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Navigera i ständig förändring: facilitering av utvecklingsarbete inom vård och omsorg
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. (SOLIID)ORCID iD: 0000-0001-4927-2014
2014 (Swedish)Doctoral thesis, comprehensive summary (Other academic)
Abstract [sv]

Bakgrund Vård och omsorg arbetar under höga krav på kvalitet och säkerhet i sin verksamhet. Många förbättringsområden är kända, och nya tillkommer hela tiden. Vårdens och omsorgens organisationer arbetar hårt för att möta de utmaningar, krav och möjligheter de ställs inför. Många metoder och förslag på lösningar finns att tillgå, men det har visat sig svårt att med säkerhet veta vad som fungerar, och i vilket sammanhang. Kanske är frågorna om hur och varför någonting fungerar, eller ej, ännu viktigare att söka svar på. Avhandlingen riktar sitt fokus mot facilitering av förändring och utvecklingsarbete i vårdens och omsorgens organisationer. Omfattande forskning finns kring stöd och facilitering av utvecklings- och förbättringsarbete för små grupper, främst i kärnverksamheten. Forskning om systemövergripande och organiserad facilitering av utvecklingsarbete är inte lika vanligt förekommande. Genom att i min avhandling följa tre fall, där faciliterande grupperingar var aktiva under pågående systemövergripande ansatser för utveckling och förändring, önskar jag att jag kan bidra till ökad kunskap om utmaningar för och potentialen i att skapa förutsättningar för sådana faciliterande funktioner.

Metoder Avhandlingen bygger på fyra studier från tre empiriska fall. I samtliga fall studerades faciliterande grupperingar med uppdrag att stödja systemövergripande utvecklingsarbete i en geografisk region med många aktörer, organisationer och verksamheter, enheter, avdelningar och beslutsnivåer. De flesta av respondenterna tillhörde någon av de faciliterande grupperingarna, men data samlades också in från andra nyckelaktörer, aktiva i utvecklingsarbete. Datainsamlingen omfattade semistrukturerade intervjuer, processdagböcker, observationer och dokument. Avhandlingen bygger på innehållsanalys av kvalitativa data. Den innehållsanalys som tillämpats innefattar en systematisk och replikerbar teknik för att innehållskategorisera stora mängder data genom att tillämpa fasta definitioner och regler för kategorisering. För att stärka validiteten tillämpades triangulering av data från flera källor. För ökad reliabilitet har flera bedömare oberoende analyserat samma data när så varit möjligt.

Resultat Analysen av data från de tre fallen visar på stora utmaningar, men också lovande utsikter för stöd till förändring och utvecklingsarbete i vård och omsorg med hjälp av faciliterande grupperingar. Resultaten kan sammanfattas i fyra perspektiv: de faciliterande grupperingarnas interna relationer, roller och arbete; relationen mellan de faciliterande grupperingarna och de organisationer och verksamheter de arbetade med; förutsättningarna som skapades för facilitering inom organisationerna; och utvecklingen av faciliterande funktioner med kapacitet att fungerar som ett stöd för det uppdrag som organisationen har att utföra.

Slutsatser För att leda och stödja ett uthålligt förändrings- och utvecklingsarbete inom vård och omsorg behövs solid och mångfacetterad information och kunskap, förståelse för många typer av processer, och en flexibilitet som gör det möjligt att arbeta i ständig förändring och i en verklighet som uppvisar stor variation. Det förefaller finnas en stor potential i att använda faciliterande grupperingar med uppdrag att stödja utvecklingsarbete. För att kunna nyttja potentialen i sådana funktioner krävs kapacitet både inom grupperingarna och inom organisationen. Att bygga kapacitet för en fungerande faciliterande funktion omfattar både internt arbete i den faciliterande grupperingen och arbete på alla nivåer i organisationen. Något som omfattar planering, genomförande och uppföljningssystem där det dagliga arbetet och arbetet med att utveckla är sammanvävt och systematiskt. Det är idag oklart var nödvändig analys och reflektion kring utvecklingsarbete i ett systemövergripande perspektiv sker. Faciliterande grupperingar skulle kunna utgöra navet för en sådan kontinuerlig process om de äger kapacitet, mandat och förtroende att fylla den funktionen.

Abstract [en]

Background Health care and social services are complex entities, operating under high demands of quality and safety. There are many areas for development and new findings on what can be improved are presented continuously. To meet these demands and options organizations engage in efforts to change and develop what they do, and how they do it. Many interventions and methods are at hand, but it has proven difficult to answer the question of what works where and when. It is also stressed that an even more important question is how and why things work, or do not work. This thesis is focused on the facilitation of organizational development and quality improvement efforts. While a lot of research is found on the facilitation of improvement work in smaller workgroups, there is less on the more strategic and system-wide facilitation of organizational development and quality improvement. By following the facilitation of change and development work in three cases I aim to generate knowledge on the challenges in and the potential of using facilitation teams.

Methods The thesis is based on four studies from three empirical cases. In all case settings, the teams had the task of facilitating system-wide organizational development and quality improvement, covering geographical regions with several actors, organizations, units and decision levels. Key respondents where the facilitation team members, and data was also collected from other key actors involved in development efforts. Data collection included semi structured interviews, process diaries with defined areas for reflection, observations and archival data such as minutes, information sheets, presentations, annual reports and project reports. Qualitative data was analysed using content analysis, which is “a systematic, replicable technique for compressing many words of text into fewer content categories based on explicit rules of coding”. The two keystones for the type of content analysis used are the clear definitions of categories and mutually exclusive and exhaustive categories. Validity is strengthened by triangulation of data from multiple sources and reliability, when possible, by independent classification of data by two researchers.

Results Data from the three empirical cases show patterns of challenges as well as common promising prospects for facilitation of change and development in health care and social services. Challenges were identified within the formal and informal aspects of facilitation teams, in composition and organizational positions of facilitating teams, and in their understanding of premises, change and development processes. Results also revealed important factors influencing the possibilities to apply a facilitating approach that would be sustainable, serving the perspectives of a multi-level organization and building capacity for continuous development and improvement in the organisations, as well as within the facilitating teams.

Conclusion Sustainable change and development work in health care and social services organizations must be built on solid and multifaceted information, great understanding of processes in a broad sense and an ability to function in continuous change. There seems to be a great potential in having teams function with a role and mandate to facilitate organizational development and quality improvement processes through capacity building. This capacity building involves the facilitating team, the staff and management of the organization, and the forms and structures of planning, and implementation and follow-up systems where daily work and improvement efforts are interlinked. It is unclear where analysis and reflection on development work and improvement processes are carried out in health care and social services organizations today. Facilitating teams could be the hub of such an ongoing process, provided that they have the capacity, mandate and trust to fullfill such a function.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2014. , 61 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1639
Keyword [sv]
Organisationsutveckling, organisationsförändring, förändringsarbete, utvecklingsarbete, facilitering, uppföljning
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-87916ISBN: 978-91-7601-032-7 (print)OAI: oai:DiVA.org:umu-87916DiVA: diva2:712238
Public defence
2014-05-09, Hörsal Betula, Unod L, plan 0, Byggnad 6M, Norrlands universitetssjukhus, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Projects
På väg mot uthållighet i innovationer och organisatoriskt lärande inom vårdenFramtidens välfärdstjänsterNationella riktlinjer för vårdens hälsofrämjande arbeteSFO-Vård
Available from: 2014-04-16 Created: 2014-04-14 Last updated: 2015-04-29Bibliographically approved
List of papers
1. Challenges in managing a multi-sectoral health promotion program
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2013 (English)In: Leadership in Health Services, ISSN 1751-1879, E-ISSN 1751-1887, Vol. 26, no 4, 368-386 p.Article in journal (Refereed) Published
Abstract [en]

Purpose: The purpose of this paper is to investigate program management teams’ views on issuesand challenges in managing a large, multi-sectoral child health promotion program in Sweden.

Design/methodology/approach: In total, 17 participants representing two autonomous programmanagement teams, one strategic and one operational, were interviewed. Analysis of interview datawas complemented with reviews of program documents.

Findings: Program management teams identified important issues concerning the program’sformal structure, goals, role distribution, and change and dissemination processes, but lacked a sharedmental model of the situation. Inter and intra group communication, long- and short-term strategicplanning were further areas in need of improvement. While issues and challenges might seem to beagreed upon by the program’s change agents, closer inspection reveals variation in key characteristicsas well as in perspectives on solutions.

Originality/value: Health promotion programs are challenging. Researchers trying tounderstand program success have focused on particular interventions, contextual factors andprogram recipients. Less research has focused on the internal processes of teams tasked withwide-ranging change mandates and the effects such processes can have on program outcomes. Thisstudy contributes to a deeper understanding on internal processes and mental models of changeagent teams.

Place, publisher, year, edition, pages
Emerald Group Publishing Limited, 2013
Keyword
health promotion, Sweden, mental models, change management, implementation process, program management
National Category
Health Sciences
Identifiers
urn:nbn:se:umu:diva-85029 (URN)10.1108/LHS-12-2011-0048 (DOI)
Available from: 2014-01-27 Created: 2014-01-27 Last updated: 2017-12-06Bibliographically approved
2. Change and learning strategies in large scale change programs: describing the variation of strategies used in a health promotion program
Open this publication in new window or tab >>Change and learning strategies in large scale change programs: describing the variation of strategies used in a health promotion program
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2013 (English)In: Journal of Organizational Change Management, ISSN 0953-4814, E-ISSN 1758-7816, Vol. 26, no 6, 1020-1044 p.Article in journal (Refereed) Published
Abstract [en]

Purpose The study identifies the variation of change strategies used in a complex large scale change program in health and social services in Sweden, aimed at changing professionals' health promoting practices. The purpose is to investigate the change strategies used over time and describe the potential variation in key change agent views, using a framework inspired by De Caluwe and Vermaak's multi paradigm change typology.

Design/methodology/approach The first six years of the regional multi-sector program are examined. Results are based on content analyses of interviews with key change actors, and archival data describing program activities. Respondents belonged to either the strategic or the operational program management team, representing different sectors of health and social services in a region.

Findings Multiple strategy paradigms showed varying influence over the program's different phases, partly due to program progress, change agent influence and/or varying contextual demands. Respondents' views on strategies and program focus varied depending on their program roles. Respondents expressed insights about the varying conditions for change and on the conflicting expectations within and between program management teams.

Originality/value This study introduces the application of a new framework on a large scale, complex change program. The framework sheds light on a number of basic assumptions and change strategies that can be further compared with content and context factors, barriers, facilitators, outcomes, and in turn with other programs.

Place, publisher, year, edition, pages
Emerald Group Publishing Limited, 2013
Keyword
Strategy, Change management, Organizational development, Organizational learning, Change agents, Large scale change programs, Sweden
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-83106 (URN)10.1108/JOCM-08-2012-0132 (DOI)000325783700006 ()
Available from: 2013-11-18 Created: 2013-11-18 Last updated: 2017-12-06Bibliographically approved
3. Quality improvement in large health care organizations: searching for system-wide and coherent monitoring and follow-up strategies
Open this publication in new window or tab >>Quality improvement in large health care organizations: searching for system-wide and coherent monitoring and follow-up strategies
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(English)In: Article in journal (Other academic) Submitted
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-87912 (URN)
Available from: 2014-04-14 Created: 2014-04-14 Last updated: 2015-04-29Bibliographically approved
4. Building capacity for capacity building: challenges in developing an R&D unit approcach
Open this publication in new window or tab >>Building capacity for capacity building: challenges in developing an R&D unit approcach
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(English)Manuscript (preprint) (Other academic)
Keyword
Change facilitation,  Organizational development,  Organizational learning 
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-87915 (URN)
Available from: 2014-04-14 Created: 2014-04-14 Last updated: 2015-04-29Bibliographically approved

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