Exploring the potential of a multi-level approach to improve capability for continuous organizational improvement and learning in a Swedish healthcare region.

BACKGROUND: Eldercare and care of people with functional impairments is organized by the municipalities in Sweden. Improving care in these areas is complex, with multiple stakeholders and organizations. Appropriate strategies to develop capability for continuing organizational improvement and learning (COIL) are needed. The purpose of our study was to develop and pilot-test a flexible, multilevel approach for COIL capability building and to identify what it takes to achieve changes in key actors' approaches to COIL. The approach, named "Sustainable Improvement and Development through Strategic and Systematic Approaches" (SIDSSA), was applied through an action-research and action-learning intervention. METHODS: The SIDSSA approach was tested in a regional research and development (R&D) unit, and in two municipalities handling care of the elderly and people with functional impairments. Our approach included a multilevel strategy, development loops of five flexible phases, and an action-learning loop. The approach was designed to support systems understanding, strategic focus, methodological practices, and change process knowledge - all of which required double-loop learning. Multiple qualitative methods, i.e., repeated interviews, process diaries, and documents, provided data for conventional content analyses. RESULTS: The new approach was successfully tested on all cases and adopted and sustained by the R&D unit. Participants reported new insights and skills. The development loop facilitated a sense of coherence and control during uncertainty, improved planning and problem analysis, enhanced mapping of context and conditions, and supported problem-solving at both the individual and unit levels. The systems-level view and structured approach helped participants to explain, motivate, and implement change initiatives, especially after working more systematically with mapping, analyses, and goal setting. CONCLUSIONS: An easily understood and generalizable model internalized by key organizational actors is an important step before more complex development models can be implemented. SIDSSA facilitated individual and group learning through action-learning and supported systems-level views and structured approaches across multiple organizational levels. Active involvement of diverse organizational functions and levels in the learning process was facilitated. However, the time frame was too short to fully test all aspects of the approach, specifically in reaching beyond the involved managers to front-line staff and patients.

Matching physicians' treatment recommendations to patients' treatment preferences is associated with improvement in treatment satisfaction.

BACKGROUND: Dissatisfaction with treatment is common among those with psoriasis. While incorporating patients' preferences into the process of treatment decision-making may improve satisfaction, this relationship has not been clearly established. OBJECTIVE: To assess the extent to which matching physicians' treatment recommendations to patients' treatment preferences is associated with improvement in treatment satisfaction in patients with moderate-to-severe psoriasis. METHODS: This prospective cohort study design examined change from baseline to 3-month follow-up in four subscales of an established measure of treatment satisfaction. Separate multivariate regression models investigated the association of change in these subscale scores with an index measuring the match between physicians' treatment recommendations and patients' treatment preferences at the initial study visit. RESULTS: A closer match between physicians' recommendations and patients' preferences was associated with greater improvement in treatment satisfaction over time in each of the four subscales: effectiveness (ß = 0.53, P < 0.001), side-effects (ß = 0.25, P = 0.009), convenience (ß = 0.78, P < 0.001) and global satisfaction (ß = 0.49, P < 0.001). Adjusted models explained as much as 76% of the variation in change in treatment satisfaction subscales over 3 months. CONCLUSIONS: Further efforts to incorporate patients' preferences in treatment decision-making appear justified given the strength of independent associations between preference matching and improved treatment satisfaction and the extent to which our models explained variation in this relationship. An approach based on preference matching shows promise for increasing satisfaction in the management of other chronic diseases.

Patient preferences for psoriasis treatments: impact of treatment experience.

BACKGROUND: Patient preferences for psoriasis treatments can impact treatment satisfaction and adherence and may therefore influence clinical outcome. OBJECTIVE: To assess the impact of treatment experience (satisfaction with current treatment, number of prior visits, disease duration, number of preceding therapies and currently prescribed treatment modalities) on treatment preferences. METHODS: A computer-based conjoint analysis experiment was conducted to analyse preferences of patients with moderate or severe psoriasis (n = 163) treated at a German University Medical Center for outcome (probability, magnitude and duration of benefit; probability, severity and reversibility of side effects) and process attributes (location, frequency, duration, delivery method, individual cost) of psoriasis treatments. Relative importance scores (RIS) were calculated for each attribute and compared using anova, post hoc test and multivariate regression analysis. RESULTS: Participants with longer disease duration attached significantly greater importance to duration of benefit (ß = 0.206, P = 0.018), whereas participants on oral therapy were more concerned about magnitude of benefit by trend (ß = 0.218, P = 0.058). Participants receiving injectables not only set higher value to probability of benefit (RIS = 32.80 vs. 21.89, P = 0.025) but also to treatment location (RIS = 44.74 vs. 23.03, P = 0.011), delivery method (RIS = 43.75 vs. 19.29, P = 0.019), treatment frequency (RIS = 31.24 vs. 16.89, P = 0.005) and duration (RIS = 32.54 vs. 16.57, P = 0.003) when compared with others. Treatment satisfaction was significantly higher in participants on infusions or injections compared with those on phototherapy and mere topical therapy. CONCLUSIONS: Treatment preferences may change over time course and with treatment experience. Participants on injectables attach great importance to efficiency and convenience of therapies, and are highly satisfied with their treatment.

Process analysis to reduce MRI access time at a German University Hospital.

QUALITY PROBLEM OR ISSUE: Long access times for magnetic resonance imaging (MRI) can negatively impact the quality of care provided to patients. We investigated improving access by reducing MRI processing time. INITIAL ASSESSMENT: Data were collected for scans (n= 360) performed over 3 weeks (April-May 2008) at the University Hospital of Mannheim, Germany. Average access time, excluding emergencies, was 44 (±44) days for outpatients and 3 (±5) days for inpatients. Factors influencing total MRI processing time were identified using multivariate linear regression. In addition to region scanned, the total MRI processing time was significantly related to performing multiple scans (ß = 33.57, P< 0.01), using oral contrast media (ß = 13.58, P< 0.01), placing an intravenous (IV) catheter (ß = 5.00, P= 0.04) and scanning patients ≤8 years old (ß = 0.41, P= 0.03). Contrary to prior perceptions, emergency cases (5.6%) and late arrivals (12.8% >5 min late) were less than expected. CHOICE OF SOLUTION: Increasing scheduling flexibility to address non-modifiable process variation and completing preparatory activities outside the scanner room were identified as process improvement targets. IMPLEMENTATION: Scheduling was adapted to utilize three expected total MRI processing times and IV placement was moved outside the scanner room. EVALUATION: Planned hardware and software upgrades were completed concurrent to the process improvements. As a result, it was not possible to accurately measure the effect of implementing the scheduling and preparatory activity changes. LESSONS LEARNED: Clinical study team members' prior perceptions of workflow obstacles did not match the study findings. Utilizing insiders and outsiders during process analysis may limit bias in identification of process improvement opportunities.

Gender moderates the health-effects of job strain in managers.

PURPOSE: To investigate cross-sectional associations between main, interactive and gender-dependent effects of the demand-control-support (DCS) model and subjective health in managers. METHODS: Data of 424 German, Austrian and Swiss managers were collected at leadership seminars and through presentation of the study at meetings of staff managers and senior executives. Hierarchical regression models controlling for age, hierarchy and non-linear relationships were computed to assess associations between main, interactive and gender-dependent effects of the DCS dimensions (measures of job demands, job control, social support) and subjective health (measures of self rated health and psychosomatic complaints). RESULTS: Social support was associated with both indicators of subjective health. Inconsistent results were obtained for the main effects of job demands and job control. Concerning the interaction effects of the model, a significant three-way interaction was observed: high job control and high social support seem to buffer the adverse health effects of high job demands. This interaction was moderated by gender. Female managers experience more psychosomatic complaints working in high demand, low control, low support settings than their male colleagues. While women seem to experience a higher buffering effect from social support than from job control, male managers may benefit equally from social support and job control. CONCLUSIONS: In managers, gender moderates the health-related effects of the psychosocial work environment. The gender-dependent effects of the DCS model may play a crucial role in the understanding of female managers' adverse health perceptions. Increasing social support for female managers may help to overcome gender inequalities in management positions.