of these guidelines. The National Board of Health and Welfare has also since January 2011 been assigned to support its implementation. It turns out that there is variation regarding how far the various county councils have A utilize these guidelines in clinical work. A central question is why there is varied result and how implementation efforts may be strengthened. This report addresses these two issues. More specifically we analyze the implementation processes of the guidelines for methods of preventing disease in a multi-level perspective and with respect to how they are translated into clinical activities in meetings with patients. The overall aim is to analyze the translation of the guidelines for disease prevention methods from policy level through administrative levels of administration to the clinical activities in meetings with patient. We are, thus, especially interested in how translation processes are constructed and sustained in the interplay between policy making and healthcare management.

    The central problem motivating our study is the perceived difficulty of managing policy guidelines into practice. From experience we know that there are an increasing number of attempts that fail to effectively deliver implemented policy initiates. Therefore, a great deal of scholarly work focus on analyses and explanation of why organizations accomplish their policy implementation initiative and why others have good, well-founded reasons to refrain from applying new ideas.

    As a starting point for our analysis, we argue that there is a need to view healthcare organizational systems and their policy implementations from a network perspective. The theoretical input that frame our analysis of the implementation, management and control of public services is about making sure these implementation processes function as a continuous translation between different actors of a rather complex organization.

    We used a multiple case study approach of efforts in four regions to implement the guidelines for methods of preventing disease. The four regions studied were: Norrbottens County Council, Stockholm County Council, Region Östergötland and Skåne Region . The case studies are based mainly on interviews with key people in each county / region as well as the study of policy documents. Overall, 31 people were interviewed in different parts of the county councils/regions; from public policy makers, administrative management, healthcare developers and clinicians. The interviews have both given insight into implementation efforts, the current work on the guidelines and settings in which these guidelines, with various success, have been immersed.

    Our findings show that there are several ways in which the policy guidelines enter the regional level: (1) directly from the national guidelines, (2) through earlier efforts in nearby areas, and (3) through participation in the development of the guidelines along with previous work in nearby areas. The various entries into the regional level also have different implications as it assembles different networks of actors. A mechanism that explains this is problematization where the leading actors define the orientation of the work.

    Management of the guidelines are then carried out through a variety of activities: prioritization of actions, initiating projects, financial prioritization, competence development efforts, technology and process development of clinical guidelines in clinical care programs.  All of these activities take place at the system-wide regional level, leading then to various entries into clinical work. However, uncertainties in the environment create constrains for actors in their implementation efforts. It may be a county’s internal financial and organizational choices that lead to a slowdown of the translation process. Also uncertainty about how to interpret and understand the use of the methods may have important impact on the effectiveness of implementation.

    Further, ideas about how to handle methods of preventing disease developed at the regional level are to various extent translated into local practice. In primary care units the guidelines are when implemented fully adapted and integrated into the local clinics management structure. An important mechanism for use in these work units is dedicated, active employees. The final choice weather a patient may or may not enter the health promotion activities are decided mainly by the individual caregiver.

    The conclusions in the report points to a number of mechanisms that support guideline implementation:

    • Active ownership - a necessary factor for success in the work of implementing the guidelines is that it is driven by active players in all parts of the health care system. It is manifested for example by the National Board of Health and Welfare’s support to implementation in order to clarify the statutory mandate, further development of the disease prevention methods and support in learning between the county councils. At the county level overall is the active ownership of the questions to prioritize and allocate resources. But the top management leaders also need to be more actively involved and engaged in the process of developing the utilization of disease prevention methods.
    • Wide anchored processes - It is clear that in the context in which the disease-prevention work has leveled out into clinical practice, there have been inclusive, participatory processes. The leading players who control the implementation work therefore should be aware of how exclusion may be created through a variety of resources at their disposal. For example, our study shows that the actors involved in public health issues in the county councils / regions have had an influence on how the work has been formulated.
    • Translators who create and support conditions - In addition to the need for an active ownership at the political level on the issues we also see a great need for resource support in the operations environment. This is an important component of maintaining a sustainable implementation chain. The translators create the links in this chain and binds together different activities with its surroundings. Translators can provide support and create conditions by participating in the development of clinical guidelines and decision support, support and drive improvement, skills development, develop new IT solutions and quality work at operational level.
    • Developmental oriented leadership among operations managers - the same way that other levels of the health care system requires a development-oriented leadership among managers. We see that these managers can use a range of different approaches and tools to support the implementation of the guidelines. They have a key role in the translation, motivations and the design of the work in the clinical practice. It is therefore necessary that the managers of the clinical departments have the ability and discretion to run the operations in such a way that the implementation is enhanced - that the chain is held together. When managers and other professionals succeed in this then it will increase guideline legitimacy both internally within the organization and towards others.
    • Impact of projects and its embeddedness in everyday work - Many projects run test new solutions and have short time horizons. Evaluation of the projects is ongoing and changes are recorded continuously. The effects of a sustainable work can only be realized if the project results are integrated in daily work - something that is perceived problematic when the project will move into daily operations and management. This means that project ideas that go well must be embedded in the everyday work and become more long-term in order to really have an impact.
    • Meanings of role models - We note in particular that there are no stories about best practices and successful implementation in organizations or among individuals. A hallmark of successful realization is that any activity can be highlighted as a good example that shows the possibilities for a good implementation with good effects.
  • 2.
    Olsson, Olle
    et al.
    Linköping University, Department of Management and Engineering, Logistics Management. Linköping University, The Institute of Technology.
    Wiger, Malin
    Linköping University, Department of Management and Engineering, Logistics Management. Linköping University, The Institute of Technology.
    Aronsson, Håkan
    Linköping University, Department of Management and Engineering, Logistics Management. Linköping University, The Institute of Technology.
    Developments in the field of healthcarelogistics and SCM: A patient flow focus2012Manuscript (preprint) (Other academic)
    Abstract [en]

    Purpose

    During the last years, attention for healthcare logistics and SCM has begun. This is a novel topic, with a lack of literature reviews on research related to this field. Therefore, the aim of this paper is to provide guidance in how to develop healthcare logistics and SCM research related to patient flows.

    Design/methodology/approach

    This paper adopted an exploratory literature review, focusing on patient flow issues, through a scanning of logistics and SCM journals. The identified articles references as well as the papers that had referred to the papers were also included in the review.

    Findings

    The field of healthcare logistics and SCM is still in its infancy, with few papers published. The papers with a supply chain or network as unit of analysis are mostly conceptual and the case studies mainly descriptive studies on a single healthcare unit. Some major challenges for future research is how to manage a complex service context, how to create flexibility in healthcare provision and coordinate multiple healthcare actors.

    Research limitations/implications

    The findings should be considered as conceptual, and provides a basis for further empirical and theoretical based research.

    Practical implications

    The results provide a basis for healthcare organizations and their managers, to build upon in their continuing efforts to develop more efficient patient flows.

    Original/value

    This literature review responds to the absence of an overview on research in healthcare logistics and SCM. It contributes to both logistics and SCM literature by identifying some important challenges and gaps for future research.

  • 3.
    Wiger, Malin
    Linköping University, Department of Management and Engineering, Logistics Management. Linköping University, The Institute of Technology.
    Logistics Management in a Healthcare Context: Methodological development for describing and evaluating a healthcare organisation as a logistics system2013Licentiate thesis, monograph (Other academic)
    Abstract [en]

    This thesis tests whether logistics knowledge, theories and principles can be used to provide potential patient flow efficiency improvements. By emphasizing an ideal logistics system by means of its main features and then using these to evaluate two different healthcare organisations, it is assumed that knowledge regarding patient flows can be obtained and potentials for improvement highlighted. Hence, this licentiate thesis presents a developed method intended for evaluating a healthcare organisation by means of a logistics system’s main features. The purpose rests on the assumption that effective management and real flow-efficient improvements can only be accomplished by viewing logistics as an integrated system.

    Demographics, increased costs, strong technical and medical developments, new kinds of customer requirements, stressed staff and preventable adverse events are some of the challenges the Swedish healthcare system is currently facing. In addition, there is a constant demand on healthcare to be more cost-effective while fulfilling demands as regards waiting times, quality and availability. Experience from structural changes in other industries gives reason to be positive about the potential for long-term productivity leaps in the healthcare sector. The challenge is to simultaneously find successful application of efficient production and flexible adaptation to changing patients’ demands and requirements. Taking advantage of the logistics expertise that already exists can be a way to meet these challenges. It can be assumed that logistics knowledge applied in healthcare can lead to lower costs, shorter waiting lists, better patient service, shorter treatment times and increased capacity. Nevertheless, flow-oriented design of healthcare delivery systems is novel and positions much currently isolated research on a conceptual level or within single wards (Wiger and Aronsson, 2012).

    The research is part of a three-year project, "Lean and agile – logistics driven improvement in health and social care”, funded by Vinnvård, a collaboration between the Department of Management and Engineering at Linköping University, Hässleholm Healthcare Organisation and the Medical Management Center at Karolinska Institutet in Stockholm. This thesis is partly a theoretical development of logistics models. This is done in order to create an ideal logistics system’s main features and description aspects to describe a system to be able to evaluate it using these features. The two cases are used to test the adequacy of the developed method and its associated models and to identify potential for improvement towards a more flow-oriented business. Four series of interview sessions were conducted with a total of 23 respondents and 18 interviews and over 500 Excel files were collected from the business system.

    It is suggested that a healthcare organisation can be evaluated by the developed logistics main features. These features, listed below, together provide a possibility to complement a healthcare organisation’s ability to meet patient requirements by flow-efficiency and demonstrate logistical operational excellence.

    1. A logistics system’s purpose is to meet customer requirements by cost-effective delivery service through flow orientation by prioritising the total performance
    2. A logistics system has a flow-oriented structure
    3. A logistics system transforms orders into customer services in a flow-oriented process
    4. A logistics system can control the transformation of input (demand) to output (customer service) and thus the cost of resources
    5. A logistics system measures to capture the whole system’s logistics performance, including total logistics costs, lead times and customer service
    6. A logistics system has a strategy to meet demand
    7. A logistics system uses logistics measurements as feedback to regulate its behaviour to reduce differences between actual and desired performance

    The analysis of the two cases confirms the picture of an organisational design driven by medical specialties. This implies a possibility to change perspective to a more holistic view with the patient flow in focus. The fact that there are very few possibilities to control the transformation has partly to do with ownership of patient flows being less well-defined than clearly defined medical responsibilities within each specialty. It also has to do with the inability to distinguish between the uncertainty regarding unique patients on a low level of aggregation and at the higher level where there should be complete and explicit specifications of the end-product requirements and delivery requirements. The lack of demand strategies that support the total logistics performance ultimately leads to both clinics having to use a sacrificing work effort rather than working systematically to be able to meet the demand. At the case hospital, there is a lack of information aggregated from operational level about patient processes that is made available for strategic decision-making. Neither of the two cases measure on the basis of improving patient flow efficiency, especially not the total patient flow costs or the total logistics costs.

    The major contribution is the analysis based on the logistics system’s main features, which gives a more purposive understanding of what can be done to improve flow efficiency within a healthcare organisation to make healthcare organisations progress in their ability to be more flow-oriented. A further contribution is a more clearly defined field of healthcare logistics research and the stressed importance of the “new” research field of logistics management.

  • 4.
    Wiger, Malin
    et al.
    Linköping University, Department of Management and Engineering, Logistics Management. Linköping University, The Institute of Technology.
    Aronsson, Håkan
    Linköping University, Department of Management and Engineering, Logistics Management. Linköping University, The Institute of Technology.
    Decision support by process-oriented cost accounting for the healthcare industry: PFC - patient flow costing2011Conference paper (Other academic)
    Abstract [en]

    This paper presents a cost accounting model with the aim to facilitate process owners in decision-making and to keep track of the patient flow by combining Total cost analysis, Activity based costing and systemic approach. The patient flow costing (PFC) model has been developed through an iterative process with a Swedish hospital. Costs not tied to the patient flows are by the model collected to a residual, which makes them visible and therefore approachable. Furthermore, the PFC-model is a tool to help analyze the cost of logistic decisions as a means to increase the efficiency in the flow of patients.

  • 5.
    Wiger, Malin
    et al.
    Linköping University, Department of Management and Engineering, Logistics Management. Linköping University, The Institute of Technology.
    Aronsson, Håkan
    Linköping University, Department of Management and Engineering, Logistics Management. Linköping University, The Institute of Technology.
    Healthcare logistics - a patient flow focus: What has been done?2012In: NoFoMa Conference: Book of proceedings / [ed] Juuso Töyli, Laura Johansson, Harri Lorentz, Lauri Ojala and Sini Laari, Naantali, Finland, 2012, 827-842 p.Conference paper (Other academic)
    Abstract [en]

    Purpose of this paper

    During the last years attention for healthcare logistics has increased along with the healthcare sector evolvements towards more process oriented business models. The Supply Chain Management: An International Journal recently published a special issue on supply chain management in health services (Issue 3, 2011). This is though a novel topic, with a lack of literature reviews on research related to this field. Therefore, the purpose of this paper is to present an outline of helthcare logistics and supply chain management research related to patient flows.

    Design/methodology/approach

    A literature review was conducted on what is written in logistics and supply chain journals focusing on patient flow issues and practical logistics implication in a healthcare context, as a first phase. A second phase was conducted using a “snowball approach” to trace the “first phase” article´s references.

    Findings

    The field of healthcare logistics is still in its infancy, few articles are published in traditional logistics journals. However, most of the reviewed articles from the first search phase are published during the last years. The second search phase shows that the articles in the reference list were published in a wide range of journals.

    Research limitations/implications (if applicable)

    This paper is based on theories about patient flows and healthcare organization's capacity to provide service. The findings should be considered as conceptual, and provides a basis for further empirical and theoretical based research.

    Practical implications (if applicable)

    The results provide a basis for healthcare organizations and their managers, to build upon in their continuing efforts to develop and enhance more efficient patient flows.

    Originality/value

    This literature review responds to the absence of an overview on research in a healthcare context using theories based in the logistics and a supply chain management field.

     

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