Who counts when health counts? A case-study of multi-stakeholder initiative to promote value-creation in Swedish healthcare.

A European initiative to design a "medical information framework" conceptualised how multiple stakeholders join in collaborative networks to create innovations. It conveyed the ways in which value is created and captured by stakeholders. We applied those insights to analyse a multi-stakeholder initiative to promote improvement of Swedish healthcare. Our longitudinal case study covered totally fifty stakeholders involved in a national project, aiming at designing a system to support value-based evaluation and reimbursement. During the project the focus changed from reimbursement to benchmarking. Sophisticated case-mix adjusting algorithms were designed to make outcome comparisons valid and incorporated in a software platform enabling detailed analysis of eight patient groups across seven regional health authorities. Those were deliverables demonstrating value created. However, the project was unable to transfer the system into routine use in the regions, a failed value-capture. The initial success was promoted by collaborative processes in diagnosis-specific working groups of well-informed and engaged professionals. The change of focus away from reimbursement decreased the involvement among health authorities, leaving no centrally placed persons to push for implementation. It highlights the importance of health professionals as the key stakeholder, who has both the know-how instrumental to creating an innovation, and the local involvement guaranteeing its implementation.

One size fits none - a qualitative study investigating nine national quality registries' conditions for use in quality improvement, research and interaction with patients.

BACKGROUND: Swedish National Quality Registries (NQRs) are observational clinical registries that have long been seen as an underused resource for research and quality improvement (QI) in health care. In recent years, NQRs have also been recognised as an area where patients can be involved, contributing with self-reported experiences and estimations of health effects. This study aimed to investigate what the registry management perceived as barriers and facilitators for the use of NQRs in QI, research, and interaction with patients, and main activities undertaken to enhance their use for these purposes. The aim was further to identify potential differences between various types of NQRs for their use in these areas. METHODS: In this multiple case study, nine NQRs were purposively selected. Interviews (n = 18) were conducted and analysed iteratively using conventional and directed content analysis. RESULTS: A recent national investment initiative enabled more intensive work with development areas previously identified by the NQR management teams. The recent focus on value-based health care and other contemporary national healthcare investments aiming at QI and public benchmarking were perceived as facilitating factors. Having to perform double registrations due to shortcomings in digital systems was perceived as a barrier, as was the lack of authority on behalf of the registry management to request participation in NQRs and QI activities based on registry outcomes. The registry management teams used three strategies to enhance the use of NQRs: ensuring registering of correct and complete data, ensuring updated and understandable information available for patients, clinicians, researchers and others stakeholders, and intensifying cooperation with them. Varied characteristics of the NQRs influenced their use, and the possibility to reach various end-users was connected to the focus area and context of the NQRs. CONCLUSIONS: The recent national investment initiative contributed to already ongoing work to strengthen the use of NQRs. To further increase the use, the demands of stakeholders and end-users must be in focus, but also an understanding of the NQRs' various characteristics and challenges. The end-users may have in common a need for training in the methodology of registry based research and benchmarking, and how to be more patient-centred.

Understanding the dynamics of sustainable change: A 20-year case study of integrated health and social care.

BACKGROUND: Change initiatives face many challenges, and only a few lead to long-term sustainability. One area in which the challenge of achieving long-term sustainability is particularly noticeable is integrated health and social care. Service integration is crucial for a wide range of patients including people with complex mental health and social care needs. However, previous research has focused on the initiation, resistance and implementation of change, while longitudinal studies remain sparse. The objective of this study was therefore to gain insight into the dynamics of sustainable changes in integrated health and social care through an analysis of local actions that were triggered by a national policy. METHODS: A retrospective and qualitative case-study research design was used, and data from the model organisation's steering-committee minutes covering 1995-2015 were gathered and analysed. The analysis generated a narrative case description, which was mirrored to the key elements of the Dynamic Sustainability Framework (DSF). RESULTS: The development of inter-sectoral cooperation was characterized by a participatory approach in which a shared structure was created to support cooperation and on-going quality improvement and learning based on the needs of the service user. A key management principle was cooperation, not only on all organisational levels, but also with service users, stakeholder associations and other partner organisations. It was shown that all these parts were interrelated and collectively contributed to the creation of a structure and a culture which supported the development of a dynamic sustainable health and social care. CONCLUSION: This study provides valuable insights into the dynamics of organizational sustainability and understanding of key managerial actions taken to establish, develop and support integration of health and social care for people with complex mental health needs. The service user involvement and regular reviews of service users' needs were essential in order to tailor services to the needs. Another major finding was the importance of continuously adapting the content of the change to suit its context. Hence, continuous refinement of the change content was found to be more important than designing the change at the pre-implementation stage.

[Patient involvement in patient safety]. / Patienter kan bidra till säkrare vård - ­ men patientmedverkan i patientsäkerhetsarbetet kräver nya attityder hos vårdarbetare och forskare.

Patient involvement in patient safety  The prospect of patients contributing to safer care with their unique knowledge and experiences demands a profound change in roles and attitudes among healthcare staff and researchers. The path forward involves designing ways of coproduction in healthcare quality and safety improvement as well as in research.

Self-reported exposure to severe events on the labour ward among Swedish midwives and obstetricians: A cross-sectional retrospective study.

BACKGROUND: The process of delivery entails potentially traumatic events in which the mother or child becomes injured or dies. Midwives and obstetricians are sometimes responsible for these events and can be negatively affected by them as well as by the resulting investigation or complaints procedure (clinical negligence). OBJECTIVE: To assess the self-reported exposure rate of severe events among midwives and obstetricians on the delivery ward and the cumulative risk by professional years and subsequent investigations and complaints. DESIGN: Cross-sectional survey. PARTICIPANTS: Members of the Swedish Association of Midwives (SFB) and the Swedish Society of Obstetrics and Gynaecology (SFOG). METHODS: A questionnaire covering demographic characteristics, experiences of self-reported severe events on the delivery ward, and complaints of medical negligence was developed. Potential consequences of the complaint was not reported. A severe event was defined as: 1) the death of an infant due to delivery-related causes during childbirth or while on the neonatal ward; 2) an infant being severely asphyxiated or injured at delivery; 3) maternal death; 4) very severe or life threatening maternal morbidity; or 5) other stressful events during delivery, such as exposure to violence or aggression. RESULTS: The response rate was 39.9% (n=1459) for midwives and 47.1% (n=706) for obstetricians. Eighty-four percent of the obstetricians and almost 71% of responding midwives had experienced one or more self-reported severe obstetric event with detrimental consequences for the woman or the new-born. Fourteen percent of the midwives and 22.4% of the obstetricians had faced complaints of medical negligence from the patient or the family of the patient. CONCLUSIONS: A considerable proportion of midwives and obstetricians will, in the course of their working life, experience severe obstetric events in which the mother or the new-born is injured or dies. Preparedness for such exposure should be part of the training, as should managerial and peer support for those in need. This could prevent serious consequences for the health care professionals involved and their subsequent careers.

[When the behavior becomes a patient safety risk]. / När beteendet blir en patientsäkerhetsrisk.

A less discussed aspect of patient safety issues in Sweden has been the correlation between disruptive behaviour and adverse advents. Disruptive behaviour, according to international studies, can affect team collaboration and communication, and hence the safety of care. Disruptive behaviour also exists in Swedish health-care. Dealing with the problem requires acknowledgement of its existence, and international examples have shown how to identify and prevent disruptive behaviour among health care staff.

Suffering in silence: a qualitative study of second victims of adverse events.

INTRODUCTION: The term 'second victim' refers to the healthcare professional who experiences emotional distress following an adverse event. This distress has been shown to be similar to that of the patient-the 'first victim'. The aim of this study was to investigate how healthcare professionals are affected by their involvement in adverse events with emphasis on the organisational support they need and how well the organisation meets those needs. METHODS: 21 healthcare professionals at a Swedish university hospital who each had experienced an adverse event were interviewed. Data from semi-structured interviews were analysed by qualitative content analysis using QSR NVivo software for coding and categorisation. RESULTS: Our findings confirm earlier studies showing that emotional distress, often long-lasting, follows from adverse events. In addition, we report that the impact on the healthcare professional was related to the organisation's response to the event. Most informants lacked organisational support or they received support that was unstructured and unsystematic. Further, the formal investigation seldom provided adequate and timely feedback to those involved. The insufficient support and lack of feedback made it more difficult to emotionally process the event and reach closure. DISCUSSION: This article addresses the gap between the second victim's need for organisational support and the organisational support provided. It also highlights the need for more transparency in the investigation of adverse events. Future research should address how advanced support structures can meet these needs and provide learning opportunities for the organisation. These issues are central for all hospital managers and policy makers who wish to prevent and manage adverse events and to promote a positive safety culture.

Implementing organisation and management innovations in Swedish healthcare: lessons from a comparison of 12 cases.

PURPOSE: The purpose of this paper is to compare the implementation of 12 different organisation and management innovations (OMIs) in Swedish healthcare, to discover the generic and specific factors important for successful healthcare improvement change in a public health system. DESIGN/METHODOLOGY/APPROACH: Longitudinal cross-case comparison of 12 case studies was employed, where each case study used a common framework for collecting data about the process of change, the content of the change, the context, and the intermediate and final outcomes. FINDINGS: Clinical leaders played a more important part in the development of these successful service innovations than managers. Strategies for and patterns of change implementation were found to differ according to the type of innovation. Internal organisational context factors played a significant role in the development of nearly all, but external factors did not. "Developmental evolution" better described the change process than "implementation". RESEARCH LIMITATIONS/IMPLICATIONS: The 12 cases were all of relatively successful change processes: some unsuccessful examples would have provided additional testing of the hypotheses about what would predict successful innovation which were used in the case comparison. The cross-case comparative hypothesis testing method allows systematic comparison if the case data are collected using similar frameworks, but this approach to management research requires considerable resources and coordination. PRACTICAL IMPLICATIONS: Management innovations that improve patient care can be carried out successfully by senior clinicians, under certain circumstances. A systematic approach is important both for developing and adapting an innovation to a changing situation. A significant amount of time was required for all involved, which could be reduced by "fast-tracking" approval for some types of change. ORIGINALITY/VALUE: This is the first empirical report comparing longitudinal and contextualised findings from a number of case studies of different organisational and management healthcare innovations. The findings made possible explanations for success factors and useful practical recommendations for conditions needed to nurture such innovation in public healthcare.

[Comprehensive quality indicators for health care services]. / Overgripande kvalitetsindikatorer framtagna för hälso- och sjukvården.

On behalf of the Swedish government, the National Board of Health and Welfare recently issued a recommended set of 60 quality indicators for broad monitoring of the quality of national health care. This initiative is in concordance with similar international initiatives. The Swedish process, however, is unique in the sense that the professions have developed the indicator and more than 40 national quality registers already monitor most of them. Health care professionals in Sweden have a long-standing tradition of measuring and monitoring results including comparing the quality of different health providers by means of the quality registers. However, the transparency by which these measures are presented, the general understanding of how such data should be interpreted and used in practice is as yet not sufficiently developed. Transparency of data combined with knowledgeable interpretation by health professionals will provide patients with sound information about health care quality and the necessary prerequisites for making comparisons between providers. It will also help guiding managers and politicians making decisions. In order to reach this objective, close co-operation between patient organisations, health care managers and the professionals is needed including a common understanding of the needs and perspectives of all parties.