Great expectations - introduction of flow managers in a university hospital.

A major reorganization of a university hospital included the clinical structure as well as the administrative structure of the hospital. The focus of the reorganization was to improve the coordination of patient flows through the hospital. An important part of the organizational change was the introduction of flow managers. The aim of the article is to describe and analyze the challenges of the flow managers in the implementation of the reorganization. The description is based on a number of individual and focus group interviews with professionals and managers on different organizational levels. The analysis is guided by a broad conceptual framework, focusing on the processes of change in a professional organization like a hospital. The results show that the flow managers started with a lot of uncertainty regarding their responsibilities. There was also a lot of resistance to the reorganization, which the flow managers came to personify. They proceeded by building relationships and shaping their role and tasks. They tried to balance proactive and reactive strategies of change. There were some positive results, but they felt that that the expectations placed on them had been unrealistic. The introduction of flow managers in a university hospital has touched upon many elements of the conceptual framework. There were a number of structural, cultural, financial and strategic barriers influencing the change process. The main conclusion of the analysis is that the flow managers need more power and legitimacy in the organization to deal with these barriers. Copyright © 2015 John Wiley & Sons, Ltd.

Interorganizational Collaboration in Transitional Care - A Study of a Post-Discharge Programme for Elderly Patients.

INTRODUCTION AND AIM: This article reports a study of a post-discharge programme for elderly patients in Norway. It took place in an intermediate ward for transitional care and was based on collaboration between a municipality and a hospital, which was part of a health enterprise. The aim of the study was to analyse the collaboration and its possible effects on the quality of patient care, and the economic efficiency of the project for the organizations involved. METHODOLOGY: A mixed-methods approach, consisting of interviews, questionnaires and analyses of official documents and statistics. RESULTS: The collaboration was working well on the top level of the organizations, but was more problematic on the operative level. However, there were clear signs of improvement. The patients who received transitional care were more satisfied with their stay at the ward than their previous stay at the hospital. They were discharged to their homes more often and perceived to have a higher level of functioning than the hospital patients. Average costs per patient were also lower in the ward than in the hospital departments. CONCLUSION: The collaboration had mainly positive impacts on the quality of patient care and the economic efficiency of elderly care in the municipality. However, the board of the health enterprise decided to close down the intermediate ward.

Quality, efficiency and integrity: value squeezes in management of hospital wards.

AIM: The aim of this study was to explore and describe the value squeezes experienced by ward managers in connection with quality management in hospital wards. The study focused on integrity pressure and coping strategies to deal with such pressure. BACKGROUND: Nurses in the role of ward managers have a key function in the field of quality improvement. These managers are also responsible for the efficient running of their wards and thus face tensions between demands for both quality and efficiency. METHOD: Data were collected through interviews conducted with 10 ward managers from six Norwegian hospitals. The data were analysed using both content and template analysis. RESULTS: Ward managers felt squeezed between conflicting values associated with demands for both quality and efficiency. These tensions resulted in pressure on integrity for the managers as well as their nursing colleagues. Three different management strategies were used to cope with such pressure: quality conscious, efficiency adjusting and hybrid. CONCLUSION: A hybrid strategy appeared to be the best, both for the ward managers and the hospital organisations, despite the fragmentation associated with this strategy. IMPLICATIONS FOR NURSING MANAGEMENT: Hybrid management may be beneficial for coping with pressure on integrity, although more empirical research is needed.

Organizing integrated care in a university hospital: application of a conceptual framework.

BACKGROUND AND AIM: As a result of New Public Management, a number of industrial models of quality management have been implemented in health care, mainly in hospitals. At the same time, the concept of integrated care has been developed within other parts of the health sector. The aim of the article is to discuss the relevance of integrated care for hospitals. THEORY AND METHODS: The discussion is based on application of a conceptual framework outlining a number of organizational models of integrated care. These models are illustrated in a case study of a Danish university hospital implementing a new organization for improving the patient flows of the hospital. The study of the reorganization is based mainly on qualitative data from individual and focus group interviews. RESULTS: The new organization of the university hospital can be regarded as a matrix structure combining a vertical integration of clinical departments with a horizontal integration of patient flows. This structure has elements of both interprofessional and interorganizational integration. A strong focus on teamwork, meetings and information exchange is combined with elements of case management and co-location. CONCLUSIONS: It seems that integrated care can be a relevant concept for a hospital. Although the organizational models may challenge established professional boundaries and financial control systems, this concept can be a more promising way to improve the quality of care than the industrial models that have been imported into health care. This application of the concept may also contribute to widen the field of integrated care.

Actor or arena: contrasting translations of a law on interorganizational integration.

PURPOSE: A Swedish framework law has enabled integration between public agencies in vocational rehabilitation. With the support of this law, coordination associations can be formed to fund and organize joint activities. The purpose of this study is to describe and analyze how the law has been interpreted and translated into local coordination associations and how local institutional logics have developed to guide the organization of these associations. DESIGN/METHODOLOGY/APPROACH: Data was collected through observations of meetings within two coordination associations and supplemented with documents. The material was analyzed by compilation and examination of data from field notes, whereupon the most important aspects were crystallized and framed with institutional organization theory. FINDINGS: Two different translations of the law were seen in the associations studied: the association as an independent actor, and as an arena for its member organizations. Two subsequent institutional logics have developed, influencing decisions on autonomy, objectives and rationality for initiating and organizing in the two associations and their activities. The institutional logics are circular, further enhancing the different translations creating different forms of integration. RESEARCH IMPLICATIONS/LIMITATIONS: Both forms of integration are legitimate, but the different translations have created integration with different degrees of autonomy in relation to the member organizations. Only a long-term analysis can show whether one form of integration is more functional than the other. ORIGINALITY/VALUE: This article is based on an extensive material providing insights into a form of interorganizational integration which has been scarcely researched. The findings show how different translations can influence the integration of welfare services.

Organizational health in health organizations: towards a conceptualization.

This article is introducing a new concept of organizational health and discussing its possible implications for health organizations and health management. The concept is developed against the background of New Public Management, which has coincided with increasing workplace health problems in health organizations. It is based on research mainly in health promotion and health management. Organizational health is defined in terms of how an organization is able to deal with the tensions of diverse and competing values. This requires a dialectical perspective, integration as well as disintegration, and a tricultural approach to value tensions. The concept of organizational health is pointing towards an inverse value pyramid and a hybrid- and value-based form of management in health organizations. An application of this concept may clarify competing values and help managers to deal with the value tensions underlying workplace health problems on an organizational as well as an individual and group level. More empirical research is required, however, to link more closely the different aspects of organizational health in health organizations.

Organizational approaches to collaboration in vocational rehabilitation-an international literature review.

INTRODUCTION: Collaboration between welfare organizations is an important strategy for integrating different health and welfare services. This article reports a review of the international literature on vocational rehabilitation, focusing on different organizational models of collaboration as well as different barriers and facilitating factors. METHODS: The review was based on an extensive search in scientific journals from 1995 to 2010, which generated more than 13,000 articles. The number of articles was reduced in different steps through a group procedure based on the abstracts. Finally, 205 articles were read in full text and 62 were included for content analysis. RESULTS: Seven basic models of collaboration were identified in the literature. They had different degrees of complexity, intensity and formalization. They could also be combined in different ways. Several barriers and facilitators of collaboration were also identified. Most of these were related to factors as communication, trust and commitment. CONCLUSION: There is no optimal model of collaboration to be applied everywhere, but one model could be more appropriate than others in a certain context. More research is needed to compare different models and to see whether they are applicable also in other fields of collaboration inside or outside the welfare system.

Health promoting leadership - different views of the concept.

OBJECTIVE: To describe and analyse different views of health promoting leadership among actors involved in workplace health promotion in eight Swedish municipalities. METHODS: Twenty individuals were interviewed and their views were analysed according to the methodology of phenomenograpic research, exploring how health promoting leadership was described, what motives were expressed, and what critical conditions were perceived for developing such leadership. RESULTS: The informants described health promoting leadership in three ways: organising health promoting activities, having a supportive leadership style, and developing a health promoting workplace. The motives mentioned for developing health promoting leadership were instrumental motives and improved health. The critical conditions for health promoting leadership were organisational conditions, characteristics of individual managers, and support to managers. CONCLUSIONS: It seems that the concept of health promoting leadership was often used to link ideas about good leadership to the health of employees. Organisational goals and management trends may also have influenced the motives as well as the conditions for development of health promoting leadership.

A decade of integration and collaboration: the development of integrated health care in Sweden 2000-2010.

INTRODUCTION: The recent history of integrated health care in Sweden is explored in this article, focusing on the first decade of the 2000s. In addition, there are some reflections about successes and setbacks in this development and challenges for the next decade. DESCRIPTION OF POLICY AND PRACTICE: The first efforts to integrate health care in Sweden appeared in the beginning of the 1990s. The focus was on integration of intra-organisational processes, aiming at a more cost-effective health care provision. Partly as a reaction to the increasing economism at that time, there was also a growing interest in quality improvement. Out of this work emerged the 'chains of care', integrating all health care providers involved in the care of specific patient groups. During the 2000s, many county councils have also introduced inter-organisational systems of 'local health care'. There has also been increasing collaboration between health professionals and other professional groups in different health and welfare services. DISCUSSION AND CONCLUSION: Local health care meant that the chains of care and other forms of integration and collaboration became embedded in a more integrative context. At the same time, however, policy makers have promoted free patient choice in primary health care and also mergers of hospitals and clinical departments. These policies tend to fragment the provision of health care and have an adverse effect on the development of integrated care. As a counterbalance, more efforts should be put into evaluation of integrated health care, in order to replace political convictions with evidence concerning the benefits of such health care provision.

Organizing vocational rehabilitation through interorganizational integration--a case study in Sweden.

This study describes and analysis five years of experiences from organising an interorganisational project on vocational rehabilitation. A qualitative case study approach was used based on interviews, focus group discussions and documents. The aim was to analyse how and why the project was organised in the way it was in relation to theories of integration, organisational change and learning. The results show that the vocational rehabilitation project was initiated mainly for financial reasons. It was organised as a mechanistic system with the aim of producing different activities, where financial control and support from all the levels of the organisations involved was important. A new bureaucracy between the different authorities involved was built up, where the vertical (top-down) integration was more important than the horizontal. The result was scattered islands of interprofessional work in different teams, but without contacts between them. The project did not influence the processes or workflows of the organisations involved in the project, which would be important from a service-user perspective. It may therefore be questionnable to organise the development of interorganisational integration for vocational rehabilitation in a separate project organisation. Instead, interorganisational networks with focus on interconnections of processes and workflows may be more flexible and adaptable.

The double spiral of change--experiences of privatization in a Swedish hospital.

UNLABELLED: Privatization is a trend in countries with a public health system. It involves organizational change, a cultural transformation and changes for the employees as well as a more strictly controlled work. The objective of this study is to describe, analyse and interpret how privatization is perceived by the employees of a health care organization in Sweden. METHODOLOGY: In-depth interviews have been performed with physicians, paramedics, secretaries, nurses, assistant nurses and local managers, in all 14 respondents, after a private entrepreneur had taken over the management of a hospital. The interviews were tape-recorded and have been analysed and interpreted following a grounded theory approach. FINDINGS: The transcribed interviews show that trust is a core category and linked with emotions, commitment and security. The analysis shows that employees' experience of privatization within a health care organization differs and is full of nuances and complexities. CONCLUSION: A simultaneous virtuous and a vicious circle of experiences and reactions may describe how employees experience privatization. It can also be concluded that leadership is an important factor in the success of organizational change.

From territoriality to altruism in interprofessional collaboration and leadership.

Interprofessional collaboration has become more and more necessary in health and social care, mainly because of the increasing specialization of services and the increasing professionalization of different occupational groups. Most interprofessional collaboration is at the same time also interorganizational and it is taking place within a complicated structure, where collaborative teamwork is combined with hierarchical co-ordination and control in a sort of matrix organization. Based on the literature on organization, leadership and collaboration, this paper discusses territorial behaviour among professional groups and agencies as a difficult barrier to interprofessional collaboration. In order to overcome that barrier, the concept of altruism is explored as an alternative to territoriality. Professional altruism as well as altruistic leadership is discussed as a condition and a possibility for interprofessional collaboration. The discussion is illustrated with empirical data from a case study of collaboration in vocational rehabilitation.

Evaluating intersectoral collaboration: a model for assessment by service users.

INTRODUCTION: DELTA was launched as a project in 1997 to improve intersectoral collaboration in the rehabilitation field. In 2005 DELTA was transformed into a local association for financial co-ordination between the institutions involved. Based on a study of the DELTA service users, the purpose of this article is to develop and to validate a model that can be used to assess the integration of welfare services from the perspective of the service users. THEORY: The foundation of integration is a well functioning structure of integration. Without such structural conditions, it is difficult to develop a process of integration that combines the resources and competences of the collaborating organisations to create services advantageous for the service users. In this way, both the structure and the process will contribute to the outcome of integration. METHOD: The study was carried out as a retrospective cross-sectional survey during two weeks, including all the current service users of DELTA. The questionnaire contained 32 questions, which were derived from the theoretical framework and research on service users, capturing perceptions of integration structure, process and outcome. Ordinal scales and open questions where used for the assessment. RESULTS: The survey had a response rate of 82% and no serious biases of the results were detected. The study shows that the users of the rehabilitation services perceived the services as well integrated, relevant and adapted to their needs. The assessment model was tested for reliability and validity and a few modifications were suggested. Some key measurement themes were derived from the study. CONCLUSION: The model developed in this study is an important step towards an assessment of service integration from the perspective of the service users. It needs to be further refined, however, before it can be used in other evaluations of collaboration in the provision of integrated welfare services.

Barriers of inter-organisational integration in vocational rehabilitation.

INTRODUCTION: A project of vocational rehabilitation was studied in Sweden between 1999 and 2002. The project included four public organisations: the social insurance office, the local health services, the municipal social service and the office of the state employment service. The aim of this paper was to analyse perceived barriers in the development of inter-organisational integration. THEORY: Theories of inter-professional and inter-organisational integration, and theories on organisational change. METHODS: In total, 51 semi-structured interviews and 14 focus group discussions were performed with actors within the project between 1999 and 2002. A thematic approach was used for the analysis of the data. RESULTS: THREE DIFFERENT MAIN THEMES OF BARRIERS EMERGED FROM THE DATA: A Uncertainty, B Prioritising own organisation and C Lack of communication. The themes are interconnected in an intricate web and hence not mutually exclusive. CONCLUSIONS AND DISCUSSION: The barriers found are all related partly to organisational change in general and partly to the specific development of organisational integration. Prioritising of own organisation led to flaws in communication, which in turn led to a high degree of uncertainty within the project. This can be seen as a circular relationship, since uncertainty might increase focus on own organisation and lack of communication. A way to overcome these barriers would be to take the needs of the clients as a point of departure in the development of joint services and to also involve them in the development of inter-organisational integration.

Leadership, organization and health at work: a case study of a Swedish industrial company.

The application of knowledge on organization and leadership is important for the promotion of health at workplace. The purpose of this article is to analyse the leadership and organization, including the organizational culture, of a Swedish industrial company in relation to the health of the employees. The leadership in this company has been oriented towards developing and actively promoting a culture and a structure of organization where the employees have a high degree of control over their work situation. According to the employees, this means extensive possibilities for personal development and responsibility, as well as good companionship, which makes them feel well at work. This is also supported by the low sickness rate of the company. The results indicate that the leadership and organization of this company may have been conducive to the health of the employees interviewed. However, the culture of personal responsibility and the structure of self-managed teams seemed to suit only those who were able to manage the demands of the company and adapt to that kind of organization. Therefore, the findings indicate that the specific context of the technology, the environment and the professional level of the employees need to be taken into consideration when analysing the relation between leadership, organization and health at work.

The impact of organisational settings on physician wellbeing.

PURPOSE: The purpose of this research is to show that the Swedish health care system has undergone major changes during the last decades, which have exerted strong influence on the operational freedom of physicians. DESIGN/METHODOLOGY/APPROACH: This study consisted of 169 physicians in management positions, who answered a questionnaire assessing the relationship between their organizational settings and their perceived wellbeing. The organizational setting was defined as contact with top management, decision-making influence, well defined organization and whether the physician is acting as a leader. The perceived wellbeing was defined as social climate, work related exhaustion, work satisfaction, influence, development ability and supportive leadership. FINDINGS: According to the results, organizational support improves work satisfaction and mental energy, and decreases work related exhaustion among physicians. This all leads to decreasing turnover rate among physicians. ORIGINALITY/VALUE: These results point to the importance of maintaining a positive and supportive atmosphere for physicians in their work environment in order to encourage physicians to remain and take on management positions in the health care system. Furthermore enhancing physician influence over decision making processes is important to counteract work-related exhaustion and it might also contribute to a more efficient organization.

Variation in views on clients in interprofessional work for vocational rehabilitation in Sweden.

To deal with long-term sickness absence, inter-organizational and interprofessional projects for rehabilitation were established in Sweden in the late 1990s. This study explores the different views about the clients of such a project from the professionals of the organizations involved. Twenty-one key informants were interviewed in 1999 and 22 in 2002. The interviews were semi-structured and analysed with a phenomenographic approach. Four descriptive categories emerged: (A) the individual as consisting of components, (B) the individual in his/her context, (C) the individual as part of a group, and (D) the individual as part of the population. Category A included a paternalistic view and B included a maternalistic as well as an autonomous view. Both paternalism and maternalism imply an inequality in the relationship between the professional and the client. Category C had an organizational perspective, whereas category D had a community perspective. Both of these perspectives included an abstract view of the client. The conclusions were that the professionals had qualitatively different views on clients, which might lead to unequal encounters as well as differences in opportunities for rehabilitation. The results stress the importance of discussing what ethical values are desirable, not least in inter-organizational and interprofessional projects.

Determinants of integrated health care development: chains of care in Sweden.

Local health care in Sweden is an emerging form of integrated care, linked together by chains of care. Experiences show, however, that the development of chains of care is making slow progress. In order to study the factors behind this development, an embedded multiple-case study design was chosen. The study compared six health authorities in Sweden, three with successful and three with unsuccessful chain of care development. Three major determinants of integrated health care development were identified: professional dedication, legitimacy and confidence. In more detail, space for prime movers and trust between participants were crucial success factors, while top-down approaches targeting at the same time a change of management systems were negative for the development of chains of care. Resistance from the body of physicians was a serious obstacle to such a development. Local health care depends on developed chains of care, but it seems that health care managers do not have the management systems necessary to run these clinical networks, mainly due to a lack of acceptance from the medical profession. This is an impossible situation in the long run, since the number of chains of care is likely to increase as a result of the emerging local health care.

How do newspapers deal with health in Sweden? A descriptive study.

OBJECTIVE: Newspapers in Sweden have a high amount of readers compared with other European countries. The purpose of this essay is to analyse the space related to health found in the Swedish newspapers and to discuss what readers consume about health. METHODS: This study is based on an observational cross-sectional design. The sample was constituted by daily editions from three major Swedish newspapers selected during 1 month-Svenska Dagbladet, Dagens Nyheter and Göteborgs-Posten. Descriptive analyses was used. RESULTS: The main findings show that newspapers included 2.4% on average of health contents (HC), being "Svenska Dagbladet" the one with most publications (3.3%). HC used to be published within the first pages (median in page 13, main mode in 4). 81.3% of all contents were written by journalists, and writers used sources of information in 73,6%. Most frequent topics were about cancer, alcohol, euthanasia and sick leave at work. CONCLUSIONS: "Svenska Dagbladet" is the newspaper publishing more HC and also has more specialised health writers. Different sources are used in the contents like health professionals, professors and politicians. Research is needed on evaluating the quality of health contents. PRACTICE IMPLICATIONS: It is a need to increase the number of health specialist journalists and to promote independence when dealing about health.

Co-operation as a strategy for provision of welfare services--a study of a rehabilitation project in Sweden.

BACKGROUND: During the past 15 years, there have been many initiatives to improve the integration between different welfare agencies. This study is describing and analysing the co-operation between agencies involved in a rehabilitation project in Sweden, and discussing such inter-agency co-operation as a strategy for provision of complex welfare services. METHODS: The study is based on a process evaluation, where the co-operation between the agencies was followed and documented during the time of the project. Different kinds of data were collected through interviews, focus groups and diaries. The contents of these data were analysed in order to evaluate the process of co-operation. In addition, there was also an evaluation of the effects of the co-operation, based on official documents, statistics, etc. RESULTS: The evaluation shows that it was possible to co-operate across the organizational boundaries of the different agencies, but there were obstacles related to organizational and cultural differences of the agencies, divided loyalties of the officials and limited resources available to deal with the complex needs of the clients. At the same time, the commitment and the relations between the officials were facilitating the co-operation. DISCUSSION: Based on the evaluation of this project, it seems that co-operation could be an effective strategy to deal with clients who need services from different welfare agencies. At the same time, however, it is clear that inter-agency co-operation requires a lot of time and energy and should therefore be used with caution.