Rapid implementation of remote digital primary care in Stockholm and implications for further system-wide implementation: practitioner's and manager's experience of the Always Open mobile application.

OBJECTIVE: To contribute actionable knowledge how to increase appropriate use of digital technologies in primary care by understanding clinical managers experiences with a digital connection system, Always Open, during the COVID-19 pandemic. DESIGN AND SUBJECTS: The overall design was a qualitative study with directed content analysis method. Data were collected from documents and focus group (n = 12) interviews with clinical managers (n = 99) of primary care. The seven domains of the Non-adoption, Abandonment, and challenges to the Scale-up, Spread and Sustainability (NASSS) framework was used to understand the implementation process, as described by the clinical managers. RESULTS: Focus group participants reported that their units made their own local decisions to make more use of the technology provided by the health system. Most participants considered that the technology was ready to use, despite some limitations, that included individual clinician's and patient preferences, and how ready their unit was for making changes to practice and organization. Some raised concerns about how standardizing some aspects possibly conflicted with the decentralized management model of the organization. The overall experience was reported to be positive, with an intention to sustain the achievements. CONCLUSION: Focus group interviews found that clinical unit managers reported that they and their staff were positive about the digital technology system for remote care. For the future, they wanted changes to be made at different levels of the health system to better combine digital and physical care. Possibilities to use digital technology to integrate primary and hospital health care were identified.

Rapid adoption of Always Open as a digital connection mHealth system for remote digital care was observed during the pandemic without a structured implementation program.Many factors could explain the rapid adoption and the intention to sustain the use of Always Open such as professional ethics, financial reimbursement, patient needs and support.Standardization needs to be balanced with flexibility to ensure that staff can decide what is appropriate for patients.The general experience was positive and a continual high use of Always Open was reported in units that adopted the system.The decentralized management model may have contributed to the capacity to provide flexible services suited to local needs.

No man is an island: management of the emergency response to the SARS-CoV-2 (COVID-19) outbreak in a large public decentralised service delivery organisation.

BACKGROUND: We wanted to better understand whether and how agility can be achieved in a decentralised service delivery organisation in Sweden. The pandemic outbreak of SARS-Cov-2 (Covid-19) provided an opportunity to assess decentralisation as a strategy to improve the responsiveness of healthcare and at the same time handle an unpredictable and unexpected event. METHODS: Data from in-depth interviews with a crisis management team (n = 23) and free text answers in a weekly survey to subordinated clinical directors, i.e. unit managers, (n = 108) were scrutinised in a directed content analysis. Dynamic capabilities as a prerequisite for dynamic effectiveness, understood as reaching strategic and operative effectiveness simultaneously, were explored by using three frameworks for dynamic effectiveness, dynamic capabilities and delegated authority in a decentralised organisation. RESULTS: Unpredictable events, such as the pandemic Covid-19 outbreak, demand a high grade of ability to be flexible. We find that a high degree of operational effectiveness, which is imperative in an emergency situation, also is a driver of seeking new strategic positions to even better meet new demands. The characteristics of the dynamic capabilities evolving from this process are described and discussed in relation to decentralisation, defined by decision space, organisational and individual capacity as well as accountability. We present arguments supporting that a decentralised management model can facilitate the agility required in an emergency. CONCLUSIONS: This study is, to our knowledge, the first of its kind where a decentralised management model in a service delivery organisation in healthcare is studied in relation to crisis management. Although stemming from one organisation, our findings indicating the value of decentralisation in situations of crisis are corroborated by theory, suggesting that they could be relevant in other organisational settings also.

Managers do it their way: How managers act in a decentralised healthcare services provider organisation - a mixed methods study.

Purpose: Decentralisation is considered a way to get managers more committed and more prone to respond to local needs. This study analyses how managers perceive a decentralised management model within a large public healthcare delivery organisation in Sweden. Design/methodology/approach: A programme theory evaluation was performed applying direct content analysis to in-depth interviews with healthcare managers. Balance score card data were used in a blinded comparative content analysis to explore relations between performance and how the delegated authority was perceived and used by the managers. Findings: Managers' perceptions of the decentralised management model supported its intentions to enable the front-line to make decisions to better meet customer needs and flexibly adapt to local conditions. The managers appreciated and used their delegated authority. Central policies and control on human resources and investments were accepted as those are to the benefit of the whole organisation. Leadership development and organisation-wide improvement programmes were of support. Units showing high organisational performance had proactive managers, although differences in manager perceptions across units were small. Originality: This, one of the first of its kind, study of a decentralisation in service delivery organisation shows a congruence between the rationale of a management model, the managers' perceptions of the authority and accountability as well as management practises. These observations stemming from a large public primary and community healthcare organisation has not, to our knowledge, been reported and provide research-informed guidance on decentralisation as one strategy for resolving challenges in healthcare service delivery organisations.

That's how it should work: the perceptions of a senior management on the value of decentralisation in a service delivery organisation.

PURPOSE: Decentralisation in health care has been proposed as a way to make services more responsive to local needs and by that improve patient care. This study analyses how the senior management team conceptualised and implemented a decentralised management model within a large public health care delivery organisation. DESIGN/METHODOLOGY/APPROACH: Data from in-depth interviews with a senior management team were used in a directed content analysis. Underlying assumptions and activities in the decentralisation process are presented in the logic model and scrutinised in an a priori logic analysis using relevant scientific literature. FINDINGS: The study found support in the scientific literature for the underlying assumptions that increased responsibility will empower managers as clinical directors know their local prerequisites best and are able to adapt to patient needs. Top management should function like an air traffic control tower, trust and loyalty improve managerial capacity, increased managerial skills release creativity and engagement and a system perspective will support collaboration and learning. ORIGINALITY/VALUE: To the authors' knowledge this is the first a priori logic analysis of a decentralised management model in a healthcare delivery organisation in primary and community care. It shows that the activities consist with underlying assumptions, supported by evidence, and timely planned give managers decision space and ability to use their delegated authority, not disregarding accountability and fostering necessary organisational and individual capacities to avoid suboptimisation.