Organizing visions for data-centric management: how Norwegian policy documents construe the use of data in health organizations.

PURPOSE: Norway, like other welfare states, seeks to leverage data to transform its pressured public healthcare system. While managers will be central to doing so, we lack knowledge about how specifically they would do so and what constraints and expectations they operate under. Public sources, like the Norwegian policy documents investigated here, provide important backdrops against which such managerial work emerges. This article therefore aims to analyze how key Norwegian policy documents construe data use in health management. DESIGN/METHODOLOGY/APPROACH: We analyzed five notable policy documents using a "practice-oriented" framework, considering these as arenas for "organizing visions" (OVs) about managerial use of data in healthcare organizations. This framework considers documents as not just texts that comment on a topic but as discursive tools that formulate, negotiate and shape issues of national importance, such as expectations about data use in health management. FINDINGS: The OVs we identify anticipate a bold future for health management, where data use is supported through interconnected information systems that provide relevant information on demand. These OVs are similar to discourse on "evidence-based management," but differ in important ways. Managers are consistently framed as key stakeholders that can benefit from using secondary data, but this requires better data integration across the health system. Despite forward-looking OVs, we find considerable ambiguity regarding the practical, social and epistemic dimensions of data use in health management. Our analysis calls for a reframing, by moving away from the hype of "data-driven" health management toward an empirically-oriented, "data-centric" approach that recognizes the situated and relational nature of managerial work on secondary data. ORIGINALITY/VALUE: By exploring OVs in the Norwegian health policy landscape, this study adds to our growing understanding of expectations towards healthcare managers' use of data. Given Norway's highly digitized health system, our analysis has relevance for health services in other countries.

Games of uncertainty: the participation of older patients with multimorbidity in care planning meetings - a qualitative study.

BACKGROUND: Active patients lie at the heart of integrated care. Although interventions to increase the participation of older patients in care planning are being implemented in several countries, there is a lack of knowledge about the interactions involved and how they are experienced by older patients with multimorbidity. We explore this issue in the context of care-planning meetings within Norwegian municipal health services. METHODS: This qualitative study drew on direct observations of ten care-planning meetings and an interview with each patient right after the meeting. Following a stepwise-deductive induction approach, the analysis began inductively and then considered the interactions through the lens of game theory. RESULTS: The care-planning interactions were influenced by uncertainty about the course of the disease and how to plan service delivery. In terms derived from game theory, the imaginary and unpredictable player 'Nature' generated uncertainty in the 'game' of care planning. The 'players' assessed this uncertainty differently, leading to three patterns of game. 1) In the 'game of chance', patients viewed future events as random and uncontrollable; they felt outmatched by the opponent Nature and became passive in their decision-making. 2) In the 'competitive game', participants positioned themselves on two opposing sides, one side perceiving Nature as a significant threat and the other assigning it little importance. The two sides negotiated about how to accommodate uncertainty, and the level of patient participation varied. 3) In the 'coordination game', all participants were aligned, either in viewing themselves as teammates against Nature or in ascribing little importance to it. The level of patient participation was high. CONCLUSIONS: In care planning meetings, the level of patient participation may partly be associated with how the various actors appraise and respond to uncertainty. Dialogue on uncertainty in care-planning interventions could help to increase patient participation.

'What matters to you?' Normative integration of an intervention to promote participation of older patients with multi-morbidity - a qualitative case study.

BACKGROUND: Interventions in which individual older patients with multi-morbidity participate in formulating goals for their own care are being implemented in several countries. Successful service delivery requires normative integration by which values and goals for the intervention are shared between actors at macro-, meso- and micro-levels of health services. However, health services are influenced by multiple and different institutional logics, which are belief systems guiding actors' cognitions and practices. This paper examines how distinct institutional logics materialize in justifications for patient participation within an intervention for patients with multi-morbidity, focusing on how variations in the institutional logics that prevail at different levels of health services affect vertical normative integration. METHODS: This qualitative case study of normative integration spans three levels of Norwegian health services. The macro-level includes a white paper and a guideline which initiated the intervention. The meso-level includes strategy plans and intervention tools developed locally in four municipalities. Finally, the micro-level includes four focus group discussions among 24 health professionals and direct observations of ten care-planning meetings between health professionals and patients. The content analysis draws on seven institutional logics: professional, market, family, community, religious, state and corporate. RESULTS: The particular institutional logics that justified patient participation varied between healthcare levels. Within the macro-level documents, seven logics justified patients' freedom of choice and individualization of service delivery. At meso-level, the operationalization of the intervention into tools for clinical practice was dominated by a state logic valuing equal services for all patients and a medical professional logic in which patient participation meant deciding how to maintain patients' physical abilities. At micro-level, these two logics were mixed with a corporate logic prioritizing cost-efficient service delivery. CONCLUSION: Normative integration is challenging to achieve. The number of institutional logics in play was reduced downwards through the three levels, and the goals behind the intervention shifted from individualization to standardization. The study broadens our understanding of the dynamic between institutional logics and of how multiple sets of norms co-exist and guide action. Knowledge of mechanisms by which normative justifications are put into practice is important to achieve normative integration of patient participation interventions.

Sharing responsibility: municipal health professionals' approaches to goal setting with older patients with multi-morbidity - a grounded theory study.

BACKGROUND: Recent health policy promoting integrated care emphasizes to increase patients' health, experience of quality of care and reduce care utilization. Thus, health service delivery should be co-produced by health professionals and individual patients with multiple diseases and complex needs. Collaborative goal setting is a new procedure for older patients with multi-morbidity. The aim is to explore municipal health professionals' experiences of collaborative goal setting with patients with multi-morbidity aged 80 and above. METHODS: A qualitative study with a constructivist grounded theory approach. In total twenty-four health professionals from several health care services in four municipalities, participated in four focus group discussions. RESULTS: Health professionals took four approaches to goal setting with older patients with multi-morbidity: motivating for goals, vicariously setting goals, negotiating goals, and specifying goals. When 'motivating for goals', they educated reluctant patients to set goals. Patients' capacity or willingness to set goals could be reduced, due to old age, illness or less knowledge about the health system. Health professionals were 'vicariously setting goals' when patients did not express or take responsibility for goals due to adaptation processes to disease, or symptoms as cognitive impairment or exhaustion. By 'Negotiating goals', health professionals handled disagreements with patients, and often relatives, who expected to receive more services than usual care. They perceived some patients as passive or having unrealistic goals to improve health. 'Specifying goals' was a collaboration. Patients currently treated for one condition, set sub-goals to increase health. Patients with complex diseases prioritized one goal to maintain health. These approaches constitute a conceptual model of how health professionals, to varying extents, share responsibility for goal setting with patients. CONCLUSIONS: Goal setting for patients with multi-morbidity were carried out in an interplay between patients' varying levels of engagement and health professionals' attitudes regarding to what extents patients should be responsible for pursuing the integrated health services' objectives. Even though goal setting seeks to involve patients in co-production of their health service delivery, the health services´ aims and context could restrict this co-production.