Mass flow of per- and polyfluoroalkyl substances (PFAS) in a Swedish municipal wastewater network and wastewater treatment plant.

PER: and polyfluoroalkyl substances (PFAS) are ubiquitously distributed in wastewater, due to their numerous uses in industry and consumer products, but little is known of PFAS mass flows in municipal wastewater network systems and within wastewater treatment plants (WWTPs). This study assessed mass flows of 26 PFAS in a wastewater network and WWTP, to provide new insights into their sources, transport, and fate in different treatment steps. Wastewater and sludge samples were collected from pumping stations and the main WWTP in Uppsala, Sweden. PFAS composition profiles and mass flows were used to identify sources within the sewage network. Wastewater from one pumping station showed elevated concentrations of C3-C8 PFCA, likely caused by an industrial source, and two stations had elevated concentrations of 6:2 FTSA, probably originating from a nearby firefighter training facility. Within the WWTP, short-chain PFAS dominated in wastewater, whereas long-chain PFAS dominated in sludge. The ratio of perfluoroalkyl sulfonates (PFSA) and ethylperfluorooctanesulfonamidoacetic acid (EtFOSAA) to ∑26PFAS decreased during the WWTP process, likely due to sorption to sludge, but also transformation (EtFOSAA). Overall, PFAS were not efficiently removed in the WWTP, with mean removal efficiency of 10 ± 68% for individual PFAS, resulting in discharge of 7000 mg d-1 ∑26PFAS into the recipient. This shows that conventional WWTPs are inefficient in removing PFAS from wastewater and sludge, so advanced treatment techniques are needed.

Co-digestion of cultivated microalgae and sewage sludge from municipal waste water treatment.

In this study two wet microalgae cultures and one dried microalgae culture were co-digested in different proportions with sewage sludge in mesophilic and thermophilic conditions. The aim was to evaluate if the co-digestion could lead to an increased efficiency of methane production compared to digestion of sewage sludge alone. The results showed that co-digestion with both wet and dried microalgae, in certain proportions, increased the biochemical methane potential (BMP) compared with digestion of sewage sludge alone in mesophilic conditions. The BMP was significantly higher than the calculated BMP in many of the mixtures. This synergetic effect was statistically significant in a mixture containing 63% (w/w VS based) undigested sewage sludge and 37% (w/w VS based) wet algae slurry, which produced 23% more methane than observed with undigested sewage sludge alone. The trend was that thermophilic co-digestion of microalgae and undigested sewage sludge did not give the same synergy.

Swedish healthcare management practices and quality improvement work: development trends.

PURPOSE: The purpose of this paper is to empirically examine developmental trends in healthcare organisation management practice and improvement work. DESIGN/METHODOLOGY/APPROACH: Primary healthcare centre (n = 1,031) and clinical hospital department (n = 1,542) managers were surveyed in spring 2007 (response rate 46 per cent). This article compares results from this survey with a study in 2003. A theoretical framework based on organisational inner context, organisational outer context, external environment and outcomes form the analytical base. Comparisons were made using independent two-sample t-tests. FINDINGS: A general aspect, identified empirically, is the tendency toward increased external pressure on leaders in their improvement work. Higher management decisions, patient pressure and decisions made by policymakers increasingly influence and shape the choices made by healthcare managers about where to focus improvement efforts. Three different trends are empirically identified and elaborated: take-control logic; practice-based improvement; and patient-centeredness. RESEARCH LIMITATIONS/IMPLICATIONS: Healthcare leaders should carefully design new management control systems that support healthcare micro systems. Findings support the general assumption that staff increasingly tend to focus organisational changes on management control. ORIGINALITY/VALUE: This study extends management research with a unique survey. Through two measurements made in 2003 and 2007, several important trends about how healthcare organisations are managed and developed are identified.

Application of statistical process control in healthcare improvement: systematic review.

OBJECTIVE: To systematically review the literature regarding how statistical process control--with control charts as a core tool--has been applied to healthcare quality improvement, and to examine the benefits, limitations, barriers and facilitating factors related to such application. DATA SOURCES: Original articles found in relevant databases, including Web of Science and Medline, covering the period 1966 to June 2004. STUDY SELECTION: From 311 articles, 57 empirical studies, published between 1990 and 2004, met the inclusion criteria. METHODS: A standardised data abstraction form was used for extracting data relevant to the review questions, and the data were analysed thematically. RESULTS: Statistical process control was applied in a wide range of settings and specialties, at diverse levels of organisation and directly by patients, using 97 different variables. The review revealed 12 categories of benefits, 6 categories of limitations, 10 categories of barriers, and 23 factors that facilitate its application and all are fully referenced in this report. Statistical process control helped different actors manage change and improve healthcare processes. It also enabled patients with, for example asthma or diabetes mellitus, to manage their own health, and thus has therapeutic qualities. Its power hinges on correct and smart application, which is not necessarily a trivial task. This review catalogs 11 approaches to such smart application, including risk adjustment and data stratification. CONCLUSION: Statistical process control is a versatile tool which can help diverse stakeholders to manage change in healthcare and improve patients' health.

System characteristics of healthcare organizations conducting successful improvements.

PURPOSE: In a previous study, based on a survey to all clinical department and primary care center managers in Sweden, it was concluded that the prevailing general improvement strategy is characterized by: drivers for improvement are staff needs; patients and data are not as important; improvements mainly focus on administrative routines and stress management; improvements are mainly reached, by writing guidelines, and conducting meetings; the majority of managers perceive outcomes from this strategy as successful. The purpose of current research in this paper is to investigate whether there is any other improvement strategy at play in Swedish health care. DESIGN/METHODOLOGY/APPROACH: Data from the study of all Swedish managers were stratified into two populations based on an instrument predicting successful improvement. One population represented organizations with exceptionally high probability of successful imrpovement and remaining organizations represented the general improvement strategy. FINDINGS: The paper finds that organizations with high probability for successful change differed from the comparison population at the p = 0.05 level in many of the surveyed characteristics. They put emphasis on patient focus, measuring outcomes, feedback of data, interorganizational collaboration, learning and knowledge, communication/information, culture, and development of administration and management. Thus these organizations center their attention towards behavioral changes supported by data. PRACTICAL IMPLICATIONS: Organizations predicted to conduct successful improvement apply comprehensive improvement strategies as suggested in the literature. Such actions are part of the Patient Centered Task Alignment strategy and it is suggested that this concept has managerial implications as well, as it might be useful in further studies on improvement work in health care. ORIGINALITY/VALUE: This paper provides empirically based findings on a successful improvement strategy that can aid research-informed policy decisions on organizational improvement strategies.

Goal orientation and conflicts: Motors of change in development projects in health care service.

In this article we present parts of a larger research study, which aims at explaining how a process-oriented innovation unfolds and develops over time in Swedish health care. Through a longitudinal field study of a national and a local development project, we analyze how the flow model--a process-oriented innovation that emphasizes the sequence of activities a patient undertakes through the health care system--has been developed in Swedish health care. We propose to explain how the development projects unfold over time through the use of process theories of organizational development and change. The national project is best understood as a process of evolution from the phase of selection of projects and teleological (goal-oriented, socially constructed development) and dialectic theory (development via conflict of 2 opposing ideas from different organizational entities) through the process in which national ideas face real-world practice. We also propose a synthesis of dialectics and teleological motors for explaining local development. This synthesis proposes that local development teams have a rather broad notion of what it takes to implement the flow model. The team knows the goal, procedures, and activities from a broad perspective. Through a search-and-interact process, in which other organizational entities such as IT consultants, medical units and politicians have a heavy influence, the group sets and implements goals. Details of how to proceed are, however, constructed in the process of acting. This occurs as ideas are developed and tested in real settings. We conclude the article by presenting managerial implications for understanding these process patterns.

The one-person randomized controlled trial.

Currently, the gold standard for collection of clinical evidence is the randomized controlled trial (RCT), preferably with large, multicenter samples of subjects. Although this approach provides valuable information, many clinicians find it difficult to translate RCT results to the individual patient level. In this report, a statistical approach called Design of Experiments (DOE) is described as a method of applying the principles of RCTs one person at a time. An overview of the method, with a simple clinical example, is presented. As shown, DOE is a more efficient method than the sequential approach often taken by clinicians and their patients when evaluating various treatment choices. Further, the effect of multiple interventions can be assessed, alone or in combination with each other. In this way, DOE can be an important addition to the field of evidence-based medicine, although further studies are needed.

Prospective evaluation of a Bayesian model to predict organizational change.

This research examines a subjective Bayesian model's ability to predict organizational change outcomes and sustainability of those outcomes for project teams participating in a multi-organizational improvement collaborative.

Surveying improvement activities in health care on a national level--the Swedish internal collaborative strategy and its challenges.

In order to map improvement activities in Swedish health care, we surveyed the managers of all primary health care centers (n = 958) and clinical hospital departments (n = 1355), with a response rate of 46%. The majority reports that their staff view improvement work positively. The most common driver of improvement is work environment problems, whereas external drivers have less influence. Among 35 methods, the most commonly used are educational initiatives, stress management, guidelines, and leadership development, whereas accreditation is used the least. Respondents who report extensive improvement efforts indicate the greatest benefit from educational interventions, analysis of patient incidents, guidelines, and rapid cycle tests. Respondents claim that improvement initiatives yield positive results, in particular regarding the working environment, administrative routines, workflow, and communication, although only 15%-30% of respondents report having data to support their claims. Our findings indicate an introverted focus of most improvement efforts, starting with staff and administration needs. Further research is needed to understand how and why some centers and departments have managed to achieve strategic, measurable, patient-focused, systems improvements, whereas most have not.

Perceptions of improvement work in Swedish health care: implications for improvement practices.

This study explored perceptions of improvement work in Swedish health care. The article discusses effects that these perceptions may have on improvement processes. As part of a broader study surveying managers' (n = 2313) view of improvement work in Swedish health care, this study focused on those 845 managers who regarded their improvement work as bringing about benefits. Three underlying factors that may characterize the managers' perceptions are exposed. More than 50% of the respondents perceive a complexity in the practices and techniques associated with improvement work. Furthermore, approximately 50% of the managers recognize a conflict in the meeting between the improvement work and the organization. This indicates that adaptation is a primary concern in this work. The managers' perceptions also reveal that the experience of improvement work in Swedish health care may be positive, although the perception is that it does not necessarily generate more health care per monetary unit.

Do health care managers know the comparative quality of their care?

Compared with other industries, health care is a high-risk industry. In this study, two national data sets on patient claims and a survey of improvement efforts in Swedish health care were used to investigate the linkage between how health care managers perceive their performance regarding adverse medical events and their performance as reflected in patient malpractice claims rates. The departments' focus on patient safety issues in their improvement efforts was also evaluated. Our results show that Swedish health care department managers underestimate their departments' frequency of adverse medical events relative to that of similar units. Also, there is no correlation between the managers' perception of adverse medical events and their actual frequency of patient malpractice claims. More research is needed on the use of patient-generated malpractice claims and claims rates to promote a higher awareness of the magnitude of the safety problems in health care.

Developing and testing a model to predict outcomes of organizational change.

Health care decisions could be better informed by research evidence, but there are many areas in which there is little or inconclusive research. Pooling expert knowledge is one way to generate theories and make predictions in areas where there is little clear research evidence. This article addresses these two perspectives in parallel: (1) how to systematically build expert models that have a high predictive and explanatory value by the use of the Integrative Group Process and (2) a model to predict which quality improvement initiatives will be successful, the Swedish Organizational Change Model. The model reveals 11 factors important for successful improvement. Tests of the model conclude that it predicts a high number of successful and unsuccessful initiatives. It can thus be used to diagnose weaknesses in improvement efforts, to measure an organization's overall potential for successful improvement, and to prioritize potential initiatives under consideration.

Reflections on transnational transferability of improvement technologies--a comparison of factors for successful change in the United States and northern Europe.

Two reliable models for predicting the success of change initiatives have been developed through the same research process. One model represents what is important in order to conduct successful improvements in the United States. The other model has been developed to predict successful improvement initiatives in Sweden. Through qualitative comparison between two reliable models we found some similarities and differences framing the underlying management heuristics for driving improvement initiatives. These findings are important pieces in transnational knowledge acquirement on quality improvements. They contribute a basis for discussions on transferability of management change concepts, and prompts for areas in need of considerations of adaptation before using different improvement ideas in other contexts than those for which they were developed.