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Andersson, A.-C., Johansson, R.-M., Elg, M., Andersson-Gäre, B. & Christensson, L. (2017). Using quality improvement methods to implement guidelines to decrease the proportion of urinary retention in orthopaedic care. International Archives of Nursing and Health Care, 3(1), Article ID IANHC-3-065.
Open this publication in new window or tab >>Using quality improvement methods to implement guidelines to decrease the proportion of urinary retention in orthopaedic care
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2017 (English)In: International Archives of Nursing and Health Care, ISSN 2469-5823, Vol. 3, no 1, article id IANHC-3-065Article in journal (Refereed) Published
Abstract [en]

In patients treated with indwelling urethral catheter (IUC), complications such as catheter associated urinary tract infections are common, while underuse of IUC may cause harmful urinary retention (UR). A quality improvement (QI) program called ‘Indwelling urethral catheter (IUC) - only when needed’ was developed in Jönköping County Council, Sweden, aiming at creating a new approach: hospital staff should be able to identify and manage patients with risk of UR, prevent UR or treat UR without delay, and only use urinary IUCs on appropriate indications. The aim of this study was to describe the process of application of the quality improvement program. The Model for Improvement was used, and process coaches were appointed in the participating units. Their training was based on clinical issues and facts about UR, IUCs, guidelines, QI methods and measurements. Data were collected through prospective and retrospective patient record reviews, and differences were analyzed by inferential statistics.

Before the intervention, only two patients out of 296 were cared for following the guidelines perfectly. During the intervention, adherence to guidelines showed a rising trend, and reached a new stable level, with an average of 67% adherence to guidelines. A systematic improvement program supported by coaches and improvement tools can increase the adherence to new guidelines and incorporate them into local practice. This study also shows that adherence to guidelines can improve patient safety, in this case a decreased risk for and incidence of UR in an orthopaedic patient population.

Place, publisher, year, edition, pages
ClinMed International Library, 2017
Keywords
Guidelines, Indwelling urinary catheters, Model for improvement, Orthopaedic care, Quality improvement, Urinary retention
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-35282 (URN)10.23937/2469-5823/1510065 (DOI)
Available from: 2017-03-31 Created: 2017-03-31 Last updated: 2018-09-12Bibliographically approved
Andersson Hagiwara, M., Andersson-Gäre, B. & Elg, M. (2016). Interrupted time series versus statistical process control in quality improvement projects. Journal of Nursing Care Quality, 31(1), E1-E8
Open this publication in new window or tab >>Interrupted time series versus statistical process control in quality improvement projects
2016 (English)In: Journal of Nursing Care Quality, ISSN 1057-3631, E-ISSN 1550-5065, Vol. 31, no 1, p. E1-E8Article in journal (Refereed) Published
Abstract [en]

To measure the effect of quality improvement interventions, it is appropriate to use analysis methods that measure data over time. Examples of such methods include statistical process control analysis and interrupted time series with segmented regression analysis. This article compares the use of statistical process control analysis and interrupted time series with segmented regression analysis for evaluating the longitudinal effects of quality improvement interventions, using an example study on an evaluation of a computerized decision support system.

Keywords
computerized decision support system, quality improvement, segmented regression, statistical process control, time series
National Category
Nursing Information Systems
Identifiers
urn:nbn:se:hj:diva-28753 (URN)10.1097/NCQ.0000000000000130 (DOI)000378245700001 ()26018566 (PubMedID)2-s2.0-84948460041 (Scopus ID)1550-5065 (Electronic) 1057-3631 (Linking) (ISBN)
Available from: 2015-12-22 Created: 2015-12-22 Last updated: 2018-08-29Bibliographically approved
Mazzocato, P., Unbeck, M., Elg, M., Sköldenberg, O. G. & Thor, J. (2015). Unpacking the key components of a programme to improve the timeliness of hip-fracture care: a mixed-methods case study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 23, 1-12, Article ID 93.
Open this publication in new window or tab >>Unpacking the key components of a programme to improve the timeliness of hip-fracture care: a mixed-methods case study
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2015 (English)In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 23, p. 1-12, article id 93Article in journal (Refereed) Published
Abstract [en]

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

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

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

Keywords
Hip fracture, Process improvement, Quality improvement, Timeliness, Case study, Statistical process control charts
National Category
Other Clinical Medicine
Identifiers
urn:nbn:se:hj:diva-28776 (URN)10.1186/s13049-015-0171-6 (DOI)000365486700001 ()26552579 (PubMedID)2-s2.0-84946561644 (Scopus ID)
Available from: 2015-12-28 Created: 2015-12-28 Last updated: 2018-08-29Bibliographically approved
Neubeck, T., Elg, M. & Schneider, T. (2014). Managing the gap between policy and practice through Intermediaries for Quality Improvement. Scandinavian Journal of Public Administration, 18(4), 73-89
Open this publication in new window or tab >>Managing the gap between policy and practice through Intermediaries for Quality Improvement
2014 (English)In: Scandinavian Journal of Public Administration, ISSN 2001-7405, E-ISSN 2001-7413, Vol. 18, no 4, p. 73-89Article in journal (Refereed) Published
Abstract [en]

A gap exists between policymaking for quality improvement and the realization of these policies in practice. Using previous research on intermediaries, a conceptual model of an Intermediary for Quality Improvement (IQI) is developed. The model highlights the characteristics of structural positions, mediating approaches, and duration as a way to describe an IQI. The conceptual model is used to examine two cases in which Famna, the Swedish Association for Non-profit Health and Social Service Providers, has supported both policymaking and the implementation of policies at a provider level. The cases are the national strategy for quality improvement by open comparisons in health care and social services and a new regulation on quality management systems in health care and social services. Using the concept of an IQI deepens the understanding of how top-down and bottom-up perspectives may be managed to realize good quality of services.

Keywords
Intermediaries, Quality, Policy, Implementation, Improvement
National Category
Other Social Sciences
Identifiers
urn:nbn:se:hj:diva-25546 (URN)
Available from: 2015-01-08 Created: 2015-01-08 Last updated: 2018-09-13Bibliographically approved
Neubeck, T., Elg, M., Schneider, T. & Andersson-Gäre, B. (2014). Prospects and problems of transferring quality-improvement methods from health care to social services: two case studies. The Permanente Journal, 18(2), 38-42
Open this publication in new window or tab >>Prospects and problems of transferring quality-improvement methods from health care to social services: two case studies
2014 (English)In: The Permanente Journal, ISSN 1552-5767, E-ISSN 1552-5775, Vol. 18, no 2, p. 38-42Article in journal (Refereed) Published
Abstract [en]

Introduction: This study examines the use of quality-improvement(QI) methods in social services. Particularly the keyaspects—generalizable knowledge, interprofessional teamwork,and measurements—are studied in projects from the QI programForum for Values in Sweden.Methods: This is a mixed-method case study. Two projectsusing standard QI methods and tools as used in health carewere chosen as critical cases to highlight some problems andprospects with the use of QI in social services. The cases wereanalyzed through documented results and qualitative interviewswith participants one year after the QI projects ended.Results: The social service QI projects led to measurableimprovements when they used standard methods and tools forQI in health care. One year after the projects, the improvementswere either not continuously measured or not reported in anyinfrastructure for measurements. The study reveals that socialservices differ from health care regarding the availability and useof evidence, the role of professional expertise, and infrastructurefor measurements.Conclusions: We argue that QI methods as used in healthcare are applicable in social services and can lead to measurableimprovements. The study gives valuable insights for QI,not only in social services but also in health care, on howto assess and sustain improvements when infrastructures formeasurements are lacking. In addition, when one forms QIteams, the focus should be on functions instead of professions,and QI methods can be used to support implementation ofevidence-based practice.

National Category
Health Sciences
Identifiers
urn:nbn:se:hj:diva-25545 (URN)10.7812/TPP/13-078 (DOI)24867549 (PubMedID)2-s2.0-84922218226 (Scopus ID)
Available from: 2015-01-08 Created: 2015-01-08 Last updated: 2018-08-29Bibliographically approved
Andersson, A.-C., Idvall, E., Perseius, K.-I. & Elg, M. (2014). Two Different Strategies to Facilitate Involvement in Healthcare Improvements: A Swedish County Council Initiative. Global Advances in Health and Medicine, 3(5), 22-28
Open this publication in new window or tab >>Two Different Strategies to Facilitate Involvement in Healthcare Improvements: A Swedish County Council Initiative
2014 (English)In: Global Advances in Health and Medicine, ISSN 2164-957X, E-ISSN 2164-9561, Vol. 3, no 5, p. 22-28Article in journal (Refereed) Published
Abstract [en]

Background: From a management point of view, there are many different approaches from which to choose to engage staff members in initiatives to improve performance.

Objective: The present study evaluated how two different types of improvement strategies facilitate and encourage involvement of different professional groups in health-care organizations.

Methods/Design: Empirical data of two different types of strategies were collected within an improvement project in a County Council in Sweden. The data analysis was carried out through classifying the participants' profession, position, gender, and the organizational administration of which they were a part, in relation to their participation.

Setting: An improvement project in a County Council in Sweden.

Participants: Designed Improvement Processes consisted of n=105 teams and Intrapreneurship Projects of n=202 projects.

Intervention: Two different types of improvement strategies, Designed Improvement Processes and Intrapreneurship Projects.

Main Outcome Measures: How two different types of improvement strategies facilitate and encourage involvement of different professional groups in healthcare organizations.

Results: Nurses were the largest group participating in both improvement initiatives. Physicians were also well represented, although they seemed to prefer the less structured Intrapreneurship Projects approach. Assistant nurses, being the second largest staff group, were poorly represented in both initiatives. This indicates that the benefits and support for one group may push another group aside.

Conclusions: Managers need to give prerequisites and incentives for staff who do not participate in improvements to do so. Comparisons of different types of improvement initiatives are an underused research strategy that yields interesting and thoughtful results.

Read More: http://www.gahmj.com/doi/abs/10.7453/gahmj.2014.040

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:hj:diva-24774 (URN)10.7453/gahmj.2014.040 (DOI)25568821 (PubMedID)
Available from: 2014-09-19 Created: 2014-09-19 Last updated: 2018-08-29Bibliographically approved
Unbeck, M., Sterner, E., Elg, M., Fossum, B., Thor, J. & Pukk Härenstam, K. (2013). Design, application and impact of quality improvement 'theme months' in orthopaedic nursing: A mixed method case study on pressure ulcer prevention. International Journal of Nursing Studies, 50(4), 527-535
Open this publication in new window or tab >>Design, application and impact of quality improvement 'theme months' in orthopaedic nursing: A mixed method case study on pressure ulcer prevention
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2013 (English)In: International Journal of Nursing Studies, ISSN 0020-7489, E-ISSN 1873-491X, Vol. 50, no 4, p. 527-535Article in journal (Refereed) Published
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.

Keywords
Case study, Nursing, Orthopaedic care, Patient safety, Pressure ulcer, Quality improvement
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:hj:diva-23471 (URN)10.1016/j.ijnurstu.2013.02.002 (DOI)000316977600010 ()23453324 (PubMedID)2-s2.0-84875278871 (Scopus ID)
Available from: 2014-02-12 Created: 2014-02-12 Last updated: 2018-10-22Bibliographically approved
Rejler, M., Tholstrup, J., Elg, M., Spångéus, A. & Andersson-Gäre, B. (2012). Framework for assessing quality of care for inflammatory bowel disease in Sweden. World Journal of Gastroenterology, 18(10), 1085-1092
Open this publication in new window or tab >>Framework for assessing quality of care for inflammatory bowel disease in Sweden
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2012 (English)In: World Journal of Gastroenterology, ISSN 1007-9327, E-ISSN 2219-2840, Vol. 18, no 10, p. 1085-1092Article in journal (Refereed) Published
Abstract [en]

AIM: To create and apply a framework for quality assessment and improvement in care for inflammatory bowel disease (IBD) patients.

METHODS: A framework for quality assessment and improvement was created for IBD based on two generally acknowledged quality models. The model of Donabedian (Df) offers a logistical and productive perspective and the Clinical Value Compass (CVC) model adds a management and service perspective. The framework creates a pedagogical tool to understand the balance between the dimensions of clinical care (CVC) and the components of clinical outcome (Df). The merged models create a framework of the care process dimensions as a whole, reflecting important parts of the IBD care delivery system in a local setting. Clinical and organizational quality measures were adopted from clinical experience and the literature and were integrated into the framework. Data were collected at the yearly check-up for 481 IBD patients during 2008. The application of the quality assessment framework was tested and evaluated in a local clinical IBD care setting in Jonkoping County, Sweden.

RESULTS: The main outcome was the presentation of how locally-selected clinical quality measures, integrated into two complementary models to develop a framework, could be instrumental in assessing the quality of care delivered to patients with IBD. The selected quality measures of the framework noted less anemia in the population than previously reported, provided information about hospitalization rates and the few surgical procedures reported, and noted good access to the clinic.

CONCLUSION: The applied local quality framework was feasible and useful for assessing the quality of care delivered to IBD patients in a local setting.

Place, publisher, year, edition, pages
Baishideng Publishing Group, 2012
Keywords
Adolescent, Adult, Aged, Aged, 80 and over, Ambulatory Care Facilities, Delivery of Health Care, Female, Humans, Inflammatory Bowel Diseases/*therapy, Male, Middle Aged, Outcome Assessment (Health Care), Quality Assurance, Health Care/*methods, Sweden, Young Adult
National Category
Gastroenterology and Hepatology
Identifiers
urn:nbn:se:hj:diva-20041 (URN)10.3748/wjg.v18.i10.1085 (DOI)000301627900011 ()22416183 (PubMedID)2-s2.0-84858610569 (Scopus ID)1007-9327 (Print) 1007-9327 (Linking) (ISBN)
Available from: 2012-12-04 Created: 2012-12-04 Last updated: 2020-02-25Bibliographically approved
Mazzocato, P., Holden, R., Brommels, M., Aronsson, H., Bäckman, U., Elg, M. & Thor, J. (2012). How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren Children's Hospital, Stockholm, Sweden. BMC Health Services Research, 12(1), 28
Open this publication in new window or tab >>How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren Children's Hospital, Stockholm, Sweden
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2012 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 12, no 1, p. 28-Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:There is growing interest in applying lean thinking in healthcare, yet, there is still limited knowledge of how and why lean interventions succeed (or fail). To address this gap, this in-depth case study examines a lean-inspired intervention in a Swedish pediatric Accident and Emergency department.

METHODS:We used a mixed methods explanatory single case study design. Hospital performance data were analyzed using analysis of variance (ANOVA) and statistical process control techniques to assess changes in performance one year before and two years after the intervention. We collected qualitative data through non-participant observations, semi-structured interviews, and internal documents to describe the process and content of the lean intervention. We then analyzed empirical findings using four theoretical lean principles (Spear and Bowen 1999) to understand how and why the intervention worked in its local context as well as to identify its strengths and weaknesses.

RESULTS:Improvements in waiting and lead times (19-24%) were achieved and sustained in the two years following lean-inspired changes to employee roles, staffing and scheduling, communication and coordination, expertise, workspace layout, and problem solving. These changes resulted in improvement because they: (a) standardized work and reduced ambiguity, (b) connected people who were dependent on one another, (c) enhanced seamless, uninterrupted flow through the process, and (d) empowered staff to investigate problems and to develop countermeasures using a "scientific method". Contextual factors that may explain why not even greater improvement was achieved included: a mismatch between job tasks, licensing constraints, and competence; a perception of being monitored, and discomfort with inter-professional collaboration.

CONCLUSIONS:Drawing on Spear and Bowen's theoretical propositions, this study explains how a package of lean-like changes translated into better care process management. It adds new knowledge regarding how lean principles can be beneficially applied in healthcare and identifies changes to professional roles as a potential challenge when introducing lean thinking there. This knowledge may enable health care organizations and managers in other settings to configure their own lean program and to better understand the reasons behind lean's success (or failure).

Place, publisher, year, edition, pages
BioMed Central, 2012
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:hj:diva-20024 (URN)10.1186/1472-6963-12-28 (DOI)000301444400001 ()22296919 (PubMedID)2-s2.0-84856402018 (Scopus ID)
Available from: 2012-12-03 Created: 2012-11-30 Last updated: 2019-09-02Bibliographically approved
Elg, M. & Andersson-Gäre, B. (Eds.). (2009). Vägval och dilemman i interaktiv forskning: kurspapper från Bridging the Gaps doktorandkurs Interaktiv forskning 2008. Linköping: Linköpings universitet
Open this publication in new window or tab >>Vägval och dilemman i interaktiv forskning: kurspapper från Bridging the Gaps doktorandkurs Interaktiv forskning 2008
2009 (Swedish)Collection (editor) (Other academic)
Place, publisher, year, edition, pages
Linköping: Linköpings universitet, 2009. p. 239
National Category
Social Sciences
Identifiers
urn:nbn:se:hj:diva-20014 (URN)9197601551 (ISBN)
Available from: 2012-12-04 Created: 2012-11-30 Last updated: 2018-08-29Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0003-4730-5453

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