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  • 1.
    Algurén, Beatrix
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. University of Gothenburg, Faculty of Education, Department of Food and Nutrition, and Sport Science, Sweden.
    Andersson Gäre, Boel
    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). Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping). Region Jönköping County, Futurum, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Andersson, Ann-Christine
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Quality indicators and their regular use in clinical practice – results from a survey among users of two cardiovascular National Registries in Sweden2018In: International Journal for Quality in Health Care, ISSN 1353-4505, E-ISSN 1464-3677, Vol. 30, no 10, p. 786-792Article in journal (Refereed)
    Abstract [en]

    Objective: To examine the regular use of quality indicators from Swedish cardiovascular National Quality Registries (NQRs) by clinical staff; particularly differences in use between the two NQRs and between nurses and physicians.

    Design: Cross-sectional online survey study.

    Setting: Two Swedish cardiovascular NQRs: a) Swedish Heart Failure Registry and b) Swedeheart.

    Participants: Clinicians (n=185; 70% nurses, 26% physicians) via the NQRs’ email networks.

    Main outcome measures: Frequency of NQR use for a) producing healthcare activity statistics; b) comparing results between similar departments; c) sharing results with colleagues; d) identifying areas for quality improvement (QI); e) surveilling the impact of QI efforts; f) monitoring effects of implementation of new treatment methods; g) doing research; h) educating and informing healthcare professionals and patients.

    Results: Median use of NQRs was ten times a year (25th and 75th percentiles range: 3 – 23 times/year). Quality indicators from the NQRs were used mainly for producing healthcare activity statistics. Median use of Swedeheart was six times greater than SwedeHF (p<0.000). Physicians used the NQRs more than twice as often as nurses (18 vs. 7.5 times/year; p<0.000) and perceived NQR work more often as meaningful. Around twice as many Swedeheart users had the role to participate in data analysis and in QI efforts compared to SwedeHF users.

    Conclusions: Most respondents used quality indicators from the two cardiovascular NQRs infrequently (< 3 times/year). The results indicate that linking registration of quality indicators to using them for QI activities increases their routine use and makes them meaningful tools for professionals.

  • 2.
    Andersson, Ann-Christine
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Andersson Gäre, Boel
    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). Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    Thor, Johan
    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).
    Lenrick, Raymond
    Rapport om utvärdering av IVO:s lärande tillsyn2018Report (Other academic)
    Abstract [sv]

    Inspektionen för vård och omsorg (IVO) har i sin tillsynspolicy lagt fokus på att främja lärande för att stödja utvecklingen av god kvalitet och säkerhet i vård och omsorg. Under 2017 har IVO givit Jönköping Academy for Improvement of Health and Welfare vid Jönköping University i uppdrag att utvärdera tillämpning av lärande tillsyn. Syftet med denna studie var att belysa om, och om möjligt hur, IVO:s tillsyn kan stödja verksamhetsutveckling och förbättring i de tillsynade verksamheter. Det finns många teoribildningar kring lärande och kvalitetsutveckling. Denna rapport tar utgångspunkt i teorier om organisatoriskt lärande, samskapande och förbättringskunskap och belyser vad som kan bidra, och i så fall hur, till en ömsesidig tillit som leder till ett fördjupat lärande som grund för förbättring.

    Studien omfattar två tillsyner, där deltagarna bestod av personal från de berörda verksamheterna, samt IVO-inspektörer från de regionala IVO avdelningar. Det empiriska materialet samlades in genom intervjuer och en observation. En dokumentgenomgång av relevanta IVO dokument skapade underlag för utvecklandet av studiens intervjuguider. Intervjuerna bandades, transkriberades och analyserades med en metod inspirerad av tematisk analys, som utmynnade i fem teman: (I) Förberedelse inför tillsyn; (II) Genomförande i verksamheten; (III) Resultat i verksamheten; (IV) Förutsättningar för lärande; och (V) Önskemål för ökat lärande. Samtliga teman innehåller både förhållanden som stödjer (främjar) och som försvårar (hindrar) lärande:

    • Förberedelsearbetet ansågs inte bidra till en ökad tillit som förutsättning för lärande. Det uttrycktes en önskan om mer samskapande i förberedelsearbetet redan innan tillsynstillfället
    • Det framkom önskemål om att lärandet, som ett av målen med tillsynen, skulle lyftas tydligare i dialogen vid tillsynstillfället.
    • Det uppfattades som svårt att peka på reella resultat i verksamheterna som direkt berodde på tillsynen, men det beskrevs ändå som viktigt att tillsynen fanns.
    • Det fanns olika uppfattningar om hur IVO:s roll som tillsynsmyndighet påverkade lärandet. Ett större fokus på gemensam uppföljning skulle vara ett sätt att optimera lärandet både i verksamheterna och hos IVO:s inspektörer.
    • Ett lärande skulle gynnas av en tydlig gemensam problembeskrivning, samt fortlöpande uppföljningar och delad kunskap, exempelvis genom goda exempel och dialogkonferenser.

    Generellt fanns en stor samstämmighet mellan IVO:s inspektörer och de verksamhetsföreträdare som intervjuats, men vissa skillnader framkom också. Rapporten avslutas med några avslutande reflektioner.

  • 3.
    Bergerum, Carolina
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Johan, Thor
    Jönköping University.
    Josefsson, Karin
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Wolmesjö, Maria
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    How might patient involvement in healthcare quality improvement efforts work—A realist literature review2019In: Health Expectations, ISSN 1369-6513, E-ISSN 1369-7625, Vol. 00, no 00, p. 1-13Article in journal (Refereed)
    Abstract [en]

    Introduction This realist literature review, regarding active patient involvement in healthcare quality improvement (QI), seeks to identify possible mechanisms that contribute to success or failure. Furthermore, the paper outlines key considerations for organising and supporting patient involvement in healthcare QI efforts.

     

    Methods Two literature searches were performed. Altogether, 1,204 articles from a healthcare context were screened, focusing on improvement efforts that involve patients, healthcare professionals and/or managers and leaders. Among these, 107 articles fulfilled the chosen study selection criteria and were further analysed. 18 articles underwent a full realist review. In the realist synthesis, context-mechanism-outcome configurations were articulated as middle-range theories and organised thematically to generate a program theory on how active patient involvement in QI efforts might work.

     

    Results The articles exhibited a diversity of patient involvement approaches at different levels of healthcare organisations. To be successful, organisations’ support of QI efforts that actively involved patients tailored the QI efforts to their context to achieve the desired outcomes, and involved the relevant microsystem members. Furthermore, it promoted interaction and partnership within the microsystem, and supported the behavioural change that follows.

    Conclusion This realist synthesis generates a program theory for active patient involvement in QI efforts; active patient involvement can be a tool (resource), if tailored for interaction and partnership (reasoning), that leads to behaviour change (outcome) within healthcare QI efforts. The theory explains essential resource and reasoning mechanisms, and outcomes that together form guidance for healthcare organisations when managing active patient involvement in QI efforts.

  • 4.
    Bergerum, Carolina
    et al.
    Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden.
    Thor, Johan
    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).
    Josefsson, Karin
    Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden.
    Wolmesjö, Maria
    Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden.
    How might patient involvement in healthcare quality improvement efforts work—A realist literature review2019In: Health Expectations, ISSN 1369-6513, E-ISSN 1369-7625, Vol. 22, no 5, p. 952-964Article, review/survey (Refereed)
    Abstract [en]

    Introduction

    This realist literature review, regarding active patient involvement in healthcare quality improvement (QI), seeks to identify possible mechanisms that contribute to success or failure. Furthermore, the paper outlines key considerations for organizing and supporting patient involvement in healthcare QI efforts.

    Methods

    Two literature searches were performed. Altogether, 1204 articles from a healthcare context were screened, focusing on improvement efforts that involve patients, healthcare professionals and/or managers and leaders. Among these, 107 articles fulfilled the chosen study selection criteria and were further analysed. Eighteen articles underwent a full realist review. In the realist synthesis, context-mechanism-outcome configurations were articulated as middle-range theories and organized thematically to generate a program theory on how active patient involvement in QI efforts might work.

    Results

    The articles exhibited a diversity of patient involvement approaches at different levels of healthcare organizations. To be successful, organizations? support of QI efforts that actively involved patients tailored the QI efforts to their context to achieve the desired outcomes, and involved the relevant microsystem members. Furthermore, it promoted interaction and partnership within the microsystem, and supported the behavioural change that follows.

    Conclusion

    This realist synthesis generates a program theory for active patient involvement in QI efforts; active patient involvement can be a tool (resource), if tailored for interaction and partnership (reasoning), that leads to behaviour change (outcome) within healthcare QI efforts. The theory explains essential resource and reasoning mechanisms, and outcomes that together form guidance for healthcare organizations when managing active patient involvement in QI efforts.

  • 5.
    Goodman, Daisy
    et al.
    Dartmouth Hitchcock Medical Center, USA.
    Ogrinc, Greg
    Veterans Health Administration, USA.
    Davies, Louise
    Veterans Health Administration, USA.
    Baker, G. Ross
    University of Toronto, Canada.
    Barnsteiner, Jane
    University of Pennsylvania, USA.
    Gali, Kari
    Cleveland Clinic Children’s Hospital, USA.
    Hilden, Joanne
    Colorado Children’s Hospital, USA.
    Horwitz, Leora
    New York University, USA.
    Kaplan, Heather C.
    Cincinnati Children’s Hospital Medical Center, USA.
    Leis, Jerome
    University of Toronto, Canada.
    Matulis, John C.
    Dartmouth Hitchcock Medical Center, USA.
    Michie, Susan
    University College, UK.
    Miltner, Rebecca
    University of Alabama, USA.
    Neily, Julia
    Veterans Health Administration, USA.
    Nelson, William A.
    Geisel School of Medicine, USA.
    Niedner, Matthew
    University of Michigan Medical Center, USA.
    Oliver, Brant
    MGH Institute of Health Professions, USA.
    Rutman, Lori
    Seattle Children’s Hospital, USA.
    Thomson, Richard
    Newcastle University, UK.
    Thor, Johan
    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).
    Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: Examples of SQUIRE elements in the healthcare improvement literature2016In: BMJ Quality and Safety, ISSN 2044-5415, E-ISSN 2044-5423, Vol. 25, no 12, article id e7Article in journal (Refereed)
    Abstract [en]

    Since its publication in 2008, SQUIRE (Standards for Quality Improvement Reporting Excellence) has contributed to the completeness and transparency of reporting of quality improvement work, providing guidance to authors and reviewers of reports on healthcare improvement work. In the interim, enormous growth has occurred in understanding factors that influence the success, and failure, of healthcare improvement efforts. Progress has been particularly strong in three areas: the understanding of the theoretical basis for improvement work; the impact of contextual factors on outcomes; and the development of methodologies for studying improvement work. Consequently, there is now a need to revise the original publication guidelines. To reflect the breadth of knowledge and experience in the field, we solicited input from a wide variety of authors, editors and improvement professionals during the guideline revision process. This Explanation and Elaboration document (E&E) is a companion to the revised SQUIRE guidelines, SQUIRE 2.0. The product of collaboration by an international and interprofessional group of authors, this document provides examples from the published literature, and an explanation of how each reflects the intent of a specific item in SQUIRE. The purpose of the guidelines is to assist authors in writing clearly, precisely and completely about systematic efforts to improve the quality, safety and value of healthcare services. Authors can explore the SQUIRE statement, this E&E and related documents in detail at http://www.squire-statement.org.

  • 6.
    Holmqvist, Malin
    et al.
    Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Region Jönköpings län.
    Thor, Johan
    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).
    Ros, Axel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Region Jönköpings län.
    Johansson, Linda
    Jönköping University, School of Health and Welfare, HHJ, Institute of Gerontology. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    "I trust my physician but want to be involved"  - Older persons' Experiences of regarding evaluation of their medication treatment2019Conference paper (Refereed)
  • 7.
    Holmqvist, Malin
    et al.
    Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Thor, Johan
    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).
    Ros, Axel
    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).
    Johansson, Linda
    Jönköping University, School of Health and Welfare, HHJ, Institute of Gerontology. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    Older persons’ experiences regarding evaluation of their medication treatment: An interview study in Sweden2019In: Health Expectations, ISSN 1369-6513, E-ISSN 1369-7625Article in journal (Refereed)
    Abstract [en]

    Background: Older persons with polypharmacy are at increased risk of harm from medications, and this issue is a global patient safety challenge. Harm may arise at all stages of medication use and may cause hospital admission, additional resource uti ‐lization and lower patient satisfaction. Older persons’ participation in their own care may increase patient safety. Their views on the evaluation of their medication treat ‐ment, and their own involvement in it, are crucial yet poorly understood.

    Objectives: To identify opportunities to make the medication use process safer, we explored and described older persons’ experiences of evaluation of their medicationtreatment.

    Design: Semi‐structured interviews were performed with 20 community‐dwelling older persons (age 75‐91 years) in Sweden. Data were analysed using inductive quali ‐tative content analysis.

    Results: These older persons reported having a responsibility to engage in their med ‐ication evaluations, although some felt unable to do so or considered themselves un ‐concerned. Evaluation, in their experience, was facilitated by continuity of care and an invitation to participate. However, some older persons experienced not receivinga comprehensive medication evaluation.

    Discussion and conclusion: Older persons want to be actively involved in their medi ‐cation evaluations, and this may represent an underutilized resource in the pursuit of patient safety. Their trust in physicians to undertake evaluations on a regular basis, although that does not necessarily occur, may cause harm. Patient safety could benefit from a co‐production approach to medication evaluations, with health‐care professionals explicitly sharing information with older persons and agreeing on re ‐sponsibilities related to on‐going medication treatment.

  • 8.
    Kilander, Helena
    et al.
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Berterö, Carina
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Brynhildsen, Jan
    Department of Obstetrics and Gynaecology and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
    Alehagen, Siw
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Women's experiences of contraceptive counselling in the context of an abortion – An interview study2018In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 17, p. 103-107Article in journal (Refereed)
    Abstract [en]

    Objective: To identify and understand women's lived experiences of contraceptive counselling given at the same time as abortion counselling.

    Methods: We interviewed 13 women aged 20–39 who had experienced an abortion and the related counselling. The women were recruited from five hospitals in Sweden. Interviews were analysed using an interpretative phenomenological approach.

    Results: We identified two themes: need for respectful counselling and needs for guidance and access to contraceptives. The essence “Being in a state of limbo and feeling sceptical” was coalesced from the themes. The women described a state of limbo, as being caught in an unwanted and emotionally charged situation. They reported that respectful counselling and meeting a skilled health professional helped to dispel their scepticism and influenced their plans for contraceptive use post abortion. Furthermore, women who wanted an intrauterine device described difficulties in access post abortion.

    Conclusion: The women seem to have a limited receptivity to contraceptive counselling when they have an unwanted pregnancy and are sceptical about contraceptives. Women, who experience respect in the counselling, report being helped in contraceptive decision-making. To receive respectful counselling and to have good access to intrauterine devices emerged as central needs among women at the time of an abortion.

  • 9.
    Kilander, Helena
    et al.
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Brynhildsen, Jan
    Obstetrics and Gynecology, Clinical and Experimental Medicine, Linköping, Sweden.
    Alehagen, Siw
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Fagerkrantz, Amanda
    Department of Obstetrics and Gyneacology, Norrköping, Region Ostergotland, Linköping, Sweden.
    Thor, Johan
    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).
    Collaboratively seeking to improve contraceptive counselling at the time of an abortion: A case study of quality improvement efforts in Sweden2019In: BMJ Sexual and Reproductive Health, ISSN 2515-1991, Vol. 45, no 3, p. 190-199Article in journal (Refereed)
    Abstract [en]

    Background Many women find it difficult to choose and initiate a contraceptive method at the time of an abortion. There is a gap between regular clinical practice and existing evidence on motivational and person-centred counselling, as well as on use of long-acting reversible contraception (LARC). This study aims to describe and evaluate a Quality Improvement Collaborative (QIC) designed to enhance contraceptive services, with regard to changes in healthcare professionals' (HCPs') counselling in clinical practice, and in women's subsequent choice of, and access to, contraception. Methods Three multiprofessional teams working in abortion services from three hospitals in Sweden, and two women contributing with user experience, participated in a QIC during the period March-November 2017. Using a case study design, we collected and analysed both quantitative and qualitative data. Results Teams agreed on QIC goals, including that ≥50% of women would start LARC within 30 days post-abortion, and tested multiple evidence-based changes, aided by the two women's feedback. During the QIC, participating HCPs reported that they gained new knowledge and developed skills in contraceptive counselling at the time of an abortion. The teams welcomed the development of a performance feedback system regarding women's post-abortion contraception. While the majority of women counselled during the QIC chose LARC, only 20%-40% received it within 30 days post-abortion. Conclusion The QIC, incorporating user feedback, helped HCPs to develop capability in providing contraceptive services at the time of an abortion. Timely access to LARC remains a challenge in the present setting.

  • 10.
    Kilander, Helena
    et al.
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Salomonsson, Birgitta
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden .
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Brynhildsen, Jan
    Department of Obstetrics and Gynaecology and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden .
    Alehagen, Siw
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden .
    Contraceptive counselling of women seeking abortion – a qualitative interview study of health professionals’ experiences2017In: European journal of contraception & reproductive health care, ISSN 1362-5187, E-ISSN 1473-0782, Vol. 22, no 1, p. 3-10Article in journal (Refereed)
    Abstract [en]

    Objectives: A substantial proportion of women who undergo an abortion continue afterwards without switching to more effective contraceptive use. Many subsequently have repeat unintended pregnancies. This study, therefore, aimed to identify and describe health professionalś experiences of providing contraceptive counselling to women seeking an abortion.

    Methods: We interviewed 21 health professionals (HPs), involved in contraceptive counselling of women seeking abortion at three differently sized hospitals in Sweden. The interviews were recorded and transcribed verbatim and analysed using conventional qualitative content analysis.

    Results: Three clusters were identified: ‘Complex counselling’, ‘Elements of counselling’ and ‘Finding a method’. HPs often experienced consultations including contraceptive counselling at the time of an abortion as complex, covering both pregnancy termination and contraceptive counselling. Women with vulnerabilities placed even greater demands on the HPs providing counselling. The HPs varied in their approaches when providing contraceptive counselling but also in their knowledge about certain contraception methods. HPs described challenges in finding out if women had found an effective method and in the practicalities of arranging intrauterine device (IUD) insertion post-abortion, when a woman asked for this method.

    Conclusions: HPs found it challenging to provide contraceptive counselling at the time of an abortion and to arrange access to IUDs post-abortion. There is a need to improve their counselling, their skills and their knowledge to prevent repeat unintended pregnancies.

  • 11.
    Mazzocato, Pamela
    et al.
    Karolinska Institutet.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare. Karolinska Institutet.
    Bäckman, Ulrika
    Karolinska Institutet.
    Brommels, Mats
    Karolinska Institutet.
    Carlsson, Jan
    Karolinska Institutet.
    Jonsson, Fredrik
    Karolinska Institutet.
    Hagmar, Magnus
    Karolinska Institutet.
    Savage, Carl
    Karolinska Institutet.
    Complexity complicates lean: lessons from seven emergency services2014In: Journal of Health Organisation & Management, ISSN 1477-7266, E-ISSN 1758-7247, Vol. 28, no 2, p. 266-288Article in journal (Refereed)
    Abstract [en]

    Purpose – The purpose of this paper is to explain how different emergency services adopt and adapt the same hospital-wide lean-inspired intervention and how this is reflected in hospital process performance data.

    Design/methodology/approach – A multiple case study based on a realistic evaluation approach to identify mechanisms for how lean impacts process performance and services’ capability to learn and continually improve. Four years of process performance data were collected from seven emergency services at a Swedish University Hospital: ear, nose and throat (ENT) (two), pediatrics (two), gynecology, internal medicine, and surgery. Performance patterns were linked with qualitative data collected through realist interviews.

    Findings – The complexity of the care process influenced how improvement in access to care was achieved. For less complex care processes (ENT and gynecology), large and sustained improvement was mainly the result of a better match between capacity and demand. For medicine, surgery, and pediatrics, which exhibit greater care process complexity, sustainable, or continual improvement were constrained because the changes implemented were insufficient in addressing the higher degree of complexity.

    Originality/value – The variation in process performance and sustainability of results indicate that lean efforts should be carefully adapted to the complexity of the care process and to the educational commitment of healthcare organizations. Ultimately, the ability to adapt lean to a particular context of application depends on the development of routines that effectively support learning from daily practices.

  • 12.
    Mazzocato, Pamela
    et al.
    Karolinska Institutet.
    Unbeck, Maria
    Karolinska Institutet.
    Elg, Mattias
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Linköping University.
    Sköldenberg, Olof Gustaf
    Karolinska Institutet.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Karolinska Institutet.
    Unpacking the key components of a programme to improve the timeliness of hip-fracture care: a mixed-methods case study2015In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 23, p. 1-12, article id 93Article in journal (Refereed)
    Abstract [en]

    Background: Delay to surgery for patients with hip fracture is associated with higher incidence of post-operative complications, prolonged recovery and length of stay, and increased mortality. Therefore, many health care organisations launch improvement programmes to reduce the wait for surgery. The heterogeneous application of similar methods, and the multifaceted nature of the interventions, constrain the understanding of which method works, when, and how. In complex acute care settings, another concern is how changes for one patient group influence the care for other groups. We therefore set out to analyse how multiple components of hip-fracture improvement efforts aimed to reduce the time to surgery influenced that time both for hip-fracture patients and for other acute surgical orthopaedic inpatients.

    Methods: This study is an observational mixed-methods single case study of improvement efforts at a Swedish acute care hospital, which triangulates control chart analysis of process performance data over a five year period with interview, document, and non-participant observation data. Results: The improvement efforts led to an increase in the monthly percentage of hip-fracture patients operated within 24 h of admission from an average of 47 % to 83 %, with performance predictably ranging between 67 % and 98 % if the process continues unchanged. Meanwhile, no significant changes in lead time to surgery for other acute surgical orthopaedic inpatients were observed. Interview data indicated that multiple intervention components contributed to making the process more reliable. The triangulation of qualitative and quantitative data, however, indicated that key changes that improved performance were the creation of a process improvement team and having an experienced clinician coordinate demand and supply of surgical services daily and enhance pre-operative patient preparation.

    Conclusions: Timeliness of surgery for patients with hip fracture in a complex hospital setting can be substantially improved without displacing other patient groups, by involving staff in improvement efforts and actively managing acute surgical procedures.

  • 13.
    Nordenström, Jörgen
    et al.
    Karolinska institutet.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Karolinska institutet.
    Bästa praxis - en nyckel till bättre vårdkvalitet och mer effektiv vård2016In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 113, p. 34-37, article id DWYWArticle in journal (Other academic)
    Abstract [sv]

    Medicinska paradigm har en tendens att samlas under mer eller mindre lättfattliga begrepp. De senaste decennierna har paradigmen »evidens« och »kvalitet« dominerat [1]. Paradigmet skiftar nu mot »värde«.

  • 14.
    Odhagen, Erik
    et al.
    University of Gothenburg, Gothenburg, Sweden.
    Sunnergren, Ola
    Ryhov County Hospital Jönköping, Jönköping, Sweden.
    Söderman, Anne-Charlotte Hessén
    Karolinska Institutet, Stockholm, Sweden.
    Thor, Johan
    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).
    Stalfors, Joacim
    University of Gothenburg, Gothenburg, Sweden.
    Reducing post-tonsillectomy haemorrhage rates through a quality improvement project using a Swedish National quality register: a case study2018In: European Archives of Oto-Rhino-Laryngology, ISSN 0937-4477, E-ISSN 1434-4726, Vol. 275, no 6, p. 1631-1639Article in journal (Refereed)
    Abstract [en]

    Tonsillectomy (TE) is one of the most frequently performed ENT surgical procedures. Post-tonsillectomy haemorrhage (PTH) is a potentially life-threatening complication of TE. The National Tonsil Surgery Register in Sweden (NTSRS) has revealed wide variations in PTH rates among Swedish ENT centres. In 2013, the steering committee of the NTSRS, therefore, initiated a quality improvement project (QIP) to decrease the PTH incidence. The aim of the present study was to describe and evaluate the multicentre QIP initiated to decrease PTH rates.

  • 15.
    Schmidt, Ingrid
    et al.
    Socialstyrelsen National Board of Health and Welfare, Department of Evaluation and Analysis, Stockholm, Sweden.
    Thor, Johan
    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).
    Davidson, Thomas
    Linkopings universitet, Department of Management and Engineering, Linkoping, Sweden.
    Nilsson, Fredrik
    Lunds Universitet, Department of Design Sciences, Lund, Sweden.
    Carlsson, Christina
    Lunds Universitet, Department of Clinical Sciences, Lund, Sweden.
    The national program on standardized cancer care pathways in Sweden: Observations and findings half way through2018In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 122, no 9, p. 945-948Article in journal (Refereed)
    Abstract [en]

    In 2015, the Swedish government initiated a national cancer reform program to standardize cancer care pathways. Primary aims included shortened waiting times among patients with suspected cancer, increased patient satisfaction and reduced regional variation. The implementation phase of the program is now more than half way through and both achievements and challenges have been identified. The ongoing evaluation demonstrates that professional engagement and adjustments on the meso- and micro-level of the system are essential to achieving sustainable improvements. Waiting times have shortened for the pathways launched first, and patients are satisfied with a more transparent process. Physicians in primary care are satisfied to inform patients about the pathways but point out problems with comorbidity and complicated diagnostic procedures related to unspecific symptoms. Mechanisms and ethical considerations behind possible crowding-out effects need to be thoroughly highlighted and discussed with staff and management. The results so far appear promising but meso- and micro-levels of the system need to be more involved in the design processes.

  • 16.
    Staines, Anthony
    et al.
    University Lyon III, France and Fédération des hôpitaux vaudois, Prilly, Switzerland.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare. Karolinska Institutet.
    Robert, Glenn
    National Nursing Research Unit, King’s College, London, United Kingdom.
    Sustaining improvement? The 20-year Jönköping Quality Improvement program revisited2015In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 24, no 1, p. 21-37Article in journal (Refereed)
    Abstract [en]

    Background: There is scarce evidence of organization-wide and sustained impact of quality improvement (QI) programsin health care. For 20 years, the Jönköping County Council’s (Sweden) ambitious program has attracted attention from practitioners and researchers alike. Methods: This is a follow-up case of a 2006 study of Jönköping’s improvement program, triangulating data from 20 semi-structured interviews, observation and secondary analysis of internal performance data. Results: In 2010, clinical outcomes had clearly improved in 2 departments (pediatrics, intensive care), while process improvements were evident in many departments. In an overall index of the 20 Swedish county councils’ performance, Jönköping had improved its ranking since 2006 to lead in 2010. Five key issues shaped Jönköping’s improvement program since 2006: a rigorously managed succession of chief executive officer; adept management of a changing external context; clear strategic direction relating to integration; a broadened conceptualization of “quality” (incorporating clinical effectiveness, patient safety, and patient experience); and continuing investment in QI education and research. Physician involvement in formal QI initiatives had increased since 2006 but remained a challenge in 2010. A new clinical information system was being deployed but had not yet met expectations. Conclusions: This study suggests that ambitious approaches can carry health care organizations beyond the sustainability threshold.

  • 17.
    Suutari, Anne-Marie
    et al.
    Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Department of Internal Medicine and Geriatrics, the Highland Hospital (Höglandssjukhuset), Eksjö, Region Jönköping County, Sweden.
    Areskoug Josefsson, Kristina
    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).
    Kjellström, Sofia
    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).
    Nordin, Annika
    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).
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Promoting a sense of security in everyday life—A case study of patients and professionals moving towards co-production in an atrial fibrillation “learning café”2019In: Health Expectations, ISSN 1369-6513, E-ISSN 1369-7625Article in journal (Refereed)
    Abstract [en]

    Background

    An improvement initiative sought to improve care for atrial fibrillation (AF) patients; many felt insecure about how to cope with AF.

    Objective

    To reveal AF patients' and professionals' experiences of pilot-testing a Learning Café group education programme, aimed at increasing the patients' sense of security in everyday life.

    Design

    Using an organizational case study design, we combined quantitative data (patients' sense of security) and qualitative data (project documentation; focus group interviews with five patients and five professionals) analysed using inductive qualitative content analysis.

    Setting

    AF patients and a multiprofessional team at a cardiac care unit in a Swedish district hospital.

    Improvement activities

    Two registered nurses invited AF patients and partners to four 2.5-hour Learning Café sessions. In the first session, they solicited participants' questions about life with AF. A physician, a registered nurse and a physiotherapist were invited to address these questions in the remaining sessions.

    Results

    AF patients reported gaining a greater sense of security in everyday life and anticipating a future shift from emergency care to planned care. Professionals reported enhanced professional development, learning more about person-centredness and gaining greater control of their own work situation. The organization gained knowledge about patient and family involvement.

    Conclusions

    The Learning Café pilot test?exemplifying movement towards co-production through patient-professional collaboration?generated positive outcomes for patients (sense of security), professionals (work satisfaction; learning) and the organization (better care) in line with contemporary models for quality improvement and with Self-Determination Theory. This approach merits further testing and evaluation in other contexts.

  • 18.
    Suutari, Anne-Marie
    et al.
    Jönköping University, School of Health and Welfare. The Highland Hospital (Höglandssjukhuset), Eksjö, Sweden.
    Thor, Johan
    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).
    ‘Learning Café’ group education program with atrial fibrillation patients – a model for co-production2018Conference paper (Other academic)
  • 19.
    Thor, Johan
    Jönköping University, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health Science, HHJ, Quality Improvement and Leadership in Health and Welfare. Karolinska Institutet.
    Förbättringsarbete och förändringsprocessen2012In: Kvalitetsarbete för bättre och säkrare vård / [ed] Gun Nordström, Bodil Wilde Larsson, Lund: Studentlitteratur AB, 2012, 1, p. 89-109Chapter in book (Other academic)
  • 20.
    Thor, Johan
    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). Karolinska Institutet.
    Förbättringsarbete och förändringsprocessen2017In: Kvalitetsarbete för bättre och säkrare vård / [ed] Anne-Marie Boström, Gun Nordström, Bodil Wilde Larsson, Lund: Studentlitteratur AB, 2017, 2, p. 107-126Chapter in book (Other academic)
  • 21.
    Thor, Johan
    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).
    Kvalitet och förbättringsarbete i hemsjukvård2019In: Hemsjukvård: olika perspektiv på trygg och säker vård / [ed] Mirjam Ekstedt & Maria Flink, Stockholm: Liber, 2019, 1 uppl., p. 282-293Chapter in book (Other academic)
  • 22.
    Thor, Johan
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Karolinska institutet.
    Olsson, Daniel
    Karolinska institutet.
    Nordenström, Jörgen
    Karolinska institutet.
    The design, fate and impact of a hospital-wide training program in evidence-based medicine for physicians: An observational study2016In: BMC Medical Education, ISSN 1472-6920, E-ISSN 1472-6920, Vol. 16, article id 86Article in journal (Refereed)
    Abstract [en]

    Background: Many doctors fail to practice Evidence-Based Medicine (EBM) effectively, in part due to insufficient training. We report on the design, fate and impact of a short learner-centered EBM train-the-trainer program aimed at all 2400 doctors at the Karolinska University Hospital in Sweden on the heels of a tumultuous merger, focusing particularly on whether it affected the doctors' knowledge, attitudes and skills regarding EBM. 

    Methods: We used a validated EBM instrument in a before-and-after design to assess the impact of the training. Changes in responses were analyzed at the individual level using the Wilcoxon matched pairs test. We also reviewed documentation from the program - including the modular EBM training schedule and the template for participants' Critically Appraised Topic reports - to describe the training's content, design, conduct, and fate. 

    Results: The training, designed to be delivered in modules of 45 min totaling 1.5 days, failed to reach most doctors at the hospital, due to cost cutting pressures and competing demands. Among study participants (n = 174), many reported suboptimal EBM knowledge and skills before the training. Respondents' strategies for solving clinical problems changed after the training: the proportion of respondents reporting to use (or intend to use) secondary sources "Often/very often" changed from 5 % before the training to 76 % after the training; in parallel, reliance on textbooks and on colleagues fell (48 to 23 % and 79 to 65 %, respectively). Participants' confidence in assessing scientific articles increased and their attitudes toward EBM became more positive. The proportion of correct answers in the EBM knowledge test increased from 52 to 71 %. All these changes were statistically significant at p < 0.05. 

    Conclusions: Many study participants, despite working at a university hospital, lacked basic EBM knowledge and skills and used the scientific literature suboptimally. The kind of short learner-centered EBM training evaluated here brought significant improvements among the minority of hospital doctors who were able to participate and, if applied widely, could contribute to better, safer and more cost-effective care.

  • 23.
    Thor, Johan
    et al.
    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).
    Peterson, A.
    Lindahl, Bertil
    The role of quality registries in health care improvement2016In: National quality registries in Swedish health care / [ed] Gunilla Jacobsson Ekman, Bertil Lindahl, Annika Nordin, Karolinska Institutet University Press , 2016, p. 53-67Chapter in book (Other academic)
  • 24.
    Thor, Johan
    et al.
    Jönköping University, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health Science, HHJ, Quality Improvement and Leadership in Health and Welfare. Karolinska Institutet.
    Peterson, Anette
    Jönköping University, School of Health Science, HHJ, Quality Improvement and Leadership in Health and Welfare. Jönköping University, The Jönköping Academy for Improvement of Health and Welfare.
    Lindahl, Bertil
    Kvalitetsregistrens roll i förbättringsarbete2015In: Nationella kvalitetsregister i hälso- och sjukvården / [ed] Gunilla Jacobsson-Ekman, Bertil Lindahl, Annika Nordin, Stockholm: Karolinska Institutet University Press , 2015, p. 50-63Chapter in book (Other academic)
  • 25.
    Ulhassan, Waqar
    et al.
    Karolinska Institutet.
    Sandahl, Christer
    Karolinska Institutet.
    Westerlund, Hugo
    Stockholm University.
    Henriksson, Peter
    Karolinska Institutet.
    Bennermo, Marie
    Karolinska Institutet.
    von Thiele Schwarz, Ulrica
    Karolinska Institutet.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare. Karolinska Institutet.
    Antecedents and Characteristics of Lean Thinking Implementation in a Swedish Hospital: A Case Study2013In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 22, no 1, p. 48-61Article in journal (Refereed)
    Abstract [en]

    Despite the reported success of Lean in health care settings, it is unclear why and how organizations adopt Lean and how Lean transforms work design and, in turn, affects employees' work. This study investigated a cardiology department's journey to adopt and adapt Lean. The investigation was focused on the rationale and evolution of the Lean adoption to illuminate how a department with a long quality improvement history arrived at the decision to introduce Lean, and how Lean influenced employees' daily work. This is an explanatory single case study based on semistructured interviews, nonparticipant observations, and document studies. Guided by a Lean model, we undertook manifest content analysis of the data. We found that previous improvement efforts may facilitate the introduction of Lean but may be less important when forecasting whether Lean will be sustained over time. Contextual factors seemed to influence both what Lean tools were implemented and how well the changes were sustained. For example, adoption of Lean varied with the degree to which staff saw a need for change. Work redesign and teamwork were found helpful to improve patient care whereas problem solving was found helpful in keeping the staff engaged and sustaining the results over time.

  • 26.
    Ulhassan, Waqar
    et al.
    Karolinska Institutet.
    Westerlund, Hugo
    Stockholm University.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare. Karolinska Institutet.
    Sandahl, Christer
    Karolinska Institutet.
    von Thiele Schwarz, Ulrica
    Karolinska Institutet.
    Does Lean Implementation interact with group functioning?2014In: Journal of Health Organisation & Management, ISSN 1477-7266, E-ISSN 1758-7247, Vol. 28, no 2, p. 196-213Article in journal (Refereed)
    Abstract [en]

    Purpose: As healthcare often is studied in relation to operational rather than socio-technical aspects of Lean such as teamwork, this study aims to explore how a Swedish hospital Lean intervention related to changes in teamwork over time.

    Design/methodology/approach: Teamwork was measured with the Group Development Questionnaire (GDQ) employee survey during Lean implementation at three units, in 2010 (n=133) and 2011 (n=130). Qualitative data including interviews, observations and document analysis were used to characterize the Lean implementation and context. Based on this, expected teamwork change patterns were documented and tested with GDQ-data through linear regression analysis.

    Findings: At Ward-I, Lean implementation was successful and teamwork improved. At Ward-II, Lean was partially implemented and teamwork improved slightly, while both Lean and teamwork deteriorated at the emergency department (ED). The regression analysis was significant at Ward-II (p=.02) and the ED (p=.04), but not at Ward-I (p=.11).

    Practical implications: Developing expected changes based on theoretically derived assumptions and qualitative data may make it possible to detect the results of a complex change. Overall, Lean may have some impact on teamwork, if properly implemented. However, this impact may be more prominent in relation to structural and productivity issues of teamwork than group members’ relational issues. Also, effects of Lean on teamwork may differ depending on the teams’ initial stage of teamwork. Practitioners should note that, with groups struggling with initial stages of teamwork, Lean may be very challenging.

    Originality/value: This study focused specifically on implications of Lean for nurse teamwork in hospital setting using both qualitative and quantitative data.

  • 27.
    Vackerberg, Nicoline
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Levander, Märta Sund
    Department of Medical and Health Sciences, Division of Nursing, Faculty of Medicine and Health Sciences, Linköping University, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    What is best for Esther? Building improvement coaching capacity with and for users in health and social Care-A case study2016In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 25, no 1, p. 53-60Article in journal (Refereed)
    Abstract [en]

    While coaching and customer involvement can enhance the improvement of health and social care, many organizations struggle to develop their improvement capability; it is unclear how best to accomplish this. We examined one attempt at training improvement coaches. The program, set in the Esther Network for integrated care in rural Jonkoping County, Sweden, included eight 1-day sessions spanning 7 months in 2011. A senior citizen joined the faculty in all training sessions. Aiming to discern which elements in the program were essential for assuming the role of improvement coach, we used a case-study design with a qualitative approach. Our focus group interviews included 17 informants: 11 coaches, 3 faculty members, and 3 senior citizens. We performed manifest content analysis of the interview data. Creating will, ideas, execution, and sustainability emerged as crucial elements. These elements were promoted by customer focusembodied by the senior citizen trainershared values and a solution-focused approach, by the supportive coach network and by participants' expanded systems understanding. These elements emerged as more important than specific improvement tools and are worth considering also elsewhere when seeking to develop improvement capability in health and social care organizations.

  • 28.
    Vackerberg, Nicoline
    et al.
    Jönköping University, The Jönköping Academy for Improvement of Health and Welfare.
    Norman, AnnCharlott
    Jönköping University, The Jönköping Academy for Improvement of Health and Welfare. Linnéuniversitetet.
    Jutterdal, Stefan
    Thor, Johan
    Jönköping University, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health Science, HHJ, Quality Improvement and Leadership in Health and Welfare. Karolinska Institutet.
    Utveckling och förbättringsarbete är ömsesidigt beroende och berikande2015In: Att lära och utvecklas i sin profession / [ed] Gabriele Biguet, Ingrid Lindquist, Cathrin Martin, Anna Pettersson, Lund: Studentlitteratur AB, 2015, p. 169-185Chapter in book (Other academic)
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