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  • 2201.
    Tinghög, Gustav
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Hälso- och sjukvård som ekonomisk handelsvara2016In: Perspektiv på utvärdering, prioritering, implementering och hälsoekonomi: En hyllningsskrift till Per Carlsson, Linköping: Linköping University Electronic Press, 2016, p. 97-101Chapter in book (Other academic)
  • 2202.
    Tinghög, Gustav
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Linköping University, Department of Management and Engineering, Economics.
    Andersson, David
    Linköping University, Department of Science and Technology. Linköping University, The Institute of Technology.
    Tinghög, Petter
    Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Arts and Sciences.
    Lyttkens, Carl H.
    Department of Economics, Lund University.
    Horizontal Inequality in Rationing by Waiting Lists2014In: International Journal of Health Services, ISSN 0020-7314, E-ISSN 1541-4469, International Journal of Health Services, ISSN 0020-7314, Vol. 44, no 1, p. 169-184Article in journal (Refereed)
    Abstract [en]

    The objective of this article was to investigate the existence of horizontal inequality in access to care for six categories of elective surgery in a publicly funded system, when care is rationed through waiting lists. Administrative waiting time data on all elective surgeries (n = 4,634) performed in Östergötland, Sweden, in 2007 were linked to national registers containing variables on socioeconomic indicators. Using multiple regression, we tested five hypotheses reflecting that more resourceful groups receive priority when rationing by waiting lists. Low disposable household income predicted longer waiting times for orthopedic surgery (27%, p < 0.01) and general surgery (34%,p < 0.05). However, no significant differences on the basis of ethnicity and gender were detected. A particularly noteworthy finding was that disposable household income appeared to be an increasingly influential factor when the waiting times were longer. Our findings reveal horizontal inequalities in access to elective surgeries, but only to a limited extent. Whether this is good or bad depends on one's moral inclination. From a policymaker's perspective, it is nevertheless important to recognize that horizontal inequalities arise even though care is not rationed through ability to pay.

  • 2203.
    Tinghög, Gustav
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Lyttkens, Carl H.
    Lund University, Lund, Sweden.
    Individual responsibility for what?: A conceptual framework for exploring the suitability of private financing in a publicly funded health-care system2010In: Health Economics, Policy and Law, ISSN 1744-1331, E-ISSN 1744-134X, Vol. 5, no 2, p. 201-223Article in journal (Refereed)
    Abstract [en]

    Policymakers in publicly funded health-care systems are frequently required to make intricate decisions on which health-care services to include or exclude from the basic health-care package. Although it seems likely that the concept of individual responsibility is an essential feature of such decisions, it is rarely explicitly articulated or evaluated in health policy. This paper presents a tentative conceptual framwork for exploring when health-care services contain characteristics that facilitate individual responsibility through private financing. Six attributes for exploring the suitability of private financing for specific health-care commodities are identified: (i) it should enable individuals to value the need and quality both before and after utilization; (ii) it should be targeted toward individuals with a reasonable level of individual autonomy; (iii) it should be associated with low levels of positive externalities; (iv) it should be associated with a demand sufficient to generate a private market; (v) it should be associated with payments affordable for most individuals; and finally, (vi) it should be associated with 'lifestyle enhancements' rather than 'medical necessities'. The tentative framework enables exploration of individual responsibility connected to health care as a heterogeneous group of commodities, and allows policymakers to make decisions on rationing by design rather than default.

  • 2204.
    Tistad, Malin
    et al.
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Karolinska institutet; Umeå universitet.
    Flink, Maria
    Ytterberg, Charlotte
    Eriksson, Gunilla
    Guidetti, Susanne
    Tham, Kerstin
    von Koch, Lena
    Resource use of healthcare services 1 year after stroke: a secondary analysis of a cluster-randomised controlled trial of a client-centred activities of daily living intervention2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 8, article id e022222Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: The objective of the study was to compare the total use of healthcare services in the course of the first year after a stroke between participants who, after the acute care, had received occupational therapy as a client-centred activities of daily living (ADL) intervention (CADL) and participants who had received usual ADL intervention (UADL).

    DESIGN: A secondary analysis of a multicentre cluster-randomised controlled trial (RCT).

    SETTING: Primary and secondary care in Sweden.

    PARTICIPANTS: Participants were included if they: (1) had received CADL or UADL in the RCT, either as inpatients in geriatric rehabilitation units or in their own homes, and (2) data could be retrieved about their use of healthcare services provided by the county council from computerised registers.

    INTERVENTIONS: CADL or UADL.

    OUTCOME MEASURES: Inpatient and outpatient healthcare in the course of the first year after stroke.

    RESULTS: Participants from 7 of the 16 units included in the RCT met the criteria. Participants in the CADL group (n=26) who received geriatric inpatient rehabilitation had a shorter length of hospital stay (p=0.03) than participants in the UADL group (n=46), and the CADL group with home rehabilitation (n=13) had fewer outpatient contacts (p=0.01) compared with the UADL group (n=25). Multiple regression analyses showed that in four of the models, a higher age was associated with a lower use of healthcare services. The use of healthcare services was also associated (some of the models) with dependence in ADL, stroke severity and type of rehabilitation received, CADL or UADL.

    CONCLUSIONS: The provision of client-centred occupational therapy after stroke did not appear to increase the use of healthcare services during the first year after stroke.rrrrr TRIAL REGISTRATION NUMBER: NCT01417585.

  • 2205.
    Tistad, Malin
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy. School of Education, Health and Social Studies, Dalarna University, Falun, Sweden; Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.
    Palmcrantz, Susanne
    Wallin, Lars
    Ehrenberg, Anna
    Olsson, Christina B.
    Tomson, Goeran
    Holmqvist, Lotta Widen
    Gifford, Wendy
    Eldh, Ann Catrine
    Developing Leadership in Managers to Facilitate the Implementation of National Guideline Recommendations: A Process Evaluation of Feasibility and Usefulness2016In: International Journal of Health Policy and Management, ISSN 2322-5939, E-ISSN 2322-5939, Vol. 5, no 8, p. 477-486Article in journal (Refereed)
    Abstract [en]

    Background: Previous research supports the claim that managers are vital players in the implementation of clinical practice guidelines (CPGs), yet little is known about interventions aiming to develop managers' leadership in facilitating implementation. In this pilot study, process evaluation was employed to study the feasibility and usefulness of a leadership intervention by exploring the intervention's potential to support managers in the implementation of national guideline recommendations for stroke care in outpatient rehabilitation. Methods: Eleven senior and frontline managers from five outpatient stroke rehabilitation centers participated in a four-month leadership intervention that included workshops, seminars, and teleconferences. The focus was on developing knowledge and skills to enhance the implementation of CPG recommendations, with a particular focus on leadership behaviors. Each dyad of managers was assigned to develop a leadership plan with specific goals and leadership behaviors for implementing three rehabilitation recommendations. Feasibility and usefulness were explored through observations and interviews with the managers and staff members prior to the intervention, and then one month and one year after the intervention. Results: Managers considered the intervention beneficial, particularly the participation of both senior and frontline managers and the focus on leadership knowledge and skills for implementing CPG recommendations. All the managers developed a leadership plan, but only two units identified goals specific to implementing the three stroke rehabilitation recommendations. Of these, only one identified leadership behaviors that support implementation. Conclusion: Managers found that the intervention was delivered in a feasible way and appreciated the focus on leadership to facilitate implementation. However, the intervention appeared to have limited impact on managers' behaviors or clinical practice at the units. Future interventions directed towards managers should have a stronger focus on developing leadership skills and behaviors to tailor implementation plans and support implementation of CPG recommendations.

  • 2206.
    Tistad, Malin
    et al.
    School of Education, Health and Social Studies, Dalarna University, Falun, Sweden; Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden; Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden .
    Palmcrantz, Susanne
    Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden; Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
    Wallin, Lars
    School of Education, Health and Social Studies, Dalarna University, Falun, Sweden; Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden; Department of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Ehrenberg, Anna
    Örebro University, School of Health Sciences. School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
    Olsson, Christina B.
    Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden; Mörby Academic Primary Healthcare Center, Stockholm County Council, Stockholm, Sweden.
    Tomson, Göran
    International Health Systems Research, Departments of Learning, Informatics, Management, Ethics and Public Health Sciences, Karolinska Institutet, Solna, Sweden.
    Holmqvist, Lotta Widen
    Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden; Department of Physiotherapy, Karolinska University Hospital, Stockholm, Sweden.
    Gifford, Wendy
    Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa ON, Canada.
    Eldh, Ann Catrine
    School of Education, Health and Social Studies, Dalarna University, Falun, Sweden; Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.
    Developing Leadership in Managers to Facilitate the Implementation of National Guideline Recommendations: A Process Evaluation of Feasibility and Usefulness2016In: International Journal of Health Policy and Management, ISSN 2322-5939, E-ISSN 2322-5939, Vol. 5, no 8, p. 477-486Article in journal (Refereed)
    Abstract [en]

    Background: Previous research supports the claim that managers are vital players in the implementation of clinical practice guidelines (CPGs), yet little is known about interventions aiming to develop managers' leadership in facilitating implementation. In this pilot study, process evaluation was employed to study the feasibility and usefulness of a leadership intervention by exploring the intervention's potential to support managers in the implementation of national guideline recommendations for stroke care in outpatient rehabilitation.

    Methods: Eleven senior and frontline managers from five outpatient stroke rehabilitation centers participated in a four-month leadership intervention that included workshops, seminars, and teleconferences. The focus was on developing knowledge and skills to enhance the implementation of CPG recommendations, with a particular focus on leadership behaviors. Each dyad of managers was assigned to develop a leadership plan with specific goals and leadership behaviors for implementing three rehabilitation recommendations. Feasibility and usefulness were explored through observations and interviews with the managers and staff members prior to the intervention, and then one month and one year after the intervention.

    Results: Managers considered the intervention beneficial, particularly the participation of both senior and frontline managers and the focus on leadership knowledge and skills for implementing CPG recommendations. All the managers developed a leadership plan, but only two units identified goals specific to implementing the three stroke rehabilitation recommendations. Of these, only one identified leadership behaviors that support implementation.

    Conclusion: Managers found that the intervention was delivered in a feasible way and appreciated the focus on leadership to facilitate implementation. However, the intervention appeared to have limited impact on managers' behaviors or clinical practice at the units. Future interventions directed towards managers should have a stronger focus on developing leadership skills and behaviors to tailor implementation plans and support implementation of CPG recommendations.

  • 2207.
    Tistad, Malin
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet; Umeå universitet.
    Palmcrantz, Susanne
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet; Göteborgs universitet.
    Ehrenberg, Anna
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Örebro universitet.
    Olsson, Christina B.
    Tomson, Göran
    Lotta, Widén Holmqvist
    Gifford, Wendy
    Eldh, Ann Catrine
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet.
    Developing leadership in managers to facilitate the implementation of national guideline recommendations: a process evaluation of feasibility and usefulness2016In: International Journal of Health Policy and Management, ISSN 2322-5939, E-ISSN 2322-5939, Vol. 5, no 8, p. 477-486Article in journal (Refereed)
    Abstract [en]

    Background: Previous research supports the claim that managers are vital players in the implementation of clinical practice guidelines (CPGs), yet little is known about interventions aiming to develop managers’ leadership in facilitating implementation. In this pilot study, process evaluation was employed to study the feasibility and usefulness of a leadership intervention by exploring the intervention’s potential to support managers in the implementation of national guideline recommendations for stroke care in outpatient rehabilitation.

    Methods: Eleven senior and frontline managers from five outpatient stroke rehabilitation centers participated in a four-month leadership intervention that included workshops, seminars, and teleconferences. The focus was on developing knowledge and skills to enhance the implementation of CPG recommendations, with a particular focus on leadership behaviors. Each dyad of managers was assigned to develop a leadership plan with specific goals and leadership behaviors for implementing three rehabilitation recommendations. Feasibility and usefulness were explored through observations and interviews with the managers and staff members prior to the intervention, and then one month and one year after the intervention.

    Results: Managers considered the intervention beneficial, particularly the participation of both senior and frontline managers and the focus on leadership knowledge and skills for implementing CPG recommendations. All the managers developed a leadership plan, but only two units identified goals specific to implementing the three stroke rehabilitation recommendations. Of these, only one identified leadership behaviors that support implementation.

    Conclusion: Managers found that the intervention was delivered in a feasible way and appreciated the focus on leadership to facilitate implementation. However, the intervention appeared to have limited impact on managers’ behaviors or clinical practice at the units. Future interventions directed towards managers should have a stronger focus on developing leadership skills and behaviors to tailor implementation plans and support implementation of CPG recommendations.

  • 2208.
    Tistad, Malin
    et al.
    Dalarna University, School of Education, Health and Social Studies, Medical Science.
    von Koch, Lena
    Karolinska Institutet, Institutionen för Neurobiologi, vårdvetenskap och samhälle, Neurologkliniken Karolinska Universitetssjukhuset.
    Sjöstrand, Christina
    Institutionen för klinisk neurovetenskap, Karolinska Institutet, Neurologkliniken Karolinska Universitetssjukhuset.
    Tham, Kerstin
    Karolinska Institutet, Institutionen för Neurobiologi, vårdvetenskap och samhälle.
    Ytterberg, Charlotte
    Karolinska Institutet, Institutionen för Neurobiologi, vårdvetenskap och samhälle.
    What aspects of rehabilitation provision contribute to self-reported met needs for rehabilitation one year after stroke - amount, place, operator or timing?2013In: Health Expectations, ISSN 1369-6513, E-ISSN 1369-7625, Vol. 16, no 3, p. e24-35Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND OBJECTIVE: To a large extent, people who have suffered a stroke report unmet needs for rehabilitation. The purpose of this study was to explore aspects of rehabilitation provision that potentially contribute to self-reported met needs for rehabilitation 12 months after stroke with consideration also to severity of stroke.

    METHODS: The participants (n = 173) received care at the stroke units at the Karolinska University Hospital, Sweden. Using a questionnaire, the dependent variable, self-reported met needs for rehabilitation, was collected at 12 months after stroke. The independent variables were four aspects of rehabilitation provision based on data retrieved from registers and structured according to four aspects: amount of rehabilitation, service level (day care rehabilitation, primary care rehabilitation and home-based rehabilitation), operator level (physiotherapist, occupational therapist, speech therapist) and time after stroke onset. Multivariate logistic regression analyses regarding the aspects of rehabilitation were performed for the participants who were divided into three groups based on stroke severity at onset.

    RESULTS: Participants with moderate/severe stroke who had seen a physiotherapist at least once during each of the 1st, 2nd and 3rd-4th quarters of the first year (OR 8.36, CI 1.40-49.88 P = 0.020) were more likely to report met rehabilitation needs.

    CONCLUSION: For people with moderate/severe stroke, continuity in rehabilitation (preferably physiotherapy) during the first year after stroke seems to be associated with self-reported met needs for rehabilitation.

  • 2209.
    Toivanen, Susanna
    Stockholm University, Faculty of Social Sciences, Department of Sociology.
    Work stress and health: Is the association moderated by sense of coherence?2007In: Health Inequalities and Welfare Resources: Continuity and Change in Sweden / [ed] Johan Fritzell and Olle Lundberg, Bristol: Policy Press, 2007, p. 87-107Chapter in book (Other academic)
  • 2210. Tolf, Sara
    et al.
    Nyström, Monica E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Learning Informatics, Management and Ethics, Karolinska Institutet, Stockholm.
    Tishelman, Carol
    Brommels, Mats
    Hansson, Johan
    Agile, a guiding principle for health care improvement?2015In: International Journal of Health Care Quality Assurance, ISSN 0952-6862, E-ISSN 1758-6542, Vol. 28, no 5, p. 468-493Article in journal (Refereed)
    Abstract [en]

    PURPOSE: The purpose of this paper is to contribute to increased understanding of the concept agile and its potential for hospital managers to optimize design of organizational structures and processes to combine internal efficiency and external effectiveness.

    DESIGN/METHODOLOGY/APPROACH: An integrative review was conducted using the reSEARCH database. Articles met the following criteria: first, a definition of agility; second, descriptions of enablers of becoming an agile organization; and finally, discussions of agile on multiple organizational levels. In total, 60 articles qualified for the final analysis.

    FINDINGS: Organizational agility rests on the assumption that the environment is uncertain, ranging from frequently changing to highly unpredictable. Proactive, reactive or embracive coping strategies were described as possible ways to handle such uncertain environments. Five organizational capacities were derived as necessary for hospitals to use the strategies optimally: transparent and transient inter-organizational links; market sensitivity and customer focus; management by support for self-organizing employees; organic structures that are elastic and responsive; flexible human and resource capacity for timely delivery. Agile is portrayed as either the "new paradigm" following lean, the needed development on top of a lean base, or as complementary to lean in distinct hybrid strategies.

    PRACTICAL IMPLICATIONS: Environmental uncertainty needs to be matched with coping strategies and organizational capacities to design processes responsive to real needs of health care. This implies that lean and agile can be combined to optimize the design of hospitals, to meet different variations in demand and create good patient management.

    ORIGINALITY/VALUE: While considerable value has been paid to strategies to improve the internal efficiency within hospitals, this review raise the attention to the value of strategies of external effectiveness.

  • 2211.
    Toll, Pia
    et al.
    Östergötlands Läns Landsting, Heart and Medicine Centre, Department of Clinical Physiology UHL.
    Olsson, Eva
    Östergötlands Läns Landsting, Heart and Medicine Centre, Department of Clinical Physiology UHL.
    Gustafsson, Agnetha
    Linköping University, Department of Medical and Health Sciences, Radiation Physics. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre for Surgery, Orthopaedics and Cancer Treatment, Department of Radiation Physics UHL.
    Erfarenheter från avvikelsehantering i Linköping2010Conference paper (Other academic)
  • 2212. Tolley, C.
    et al.
    Mullins, A.
    Kilgariff, S.
    Arbuckle, R.
    Green, J.
    Burstedt, Marie
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Ophthalmology.
    Holopigian, K.
    Stasi, K.
    Sloesen, B.
    Qualitative interviews to inform development of a patient reported outcome (PRO) strategy in RLBP1 retinitis pigmentosa (RLBP1 RP)2017In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 20, no 9, p. A761-A761Article in journal (Other academic)
    Abstract [en]

    Objectives: RLBP1 RP is a rare autosomal recessive form of retinitis pigmentosa (RP), characterized by night blindness, prolonged dark adaptation, constricted visual fields and reduced macular function. This study aimed to better understand the patient experience of RLBP1 RP and to evaluate the content validity of existing patient reported outcome (PRO) instruments in this condition. Methods: This qualitative study involved 90 minute, semi-structured, concept elicitation and cognitive debriefing interviews with patients with RLBP1 RP in Canada (n=10) and Sweden (n=11). Qualitative analysis of anonymized, verbatim transcripts was performed using Atlas.Ti software and thematic analysis methods. Participants were cognitively debriefed on The National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25), Low Luminance Questionnaire (LLQ) and four items of the Visual Activities Questionnaire (VAQ). Results: Fourteen visual symptoms were reported. The symptoms most frequently reported were night blindness (n=21), difficulty adapting to changes in lighting (n=21) and difficulties seeing in bright lighting (n=18). Impacts on daily activities (n=21) and physical functioning (n=17) were important to participants. Other domains of quality of life affected included social functioning (n=21), emotional functioning (n=19), work and education (n=18), and psychological functioning (n=17). Participant understanding and interpretation of the NEI VFQ-25 and LLQ was mixed. Patients reported that examples in single items represented different levels of functional impairment. In addition, some items did not specify what lighting conditions should be considered when responding. LLQ items were more relevant to RLBP1 RP than NEI VFQ-25 items. The four VAQ items assessing light/dark adaptation were well understood and relevant to participants. There were both gaps and overlaps in conceptual coverage of the instruments. Conclusions: The symptoms of RLBP1 RP have a substantial impact on patients’ daily lives and physical functioning. Issues have been identified with conceptual coverage, rel- evance and patient understanding of the NEI VFQ-25, LLQ and VAQ in RLBP1 RP.

  • 2213.
    Torlén, Klara
    et al.
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    Kurland, Lisa
    Örebro University, School of Medical Sciences. Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Castrén, Maaret
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine and Services, Helsinki University Hospital and Helsinki University, Helsinki, Finland.
    Olanders, Knut
    Department of Anaesthesiology and ICU, Lund University Hospital, Lund, Sweden.
    Bohm, Katarina
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    A comparison of two emergency medical dispatch protocols with respect to accuracy2017In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 25, no 1, article id 122Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Emergency medical dispatching should be as accurate as possible in order to ensure patient safety and optimize the use of ambulance resources. This study aimed to compare the accuracy, measured as priority level, between two Swedish dispatch protocols - the three-graded priority protocol Medical Index and a newly developed prototype, the four-graded priority protocol, RETTS-A.

    METHODS: A simulation study was carried out at the Emergency Medical Communication Centre (EMCC) in Stockholm, Sweden, between October and March 2016. Fifty-three voluntary telecommunicators working at SOS Alarm were recruited nationally. Each telecommunicator handled 26 emergency medical calls, simulated by experienced standard patients. Manuscripts for the scenarios were based on recorded real-life calls, representing the six most common complaints. A cross-over design with 13 + 13 calls was used. Priority level and medical condition for each scenario was set through expert consensus and used as gold standard in the study.

    RESULTS: A total of 1293 calls were included in the analysis. For priority level, n = 349 (54.0%) of the calls were assessed correctly with Medical Index and n = 309 (48.0%) with RETTS-A (p = 0.012). Sensitivity for the highest priority level was 82.6% (95% confidence interval: 76.6-87.3%) in the Medical Index and 54.0% (44.3-63.4%) in RETTS-A. Overtriage was 37.9% (34.2-41.7%) in the Medical Index and 28.6% (25.2-32.2%) in RETTS-A. The corresponding proportion of undertriage was 6.3% (4.7-8.5%) and 23.4% (20.3-26.9%) respectively.

    CONCLUSION: In this simulation study we demonstrate that Medical Index had a higher accuracy for priority level and less undertriage than the new prototype RETTS-A. The overall accuracy of both protocols is to be considered as low. Overtriage challenges resource utilization while undertriage threatens patient safety. The results suggest that in order to improve patient safety both protocols need revisions in order to guarantee safe emergency medical dispatching.

  • 2214. Torp, Steffen
    et al.
    Bing-Jonsson, PC
    Hanson, Elizabeth
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Experiences with using information and communication technology to build a multi-municipal support network for informal carers2013In: Informatics for Health and Social Care, ISSN 1753-8157, E-ISSN 1753-8165, Vol. 38, no 3, p. 265-279Article in journal (Refereed)
    Abstract [en]

    This multi-municipal intervention study explored whether informal carers of frail older people and disabled children living at home made use of information and communication technology (ICT) to gain knowledge about caring and to form informal support networks, thereby improving their health. Seventy-nine informal carers accessed web-based information about caring and an e-based discussion forum via their personal computers. They were able to maintain contact with each other using a web camera and via normal group meetings. After the first 12 months, 17 informal carers participated in focus group interviews and completed a short questionnaire. Four staff members were also interviewed. Participant carers who had prior experiences with a similar ICT-based support network reported greater satisfaction and more extensive use of the network than did participants with no such prior experience. It seems that infrequent usage of the service may be explained by too few other carers to identify with and inappropriate recruitment procedures. Nevertheless, carers of disabled children reported that the intervention had resulted in improved services across the participant municipalities. To achieve optimal effects of an ICT-based support network due attention must be given to recruitment processes and social environment building for which care practitioners require training and support.

  • 2215. Tozan, Yesim
    et al.
    Ratanawong, Pitcha
    Sewe, Maquines Odhiambo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wilder-Smith, Annelies
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Heidelberg Univ, Med Sch, Inst Publ Hlth, Heidelberg, Germany; Nanyang Technol Univ, Lee Kong Chian Sch Med, Singapore, Singapore.
    Kittayapong, Pattamaporn
    Household costs of hospitalized dengue illness in semi-rural Thailand2017In: PLoS Neglected Tropical Diseases, ISSN 1935-2727, E-ISSN 1935-2735, Vol. 11, no 9, article id e005961Article in journal (Refereed)
    Abstract [en]

    Background

    Dengue-related illness is a leading cause of hospitalization and death in Thailand and other Southeast Asian countries, imposing a major economic burden on households, health systems, and governments. This study aims to assess the economic impact of hospitalized dengue cases on households in Chachoengsao province in eastern Thailand.

    Methods

    We conducted a prospective cost-of-illness study of hospitalized pediatric and adult dengue patients at three public hospitals. We examined all hospitalized dengue cases regardless of disease severity. Patients or their legal guardians were interviewed using a standard questionnaire to determine household-level medical and non-medical expenditures and income losses during the illness episode.

    Results

    Between March and September 2015, we recruited a total of 224 hospitalized patients (< 5 years, 4%; 5-14 years, 20%, 15-24 years, 36%, 25-34 years, 15%; 35-44 years, 10%; 45+ years, 12%), who were clinically diagnosed with dengue. The total cost of a hospitalized dengue case was higher for adult patients than pediatric patients, and was US$153.6 and US$166.3 for pediatric DF and DHF patients, respectively, and US$171.2 and US$226.1 for adult DF and DHF patients, respectively. The financial burden on households increased with the severity of dengue illness.

    Conclusions

    Although 74% of the households reported that the patient received free medical care, hospitalized dengue illness cost approximately 19-23% of the monthly household income. These results indicated that dengue imposed a substantial financial burden on households in Thailand where a great majority of the population was covered by the Universal Coverage Scheme for health care.

  • 2216.
    Tran, Anh Nhi
    et al.
    Department of Microbiology, Public Health Agency of Sweden, Solna, Sweden.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Bennet, Rutger
    Department of Woman and Child Health, Astrid Lindgren Children´s Hospital, Karolinska University Hospital, Stockholm, Sweden.
    Brytting, Maria
    Department of Microbiology, Public Health Agency of Sweden, Solna, Sweden.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Eriksson, Margareta
    Department of Woman and Child Health, Astrid Lindgren Children´s Hospital, Karolinska University Hospital, Stockholm, Sweden.
    Storsaeter, Jann
    Department of Vaccine-Preventable Illnesses, National Public Health Institute, Oslo, Norway.
    Österlin, Barbro
    Department of Microbiology, Public Health Agency of Sweden, Solna, Sweden.
    Johansen, Kari
    Department of Microbiology, Public Health Agency of Sweden, Solna, Sweden.
    Impact on affected families and society of severe rotavirus infections in Swedish children assessed in a prospective cohort study.2018In: Infectious Diseases, ISSN 2374-4235, E-ISSN 2374-4243, Vol. 50, no 5, p. 361-371Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Few prospective cohort studies have estimated the overall impact of severe rotavirus gastroenteritis (RVGE) leading to hospitalization on families and society. We assessed human and economic resources needed to care for an affected average child aged <5 years in Sweden.

    METHODS: The study was conducted in Astrid Lindgren Children's Hospital which serves approximately 14% of all Swedish children <5 years of age. All children admitted with acute gastroenteritis in the study period were tested for rotavirus. Health care consumption was collected prospectively and publically available unit costs used to calculate direct costs. Non-medical and indirect costs were collected in interviews with families using a standardized questionnaire during the hospital stay and approximately 14 days post-discharge.

    RESULTS: 144/206 children (70%) with laboratory-confirmed RVGE were included. The median age was 14 months. The average total cost per hospitalized child was €3894, of which €2169 (56%) was due to direct healthcare-related costs (including Emergency Department visits and in-patient care), €104 (2%) to non-medical direct costs and €1621 (42%) to indirect costs due to productivity loss. Carers of children with severe RVGE were absent from work on average five days per study child: four days during hospitalization of affected child and one day due to gastroenteritis in the carer.

    CONCLUSIONS: Costs for RVGE are dominated by direct costs which are similar to some other countries in Europe, but indirect costs due to productivity loss are also important, and should be considered in decisions to introduce rotavirus vaccines into national vaccination programmes.

  • 2217.
    Trosic, Branka
    Karlstad University. Karlstad University, Faculty of Social and Life Sciences.
    Att tolka dementa: Vårdpersonalens egna berättelser2009Independent thesis Advanced level (degree of Master (One Year)), 10 credits / 15 HE creditsStudent thesis
    Abstract [sv]

    Tidigare forskning pekar på försämrad kommunikationsförmåga som ett av de mest uppmärksammade symtomen vid demenssjukdom. För att förmedla ett budskap till sin omgivning använder dementa som alla andra människor både verbala och icke-verbala signaler. Med tiden försämras deras verbala uttrycksätt och de börjar istället att i allt högre grad använda sig av de icke-verbala signalerna, som till exempel ansiktsuttryck, kroppsspråk, gester, paraspråk och liknande. Eftersom dementas olika kommunikativa uttryckssätt ibland kan vara väldigt svåra att tolka av andra i deras närhet, är det av stor betydelse att ta reda på de förutsättningar som påverkar detta. Syftet med denna studie är att utifrån vårdpersonalens berättelser belysa vilka faktorer som påverkar deras tolkning av dementas olika kommunikativa uttryckssätt under omvårdnadsmötet. För att svara på detta syfte har jag använt mig av fokusgruppsintervjuer som metod för att samla in data, vilken sedan analyserades med hjälp av kvalitativ innehållsanalys. Resultatet visar att de faktorer som påverkar vårdpersonalens tolkning av dementas olika kommunikativa uttryckssätt är (1) kunskap, (2) yrkeskompetens och (3) institutionella aspekter som psykosocial miljö och tid. Den föreliggande studiens resultat kommer förhoppningsvis att bidra till en bättre kommunikation mellan dementa och vårdpersonal.

  • 2218.
    Troyse, Gianna
    Swedish School of Sport and Health Sciences, GIH, Department of Sport and Health Sciences.
    Synen på friskvårdstimmen inom Landstinget Sörmland: hur den erbjuds och används2008Independent thesis Basic level (degree of Bachelor), 10 poäng / 15 hpStudent thesis
    Abstract [en]

    Aim

    The aim with this paper is to examine how the employees on Spångagården (which is a short term accommodation for persons with some moulds of disabilities) in Torshälla and the National Dental Service on Forskliniken and Eskilshemkliniken in Eskilstuna feels about health care and how they use the health care hour. The aim is furthermore to analyse how the health care hour is offered of the employer.

    Method

    I have used a questionnaire that I distributed to the employees on Spångagården in Torshälla and the National Dental Service Fors and Eskilshem in Eskilstuna in order to investigate the extent of which the health care hour is used and what the employees think of it.

    A further intention is to see why not everybody use the health care hour and what measures are needed in order to get more people to use it.

    Results

    The health care hour is offered in different shapes in Eskilstuna and Torshälla. In Eskilstuna, it is the respective unit director who decides about the health care hour and how it should be used. Torshälla has on the other hand a policy and offers all employees to use health care one hour per week during working hours. A common form of financing from the employer is payment of health care activity upon presenting a receipt.

    Most of the participants in the survey used the health care hour. It was only a handful individuals who did not.

    When the health care hour was not used it was often due to lack of time or rather to exercise after working hours.

    Conclusion

    Most people were very positive to the health care hour and it was used to a great extent among the personnel. However, in order to reach those how did not use the health care hour certain initiatives were needed.

  • 2219.
    Tschudin-Sutter, S.
    et al.
    Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University Basel, Basel, Switzerland.
    Kuijper, E. J.
    Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands.
    Durovic, A.
    Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University Basel, Basel, Switzerland.
    Vehreschild, M. J. G. T.
    Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Germany.
    Barbut, F.
    National Reference Laboratory for Clostridium difficile, Paris, France.
    Eckert, C.
    National Reference Laboratory for Clostridium difficile, Paris, France.
    Fitzpatrick, F.
    Departments of Clinical Microbiology, Royal College of Surgeons in Ireland and Beaumont Hospital, Ireland.
    Hell, M.
    Department of Medical Microbiology and Infection Control, Academic Teaching Laboratories-Medilab OG, Paracelsus Medizinische Privatuniversität (PMU), Salzburg, Austria.
    Norén, Torbjörn
    Örebro University, School of Medical Sciences. Department of Laboratory Medicine, Clinical Microbiology.
    O'Driscoll, J.
    Department of Medical Microbiology, Stoke Mandeville Hospital, Aylesbury, UK.
    Coia, J.
    Scottish Microbiology Reference Laboratories, Glasgow, UK.
    Gastmeier, P.
    Institute of Hygiene and Environmental Medicine, Charité, Universitätsmedizin Berlin, Berlin, Germany.
    von Müller, L.
    Institute for Medical Microbiology and Hygiene, University of Saarland Medical Center, State Laboratory of Saarland, Consiliary Laboratory for Clostridium difficile, Homburg/Saar, Germany.
    Wilcox, M. H.
    Department of Microbiology, Leeds Teaching Hospitals, Leeds, UK; University of Leeds, Leeds, UK.
    Widmer, A. F.
    Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University Basel, Basel, Switzerland.
    Guidance document for prevention of Clostridium difficile infection in acute healthcare settings2018In: Clinical Microbiology and Infection, ISSN 1198-743X, E-ISSN 1469-0691, Vol. 24, no 10, p. 1051-1054, article id S1198-743X(18)30195-2Article in journal (Refereed)
    Abstract [en]

    SCOPE: Clostridium difficile infection (CDI) is the most important infective cause of healthcare-associated diarrhoea in high income countries and one of the most important healthcare-associated pathogens in both Europe and the United States. It is associated with high morbidity and mortality resulting in both societal and financial burden. A significant proportion of this burden is potentially preventable by a combination of targeted infection prevention and control measures and antimicrobial stewardship. The aim of this guidance document is to provide an update on recommendations for prevention of CDI in acute care settings to provide guidance to those responsible for institutional infection prevention and control programmes.

    METHODS: An expert group was set up by the European society of clinical microbiology and infectious diseases (ESCMID) Study Group for C. difficile (ESGCD), which performed a systematic review of the literature on prevention of CDI in adults hospitalized in acute care settings and derived respective recommendations according to the GRADE approach. Recommendations are stratified for both outbreak and endemic settings.

    QUESTIONS ADDRESSED BY THE GUIDELINE AND RECOMMENDATIONS: This guidance document provides thirty-six statements on strategies to prevent CDI in acute care settings, including 18 strong recommendations. No recommendation was provided for three questions.

  • 2220.
    Tu, Jiong
    Linköping University, Department of Medicine and Health Sciences, Health and Society.
    Privatisation of Health Care in Transitional China: A Study of Private Clinics at the County Level2010Independent thesis Advanced level (degree of Master (Two Years)), 20 credits / 30 HE creditsStudent thesis
    Abstract [en]

    The thesis examines the privatisation of China's health care since the 1980s, focusingon the privatisation of primary health care at the county level. The research choosesprivate clinics as research objects, includes a brief historical description of privatehealth care evolution and the existing health care system in China; based on theempirical data collected in the field work, it provides a current picture of private clinicand its privatisation process in a Chinese city, discusses the problems in privatemedical practice and challenges private clinic faces, and the influence of privatisationon health sector performance.The thesis notes the privatisation of primary health care by private clinics supplies analternative way for health care services. It plays a significant role in compensatingpublic system and promotes more equal health access, although the radicalprivatisation of all health sectors undermines the accessibility and quality of healthservices in general. Currently the private health sector in China is still small and yet toform a mature market, and there are multiple challenges for its further development,but it can be expected that the private sector in the health care area will expand rapidly,and China could hopefully find a suitable way of public/private mix under the newhealth reform.

  • 2221.
    Turner, Anthony
    Linköping University, Department of Physics, Chemistry and Biology, Biosensors and Bioelectronics. Linköping University, Faculty of Science & Engineering.
    e-Diagnostics: it looks okay on paper!2015In: The Royal Swedish Academy 275th Jubilee Symposium, 22-23 April 2015, Linköping/Norrköping, Sweden., Royal Swedish Academy , 2015, p. 14-15Conference paper (Refereed)
    Abstract [en]

    Healthcare spending is growing unsustainably and has already reached 18% of GDP in the USA and 9.6% of GDP in Sweden. However, several key drivers are now coming together to form a “perfect storm” that may just finally catalyse change in our 2,500 year-old model of healthcare delivery. Personalised medicine recognises that every individual is different and needs a tailor-made health package; these differences can only be identified with an appropriate suite of diagnostics. Individuals are increasing recognising that data about their bodies should be owned by them and that they should have the choice to use and supplement this information. This generates consumer choice and drives evidence-based payment, where treatments are paid for on the basis of measurable outcomes. Focus on individual needs drives decentralisation and radical restructuring of health management services. And all this is underpinned by technologies facilitating mobility and data processing. The core technology, however, is rapid, convenient and easy ways to measure our body chemistries at the genomic, proteomic and metabolomic levels. We envisage this need being met by a new generation of electronic “paper” instruments in a diversity of formats such as smart packaging, telemetric paper strips and print-on-demand analytical devices. This presentation will describe our work, together with our development partner Acreo ICT AB, on printed technologies for over-the-counter paper instruments for self-diagnosis of common diseases such as diabetes, kidney disease and urinary tract infection, inexpensive devices for use by caregivers or paramedics, home kits to support people after transplant surgery or cancer treatment, smart cartons for pharamceuticals and a variety of pocket tests, strips and patches that could communicate with mobile telecommunications.

  • 2222.
    Turner, Anthony
    Linköping University, Department of Physics, Chemistry and Biology, Biosensors and Bioelectronics. Linköping University, Faculty of Science & Engineering.
    Paper Amperometric Systems for e-Diagnostics2015In: 227th ECS Meeting, May 24-28, 2015, Chicago, USA., 2015Conference paper (Refereed)
    Abstract [en]

    Biosensors have achieved considerable success in both the commercial and academic arenas and the need for new, easy-to-use, home and decentralised diagnostics is now greater than ever. Healthcare spending is growing unsustainably and has already reached 18% of GDP in the USA and 9.5% of GDP in Europe. New thinking is crucial to finding effective solutions that deliver the high quality of life rightly demanded by our ever ageing population while leveraging technology to deliver this in a cost-effective manner. Several key drivers are coming together to form a “perfect storm” that may just finally catalyse change to our 2,500 year-old model of healthcare delivery. Personalised medicine recognises that every individual is different and needs a tailor-made health package; these differences can only be identified with an appropriate suite of diagnostics. Individuals are increasing recognising that data about their bodies should be owned by them and that they should have the choice to use and supplement this information. This generates consumer choice and drives evidence-based payment, where regimens and treatments are paid for on the basis of successful outcomes. Focus on the individual and their needs drives decentralisation and the possible radical restructuring of how we deliver health management both nationally and internationally. This is underpinned by technologies facilitating mobility and data processing. At the core of all this, however, is rapid, convenient and easy ways to measure our body chemistries at the genomic, proteomic and metabolomic levels. Next generation diagnostics fabrication is targeting fully-integrated platforms such as the all-printed biosensing systems, integrated sampling and wearable devices. Further development will result in cost reduction and a diversity of formats such as point-of-care tests, smart packaging, telemetric paper strips and print-on-demand analytical devices.

     

    This presentation will focus on meeting these challenges using amperometric and votammetric systems printed on paper or plastic substrates to deliver inexpensive instruments for a wide range of electroanalytical applications. This approach combines the sophistication of advanced electrochemical biosensors with a simple manufacturing technique to create a use-and-throw instrument. The system is manufactured under ambient conditions. All interconnections are printed and an anisotropic conductive glue is used for interconnection between the chip and conductors. A screen-printed manganese dioxide battery and a vertical electrochromic display are incorporated in the instrument. The display is paper-like in the sense that it works in reflective mode, that is, no backlight is used to light up the pixels. This integrated biosensing platform forms a workhorse in our hands for a variety of diagnostic systems including enzyme electrodes for multi-parametric diabetes monitoring and for the management of chronic kidney disease, electrochemical sensors for enzymes such as G6-P or amylase (a marker for stress), label-free affinity sensors for cancer markers and heart disease, aptasensors for cancer cells, DNA Sensors and robust devices based on imprinted and smart polymers. Using these technologies, we envision over-the-counter paper instruments for self-diagnosis of common diseases such as diabetes, kidney disease and urinary tract infection;

    inexpensive devices for use by caregivers or paramedics such as the ”Stressometer” or heart attack indicators; home kits to support people after transplant surgery or cancer treatment, smart cartons for pharmaceuticals; pocket tests for allergens, food toxicity, drinking water etc. and strips or patches that communicate with mobile telecommunications. Realisation of these paradigm-changing new products requires the effective harnessing of emerging technology, inspired vision from clinical partners or others “users” and leading-edge engineering to design and produce functional systems in appropriate volumes at the right cost.

     

    References

    Turner, A.P.F. (2013). Biosensors: sense and sensibility. Chemical Society Reviews 42 (8), 3184-3196.

    Turner, A.P.F., Beni, V., Gifford, R., Norberg, P., Arven, P., Nilsson, D., Åhlin, J., Nordlinder, S. and Gustafsson, G. (2014). Printed Paper- and Plastic-based Electrochemical Instruments for Biosensors. 24th Anniversary World Congress on Biosensors – Biosensors 2014, 27-30 May 2014, Melbourne, Australia. Elsevier.

     

    Karimian, N., Turner, A.P.F. Tiwari, A. (2014). Electrochemical evaluation of a protein-imprinted polymer receptor. Biosensors and  Bioelectronics 59, 160-165.

     

    Kashefi-Kheyrabadi, l., Mehrgardi, M.A., Wiechec, E., Turner, A.P.F. and Tiwari, A. (2014). Ultrasensitive detection of human liver hepatocellular carcinoma (HepC2) cells using a label-free aptasensor. Analytical Chemistry 86, 4956-4960.

     

    Parlak, O., Turner, A.P.F. and Tiwari, A. (2014). On/off-switchable zipper-like bioelectronics on a graphene interface. Advanced Materials 26, 482-486. DOI: 10.1002/adma.201303075

     

    Sekretaryova, A., Vagin, M., Beni, V., Turner, A.P.F. and  Karyakin, A. (2014). Unsubstituted Phenothiazine as a Superior Water-insoluble Mediator for Oxidases. Biosensors and Bioelectronics 53, 275–282.

     

    Shukla, S.K, Turner, A.P.F.  and Tiwari, A. (2015). Cholesterol oxidase functionalised polyaniline/carbon nanotube hybrids for an amperometric biosensor. Journal of Nanoscience and Nanotechnology 15, 3373-3377.

  • 2223.
    Tveter Deilkas, Ellen
    et al.
    Norwegian Directorate Heatlh, Norway; Akershus University Hospital, Norway.
    Borgstedt Risberg, Madeleine
    Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Haugen, Marion
    Norwegian Comp Centre, Norway.
    Lindström, Jonas Christoffer
    Akershus University Hospital, Norway.
    Nylen, Urban
    National Board Health and Welf, Sweden.
    Rutberg, Hans
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery. Swedish Assoc Local Author and Reg, Sweden.
    Michael, Soop
    National Board Health and Welf, Sweden.
    Exploring similarities and differences in hospital adverse event rates between Norway and Sweden using Global Trigger Tool2017In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, article id e012492Article in journal (Refereed)
    Abstract [en]

    Objectives: In this paper, we explore similarities and differences in hospital adverse event (AE) rates between Norway and Sweden by reviewing medical records with the Global Trigger Tool (GTT). Design: All acute care hospitals in both countries performed medical record reviews, except one in Norway. Records were randomly selected from all eligible admissions in 2013. Eligible admissions were patients 18 years of age or older, undergoing care with an in-hospital stay of at least 24 hours, excluding psychiatric and care and rehabilitation. Reviews were done according to GTT methodology. Setting: Similar contexts for healthcare and similar socioeconomic and demographic characteristics have inspired the Nordic countries to exchange experiences from measuring and monitoring quality and patient safety in healthcare. The co-operation has promoted the use of GTT to monitor national and local rates of AEs in hospital care. Participants: 10 986 medical records were reviewed in Norway and 19 141 medical records in Sweden. Results: No significant difference between overall AE rates was found between the two countries. The rate was 13.0% (95% CI 11.7% to 14.3%) in Norway and 14.4% ( 95% CI 12.6% to 16.3%) in Sweden. There were significantly higher AE rates of surgical complications in Norwegian hospitals compared with Swedish hospitals. Swedish hospitals had significantly higher rates of pressure ulcers, falls and other AEs. Among more severe AEs, Norwegian hospitals had significantly higher rates of surgical complications than Swedish hospitals. Swedish hospitals had significantly higher rates of postpartum AEs. Conclusions: The level of patient safety in acute care hospitals, as assessed by GTT, was essentially the same in both countries. The differences between the countries in the rates of several types of AEs provide new incentives for Norwegian and Swedish governing bodies to address patient safety issues.

  • 2224.
    Tyler, Denise A.
    et al.
    RTI Int, Aging Disabil & Long Term Care Program;Brown Univ, Sch Publ Hlth, Ctr Gerontol & Healthcare Res.
    Gadbois, Emily A.
    Brown Univ, Sch Publ Hlth, Ctr Gerontol & Healthcare Res.
    McHugh, John P.
    Columbia Univ, Mailman Sch Publ Hlth, Dept Hlth Policy & Management.
    Shield, Renee R.
    Brown Univ, Sch Publ Hlth, Ctr Gerontol & Healthcare Res.
    Winblad, Ulrika
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research. Brown Univ, Sch Publ Hlth, Ctr Gerontol & Healthcare Res.
    Mor, Vincent
    Brown Univ, Sch Publ Hlth, Hlth Serv Policy & Practice;Providence Vet Affairs Med Ctr.
    Patients Are Not Given Quality-Of-Care Data About Skilled Nursing Facilities When Discharged From Hospitals2017In: Health Affairs, ISSN 0278-2715, E-ISSN 1544-5208, Vol. 36, no 8, p. 1385-1391Article in journal (Refereed)
    Abstract [en]

    Hospitals are now being held at least partly accountable for Medicare patients' care after discharge, as a result of regulations and incentives imposed by the Affordable Care Act. However, little is known about how patients select a postacute care facility. We used a multiple case study approach to explore both how patients requiring postacute care decide which skilled nursing facility to select and the role of hospital staff members in this decision. We interviewed 138 staff members of sixteen hospitals and twenty-five skilled nursing facilities and 98 patients in fourteen of the skilled nursing facilities. Most patients described receiving only lists of skilled nursing facilities from hospital staff members, while staff members reported not sharing data about facilities' quality with patients because they believed that patient choice regulations precluded them from doing so. Consequently, patients' choices were rarely based on readily available quality data. Proposed changes to the Medicare conditions of participation for hospitals that pertain to discharge planning could rectify this problem. In addition, less strict interpretations of choice requirements would give hospitals flexibility in the discharge planning process and allow them to refer patients to higher-quality facilities.

  • 2225.
    Tyler, Denise A
    et al.
    RTI Int, Aging Disabil & Long Term Care Program;Brown Univ, Sch Publ Hlth, Ctr Gerontol & Healthcare Res..
    McHugh, John P
    Department of Health Policy and Management, Columbia University Mailman School of Public Health, New York, NY.
    Shield, Renée R
    Center for Gerontology & Health Care Research, Brown University School of Public Health, Providence, RI.
    Winblad, Ulrika
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Gadbois, Emily A
    Center for Gerontology & Health Care Research, Brown University School of Public Health, Providence, RI.
    Mor, Vincent
    Center for Gerontology & Health Care Research, Brown University School of Public Health, Providence, RI.
    Challenges and Consequences of Reduced Skilled Nursing Facility Lengths of Stay2018In: Health Services Research, ISSN 0017-9124, E-ISSN 1475-6773, Vol. 53, no 6, p. 4848-4862Article in journal (Refereed)
    Abstract [en]

    Length of stay (LOS) among postacute care patients in skilled nursing facilities (SNFs) has been steadily decreasing for the past several years. Empirical studies on overall SNF LOS are scant because most studies focus on LOS for certain conditions or procedures (e.g., Haghverdian, Wright, and Schwarzkopf 2017). However, analysis of LOS data available at Brown University's LTCFocus website (www.ltcfocus.org) illustrates that SNF LOS has been dropping in recent years. These reductions have been due, in part, to Medicare policy changes and market based pressures, including the emergence of accountable care organizations (ACOs) and bundled payment and shared savings programs, as well as the growth of Medicare Advantage. However, little is known about how shorter LOS is affecting SNFs or their postacute care patients.

    Implementation of the Affordable Care Act (ACA) included several programs to improve care quality, increase efficiency, and reduce costs through value‐based payment models. In these programs, participating providers, including doctors, hospitals, and other health care organizations, join together voluntarily to provide coordinated care to their Medicare patients. These groups are reimbursed for episodes of care, payments are capitated and risk‐adjusted, and participating organizations share savings they achieve from their Medicare population (Centers for Medicare and Medicaid Services 2017). Because over 20% of Medicare patients who are hospitalized each year are discharged to postacute care (PAC; Tian 2016), many of the patients covered by these programs are cared for in SNFs. However, research has shown that a minority of ACOs, for example, actually include SNFs as full participants (Colla et al. 2016). This means that ACOs are relying on SNFs to provide better care at lower costs without including those SNFs in the shared savings or through contractual or other formal relationships.

    In the last several years, there has also been extraordinary growth in the Medicare Advantage program, which now covers one‐third of all Medicare beneficiaries (Jacobson et al. 2017). Medicare Advantage is the managed care version of Medicare where private insurers are paid by Medicare on a per beneficiary per month basis for the care of all their enrolled beneficiaries. Unlike traditional Medicare where patients have choice among all available providers, Medicare Advantage managed care organizations (MCOs) are free to form networks of preferred providers. This affords MCOs some control over the care delivered by providers in their networks, including increased control over LOS.

    Decreases in LOS due to these market and policy pressures are likely having an effect on SNFs. Therefore, the purpose of this research was to identify the key challenges that reductions in LOS pose for SNFs, the unintended consequences of reduced LOS for SNFs and SNF patients, SNF responses to these, and suggestions for modifications to current policy.

  • 2226. Tyrberg, E
    et al.
    Smedby, B
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Indikationer för behandling med vitamin B12, prevalens av pernisiös anemi samt bedömning av patientutredningarnas kvalitet (stencil)1981Report (Other academic)
  • 2227. Tyrberg, E
    et al.
    Smedby, B
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    [Treatment with vitamin B12 and the quality of care]1982In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 79, no 12, p. 1116-19Article in journal (Refereed)
  • 2228.
    Tyrstrup, Mats
    et al.
    Stockholm School of Economics.
    Larsson, Ida
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Business Studies.
    Närvård i västra Sörmland: En berättelse om roller, relationer och avstånd2017Report (Other academic)
  • 2229.
    Tyrstrup, Mia
    et al.
    Department of Clinical Sciences, General Practice, Lund University, Lund, Sweden.
    van der Velden, Alike
    Department of Clinical Sciences, General Practice, Lund University, Lund, Sweden.
    Engström, Sven
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Primary Care Research and Development Unit, Jönköping, Sweden.
    Goderis, Geert
    Katholieke Universiteit Leuven, Academic Center for General Practice, Leuven, Belgium.
    Molstad, Sigvard
    Department of Clinical Sciences, General Practice, Lund University, Lund, Sweden.
    Verheij, Theo
    Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands.
    Coenen, Samuel
    Department of Primary and Interdisciplinary Care (ELIZA), Center for General Practice, University of Antwerp, Antwerp, Belgium.
    Adriaenssens, Niels
    Department of Primary and Interdisciplinary Care (ELIZA), Center for General Practice, University of Antwerp, Antwerp, Belgium.
    Antibiotic prescribing in relation to diagnoses and consultation rates in Belgium, the Netherlands and Sweden: use of European quality indicators2017In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 35, no 1, p. 10-18Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To assess the quality of antibiotic prescribing in primary care in Belgium, the Netherlands and Sweden using European disease-specific antibiotic prescribing quality indicators (APQI) and taking into account the threshold to consult and national guidelines.

    DESIGN: A retrospective observational database study.

    SETTING: Routine primary health care registration networks in Belgium, the Netherlands and Sweden.

    SUBJECTS: All consultations for one of seven acute infections [upper respiratory tract infection (URTI), sinusitis, tonsillitis, otitis media, bronchitis, pneumonia and cystitis] and the antibiotic prescriptions in 2012 corresponding to these diagnoses.

    MAIN OUTCOME MEASURES: Consultation incidences for these diagnoses and APQI values (a) the percentages of patients receiving an antibiotic per diagnosis, (b) the percentages prescribed first-choice antibiotics and (c) the percentages prescribed quinolones.

    RESULTS: The consultation incidence for respiratory tract infection was much higher in Belgium than in the Netherlands and Sweden. Most of the prescribing percentage indicators (a) were outside the recommended ranges, with Belgium deviating the most for URTI and bronchitis, Sweden for tonsillitis and the Netherlands for cystitis. The Netherlands and Sweden prescribed the recommended antibiotics (b) to a higher degree and the prescribing of quinolones exceeded the proposed range for most diagnoses (c) in Belgium. The interpretation of APQI was found to be dependent on the consultation incidences. High consultation incidences were associated with high antibiotic prescription rates. Taking into account the recommended treatments from national guidelines improved the results of the APQI values for sinusitis in the Netherlands and cystitis in Sweden.

    CONCLUSION: Quality assessment using European disease-specific APQI was feasible and their inter-country comparison can identify opportunities for quality improvement. Their interpretation, however, should take consultation incidences and national guidelines into account. Differences in registration quality might limit the comparison of diagnosis-linked data between countries, especially for conditions such as cystitis where patients do not always see a clinician before treatment. Key points The large variation in antibiotic use between European countries points towards quality differences in prescribing in primary care.  • The European disease-specific antibiotic prescribing quality indicators (APQI) provide insight into antibiotic prescribing, but need further development, taking into account consultation incidences and country-specific guidelines.  • The incidence of consultations for respiratory tract infections was almost twice as high in Belgium compared to the Netherlands and Sweden.  • Comparison between countries of diagnosis-linked data were complicated by differences in data collection, especially for urinary tract infections.

  • 2230.
    Tärnqvist, Julia
    et al.
    The Ambulance Service in Skaraborg, Lidköping, Sweden.
    Dahlén, Erik
    The Ambulance Service in Skaraborg, Lidköping, Sweden.
    Magnusson, Carl
    Sahlgrenska Univ Hospital.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Strömsöe, Anneli
    University of Dalarna.
    Norberg, Gabriella
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. Sahlgrenska University Hospital.
    Andersson Hagiwara, Magnus
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    On-Scene and Final Assessments and Their Interrelationship Among Patients Who Use the EMS on Multiple Occasions2017In: Prehospital and Disaster Medicine, ISSN 1049-023X, E-ISSN 1945-1938, Vol. 32, no 5, p. 528-535Article in journal (Refereed)
    Abstract [en]

    Introduction The use of Emergency Medical Services (EMS) is increasing. A number of patients call repeatedly for EMS. Early studies of frequent callers show that they form a heterogenous group. Problem There is a lack of research on frequent EMS callers. There is furthermore a lack of knowledge about characteristics and the prehospital assessment of the patients who call for EMS on several occasions. Finally, there is a general lack of knowledge with regard to the association between the prehospital assessment by health care providers and the final diagnosis. Method Patients in Skaraborg in Western Sweden, who used the EMS at least four times in 2014, were included, excluding transport between hospitals. Information on the prehospital assessment on-scene and the final diagnosis was collected from the EMS and hospital case records. Results In all, 339 individual patients who used the EMS on 1,855 occasions were included, accounting for five percent of all missions. Fifty percent were women. The age range was 10-98 years, but more than 50.0% were in the age range of 70-89 years. The most common emergency signs and symptoms (ESS) codes on the scene were dyspnea, chest pain, and abdominal pain. The most common final diagnosis was chronic obstructive pulmonary disease (eight percent). Thirteen percent of all cases had a final diagnosis defined as a potentially life-threatening condition. Among these, 22.0% of prehospital assessments were retrospectively judged as potentially inappropriate. Forty-nine percent had a defined final diagnosis not fulfilling the criteria for a potentially life-threatening condition. Among these cases, 30.0% of prehospital assessments were retrospectively judged as potentially inappropriate. Conclusion: Among patients who used EMS on multiple occasions, the most common symptoms on-scene were dyspnea, chest pain, and abdominal pain. The most common final diagnosis was chronic obstructive pulmonary disease. In 13.0%, the final diagnosis of a potentially life-threatening condition was indicated. In a minority of these cases, the assessment on-scene was judged as potentially inappropriate. Tärnqvist J , Dahlén E , Norberg G , Magnusson C , Herlitz J , Strömsöe A , Axelsson C , Andersson Hagiwara M . On-Scene and Final Assessments and Their Interrelationship Among Patients Who Use the EMS on Multiple Occasions. Prehosp Disaster Med. 2017;32(5):1–8.

  • 2231.
    Törnquist, Louise
    Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare. Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Näringsriktiga mellanmål och tätare viktkontroller minskade ofrivilligviktnedgång: En kvalitativ studie om ett förbättringsarbete på ett äldreboende2018Independent thesis Advanced level (degree of Master (Two Years)), 20 credits / 30 HE creditsStudent thesis
    Abstract [sv]

    Bakgrund: Det finns omfattande belägg om nutritionens betydelse för äldres hälsa och livskvalitet. För äldre patienter som bor på äldreboenden förekommer undernäring och ofrivillig viktnedgång vilket kan leda till ökade komplikationer såsom fall, trycksår och dödlighet.Syfte: Syftet i denna uppsats består av två delar. Syfte i det genomförda förbättringsarbetet: Att alla patienter på Solgården erbjuds bästa möjliga förutsättningar för att inta en god och näringsriktig kost. På lång sikt är målet att alla patienter ska ha ett gott nutritionsstatus. Syftet med studien av förbättringsarbetet: var att beskriva om och i så fall på vilket sätt personalen upplevde att förbättringsarbetet resulterade i förbättringar (i vården) för personer med demenssjukdom samt beskriva hur personalens erfarenheter av förbättringsarbetet kan bidra till förbättrad nutritionsvård för personer med demenssjukdom.Metod: Förbättringsarbetet genomfördes utifrån Nelson, Batalden och Godfreys (2011) Improvement ramp. I studien användes fallstudie med kvalitativ, induktiv metod och datainsamlingen bestod av intervjuer.Resultat: Förbättringsarbetets resultat visade att andelen mellanmål som innehöll tillräckligt mycket kalorier ökade och att journalförda viktuppföljningar gjordes i högre utsträckning. Studiens resultat bestod av fem kategorier som beskrev erfarenheter av förbättringsarbetet och på vilket sätt det upplevdes ha resulterat i förbättringar för patienterna.

  • 2232.
    Törnqvist, Jeanette
    et al.
    Region Halland, Halmstad University.
    Törnvall, Eva
    Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care. Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences.
    Jansson, Inger
    Göteborgs universitet.
    Double documentation in electronic health records2016In: Nordic journal of nursing research, ISSN 2057-1585, Vol. 36, no 2, p. 88-94Article in journal (Refereed)
    Abstract [en]

    Documentation in the patient record must be systematic and rigorous. However, each health care profession documents parts of the electronic health record (EHR) separately. This system can lead to double documentation. The aim of the study was to describe the amount of double documentation in health records for in-patients. A retrospective descriptive review of 30 records for in-patients diagnosed with hip fracture was conducted. Double documentation occurred on all records reviewed during the stay in hospital and in or between all professions reviewed. In total, 822 instances of double documentation were found. The EHRs available today are not designed to monitor processes. Instead, they follow each health profession, which can lead to double documentation. It would be desirable to develop an EHR from a process perspective and not a record per profession.

  • 2233. Ulhassan, Waqar
    et al.
    Sandahl, Christer
    Westerlund, Hugo
    Stockholm University, Faculty of Social Sciences, Stress Research Institute.
    Henriksson, Peter
    Bennermo, Marie
    von Thiele Schwarz, Ulrica
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Thor, Johan
    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.

  • 2234.
    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.

  • 2235.
    Ulhassan, Waqar
    et al.
    Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden.
    Schwarz, Ulrica von Thiele
    Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Westerlund, Hugo
    Stress Research Institute, Stockholm University, Stockholm, Sweden.
    Interactions between lean management and the psychosocial work environment in a hospital setting - a multi-method study2014In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, p. 480-Article in journal (Refereed)
    Abstract [en]

    Background: As health care struggles to meet increasing demands with limited resources, Lean has become a popular management approach. It has mainly been studied in relation to health care performance. The empirical evidence as to how Lean affects the psychosocial work environment has been contradictory. This study aims to study the interaction between Lean and the psychosocial work environment using a comprehensive model that takes Lean implementation information, as well as Lean theory and the particular context into consideration. Methods: The psychosocial work environment was measured twice with the Copenhagen Psychosocial Questionnaire (COPSOQ) employee survey during Lean implementations on May-June 2010 (T1) (n = 129) and November-December 2011 (T2) (n = 131) at three units (an Emergency Department (ED), Ward-I and Ward-II). Information based on qualitative data analysis of the Lean implementations and context from a previous paper was used to predict expected change patterns in the psychosocial work environment from T1 to T2 and subsequently compared with COPSOQ-data through linear regression analysis. Results: Between T1 and T2, qualitative information showed a well-organized and steady Lean implementation on Ward-I with active employee participation, a partial Lean implementation on Ward-II with employees not seeing a clear need for such an intervention, and deterioration in already implemented Lean activities at ED, due to the declining interest of top management. Quantitative data analysis showed a significant relation between the expected and actual results regarding changes in the psychosocial work environment. Ward-I showed major improvements especially related to job control and social support, ED showed a major decline with some exceptions while Ward-II also showed improvements similar to Ward-I. Conclusions: The results suggest that Lean may have a positive impact on the psychosocial work environment given that it is properly implemented. Also, the psychosocial work environment may even deteriorate if Lean work deteriorates after implementation. Employee managers and researchers should note the importance of employee involvement in the change process. Employee involvement may minimize the intervention's harmful effects on psychosocial work factors. We also found that a multi-method may be suitable for investigating relations between Lean and the psychosocial work environment.

  • 2236.
    Ulhassan, Waqar
    et al.
    Medical Management Centre, Karolinska Institutet.
    Schwarz, Ulrica von Thiele
    Medical Management Centre, Karolinska Institutet.
    Westerlund, Hugo
    Stress Research Institute, Stockholm University.
    Sandahl, Christer
    Medical Management Centre, Karolinska Institutet.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Medical Management Centre, Karolinska Institutet.
    How visual management for continuous improvement might guide and affect hospital staff: A case study2015In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 24, no 4, p. 222-228Article in journal (Refereed)
    Abstract [en]

    Visual management (VM) tools such as whiteboards, often employed in Lean thinking applications, are intended to be helpful in improving work processes in different industries including health care. It remains unclear, however, how VM is actually applied in health care Lean interventions and how it might influence the clinical staff. We therefore examined how Lean-inspired VM using whiteboards for continuous improvement efforts related to the hospital staff's work and collaboration. Within a case study design, we combined semistructured interviews, nonparticipant observations, and photography on 2 cardiology wards. The fate of VM differed between the 2 wards; in one, it was well received by the staff and enhanced continuous improvement efforts, whereas in the other ward, it was not perceived to fit in the work flow or to make enough sense in order to be sustained. Visual management may enable the staff and managers to allow communication across time and facilitate teamwork by enabling the inclusion of team members who are not present simultaneously; however, its adoption and value seem contingent on finding a good fit with the local context. A combination of continuous improvement and VM may be helpful in keeping the staff engaged in the change process in the long run.

  • 2237.
    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.

  • 2238.
    Ulin, Kerstin
    et al.
    Institute of Health and Care Science, Sahlgrenska Academy, University of Gothenburg.
    Malm, Dan
    Jönköping University, School of Health and Welfare, HHJ, Dep. of Nursing Science. Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare.
    Nygårdh, Annette
    Jönköping University, School of Health and Welfare, HHJ, Dep. of Nursing Science. Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    What is known about the benefits of patient-centered care in patients with heart failure2015In: Current Heart Failure Reports, ISSN 1546-9530, E-ISSN 1546-9549, Vol. 12, no 6, p. 350-359Article, review/survey (Refereed)
    Abstract [en]

    Treatment for chronic heart failure (CHF) has improved, and symptom burden has been identified as an important treatment goal. Because patient-centered care may ease the burden, we need to know its benefits for patients with CHF, hence this systematic literature review. We found that one benefit of person-centered care is an increase in quality of life in patients with CHF. Improvements were found in self-care, physical and mental status, health care costs, general uncertainty regarding illness and recovery, patient dignity, treatment, and systems of care. Improvements also were observed in symptom burden, self-efficacy, and quality of life. These findings indicate that person-centered care is a powerful approach to current and future health care. However, because an appropriate tool to measure person-centered care does not yet exist, it will be a challenge to determine whether the goal has been reached from a long-term and patient perspective.

  • 2239. Umefjord, G
    et al.
    Petersson, Göran
    Lund University.
    Hamberg, K
    Reasons for consulting a doctor on the internet: Web Survey of Users of an Ask the Doctor Service2003In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 5, no 4Article in journal (Refereed)
  • 2240.
    Umefjord, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Internet consultation in medicine: studies of a text-based Ask the doctor service2006Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The overall aim of this thesis was to cast light on the new phenomenon of Internet-based medical consultation. This was approached by studies of the use of an Ask the doctor service, by a web survey to the users who sent enquiries to the service, and by a questionnaire to the answering physicians of their respective expericence of the service.

    Written communication is becoming increasingly important, not only for communication between individuals outwith health care (e.g. by email, SMS and instant messaging), but also between doctors and patients. There is an ongoing shift in the way individuals look for medical information with an increasing number going first to the Internet berfore talking with their physicians. Also, there is an increasing interest from patients in accessing Internet-based services, including text-based consultations with doctors. These consultations can be part of the regular communication between a patient and his/her doctor or be carried out without any previous relationship. Our studies of the latter consultation type emanate from the free of charge Ask the doctor service at a Swedish public health web portal, Infomedica, financed by health authorities. At the Ask the doctor service, the communication has been merely text-based and the individual using the consultation service (here called the enquirer) might have been anonymous.

    We followed the development of the first four years use of the service (38 217 enquiries), finding that the typical enquirer was a woman aged 21-60 years. Three quarters of the enquirers were women, thus exceeding the gender difference seen in regular health care. The service was used all times of the day and night, seven days a week, and it was most used in densely populated areas as defined from postal codes.

    The enquiries submitted to the service included a broad variety of medical issues. Most enquirers asked on their own behalf. Almost half of the enquiries concerned a matter not previously evaluated by a medical professional. Only a few were frequent enquirers. The service was used e.g. for a primary evaluation of a medical problem, for getting more information on a medical issue under treatment, and for a second opinion. The most common reasons for turning to a doctor on the Internet were convenience, wish for anonymity and that doctors were experinced too busy. In free text a considerable number of participants expressed discontent and communication problems with a previous doctor as a reason to turn to the Ask the doctor service. Many participants expressed a view of the service as a complement to regular health care, and the majority were satisfied with the answer. Nearly half of the participants in the web survey stated that they received sufficient information in their answer and that they would not pursue their question further.

    The family physicians answering the enquiries at the Ask the doctor service were stimulated and challenged by the new task, in spite of the limitations caused by the lack of personal meetings and physical examinations. The opportunity to reflect on the answer before replying was appreciated, and the task was regarded as having a high educational value for themselves.

    The Internet not only allows easy access to medical information but also to medical consultation – to date mostly text-based. It is probable that in the near future an increasing number of doctors will adopt text-based communication via the Internet to be a natural part of their communication with patients. Therefore, training in text-based communication and carrying out Internet consultations should be integrated into the curricula of medical schools and of continuous professional development. Ethical guidelines should be established.

  • 2241. Umefjord, Göran
    et al.
    Malker, H
    Olofsson, N
    Hensjö, LO
    Petersson, G
    Primary care phycians’ experiences of carrying out consultations on the Internet2004In: Informatics in Primary Care, ISSN 1476-0320, E-ISSN 1475-9985, Vol. 12, no 2, p. 85-90Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The internet is increasingly used for health matters, including consulting a doctor. Primary care physicians (general practitioners) will probably be involved in performing text-based consultations on the internet as a complement to physical meetings. In the present study, we explored the experiences of GPs already performing consultations on the internet: the challenges, worries and educational demands of the task. MATERIALS AND METHODS: A questionnaire was given to 21 GPs performing consultations on the internet for a public, non-commercial 'ask the doctor' service. The questionnaire was carried out at a meeting or sent by mail. The doctors answered a total of 28 questions, 12 of which included graded alternatives. RESULTS: The participating GPs were stimulated and challenged by performing consultations on the internet with previously unknown enquirers, in spite of limitations caused by the lack of personal meetings and physical examinations. The participants experienced a high educational value as a result of the problem-based learning situation induced by unfamiliar questions. The asynchronous feature was appreciated as it allowed time to reflect and perform relevant information searches before replying. Prior training and long-term experience as a family doctor were recommended before embarking on this method of consultation. CONCLUSIONS: We conclude that the GPs studied experienced their new role as internet doctors mainly in a positive way, with some limitations. With the increase in consultations on the internet, training in this technique should be integrated into the curricula of medical schools and of continuous professional development (CPD).

  • 2242.
    Unbeck, Maria
    et al.
    Danderyd Hospital.
    Schildmeijer, Kristina
    Linnaeus University.
    Henriksson, Peter
    Danderyd Hospital.
    Jurgensen, Urban
    Qulturum, Jönköping.
    Muren, Olav
    Danderyd Hospital.
    Nilsson, Lena
    Linköping University, Department of Medical and Health Sciences, Anesthesiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping.
    Pukk Härenstam, Karin
    Karolinska Institute.
    Is detection of adverse events affected by record review methodology? An evaluation of the “Harvard Medical Practice Study” method and the “Global Trigger Tool”.2013In: Patient Safety in Surgery, ISSN 1754-9493, E-ISSN 1754-9493, Vol. 7, no 1, p. 10-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    There has been a theoretical debate as to which retrospective record review method is the most valid, reliable, cost efficient and feasible for detecting adverse events. The aim of the present study was to evaluate the feasibility and capability of two common retrospective record review methods, the "Harvard Medical Practice Study" method and the "Global Trigger Tool" in detecting adverse events in adult orthopaedic inpatients.

    METHODS:

    We performed a three-stage structured retrospective record review process in a random sample of 350 orthopaedic admissions during 2009 at a Swedish university hospital. Two teams comprised each of a registered nurse and two physicians were assigned, one to each method. All records were primarily reviewed by registered nurses. Records containing a potential adverse event were forwarded to physicians for review in stage 2. Physicians made an independent review regarding, for example, healthcare causation, preventability and severity. In the third review stage all adverse events that were found with the two methods together were compared and all discrepancies after review stage 2 were analysed. Events that had not been identified by one of the methods in the first two review stages were reviewed by the respective physicians.

    RESULTS:

    Altogether, 160 different adverse events were identified in 105 (30.0%) of the 350 records with both methods combined. The "Harvard Medical Practice Study" method identified 155 of the 160 (96.9%, 95% CI: 92.9-99.0) adverse events in 104 (29.7%) records compared with 137 (85.6%, 95% CI: 79.2-90.7) adverse events in 98 (28.0%) records using the "Global Trigger Tool". Adverse events "causing harm without permanent disability" accounted for most of the observed difference. The overall positive predictive value for criteria and triggers using the "Harvard Medical Practice Study" method and the "Global Trigger Tool" was 40.3% and 30.4%, respectively.

    CONCLUSIONS:

    More adverse events were identified using the "Harvard Medical Practice Study" method than using the "Global Trigger Tool". Differences in review methodology, perception of less severe adverse events and context knowledge may explain the observed difference between two expert review teams in the detection of adverse events.

  • 2243.
    Unbeck, Maria
    et al.
    Karolinska Institutet.
    Schildmeijer, Kristina
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Henriksson, Peter
    Karolinska Institutet.
    Jurgensen, Urban
    Eksjö sjukhus.
    Muren, Olav
    Karolinska Institutet.
    Nilsson, Lena
    Linköpings Universitetssjukhus.
    Pukk Härenstam, Karin
    Karolinska Institutet.
    Is detection of adverses events affected by record review merthodology? an evaluation of the "Harvard medical practice study" method and the "Global trigger tool"2013In: Patient Safety in Surgery, ISSN 1754-9493, E-ISSN 1754-9493, Vol. 7, no April, p. Article ID: 10-Article in journal (Refereed)
    Abstract [en]

    Background

    There has been a theoretical debate as to which retrospective record review method is the most valid, reliable, cost efficient and feasible for detecting adverse events. The aim of the present study was to evaluate the feasibility and capability of two common retrospective record review methods, the “Harvard Medical Practice Study” method and the “Global Trigger Tool” in detecting adverse events in adult orthopaedic inpatients.

    Methods

    We performed a three-stage structured retrospective record review process in a random sample of 350 orthopaedic admissions during 2009 at a Swedish university hospital. Two teams comprised each of a registered nurse and two physicians were assigned, one to each method. All records were primarily reviewed by registered nurses. Records containing a potential adverse event were forwarded to physicians for review in stage 2. Physicians made an independent review regarding, for example, healthcare causation, preventability and severity. In the third review stage all adverse events that were found with the two methods together were compared and all discrepancies after review stage 2 were analysed. Events that had not been identified by one of the methods in the first two review stages were reviewed by the respective physicians.

    Results

    Altogether, 160 different adverse events were identified in 105 (30.0%) of the 350 records with both methods combined. The “Harvard Medical Practice Study” method identified 155 of the 160 (96.9%, 95% CI: 92.9-99.0) adverse events in 104 (29.7%) records compared with 137 (85.6%, 95% CI: 79.2-90.7) adverse events in 98 (28.0%) records using the “Global Trigger Tool”. Adverse events “causing harm without permanent disability” accounted for most of the observed difference. The overall positive predictive value for criteria and triggers using the “Harvard Medical Practice Study” method and the “Global Trigger Tool” was 40.3% and 30.4%, respectively.

    Conclusions

    More adverse events were identified using the “Harvard Medical Practice Study” method than using the “Global Trigger Tool”. Differences in review methodology, perception of less severe adverse events and context knowledge may explain the observed difference between two expert review teams in the detection of adverse events.

  • 2244.
    Unbeck, Maria
    et al.
    Karolinska Institutet.
    Schildmeijer, Kristina
    Linnaeus University, Faculty of Health, Social Work and Behavioural Sciences, School of Health and Caring Sciences.
    Olof, Muren
    Danderyd hospital.
    Identifiering av skada kan påverkas av val av journalgranskningsmetod2011Conference paper (Refereed)
  • 2245.
    Unbeck, Maria
    et al.
    Karolinska Institutet.
    Sterner, Eila
    Karolinska Institutet.
    Elg, Mattias
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Linköping University.
    Fossum, Bjöörn
    Sophiahemmet University College.
    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.
    Pukk Härenstam, Karin
    Karolinska Institutet.
    Design, application and impact of quality improvement 'theme months' in orthopaedic nursing: A mixed method case study on pressure ulcer prevention2013In: International Journal of Nursing Studies, ISSN 0020-7489, E-ISSN 1873-491X, Vol. 50, no 4, p. 527-535Article in journal (Refereed)
    Abstract [en]

    Background: While there is growing awareness of quality problems in healthcare systems, it remains uncertain how best to accomplish and sustain improvement over time.

    Objective: To report on the design and application of quality improvement theme months in orthopaedic nursing, and evaluate the impact on pressure ulcer as an example.

    Design: Retrospective mixed method case study with time series diagrams.

    Setting: An orthopaedic department at a Swedish university hospital.

    Method: The interventions were led by nursing teams and focused on one improvement theme at a time in two-month cycles, hence the term 'improvement theme months'. These included defined objectives, easy-to-use follow-up measurement, education, changes to daily routines, "reminder months" and data feedback. The study draws on retrospective record data regarding one of the theme topics, pressure ulcer risk assessment and prevalence, in 2281 orthopaedic admissions during January 2007-October 2010 through point prevalence measurement one-day per month. Data were analysed in time series diagrams and through comparison to annual point prevalence data from mandatory county council-wide measurements prior to, during and after interventions from 2003 to 2010. By using document analysis we reviewed concurrent initiatives at different levels in the healthcare organisation and related them to the improvement theme months and their impact.

    Results: The 46 monthly point prevalence samples ranged from 28 to 66 admissions. Substantial improvements were found in risk assessment rates for pressure ulcers both in the longitudinal follow-up (p<0.001) and in the annual county council-wide measurements. A reduction in pressure ulcer rate was observed in the annual county council-wide measurements. In the longitudinal data, wider variation in the pressure ulcer rate was seen (p<0.067); however, there was a significant decrease in pressure ulcer rates during the final ten-month period in 2010, compared to the baseline period in 2007 (p=0.004). Improvements were moderate the first years and needed reinforcement to be maintained.

    Conclusions: The theme month design and the way it was applied in this case showed potential, contributing to reduced pressure ulcer prevalence, as a way to conduct quality improvement initiatives in nursing. For sustainable improvement, multi component interventions are needed with regular monitoring and reminder efforts.

  • 2246.
    Unné, Anna
    Jönköping University, School of Health Science, HHJ, Quality Improvement and Leadership in Health and Welfare.
    Smärtskattning 0 -ett värde i sig.: Ett förbättringsarbete som synliggör skillnad mellan det som sägs och görs utifrån evidensbaserade smärthanteringsrutiner inom palliativ vård.2013Independent thesis Advanced level (degree of Master (Two Years)), 20 credits / 30 HE creditsStudent thesis
  • 2247.
    Uzochukwu, Benjamin
    et al.
    Enugu, Nigeria.
    Mbachu, Chinyere
    Enugu, Nigeria.
    Onwujekwe, Obinna
    Enugu, Nigeria.
    Okwuosa, Chinenye
    Enugu, Nigeria.
    Etiaba, Enyi
    Enugu, Nigeria.
    Nyström, Monica E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Karolinska Institutet, Stockholm, Sweden.
    Gilson, Lucy
    Cape Town, South Africa; London, UK.
    Health policy and systems research and analysis in Nigeria: examining health policymakers' and researchers' capacity assets, needs and perspectives in south-east Nigeria.2016In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 14, article id 13Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Health policy and systems research and analysis (HPSR+A) has been noted as central to health systems strengthening, yet the capacity for HPSR+A is limited in low- and middle-income countries. Building the capacity of African institutions, rather than relying on training provided in northern countries, is a more sustainable way of building the field in the continent. Recognising that there is insufficient information on African capacity to produce and use HPSR+A to inform interventions in capacity development, the Consortium for Health Policy and Systems Analysis in Africa (2011-2015) conducted a study with the aim to assess the capacity needs of its African partner institutions, including Nigeria, for HPSR+A. This paper provides new knowledge on health policy and systems research assets and needs of different stakeholders, and their perspectives on HPSR+A in Nigeria.

    METHODS: This was a cross-sectional study conducted in the Enugu state, south-east Nigeria. It involved reviews and content analysis of relevant documents and interviews with organizations' academic staff, policymakers and HPSR+A practitioners. The College of Medicine, University of Nigeria, Enugu campus (COMUNEC), was used as the case study and the HPSR+A capacity needs were assessed at the individual, unit and organizational levels. The HPSR+A capacity needs of the policy and research networks were also assessed.

    RESULTS: For academicians, lack of awareness of the HPSR+A field and funding were identified as barriers to strengthening HPSR+A in Nigeria. Policymakers were not aware of the availability of research findings that could inform the policies they make nor where they could find them; they also appeared unwilling to go through the rigors of reading extensive research reports.

    CONCLUSION: There is a growing interest in HPSR+A as well as a demand for its teaching and, indeed, opportunities for building the field through research and teaching abound. However, there is a need to incorporate HPSR+A teaching and research at an early stage in student training. The need for capacity building for HPSR+A and teaching includes capacity building for human resources, provision and availability of academic materials and skills development on HPSR+A as well as for teaching. Suggested development concerns course accreditation, development of short courses, development and inclusion of HPSR+A teaching and research-specific training modules in school curricula for young researchers, training of young researchers and improving competence of existing researchers. Finally, we could leverage on existing administrative and financial governance mechanisms when establishing HPSR+A field building initiatives, including staff and organizational capacity developments and course development in HPSR+A.

  • 2248. Uzochukwu, Benjamin
    et al.
    Onwujekwe, Obinna
    Mbachu, Chinyere
    Okwuosa, Chinenye
    Etiaba, Enyi
    Nyström, Monica E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, 171 77 Stockholm, Sweden.
    Gilson, Lucy
    The challenge of bridging the gap between researchers and policy makers: experiences of a Health Policy Research Group in engaging policy makers to support evidence informed policy making in Nigeria2016In: Globalization and Health, ISSN 1744-8603, E-ISSN 1744-8603, Vol. 12, article id 67Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Getting research into policy and practice (GRIPP) is a process of going from research evidence to decisions and action. To integrate research findings into the policy making process and to communicate research findings to policymakers is a key challenge world-wide. This paper reports the experiences of a research group in a Nigerian university when seeking to 'do' GRIPP, and the important features and challenges of this process within the African context.

    METHODS: In-depth interviews were conducted with nine purposively selected policy makers in various organizations and six researchers from the universities and research institute in a Nigerian who had been involved in 15 selected joint studies/projects with Health Policy Research Group (HPRG). The interviews explored their understanding and experience of the methods and processes used by the HPRG to generate research questions and research results; their involvement in the process and whether the methods were perceived as effective in relation to influencing policy and practice and factors that influenced the uptake of research results.

    RESULTS: The results are represented in a model with the four GRIPP strategies found: i) stakeholders' request for evidence to support the use of certain strategies or to scale up health interventions; ii) policymakers and stakeholders seeking evidence from researchers; iii) involving stakeholders in designing research objectives and throughout the research process; and iv) facilitating policy maker-researcher engagement in finding best ways of using research findings to influence policy and practice and to actively disseminate research findings to relevant stakeholders and policymakers. The challenges to research utilization in health policy found were to address the capacity of policy makers to demand and to uptake research, the communication gap between researchers, donors and policymakers, the management of the political process of GRIPP, the lack of willingness of some policy makers to use research, the limited research funding and the resistance to change.

    CONCLUSIONS: Country based Health Policy and Systems Research groups can influence domestic policy makers if appropriate strategies are employed. The model presented gives some direction to potential strategies for getting research into policy and practice in the health care sector in Nigeria and elsewhere.

  • 2249.
    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.

  • 2250.
    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)
42434445464748 2201 - 2250 of 2512
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