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Expressions of shared interpretations - Intangible outcomes of continuous quality improvement efforts in health- and elderly care
Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

This thesis is anchored in improvement science, the research field of improvement. Improvement science describes and explores improvement in real-life contexts and “system of profound knowledge” (Deming, 2000) is a cornerstone. Performance measures, including their variation over time, are fundamental in the research and evaluation of outcomes of continuous quality improvement efforts (CQI efforts). However, the strong emphasis on operationalisations and measurements risks overshadowing other kinds of outcomes to which CQI efforts can lead.

Research has shown that it is advantageous that those performing change have some kind of “sharedness”, e.g. shared cognitions, understanding, knowledge, interpretations or frame of reference. Despite the diversity of concepts and scientific studies, “sharedness” is mainly described as a prerequisite for change.

This thesis addresses the call to broaden the scientific approach in improvement science and to take advantage of knowledge developed since Deming's time. It has a point of departure in the presumption that CQI efforts also lead to intangible outcomes; qualitative effects that are not easily captured with traditional performance measures. The concept “Expressions of shared interpretations” is used to study “sharedness” as intangible outcomes.

The overall aim with this thesis is to explore Expressions of shared interpretations as intangible outcomes of CQI efforts from the perspective of clinical microsystems and healthcare professionals. The specific aims are to examine and establish how Expressions of shared interpretations develop, influence CQI efforts and change over time.

Using a qualitative approach, this thesis comprises four papers, based on three studies. The empirical context is healthcare and welfare organizations providing care: hospital clinics in county councils/regions and nursing homes in municipalities. The studies include time periods from one to three and a half years, totalling six years. Expressions of shared interpretations inherently mean that the methods for data analysis need to be based on commonalities or patterns in the data. In this thesis three methods are used: qualitative content analysis, thematic analysis and directed content analysis. To examine time-related changes, year-to-year comparative analyses of themes and categories are done.

To explore Expressions of shared interpretations, different theoretical frameworks are used: team cognitions (Paper 1), sensemaking theory (Paper 2), cognitive shifts (Paper 3) and programme theories (Paper 4).

A directed content analysis is applied in a meta-analysis of the results presented in the four papers. The results indicate that Expressions of shared interpretations develop as intangible outcomes of CQI efforts and a general programme theory of CQI efforts in health- and elderly care is developed, illuminating how Expressions of shared interpretations change and influence CQI efforts. The general programme theory incorporates the PDSA cycle and describes the complex, interconnected and continuous development of Expressions of shared interpretations. It also illuminates how Expressions of shared interpretations provide change performers with momentum to engage in forthcoming PDSA cycles and how sensemaking is a central activity.

CQI efforts in health- and elderly care are characterised by a “just get on with it” attitude, while in this thesis, thoughtfulness is emphasized. Existing improvement tools support collaboration, creativity and analysis of critical aspects of the operations, yet none of the improvement tools help change performers gain understanding of the CQI effort as such. To address this, this thesis suggests that change performers complement the use of improvement tools with an inquiring mind, that they collaborate in thoughtful dialogues and that leaders function as inquirers. To support this posture, the widely used Model for improvement is complemented with a fourth question: What are our assumptions? The question pinpoints the need to be thoughtful in every step of the CQI effort, not just in the analysis of the problem at hand.

Place, publisher, year, edition, pages
Jönköping: Jönköping University, School of Health and Welfare , 2017. , 100 p.
Series
Hälsohögskolans avhandlingsserie, ISSN 1654-3602 ; 084
Keyword [en]
Continuous quality improvement, Improvement science, Outcomes
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
URN: urn:nbn:se:hj:diva-37302ISBN: 978-91-85835-83-6 (print)OAI: oai:DiVA.org:hj-37302DiVA: diva2:1140947
Public defence
2017-10-06, Qulturum, Region Jönköping County, Jönköping, 13:00 (English)
Opponent
Supervisors
Available from: 2017-09-13 Created: 2017-09-13 Last updated: 2017-09-13Bibliographically approved
List of papers
1. Revisiting empowerment: a study of improvement work in health care teams
Open this publication in new window or tab >>Revisiting empowerment: a study of improvement work in health care teams
2012 (English)In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 21, no 2, 81-92 p.Article in journal (Refereed) Published
Abstract [en]

This article reports on a study of team empowerment in a large clinic at a Swedish hospital. The focus of the study was to understand how a high degree of empowerment enabled the teams to develop and sustain a high level of performance. More specifically, a model of empowerment was used to identify important factors that contribute to team empowerment in 3 teams at the clinic. In the analysis of the empirical data, 21 factors were identified and the degree of empowerment in the 3 teams was assessed.

National Category
Social Sciences
Identifiers
urn:nbn:se:hj:diva-17592 (URN)10.1097/QMH.0b013e31824d18ee (DOI)22453819 (PubMedID)
Available from: 2012-02-06 Created: 2012-02-06 Last updated: 2017-09-13Bibliographically approved
2. Prospective sensemaking of a National Quality Register in health- and elderly care
Open this publication in new window or tab >>Prospective sensemaking of a National Quality Register in health- and elderly care
2017 (English)In: Leadership in Health Services, ISSN 1751-1879, E-ISSN 1751-1887Article in journal (Refereed) Accepted
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:hj:diva-37299 (URN)
Available from: 2017-09-13 Created: 2017-09-13 Last updated: 2017-09-13
3. Sensemaking and cognitive shifts – Learning from dissemination of a National Quality Register in health- and elderly care
Open this publication in new window or tab >>Sensemaking and cognitive shifts – Learning from dissemination of a National Quality Register in health- and elderly care
2017 (English)In: Leadership in Health Services, ISSN 1751-1879, E-ISSN 1751-1887Article in journal (Refereed) Accepted
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:hj:diva-37300 (URN)
Available from: 2017-09-13 Created: 2017-09-13 Last updated: 2017-09-13
4. Emergent programme theories of a national quality register - a longitudinal study in Swedish elderly care
Open this publication in new window or tab >>Emergent programme theories of a national quality register - a longitudinal study in Swedish elderly care
2017 (English)In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753Article in journal (Refereed) Epub ahead of print
Abstract [en]

Rationale, aim, and objective: This study aimed to explore programme theories of a national quality register. A programme theory is a bundle of assumptions underpinning how and why an improvement initiative functions. The purpose was to examine and establish programme theories of a national quality register widely used in Sweden: Senior alert. The paper reports on how programme theories among change recipients emerge in relation to the established programme theory of the initiator.

Methods: A qualitative approach and a longitudinal research design were used. To develop programme theories among change recipients, individual semistructured interviews were conducted. Three sets of interviews were conducted in the period of 2011 to 2013, totalling 22 interviews. In addition, 4 participant observations were made. To develop the initiator's programme theory, an iterative multistage collaboration process between the researchers and the initiator was used. A directed content analysis was used to analyse data.

Findings: The initiator and change recipients described similar programme logics, but differing programme theories. With time, change recipients' programme theories emerged. Their programme theories converged and became more like the programme theory of the initiator.

Conclusions: This study has demonstrated the importance of making both the initiator's and change recipients' programme theories explicit. To learn about conditions for improvement initiatives, comparisons between their programme theories are valuable. Differences in programme theories provide information on how initiators can customize support for their improvement initiatives. Similar programme logics can be underpinned by different programme theories, which can be deceptive. Programme theories emerge over time and need to be understood as dynamic phenomena. 

Place, publisher, year, edition, pages
Wiley-Blackwell, 2017
Keyword
Clinical guidelines, Healthcare, National quality registers, Programme theory
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:hj:diva-37224 (URN)10.1111/jep.12782 (DOI)28748651 (PubMedID)2-s2.0-85026366236 (Scopus ID)
Available from: 2017-09-08 Created: 2017-09-08 Last updated: 2017-09-14

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