Why publish? An interview study exploring patient innovators' reasons for and experiences of scientific publishing.

BACKGROUND: Scientific publications featuring patient-driven innovations (i.e., innovations that are developed and driven by patients or informal caregivers) are increasing. By understanding patient innovators' experiences of research publication, the scientific community may be better prepared to support or partner with patient innovators. Thus, the aim of this study was to explore patient innovators' reasons for and experiences of authoring scientific publications about their innovations. METHODS: Qualitative semi-structured interviews were conducted with 15 international patient innovators from three continents who had published in scientific journals. Participants were identified through a scoping review on patient-driven innovations and snowball sampling. Interviews were conducted from June to October 2022 and the data was analyzed using the Framework Method. FINDINGS: Participants' reasons for publishing in scientific journals were to strengthen the roles and voices of patients and informal caregivers, and to get recognition for their innovations. Some published as a response to serendipitous opportunities. Several positive experiences were reported: collaborations defined by transparency, mutual respect, and meaningful participation; learning and competence development; and gained confidence regarding the value of lived experiences in research. Participants also reported negative experiences, such as cultural barriers manifested as conservatism in academia and power imbalances between participants and researchers, and structural barriers regarding academic affiliations and research funding. CONCLUSIONS: Despite progress in increasing patient and public involvement in research and publication, our study found that patient innovators still experience barriers. This suggests that continued efforts are needed to facilitate contributions from patient innovators and other public actors to the production of relevant and meaningful research.

Rapid technological advances over the past decades have resulted in many health innovations that enable persons living with chronic conditions to better manage their health conditions in self-care. Similarly, caregivers can provide more advanced informal care. Do-it-yourself health innovations, such as automatic insulin dosing for diabetes patients, have been developed by patients and informal caregivers whom we in this study defined as patient innovators. There is an increasing trend of research focusing on such patient-driven innovations. However, we know little about the driving forces of patient innovators to contribute to scientific publications about their innovations. Therefore, the aim of this study was to explore patient innovators' reasons for publishing and their experiences thereof. We interviewed 15 international patient innovators who had experience of scientific publishing. Their main driving forces were to make patients' voices heard and receive recognition for their innovations, which could facilitate spread to other patients. The patient innovators in our study had positive experiences and meaningful collaborations with researchers that contributed to developing their scientific skills. However, they also faced challenges, such as managing their health and professional occupations besides research, being questioned by peer reviewers, and difficulties tackling the research and publication system without academic affiliation or funding. Our findings suggest that despite strong driving forces and positive experiences of scientific publishing, patient innovators face barriers that need to be addressed to facilitate the publication process for contributors without academic experience.

Building resilience: analysis of health care leaders' perspectives on the Covid-19 response in Region Stockholm.

BACKGROUND: The Covid-19 pandemic has tested health care organizations worldwide. Responses have demonstrated great variation and Sweden has been an outlier in terms of both strategy and how it was enacted, making it an interesting case for further study. The aim of this study was to explore how health care leaders experienced the challenges and responses that emerged during the initial wave of the Covid-19 pandemic, and to analyze these experiences through an organizational resilience lens. METHODS: A qualitative interview study with 12 senior staff members who worked directly with or supervised pandemic efforts. Transcripts were analyzed using traditional content analysis and the codes directed to the Integrated Resilience Attributes Framework to understand what contributed to or hindered organizational resilience, i.e. how organizations achieve their goals by utilizing existing resources during crises. RESULTS/FINDINGS: Organizational resilience was found at the micro (situated) and meso (structural) system levels as individuals and organizations dealt with acute shortages and were forced to rapidly adapt through individual sacrifices, resource management, process management, and communications and relational capacity. Poor systemic resilience related to misaligned responses and a lack of learning from previous experiences, negatively impacted the anticipatory phase and placed greater pressure on individuals and organizations to respond. Conventional crisis leadership could hamper innovation, further cement chronic challenges, and generate a moral tension between centralized directives and clinical microsystem experiences. CONCLUSIONS: The pandemic tested the resilience of the health care system, placing undue pressure on micro and meso systems responses. With improved learning capabilities, some of this pressure may be mitigated as it could raise the anticipatory resilience potential, i.e. with better health systems learning, we may need fewer heroes. How crisis leadership could better align decision-making with frontline needs and temper short-term acute needs with a longer-term infinite mindset is worth further study.

Predictive analytics support for complex chronic medical conditions: An experience-based co-design study of physician managers' needs and preferences.

PURPOSE: The literature suggests predictive technology applications in health care would benefit from physician and manager input during design and development. The aim was to explore the needs and preferences of physician managers regarding the role of predictive analytics in decision support for patients with the highly complex yet common combination of multiple chronic conditions of cardiovascular (Heart) and kidney (Nephrology) diseases and diabetes (HND). METHODS: This qualitative study employed an experience-based co-design model comprised of three data gathering phases: 1. Patient mapping through non-participant observations informed by process mining of electronic health records data, 2. Semi-structured experience-based interviews, and 3. A co-design workshop. Data collection was conducted with physician managers working at or collaborating with the HND center, Danderyd University Hospital (DSAB), in Stockholm, Sweden. HND center is an integrated practice unit offering comprehensive person-centered multidisciplinary care to stabilize disease progression, reduce visits, and develop treatment strategies that enables a transition to primary care. RESULTS: Interview and workshop data described a complex challenge due to the interaction of underlying pathophysiologies and the subsequent need for multiple care givers that hindered care continuity. The HND center partly met this challenge by coordinating care through multiple interprofessional and interdisciplinary shared decision-making interfaces. The large patient datasets were difficult to operationalize in daily practice due to data entry and retrieval issues. Predictive analytics was seen as a potentially effective approach to support decision-making, calculate risks, and improve resource utilization, especially in the context of complex chronic care, and the HND center a good place for pilot testing and development. Simplicity of visual interfaces, a better understanding of the algorithms by the health care professionals, and the need to address professional concerns, were identified as key factors to increase adoption and facilitate implementation. CONCLUSIONS: The HND center serves as a comprehensive integrated practice unit that integrates different medical disciplinary perspectives in a person-centered care process to address the needs of patients with multiple complex comorbidities. Therefore, piloting predictive technologies at the same time with a high potential for improving care represents an extreme, demanding, and complex case. The study findings show that health care professionals' involvement in the design of predictive technologies right from the outset can facilitate the implementation and adoption of such technologies, as well as enhance their predictive effectiveness and performance. Simplicity in the design of predictive technologies and better understanding of the concept and interpretation of the algorithms may result in implementation of predictive technologies in health care. Institutional efforts are needed to enhance collaboration among the health care professionals and IT professionals for effective development, implementation, and adoption of predictive analytics in health care.

[Psychological safety for health care staff: What? Why? How?] / Att skapa psykologisk trygghet bland personalen i sjukvården.

Psychological safety refers to an individual's experience of the work environment as conducive to interpersonal risk-taking without risk for reprisals. Fear of reprisals has been well documented in health care, including in Sweden. In the literature and our teaching, we have consistently found that when psychological safety is low, it can lead providers to violate the basic tenet "first, do no harm".  Psychological safety resides at the team level. It is established and maintained by the leader. Several contributing leadership qualities and behaviors have been identified. Leaders can train how to support psychological safety by how they choose to set the stage, invite participation, and respond productively when they interact with their staff. Leaders may experience this as challenging and anxiety-provoking. However, leaders need to actively improve psychological safety in care teams to support learning, improvement, and co-creation in health and care.

Decision-making on the fly: a qualitative study of physicians in out-of-hospital emergency medical services.

BACKGROUND: Out-of-hospital Emergency Medical Services (OHEMS) require fast and accurate assessment of patients and efficient clinical judgment in the face of uncertainty and ambiguity. Guidelines and protocols can support staff in these situations, but there is significant variability in their use. Therefore, the aim of this study was to increase our understanding of physician decision-making in OHEMS, in particular, to characterize the types of decisions made and to explore potential facilitating and hindering factors. METHODS: Qualitative interview study of 21 physicians in a large, publicly-owned and operated OHEMS in Croatia. Data was subjected to an inductive content analysis. RESULTS: Physicians (mostly young, female, and early in their career), made three decisions (transport, treat, and if yes on either, how) after an initial patient assessment. Decisions were influenced by patient needs, but to a greater extent by factors related to themselves and patients (microsystem), their organization (mesosystem), and the larger health system (macrosystem). This generated a high variability in quality and outcomes. Participants desired support through further training, improved guidelines, formalized feedback, supportive management, and health system process redesign to better coordinate and align care across organizational boundaries. CONCLUSIONS: The three decisions were made complex by contextual factors that largely lay outside physician control at the mesosystem level. However, physicians still took personal responsibility for concerns more suitably addressed at the organizational level. This negatively impacted care quality and staff well-being. If managers instead adopt a learning orientation, the path from novice to expert physician could be more ably supported through organizational demands and practices aligned with real-world practice. Questions remain on how managers can better support the learning needed to improve quality, safety, and physicians' journey from novice to expert.

A rocky road but worth the drive: A longitudinal qualitative study of patient innovators and researchers cocreating research.

BACKGROUND: Partnership research practices involving various stakeholder groups are gaining ground. Yet, the research community is still exploring how to effectively coproduce research together. This study describes (a) key programme developments in the creation of a 6-year partnership research programme in Sweden, and (b) explores the hopes, expectations, and experiences of patient innovators (i.e., individuals with lived experience as patients or caregivers who drive health innovations) and researchers involved in the programme during the first years. METHODS: We conducted a prospective longitudinal qualitative study spanning the first 2 years of the programme. Data consisted of meeting protocols and interviews with 14 researchers and 6 patient innovators; 39 interviews were carried out in three evenly-spaced rounds. We identified significant events and discussion themes in the meeting protocols and analyzed the interviews using thematic analysis, applying a cross-sectional recurrent approach to track changes over time. FINDINGS: Meeting protocols revealed how several partnership practices (e.g., programme management team, task forces, role description document) were cocreated, supporting the sharing of power and responsibilities among programme members. Based on the analysis of interviews, we created three themes: (1) paving the path to a better tomorrow, reflecting programme members' high expectations; (2) going on a road trip together, reflecting experiences of finding new roles and learning how to cocreate; (3) finding the tempo: from talking to doing, reflecting experiences of managing challenges and becoming productive as a team. CONCLUSIONS: Our findings suggest that sharing, respecting, and acknowledging each other's experiences and concerns helps build mutual trust and shape partnership practices. High expectations beyond research productivity suggest that we need to consider outcomes at different levels, from the individual to society, when evaluating the impact of partnership research. PATIENT OR PUBLIC CONTRIBUTION: The research team included members with formal experiences as researchers and members with lived experiences of being a patient or informal caregiver. One patient innovator coauthored this paper and contributed to all aspects of the research, including the design of the study; production of data (as interviewee); interpretation of findings; and drafting the manuscript.

What Are We Talking About When We Talk About Information-Driven Care? A Delphi-Study on a Definition.

In Sweden, the term information-driven care has recently been put forward by healthcare organizations and researchers as a means for taking a comprehensive approach to the introduction of Artificial Intelligence (AI) in healthcare. The aim of this study is to systematically generate a consensus definition of the term information-driven care. To this end, we are conducting a Delphi study utilizing literature and experts' opinions. The definition is needed to enable knowledge exchange on information-driven care and operationalize its introduction into healthcare practice.

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.

Artificial Intelligence Applications in Health Care Practice: Scoping Review.

BACKGROUND: Artificial intelligence (AI) is often heralded as a potential disruptor that will transform the practice of medicine. The amount of data collected and available in health care, coupled with advances in computational power, has contributed to advances in AI and an exponential growth of publications. However, the development of AI applications does not guarantee their adoption into routine practice. There is a risk that despite the resources invested, benefits for patients, staff, and society will not be realized if AI implementation is not better understood. OBJECTIVE: The aim of this study was to explore how the implementation of AI in health care practice has been described and researched in the literature by answering 3 questions: What are the characteristics of research on implementation of AI in practice? What types and applications of AI systems are described? What characteristics of the implementation process for AI systems are discernible? METHODS: A scoping review was conducted of MEDLINE (PubMed), Scopus, Web of Science, CINAHL, and PsycINFO databases to identify empirical studies of AI implementation in health care since 2011, in addition to snowball sampling of selected reference lists. Using Rayyan software, we screened titles and abstracts and selected full-text articles. Data from the included articles were charted and summarized. RESULTS: Of the 9218 records retrieved, 45 (0.49%) articles were included. The articles cover diverse clinical settings and disciplines; most (32/45, 71%) were published recently, were from high-income countries (33/45, 73%), and were intended for care providers (25/45, 56%). AI systems are predominantly intended for clinical care, particularly clinical care pertaining to patient-provider encounters. More than half (24/45, 53%) possess no action autonomy but rather support human decision-making. The focus of most research was on establishing the effectiveness of interventions (16/45, 35%) or related to technical and computational aspects of AI systems (11/45, 24%). Focus on the specifics of implementation processes does not yet seem to be a priority in research, and the use of frameworks to guide implementation is rare. CONCLUSIONS: Our current empirical knowledge derives from implementations of AI systems with low action autonomy and approaches common to implementations of other types of information systems. To develop a specific and empirically based implementation framework, further research is needed on the more disruptive types of AI systems being implemented in routine care and on aspects unique to AI implementation in health care, such as building trust, addressing transparency issues, developing explainable and interpretable solutions, and addressing ethical concerns around privacy and data protection.

Patient-driven innovations reported in peer-reviewed journals: a scoping review.

BACKGROUND: Awareness of patients' innovative capabilities is increasing, but there is limited knowledge regarding the extent and nature of patient-driven innovations in the peer-reviewed literature. OBJECTIVES: The objective of the review was to answer the question: what is the nature and extent of patient-driven innovations published in peer-reviewed scientific journals? ELIGIBILITY CRITERIA: We used a broad definition of innovation to allow for a comprehensive review of different types of innovations and a narrow definition of 'patient driven' to focus on the role of patients and/or family caregivers. The search was limited to years 2008-2020. SOURCES OF EVIDENCE: Four electronic databases (Medline (Ovid), Web of Science Core Collection, PsycINFO (Ovid) and Cinahl (Ebsco)) were searched in December 2020 for publications describing patient-driven innovations and complemented with snowball strategies. CHARTING METHODS: Data from the included articles were extracted and categorised inductively. RESULTS: A total of 96 articles on 20 patient-driven innovations were included. The number of publications increased over time, with 69% of the articles published between 2016 and 2020. Author affiliations were exclusively in high income countries with 56% of first authors in North America and 36% in European countries. Among the 20 innovations reported, 'Do-It-Yourself Artificial Pancreas System' and the online health network 'PatientsLikeMe', were the subject of half of the articles. CONCLUSIONS: Peer-reviewed publications on patient-driven innovations are increasing and we see an important opportunity for researchers and clinicians to support patient innovators' research while being mindful of taking over the work of the innovators themselves.

Realizing the potential of artificial intelligence in healthcare: Learning from intervention, innovation, implementation and improvement sciences.

Introduction: Artificial intelligence (AI) is widely seen as critical for tackling fundamental challenges faced by health systems. However, research is scant on the factors that influence the implementation and routine use of AI in healthcare, how AI may interact with the context in which it is implemented, and how it can contribute to wider health system goals. We propose that AI development can benefit from knowledge generated in four scientific fields: intervention, innovation, implementation and improvement sciences. Aim: The aim of this paper is to briefly describe the four fields and to identify potentially relevant knowledge from these fields that can be utilized for understanding and/or facilitating the use of AI in healthcare. The paper is based on the authors' experience and expertise in intervention, innovation, implementation, and improvement sciences, and a selective literature review. Utilizing knowledge from the four fields: The four fields have generated a wealth of often-overlapping knowledge, some of which we propose has considerable relevance for understanding and/or facilitating the use of AI in healthcare. Conclusion: Knowledge derived from intervention, innovation, implementation, and improvement sciences provides a head start for research on the use of AI in healthcare, yet the extent to which this knowledge can be repurposed in AI studies cannot be taken for granted. Thus, when taking advantage of insights in the four fields, it is important to also be explorative and use inductive research approaches to generate knowledge that can contribute toward realizing the potential of AI in healthcare.

How to design, implement and evaluate organizational interventions for maximum impact: the Sigtuna Principles.

Research on organizational interventions needs to meet the objectives of both researchers and participating organizations. This duality means that real-world impact has to be considered throughout the research process, simultaneously addressing both scientific rigour and practical relevance. This discussion paper aims to offer a set of principles, grounded in knowledge from various disciplines that can guide researchers in designing, implementing, and evaluating organizational interventions. Inspired by Mode 2 knowledge production, the principles were developed through a transdisciplinary, participatory and iterative process where practitioners and academics were invited to develop, refine and validate the principles. The process resulted in 10 principles: 1) Ensure active engagement and participation among key stakeholders; 2) Understand the situation (starting points and objectives); 3) Align the intervention with existing organizational objectives; 4) Explicate the program logic; 5) Prioritize intervention activities based on effort-gain balance; 6) Work with existing practices, processes, and mindsets; 7) Iteratively observe, reflect, and adapt; 8) Develop organizational learning capabilities; 9) Evaluate the interaction between intervention, process, and context; and 10) Transfer knowledge beyond the specific organization. The principles suggest how the design, implementation, and evaluation of organizational interventions can be researched in a way that maximizes both practical and scientific impact.

It takes two to dance the VBHC tango: A multiple case study of the adoption of value-based strategies in Sweden and Brazil.

Although Value-Based Health Care (VBHC) is widely debated and cited, there are few empirical studies focused on how its concepts are understood and applied in real-world contexts. This comparative case study of two prominent adopters in Brazil and Sweden, situated at either end of the spectrum in terms of contextual prerequisites, provides insights into the complex interactions involved in the adoption of value-based strategies. We found that the adoption of VBHC emphasized either health outcomes or costs - not both as suggested by the value equation. This may be linked to broader health system and societal contexts. Implementation can generate tensions with traditional business models, suggesting that providers should first analyze how these strategies align with their internal context. Adoption by a single provider organization is challenging, if not impossible. An effective VBHC transformation seems to require a systematic and systemic approach where all stakeholders need to clearly define the purpose and the scope of the transformation, and together steer their actions and decisions accordingly.

As predicted by theory: choice and competition in a publicly funded and regulated regional health system yield improved access and cost control.

BACKGROUND: New Public Management (NPM) has been widely used to introduce competition into public healthcare. Results have been mixed, and there has been much controversy about the appropriateness of a private sector-mimicking governance model in a public service. One voice in the debate suggested that rather than discussing whether competition is "good" or "bad" the emphasis should be on exploring the conditions for a successful implementation. METHODS: We report a longitudinal case study of the introduction of patient choice and allowing private providers to enter a publicly funded market. Patients in need of hip or knee replacement surgery are allowed to choose provider, and those are paid a fixed reimbursement for the full care episode (bundled payment). Providers are financially accountable for complications. Data on number of patients, waiting lists and times, costs to the public purchaser, and complications were collected from public registries. Providers were interviewed at three points in time during a nine-year follow-up period. Time-series of the quantitative data were exhibited and the views of actors involved were explored in a thematic analysis of the interviews. RESULTS: The policy goals of improving access to care and care quality while controlling total costs were achieved in a sustained way. Six themes were identified among actors interviewed and those were consistent over time. The design of the patient choice model was accepted, although all providers were discontent with the level of reimbursement. Providers felt that quality, timeliness of service and staff satisfaction had improved. Public and private providers differed in terms of patient-mix and developed different strategies to adjust to the reimbursement system. Private providers were more active in marketing and improving operation room efficiency. All providers intensified cooperation with referring physicians. Close attention was paid to following the rules set by the purchaser. DISCUSSION AND CONCLUSIONS: The sustained cost control was an effect of bundled payment. What this study shows is that both public and private providers adhere long-term to regulations by a public purchaser that also controls entrance to the market. The compensation was fixed and led to competition on quality, as predicted by theory.

Medical leadership: boon or barrier to organisational performance? A thematic synthesis of the literature.

OBJECTIVE: The influx of management ideas into healthcare has triggered considerable debate about if and how managerial and medical logics can coexist. Recent reviews suggest that clinician involvement in hospital management can lead to superior performance. We, therefore, sought to systematically explore conditions that can either facilitate or impede the influence of medical leadership on organisational performance. DESIGN: Systematic review using thematic synthesis guided by the Enhancing Transparency in Reporting the synthesis of Qualitative research statement. DATA SOURCES: We searched PubMed, Web of Science and PsycINFO from 1 January 2006 to 21 January 2020. ELIGIBILITY CRITERIA: We included peer-reviewed, empirical, English language articles and literature reviews that focused on physicians in the leadership and management of healthcare. DATA EXTRACTION AND SYNTHESIS: Data extraction and thematic synthesis followed an inductive approach. The results sections of the included studies were subjected to line-by-line coding to identify relevant meaning units. These were organised into descriptive themes and further synthesised into analytic themes presented as a model. RESULTS: The search yielded 2176 publications, of which 73 were included. The descriptive themes illustrated a movement from 1. medical protectionism to management through medicine; 2. command and control to participatory leadership practices; and 3. organisational practices that form either incidental or willing leaders. Based on the synthesis, the authors propose a model that describes a virtuous cycle of management through medicine or a vicious cycle of medical protectionism. CONCLUSIONS: This review helps individuals, organisations, educators and trainers better understand how medical leadership can be both a boon and a barrier to organisational performance. In contrast to the conventional view of conflicting logics, medical leadership would benefit from a more integrative model of management and medicine. Nurturing medical engagement requires participatory leadership enabled through long-term investments at the individual, organisational and system levels.

Time-driven activity-based costing for patients with multiple chronic conditions: a mixed-method study to cost care in a multidisciplinary and integrated care delivery centre at a university-affiliated tertiary teaching hospital in Stockholm, Sweden.

OBJECTIVE: This study can be applied to cost the complex non-standardised processes used to treat patients with multiple chronic conditions. DESIGN: A mixed-method approach to cost analysis, following a modified healthcare-specific version of the seven-step Time-Driven Activity-Based Costing (TDABC) approach. SETTING: A multidisciplinary integrated and person-centred care delivery centre at a university-affiliated tertiary teaching hospital in Stockholm, Sweden, designed to improve care coordination for patients with multiple chronic conditions, specifically diabetes, cardiovascular disease and kidney disease. PARTICIPANTS: 314 patients (248 men and 66 women) fit inclusion criteria. Average age was 80 years. RESULTS: This modified TDABC analysis costed outpatient care for patients with multiple chronic conditions. The approach accounted for the difficulty of conceptualising care cycles. The estimated total cost, stratified by resources, can be reviewed together with existing managerial accounting statements to inform management decisions regarding the multidisciplinary centre. CONCLUSIONS: This article demonstrates that the healthcare-specific seven-step approach to TDABC can be applied to cost care for patients with multiple chronic conditions, where pathways are not yet discernable. It became clear that there was a need for slight methodological adaptations for this particular patient group to make it possible to cost these pathways, stratified by activity and resource. The value of this approach can be discerned from the way management incorporated the results of this analysis into the development of their hospital strategy. In the absence of integrated data infrastructures that can link patients and resources across financial, clinical and process data sets, the scalability of this method will be difficult.

Make it complicated: a qualitative study utilizing a complexity framework to explain improvement in health care.

BACKGROUND: Successful application of Quality Improvement (QI) methods is challenging, and awareness of the role context plays has increased. Complexity science has been advocated as a way to inform change efforts. However, empirical support is scarce, and it is still difficult to grasp the practical implications for QI interventions. The aim of this study was to use a complexity-based leadership framework to explain how managers in a clinical department addressed external requirements to cut costs without compromising patient outcomes and experience. METHODS: Explanatory case study design of a Danish OB/GYN department tasked to improve efficiency. Data came from documents, 30 interviews, and 250 h of observations over 3 years. A Complexity Analysis Framework that combined two complexity-based leadership frameworks was developed to analyze all changes implemented to reduce cost, while maintaining clinical quality. RESULTS: Managers reframed the efficiency requirement as an opportunity for quality improvement. Multiple simple, complicated, and complex situations were addressed with an adaptive approach to quality improvement. Changes were made to clinical pathways for individual conditions (n = 37), multiple conditions (n = 7), and at the organizational level (n = 9). At the organizational level, changes addressed referral practice, physical space in the department, flow and capacity, discharge speed, and managerial support. Managers shared responsibility with staff; together they took a "professional path" and systematically analyzed each clinical pathway through process mapping, attentive to patterns that emerged, before deciding on the next steps, such as a engaging in a complex process of probing - the iterative development and testing of new responses. CONCLUSIONS: Quality improvement efforts could benefit from an understanding of the importance of learning and sharing responsibility to deal with the co-existing degrees of contextual complexity in modern health care. By "making things complicated" through a systematic analysis that engages staff in an open and reflective dialog, clinical praxis and established organizational structures can be questioned and improved. The Complexity Analysis Framework could then help managers to identify improvement opportunities, know when to implement technical solutions, and when to keep abreast of emerging patterns and allow appropriate responses to complex challenges to evolve.

Ready for the Triple Aim? Perspectives on organizational readiness for implementing change from a Danish obstetrics and gynecology department.

BACKGROUND: As health care strives towards the Triple Aim of improved population health, patient experience, and reduced costs, an organization's readiness for change may be a key factor. The concept refers to the collective commitment of organizational members to a change and belief in their shared ability to make that change happen (efficacy). This study aims to assess the organizational readiness for implementing large-scale change at a clinical department in pursuit of the Triple Aim and to determine key associated factors. METHODS: A cross-sectional study at a Danish Obstetrics and Gynecology department faced with external pressure to become more efficient without compromising patient outcomes and experience. The Organisational Readiness for Implementing Change (ORIC) questionnaire was distributed to all employees (n = 403). Descriptive statistics was used to assess overall organizational readiness and single items. The between-group differences in subject characteristics were assessed with independent t-test and non-parametric test. Multiple linear regression was employed to control for potential confounders. RESULTS: Response rate was 72%. The level of agreement with the commitment statements was high, and low with the efficacy statements. We did not observe statistically significant differences in the overall score between organizational sections or in relation to gender, age, or profession. Managerial status (B = 3.2, 95% CI = .52, 5.9, P = .02) or interim employment(B = 2.7, 95% CI = .47, 4.9, P = .02) were significant predictors of a high change efficacy score after controlling for potential confounders. CONCLUSIONS: Changes related to pursuit of the Triple Aim were seen as something that "has to" be done, but left managers, and even more so staff, wondering what "to do" and "how to" do it. Change strategies should therefore address these uncertainties by translating political "have to's" proposals that resonate with staff, spark engagement, and clarify "how to" deal with the complexity of large-scale change.

Translating 'See-and-Treat' to primary care: opening the gates does not cause a flood.

OBJECTIVE: To explore how the See-and-Treat concept can be applied in primary care and its effect on volume and productivity. DESIGN: An explanatory single-case study design with a mixed methods approach and presented according to the SQUIRE 2.0 guidelines. SETTING: A publicly-funded, private primary care provider within the Stockholm County, which caters to a diverse patient population in terms of ethnicity, religion, socioeconomic status and care needs. PARTICIPANTS: CEO, center manager, four physicians, two licensed practical nurses, one medical secretary and one lab assistant. INTERVENTION: A See-and-Treat unit was established to offer same-day service for acute unplanned visits. Standardized patient symptom forms were created that allowed patients to self-triage and then enter into a streamlined care process consisting of a quick diagnostic lab and a physician visit. MAIN OUTCOME MEASURES: Volume, productivity, staff perceptions and patient satisfaction were measured through data on number and type of contacts per 1000 listed patients, visits per physician, observations, interviews and a questionnaire. RESULTS: A significant decrease in the acute and total number of visits, a continued trend of diminishing telephone contacts, and a non-significant increase in physician productivity. Patients were very satisfied, and staff perceived an improved quality of care. CONCLUSIONS: See-and-Treat appears to be a viable approach for a specific primary care patient segment interested in acute same-day-service. Opening up access and standardizing care made it possible to efficiently address these needs and engage patients.

Extreme Consumers of Health Care: Patterns of Care Utilization in Patients with Multiple Chronic Conditions Admitted to a Novel Integrated Clinic.

PURPOSE: Patients with multiple chronic conditions (MCC) of diabetes, cardiovascular and kidney diseases; hereafter referred to as HND (heart/cardiac-, nephrology-, diabetes mellitus-) patients, are high utilizers of health care. However, the care received is often insufficiently coordinated between different specialties and health-care providers. This study aims to describe the characteristics of HND patients and to explore the initial effects of a multidisciplinary and person-centered care on total care utilization. PATIENTS AND METHODS: We conducted a sub-study of HND patients recruited in an ongoing randomized trial CareHND (NCT03362983). Descriptive statistics of patient characteristics, including diagnostic data and Charlson Comorbidity Index scores, informed a comparison of care utilization patterns between HND patient care and traditional care. Diagnostic and care utilization data were collected from a regional database. Wilcoxon signed ranked sum tests were performed to compare care utilization frequencies between the two groups. RESULTS: Patients included in the study were care-intensive with several diagnoses and experienced a high level of variation in care utilization and diagnoses profiles. HND patients were sicker than their counterparts in the control group. Utilization indicators were similar between the two arms. There was some indication that the HND center is beginning to perform as expected, but no results were statistically significant. CONCLUSION: This study sits among many studies reporting difficulties obtaining statistically significant findings for MCC patients. However, previous research has shown that the key components of this intervention, such as integrated, multidisciplinary, inter-professional collaboration within patient-centered care have had a positive effect on health-care outcomes. More innovative methods beyond the RCT, such as machine learning should be explored to evaluate the impact of integrated care interventions on care utilization.