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  • 1.
    Ahmady, Soleiman
    et al.
    Shahid Beheshti Univ Med Sci, Fac Med Educ, Tehran, Iran.;Shahid Beheshti Univ Med Sci, Velenjak St,Shahid Chamran Highway, Tehran 1985717443, Iran..
    Mirmoghtadaie, Zohrehsadat
    Shahid Beheshti Univ Med Sci, Fac E Learning Med Educ, Tehran, Iran.;Shahid Beheshti Univ Med Sci, Velenjak St,Shahid Chamran Highway, Tehran 1985717443, Iran..
    Zarifsanaiey, Nahid
    Shahid Beheshti Univ Med Sci, Fac E Learning Med Educ, Tehran, Iran.;Virtual Sch, Neshat Ave, Shiraz 713451846, Iran.;Ctr Excellence Elect Learning, Neshat Ave, Shiraz 713451846, Iran..
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Univ Jonkoping, Sch Hlth & Welf, Jonkoping, Sweden.;Univ Jonkoping, Acad Improvement Hlth & Welf, GA-511, Jonkoping, Sweden..
    Designing e-learning in medical education: Toward a comprehensive model2021In: Turkish Online Journal of Distance Education (TOJDE), E-ISSN 1302-6488, Vol. 22, no 2, p. 254-271Article in journal (Refereed)
    Abstract [en]

    This study was conducted to present a comprehensive model for designing e-learning in Medical education. This qualitative study was performed in three stages. First, we used the "critical review" approach proposed by CarnWell to synthesize a conceptual model from studies that employ e-learning in Medical education. In the second stage, using Bereday's comparative method, 30 renowned virtual universities were evaluated. Finally, after aggregating and summarizing the results of the previous stages, the model was presented. The results of the study showed that designing e-learning in medical education requires making plans on national and international levels. Moreover, for qualitative and quantitative improvement of e-learning, global progress, achievements, and standards should be monitored continuously, and strategic, tactical, and executive aspects should be rigorously addressed. This comprehensive model for the design and development of e-learning in medical education is identified as an area requiring further research.

  • 2.
    Algurén, Beatrix
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. University of Gothenburg, Faculty of Education, Department of Food and Nutrition, and Sport Science, Sweden.
    Andersson Gäre, Boel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping). Region Jönköping County, Futurum, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Andersson, Ann-Christine
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Quality indicators and their regular use in clinical practice – results from a survey among users of two cardiovascular National Registries in Sweden2018In: International Journal for Quality in Health Care, ISSN 1353-4505, E-ISSN 1464-3677, Vol. 30, no 10, p. 786-792Article in journal (Refereed)
    Abstract [en]

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

    Design: Cross-sectional online survey study.

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

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

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

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

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

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  • 3.
    Andersson, Ann-Christine
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Andersson Gäre, Boel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Lenrick, Raymond
    Rapport om utvärdering av IVO:s lärande tillsyn2018Report (Other academic)
    Abstract [sv]

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

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

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

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

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  • 4.
    Bergerum, Carolina
    et al.
    Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Engström, A. K.
    Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, S-501 90, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Wolmesjö, M.
    Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, S-501 90, Sweden.
    Patient involvement in quality improvement: a ‘tug of war’ or a dialogue in a learning process to improve healthcare?2020In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 20, no 1, article id 1115Article in journal (Refereed)
    Abstract [en]

    Background: Co-production and co-design approaches to quality improvement (QI) efforts are gaining momentum in healthcare. Yet, these approaches can be challenging, not least when it comes to patient involvement. The aim of this study was to examine what might influence QI efforts in which patients are involved, as experienced by the patients and the healthcare professionals involved. Methods: This study involved a qualitative design inspired by the constructivist grounded theory. In one mid-sized Swedish hospital’s patient process organisation, data was collected from six QI teams that involved patients in their QI efforts, addressing care paths for patients with transient, chronic and/or multiple parallel diagnoses. Field notes were collected from participant observations during 53 QI team meetings in three of the six patient processes. Individual, semi-structured interviews were conducted with 12 patients and 12 healthcare professionals in all the six QI teams. Results: Patients were involved in QI efforts in different ways. In three of the QI teams, patient representatives attended team meetings regularly. One team consulted patient representatives on a single occasion, one team collected patient preferences structurally from individual interviews with patients, and one team combined interviews and a workshop with patients. The patients’ and healthcare professionals’ expressions of what might influence the QI efforts involving patients were similar in several ways. QI team members emphasized the importance of organisational structure and culture. Furthermore, they expressed a desire for ongoing interaction between patients and healthcare professionals in healthcare QI. Conclusions: QI team members recognised continuous dialogue and collective thinking by the sharing of experiences and preferences between patients and healthcare professionals as essential for achieving better matches between healthcare resources and patient needs in their QI efforts. Significant structural and cultural aspects of performing QI in complex hospital organisations were considered to be obstructions to progress. Therefore, to sustain learning and behaviour change through QI efforts at the team level, a deeper understanding of how structural and cultural aspects of QI promote or prevent success appears essential.

  • 5.
    Bergerum, Carolina
    et al.
    Hogskolan Boras, Fac Caring Sci Work Life & Social Welf, Boras, Sweden..
    Petersson, Christina
    Jönköping University, School of Health and Welfare, HHJ, Dept. of Nursing Science. Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Karolinska Inst, Med Management Ctr, Stockholm, Sweden.
    Wolmesjö, Maria
    Hogskolan Boras, Fac Caring Sci Work Life & Social Welf, Boras, Sweden..
    'We are data rich but information poor': how do patient-reported measures stimulate patient involvement in quality improvement interventions in Swedish hospital departments?2022In: BMJ Open Quality, ISSN 2399-6641, Vol. 11, no 3, article id e001850Article in journal (Refereed)
    Abstract [en]

    Objective

    This study aimed to investigate if and how patient-reported measures from national and local monitoring stimulate patient involvement in hospital quality improvement (QI) interventions. We were also interested in the factors that influence the level and degree of patient involvement in the QI interventions.

    Methods

    The study used a qualitative, descriptive design. Inspired by the Framework Method, we created a working analytical framework. Four hospital departments participated in the data collection. Collaborating with a QI leader from each department, we identified the monitoring systems for the patient-reported measures that were used to initiate or evaluate QI interventions. Thereafter, the level and degree of patient involvement and the factors that influenced this involvement were analysed for all QI interventions. Data were mapped in an Excel spreadsheet to analyse connections and differences.

    Results

    Departments used patient-reported measures from both national and local monitoring systems to initiate or evaluate their QI interventions. Thirty-one QI interventions were identified and analysed. These interventions were mainly conducted at the direct care and organisational levels. By participating in questionnaires, patients were involved to the degree of consultation. Patients were not involved to the degree of partnership and shared leadership for the identified QI interventions.

    Conclusions

    Overall, hospital departments have limited knowledge regarding patient-reported measures and how they are best applied in QI interventions and how they support improvements. Applying patient-reported measures to hospital QI interventions does not enhance patient involvement beyond the degree of consultation.

  • 6.
    Bergerum, Carolina
    et al.
    Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Josefsson, Karin
    Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden.
    Wolmesjö, Maria
    Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden.
    How might patient involvement in healthcare quality improvement efforts work—A realist literature review2019In: Health Expectations, ISSN 1369-6513, E-ISSN 1369-7625, Vol. 22, no 5, p. 952-964Article, review/survey (Refereed)
    Abstract [en]

    Introduction

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

    Methods

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

    Results

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

    Conclusion

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

  • 7.
    Bergerum, Carolina
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden.
    Wolmesjö, Maria
    Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Organising and managing patient and public involvement to enhance quality improvement – Comparing a Swedish and a Dutch hospital2022In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 126, no 7, p. 603-612Article in journal (Refereed)
    Abstract [en]

    As co-production approaches to quality improvement (QI) gain importance in healthcare, hospital leaders and managers are expected to organise and support such efforts. Yet, patient and public involvement (PPI) can be challenging. Hospital organisations, emphasising knowledge and evidence domains, are characterised by operational-professional rather than patient-preference led management. Thus, PPI adds aspects of influence and responsibility that are not clearly defined or understood, with limited knowledge about how it can be orchestrated. This study, therefore, aimed to explore hospital leaders' and managers' contextualised experiences of managing QI efforts involving patients, by comparing two European hospitals. The study draws on field observations and qualitative interviews with a total of 21 QI team leaders and hospital managers in a Swedish and a Dutch hospital organisation. The data were subjected to thematic analysis with a critical realist approach. Results define seven themes, or areas, in which mechanisms are at play: (1) patient involvement in hospital QI, and (2) improving outcomes for patients, originating from the strategic view of achieving the hospital vision. Furthermore, (3) societal influence, (4) knowledge and evidence, (5) complexity, (6) individual resources, and (7) cooperation are areas in which mechanisms operate in the process. These areas are equally relevant for both hospitals, yet the mechanisms involved play out differently depending on contextual structure and local means of action.

  • 8.
    Goodman, Daisy
    et al.
    Dartmouth Hitchcock Medical Center, USA.
    Ogrinc, Greg
    Veterans Health Administration, USA.
    Davies, Louise
    Veterans Health Administration, USA.
    Baker, G. Ross
    University of Toronto, Canada.
    Barnsteiner, Jane
    University of Pennsylvania, USA.
    Gali, Kari
    Cleveland Clinic Children’s Hospital, USA.
    Hilden, Joanne
    Colorado Children’s Hospital, USA.
    Horwitz, Leora
    New York University, USA.
    Kaplan, Heather C.
    Cincinnati Children’s Hospital Medical Center, USA.
    Leis, Jerome
    University of Toronto, Canada.
    Matulis, John C.
    Dartmouth Hitchcock Medical Center, USA.
    Michie, Susan
    University College, UK.
    Miltner, Rebecca
    University of Alabama, USA.
    Neily, Julia
    Veterans Health Administration, USA.
    Nelson, William A.
    Geisel School of Medicine, USA.
    Niedner, Matthew
    University of Michigan Medical Center, USA.
    Oliver, Brant
    MGH Institute of Health Professions, USA.
    Rutman, Lori
    Seattle Children’s Hospital, USA.
    Thomson, Richard
    Newcastle University, UK.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: Examples of SQUIRE elements in the healthcare improvement literature2016In: BMJ Quality and Safety, ISSN 2044-5415, E-ISSN 2044-5423, Vol. 25, no 12, article id e7Article in journal (Refereed)
    Abstract [en]

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

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  • 9.
    Gremyr, Andreas
    et al.
    Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Andersson-Gäre, Boel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    Greenhalgh, Trisha
    Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.
    Malm, Ulf
    Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Andersson, Ann-Christine
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Using complexity assessment to inform the development and deployment of a digital dashboard for schizophrenia care: Case study2020In: Journal of Medical Internet Research, E-ISSN 1438-8871, Vol. 22, no 4, article id e15521Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Health care is becoming more complex. For an increasing number of individuals, interacting with health care means addressing more than just one illness or disorder, engaging in more than one treatment, and interacting with more than one care provider. Individuals with severe mental illnesses such as schizophrenia are disproportionately affected by this complexity. Characteristic symptoms can make it harder to establish and maintain relationships. Treatment failure is common even where there is access to effective treatments, increasing suicide risk. Knowledge of complex adaptive systems has been increasingly recognized as useful in understanding and developing health care. A complex adaptive system is a collection of interconnected agents with the freedom to act based on their own internalized rules, affecting each other. In a complex health care system, relevant feedback is crucial in enabling continuous learning and improvement on all levels. New technology has potential, but the failure rate of technology projects in health care is high, arguably due to complexity. The Nonadoption, Abandonment, and challenges to Scale-up, Spread, and Sustainability (NASSS) framework and complexity assessment tool (NASSS-CAT) have been developed specifically to help identify and manage complexity in technology-related development projects in health care.

    OBJECTIVE: This study aimed to use a pilot version of the NASSS-CAT instrument to inform the development and deployment of a point-of-care dashboard supporting schizophrenia care in west Sweden. Specifically, we report on the complexity profile of the project, stakeholders' experiences with using NASSS-CAT, and practical implications.

    METHODS: We used complexity assessment to structure data collection and feedback sessions with stakeholders, thereby informing an emergent approach to the development and deployment of the point-of-care dashboard. We also performed a thematic analysis, drawing on observations and documents related to stakeholders' use of the NASSS-CAT to describe their views on its usefulness.

    RESULTS: Application of the NASSS framework revealed different types of complexity across multiple domains, including the condition, technology, value proposition, organizational tasks and pathways, and wider system. Stakeholders perceived the NASSS-CAT tool as useful in gaining perspective and new insights, covering areas that might otherwise have been neglected. Practical implications derived from feedback sessions with managers and developers are described.

    CONCLUSIONS: This case study shows how stakeholders can identify and plan to address complexities during the introduction of a technological solution. Our findings suggest that NASSS-CAT can bring participants a greater understanding of complexities in digitalization projects in general.

  • 10.
    Gremyr, Andreas
    et al.
    Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Department of Schizophrenia Spectrum Disorders, Sahlgrenska University Hospital, Sahlgrenska Universitetssjukhuset Psykiatri Psykos, Mölndal, Sweden.
    Andersson-Gäre, Boel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Williamson Translational Research Building, Lebanon, NH, USA.
    Elwyn, Glyn
    Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Williamson Translational Research Building, Lebanon, NH, USA.
    Batalden, Paul B.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Williamson Translational Research Building, Lebanon, NH, USA.
    Andersson, Ann-Christine
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Department of Care Science, Malmö University, Malmö, Sweden.
    The role of co-production in Learning Health Systems2021In: International Journal for Quality in Health Care, ISSN 1353-4505, E-ISSN 1464-3677, Vol. 33, no Supplement 2, p. ii26-ii32Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Co-production of health is defined as 'the interdependent work of users and professionals who are creating, designing, producing, delivering, assessing, and evaluating the relationships and actions that contribute to the health of individuals and populations'. It can assume many forms and include multiple stakeholders in pursuit of continuous improvement, as in Learning Health Systems (LHSs). There is increasing interest in how the LHS concept allows integration of different knowledge domains to support and achieve better health. Even if definitions of LHSs include engaging users and their family as active participants in aspects of enabling better health for individuals and populations, LHS descriptions emphasize technological solutions, such as the use of information systems. Fewer LHS texts address how interpersonal interactions contribute to the design and improvement of healthcare services.

    OBJECTIVE: We examined the literature on LHS to clarify the role and contributions of co-production in LHS conceptualizations and applications.

    METHOD: First, we undertook a scoping review of LHS conceptualizations. Second, we compared those conceptualizations to the characteristics of LHSs first described by the US Institute of Medicine. Third, we examined the LHS conceptualizations to assess how they bring four types of value co-creation in public services into play: co-production, co-design, co-construction and co-innovation. These were used to describe core ideas, as principles, to guide development.

    RESULT: Among 17 identified LHS conceptualizations, 3 qualified as most comprehensive regarding fidelity to LHS characteristics and their use in multiple settings: (i) the Cincinnati Collaborative LHS Model, (ii) the Dartmouth Coproduction LHS Model and (iii) the Michigan Learning Cycle Model. These conceptualizations exhibit all four types of value co-creation, provide examples of how LHSs can harness co-production and are used to identify principles that can enhance value co-creation: (i) use a shared aim, (ii) navigate towards improved outcomes, (iii) tailor feedback with and for users, (iv) distribute leadership, (v) facilitate interactions, (vi) co-design services and (vii) support self-organization.

    CONCLUSIONS: The LHS conceptualizations have common features and harness co-production to generate value for individual patients as well as for health systems. They facilitate learning and improvement by integrating supportive technologies into the sociotechnical systems that make up healthcare. Further research on LHS applications in real-world complex settings is needed to unpack how LHSs are grown through coproduction and other types of value co-creation.

  • 11.
    Gremyr, Andreas
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Department of Psychotic Disorders, Sahlgrenska University Hospital, Mölndal, Sweden.
    Holmberg, Christopher
    Department of Psychotic Disorders, Sahlgrenska University Hospital, Mölndal, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Malm, Ulf
    Sahlgrenska Academy at Gothenburg University, Institute of Neuroscience and Physiology, Göteborg, Sweden.
    Andersson-Gäre, Boel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping). Futurum Academy for Health and Care, Region Jönköping County, Jönköping, Sweden.
    Andersson, Ann-Christine
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    How a Point-of-Care Dashboard Facilitates Co-production of Health Care and Health for and with Individuals with Psychotic Disorders: A Mixed-methods Case Study2022In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 22, article id 1599Article in journal (Refereed)
    Abstract [en]

    Background

    Individuals with psychotic disorders experience widespread treatment failures and risk early death. Sweden’s largest department specializing in psychotic disorders sought to improve patients’ health by developing a point-of-care dashboard to support joint planning and co-production of care. The dashboard was tested for 18 months and included more than 400 patients at two outpatient clinics.

    Methods

    This study evaluates the dashboard by addressing two questions:

    1. Can differences in health-related outcome measures be attributed to the use of the dashboard?
    2. How did the case managers experience the accessibility, use, and usefulness of the dashboard for co-producing care with individuals with psychotic disorders? 

    This mixed-method case study used both Patient-Reported Outcome Measures (PROM) and data from a focus group interview with case managers. Data collection and analysis were framed by the Clinical Adoption Meta Model (CAMM) phases: i) accessibility, ii) system use, iii) behavior, and iv) clinical outcomes. The PROM used was the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0), which assesses functional impairment and disability. Patients at clinics using the dashboard were matched with patients at clinics not using the dashboard. PROM data were compared using non-parametric statistics due to skewness in distribution. The focus group included five case managers who had experience using the dashboard with patients.

    Results

    Compared to patients from clinics that did not use the dashboard, patients from clinics that did use the dashboard improved significantly overall (p = 0.045) and in the domain self-care (p = 0.041). Focus group participants reported that the dashboard supported data feedback-informed care and a proactive stance related to changes in patients’ health. The dashboard helped users identify critical changes and enabled joint planning and evaluation.

    Conclusion

    Dashboard use was related to better patient health (WHODAS scores) when compared with matched patients from clinics that did not use the dashboard. In addition, case managers had a positive experience using the dashboard. Dashboard use might have lowered the risk for missing critical changes in patients’ health while increasing the ability to proactively address needs. Future studies should investigate how to enhance patient co-production through use of supportive technologies.

  • 12.
    Gäre, Klas
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Andersson, Ann-Christine
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ, Department for Quality Improvement and Leadership.
    Andersson-Gäre, Boel
    Jönköping University, School of Health and Welfare, HHJ, Department for Quality Improvement and Leadership. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping). Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Thor, Johan
    Jönköping University, School of Health and Welfare, HHJ, Department for Quality Improvement and Leadership. Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Evidence informed healthcare improvement: Design and evaluation2023Report (Other academic)
    Abstract [en]

    Healthcare is in constant change with fast development in knowledge, new technology and varying needs and expectations from patients, citizens, management, and politicians. There is a challenge in balancing the involved actors´ focus, needs, preferences, and resources for healthcare improvement. Improvement of healthcare is an ongoing activity, sometimes managed and controlled, often not. A key ingredient for success is competence where the need for competence varies with perspectives of the improving actors. Actors in healthcare improvement are professionals, patients, politicians, management, citizens, researchers, research foundations and others. In this report a review of frameworks in healthcare improvement are presented together with management myths and questions around needs for healthcare improvement competence and capabilities currently on the agenda.

    Most improvement initiatives of some size have substantial parts of IT and have had so for a considerable time. This rather long experience of more and less successful IT implementation and use is transparent and useful in all kinds of healthcare improvement. One important issue in this report is what has real impact is the actual understanding and use of innovations and artefacts by healthcare actors in a broad sense for healthcare improvement (e.g., new clinical evidence, clinical guidelines, process changes, information systems and more). The aim in this report is to review frameworks which can be useful in healthcare improvement as well as in the study of healthcare improvement.

    Conclusions concern what is found to be important to study and understand healthcare improvement, considering the presented frameworks. Improvement of healthcare is present in all the frameworks but in different ways and what is emphasized concerning scope and focus. Improving healthcare take place in the interaction of at least two parts, one of which is healthcare professionals, and another is the patient/next-of-kin. Professionals and patient populations interact in processes of social networks and structures. Actors and context are useful concepts for understanding action (use) and its social contexts. The actual use of innovations is best understood in terms of integration into clinical activities and processes – actors’ interaction, coordination and communication activities and processes.

    Theoretical implications are that there is a need for more research concerning meso and macro perspectives on methods for healthcare improvement, and the interplay of perspectives regarding the understanding of improvement in healthcare. Of course, a challenge is that the objects of improvement are complex adaptive systems of healthcare is not easily to catch in simple rules. They are genuinely difficult both to change and evaluate changes. Practical implications of the report support design and contents of education programs in improvement of healthcare, in better understanding usefulness, practice, use, and experience base. To help the understanding of the need and usefulness of integrating different perspectives for successful healthcare improvement, e.g., micro, meso, and macro perspectives, use of mixed methods and more. 

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  • 13.
    Hazelzet, Jan A.
    et al.
    Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Andersson-Gäre, Boel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    Kremer, Jan A. M.
    IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands.
    van Weert, Nico
    Society Personalized Healthcare, Nijmegen, The Netherlands.
    Savage, Carl
    Medical Management Centre, Department of Learning, Informatics, Management & Ethics, Karolinska Institute, Stockholm, Sweden.
    Elwyn, Glyn
    The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, NH, USA.
    Value-based healthcare's blind spots: call for a dialogue2021In: F1000Research, Vol. 10, no 1314Article in journal (Other (popular science, discussion, etc.))
    Abstract [en]

    The value-based healthcare (VBHC) concept was first proposed as a solution to many of the ills of healthcare. Since then, we have seen the term “value” defined, used, confused, and interpreted in multiple ways. While we may disagree that competition based on value will solve healthcare’s complex challenges, value is a concept integral to the future of healthcare. Before VBHC becomes consigned to the long list of quality improvement trends and management fads that have passed through healthcare, we call for a dialogue around the term value and the implications of its different interpretations. The intention is not just to critique, but to facilitate ongoing efforts to substantially improve healthcare in ways that are relevant and sustainable for society at large.

  • 14.
    Holmqvist, Malin
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Department of Public Health and Healthcare, Region Jönköping County, Jönköping, Sweden.
    Johansson, Linda
    Jönköping University, School of Health and Welfare, HHJ, Institute of Gerontology. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    Lindenfalk, Bertil
    Jönköping University, School of Health and Welfare, HHJ, Department for Quality Improvement and Leadership. Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ, Department for Quality Improvement and Leadership.
    Ros, Axel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Futurum, Region Jönköping County, Jönköping, Sweden.
    Older persons' and health care professionals' design choices when co-designing a medication plan aiming to promote patient safety: Case study2023In: JMIR Aging, E-ISSN 2561-7605, Vol. 6, article id e49154Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Harm from medications is a major patient safety challenge among older persons. Adverse drug events tend to arise when prescribing or evaluating medications; therefore, interventions targeting these may promote patient safety. Guidelines highlight the value of a joint plan for continued treatment. If such a plan includes medications, a medication plan promoting patient safety is advised. There is growing evidence for the benefits of including patients and health care professionals in initiatives for improving health care products and services through co-design.

    OBJECTIVE: This study aimed to identify participants' needs and requirements for a medication plan and explore their reasoning for different design choices.

    METHODS: Using a case study design, we collected and analyzed qualitative and quantitative data and compared them side by side. We explored the needs and requirements for a medication plan expressed by 14 participants (older persons, nurses, and physicians) during a co-design initiative in a regional health system in Sweden. We performed a directed content analysis of qualitative data gathered from co-design sessions and interviews. Descriptive statistics were used to analyze the quantitative data from survey answers.

    RESULTS: A medication plan must provide an added everyday value related to safety, effort, and engagement. The physicians addressed challenges in setting aside time to apply a medication plan, whereas the older persons raised the potential for increased patient involvement. According to the participants, a medication plan needs to support communication, continuity, and interaction. The nurses specifically addressed the need for a plan that was easy to gain an overview of. Important function requirements included providing instant access, automation, and attention. Content requirements included providing detailed information about the medication treatment. Having the plan linked to the medication list and instantly obtainable information was also requested.

    CONCLUSIONS: After discussing the needs and requirements for a medication plan, the participants agreed on an iteratively developed medication plan prototype linked to the medication list within the existing electronic health record. According to the participants, the medication plan prototype may promote patient safety and enable patient engagement, but concerns were raised about its use in daily clinical practice. The last step in the co-design framework is testing the intervention to explore how it works and connects with users. Therefore, testing the medication plan prototype in clinical practice would be a future step.

  • 15.
    Holmqvist, Malin
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Department of Public Health and Healthcare, Region Jönköping County, Jönköping, Sweden.
    Ros, Axel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Futurum, Region Jönköping County, Jönköping, Sweden.
    Lindenfalk, Bertil
    Jönköping University, School of Health and Welfare, HHJ, Department for Quality Improvement and Leadership. Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Johansson, Linda
    Jönköping University, School of Health and Welfare, HHJ, Institute of Gerontology. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    How older persons and health care professionals co-designed a medication plan prototype remotely to promote patient safety: Case study2023In: JMIR Aging, E-ISSN 2561-7605, Vol. 6, article id e41950Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Harm from medications is a major patient safety challenge. Most adverse drug events arise when a medication is prescribed or reevaluated. Therefore, interventions in this area may improve patient safety. A medication plan, that is, a plan for continued treatment with medications, may support patient safety. Participation of patients in the design of health care products or services may improve patient safety. Co-design, as in the Double Diamond framework from the Design Council, England, can emphasize patient involvement. As the COVID-19 pandemic brought restrictions to face-to-face co-design approaches, interest in remote approaches increased. However, it is uncertain how best to perform remote co-design. Therefore, we explored a remote approach, which brought together older persons and health care professionals to co-design a medication plan prototype in the electronic health record, aiming to support patient safety.

    OBJECTIVE: This study aimed to describe how remote co-design was applied to create a medication plan prototype and to explore participants' experiences with this approach.

    METHODS: Within a case study design, we explored the experiences of a remote co-design initiative with 14 participants in a regional health care system in southern Sweden. Using descriptive statistics, quantitative data from questionnaires and web-based workshop timestamps were analyzed. A thematic analysis of the qualitative data gathered from workshops, interviews, and free-text responses to the survey questions was performed. Qualitative and quantitative data were compared side by side in the discussion.

    RESULTS: The analysis of the questionnaires revealed that the participants rated the experiences of the co-design initiative very high. In addition, the balance between how much involved persons expressed their wishes and were listened to was considered very good. Marked timestamps from audio recordings showed that the workshops proceeded according to the plan. The thematic analysis yielded the following main themes: Everyone's perspective matters, Learning by sharing, and Mastering a digital space. The themes encompassed what helped to establish a permissive environment that allowed the participants to be involved and share viewpoints. There was a dynamic process of learning and understanding, realizing that despite different backgrounds, there was consensus about the requirements for a medication plan. The remote co-design process seemed appealing, by balancing opportunities and challenges and building an inviting, creative, and tolerant environment.

    CONCLUSIONS: Participants experienced that the remote co-design initiative was inclusive of their perspectives and facilitated learning by sharing experiences. The Double Diamond framework was applicable in a digital context and supported the co-design process of the medication plan prototype. Remote co-design is still novel, but with attentiveness to power relations between all involved, this approach may increase opportunities for older persons and health care professionals to collaboratively design products or services that can improve patient safety.

  • 16.
    Holmqvist, Malin
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Department of Public Health and Healthcare, Region Jönköping County, Jönköping, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Ros, Axel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Futurum, Region Jönköping County, Jönköping, Sweden.
    Johansson, Linda
    Jönköping University, School of Health and Welfare, HHJ, Institute of Gerontology. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    Applying a Co-designed Medication Plan for SaferMedication Treatment in Older Persons – A Feasibility Study2023Manuscript (preprint) (Other academic)
  • 17.
    Holmqvist, Malin
    et al.
    Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Department of Hospital Pharmacy, Region Jönköping County; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Ros, Axel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Futurum, Region Jönköping County; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
    Johansson, Linda
    Jönköping University, School of Health and Welfare, HHJ, Institute of Gerontology. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    Evaluation of older persons' medications: a critical incident technique study exploring healthcare professionals' experiences and actions2021In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 21, no 1, article id 557Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Older persons with polypharmacy are at increased risk of harm from medications. Therefore, it is important that physicians and nurses, together with the persons, evaluate medications to avoid hazardous polypharmacy. It remains unclear how healthcare professionals experience such evaluations. This study aimed to explore physicians' and nurses' experiences from evaluations of older persons' medications, and their related actions to manage concerns related to the evaluations.

    METHOD: Individual interview data from 29 physicians and nurses were collected and analysed according to the critical incident technique.

    RESULTS: The medication evaluation for older persons was influenced by the working conditions (e.g. healthcare professionals' clinical knowledge, experiences, and situational conditions) and working in partnership (e.g. cooperating around and with the older person). Actions taken to manage these evaluations were related to working with a plan (e.g. performing day-to-day work and planning for continued treatment) and collaborative problem-solving (e.g. finding a solution, involving the older person, and communicating with colleagues).

    CONCLUSION: Working conditions and cooperation with colleagues, the older persons and their formal or informal caregivers, emerged as important factors related to the medication evaluation. By adjusting their performance to variations in these conditions, healthcare professionals contributed to the resilience of the healthcare system by its capacity to prevent, notice and mitigate medication problems. Based on these findings, we hypothesize that a joint plan for continued treatment could facilitate such resilience, if it articulates what to observe, when to act, who should act and what actions to take in case of deviations from what is expected.

  • 18.
    Holmqvist, Malin
    et al.
    Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Region Jönköpings län.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Ros, Axel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Region Jönköpings län.
    Johansson, Linda
    Jönköping University, School of Health and Welfare, HHJ, Institute of Gerontology. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    "I trust my physician but want to be involved"  - Older persons' Experiences of regarding evaluation of their medication treatment2019Conference paper (Refereed)
  • 19.
    Holmqvist, Malin
    et al.
    Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Department of Clinical pharmacy, Region Jönköping County, Jönköping, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Ros, Axel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Johansson, Linda
    Jönköping University, School of Health and Welfare, HHJ, Institute of Gerontology. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    Older persons’ experiences regarding evaluation of their medication treatment: An interview study in Sweden2019In: Health Expectations, ISSN 1369-6513, E-ISSN 1369-7625, Vol. 22, no 6, p. 1294-1303Article in journal (Refereed)
    Abstract [en]

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

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

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

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

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

  • 20.
    Kilander, H.
    et al.
    Department of Obstetrics and Gynaecology, Eksjö Hospital, Region Jönköping County, Sweden.
    Brynhildsen, J.
    Department of Obstetrics and Gynaecology and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
    Alehagen, S.
    Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Examining the pace of change in contraceptive practices in abortion services – a follow-up case study of a quality improvement collaborative2020In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 20, no 1, article id 948Article in journal (Refereed)
    Abstract [en]

    Background: Among all women who experienced an abortion in Sweden 2017, 45% had previously underwent at least one abortion. This phenomenon of increasing rates of repeat abortions stimulated efforts to improve contraceptive services through a Quality Improvement Collaborative (QIC) with user involvement. The participating teams had difficulty in coordinating access post-abortion to the most effective contraception, Long-acting reversible contraception (LARC), during the eight-month QIC. This prompted questions about the pace of change in contraceptive services post-abortion. The aim of the study is to evaluate the evolution and impact of QIC changes regarding patient outcomes, system performance and professional development over 12 months after a QIC designed to enhance contraceptive services in the context of abortion. Methods: This follow-up case study involves three multi-professional teams from abortion services at three hospitals in Sweden, which participated in a QIC during 2017. We integrated qualitative data on the evolution of changes and quantitative data regarding the monthly proportion of women initiating LARC, analysed in statistical control charts from before the QIC up until 12 months after its conclusion. Results: Teams A and B increased the average proportion of women who initiated LARC within 30 days post abortion in the 12 months after the QIC; Team A 16–25%; Team B 20–34%. Team C achieved more than 50% in individual months but not consistently in the Post-QIC period. Elusive during the QIC, they now could offer timely appointments for women to initiate LARC more frequently. Team members reported continued focus on how to create trustful relationships when counseling women. They described improved teamwork, leadership support and impact on organizing appointments for initiating LARC following the QIC. Conclusions: QIC teams further improved women’s timely access to LARC post abortion through continued changes in services 12 months after the QIC, demonstrating that the 8-month QIC was too short for all changes to materialize. Teams simultaneously improved women’s reproductive health, health services, and professional development.

  • 21.
    Kilander, Helena
    et al.
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Berterö, Carina
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Brynhildsen, Jan
    Department of Obstetrics and Gynaecology and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
    Alehagen, Siw
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Women's experiences of contraceptive counselling in the context of an abortion – An interview study2018In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 17, p. 103-107Article in journal (Refereed)
    Abstract [en]

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

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

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

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

  • 22.
    Kilander, Helena
    et al.
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Brynhildsen, Jan
    Obstetrics and Gynecology, Clinical and Experimental Medicine, Linköping, Sweden.
    Alehagen, Siw
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Fagerkrantz, Amanda
    Department of Obstetrics and Gyneacology, Norrköping, Region Ostergotland, Linköping, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Collaboratively seeking to improve contraceptive counselling at the time of an abortion: A case study of quality improvement efforts in Sweden2019In: BMJ Sexual and Reproductive Health, ISSN 2515-1991, Vol. 45, no 3, p. 190-199Article in journal (Refereed)
    Abstract [en]

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

  • 23.
    Kilander, Helena
    et al.
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Salomonsson, Birgitta
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden .
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Brynhildsen, Jan
    Department of Obstetrics and Gynaecology and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden .
    Alehagen, Siw
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden .
    Contraceptive counselling of women seeking abortion – a qualitative interview study of health professionals’ experiences2017In: European journal of contraception & reproductive health care, ISSN 1362-5187, E-ISSN 1473-0782, Vol. 22, no 1, p. 3-10Article in journal (Refereed)
    Abstract [en]

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

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

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

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

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  • 24.
    Kilander, Helena
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Department of Women’s and Children’s Health, Karolinska Institutet, and the WHO Collaborating Centre, Karolinska University Hospital, Stockholm, Sweden.
    Sorcher, R.
    Department of Global Public Health, Karolinska Institutet, Solna, Sweden.
    Berglundh, S.
    Department of Global Public Health, Karolinska Institutet, Solna, Sweden.
    Petersson, K.
    Department of Clinical Sciences, Obstetrics and Gynaecology, Umeå University, Umeå, Sweden.
    Wängborg, A.
    Department of Women’s and Children’s Health, Karolinska Institutet, and the WHO Collaborating Centre, Karolinska University Hospital, Stockholm, Sweden.
    Danielsson, K. G.
    Department of Women’s and Children’s Health, Karolinska Institutet, and the WHO Collaborating Centre, Karolinska University Hospital, Stockholm, Sweden.
    Iwarsson, K. E.
    Department of Women’s and Children’s Health, Karolinska Institutet, and the WHO Collaborating Centre, Karolinska University Hospital, Stockholm, Sweden.
    Brandén, G.
    Department of Global Public Health, Karolinska Institutet, Solna, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Larsson, E. C.
    Department of Women’s and Children’s Health, Karolinska Institutet, and the WHO Collaborating Centre, Karolinska University Hospital, Stockholm, Sweden.
    IMplementing best practice post-partum contraceptive services through a quality imPROVEment initiative for and with immigrant women in Sweden (IMPROVE it): a protocol for a cluster randomised control trial with a process evaluation2023In: BMC Public Health, E-ISSN 1471-2458, Vol. 23, no 1, article id 806Article in journal (Refereed)
    Abstract [en]

    Background: Immigrant women’s challenges in realizing sexual and reproductive health and rights (SRHR) are exacerbated by the lack of knowledge regarding how to tailor post-partum contraceptive services to their needs. Therefore, the overall aim of the IMPROVE-it project is to promote equity in SRHR through improvement of contraceptive services with and for immigrant women, and, thus, to strengthen women’s possibility to choose and initiate effective contraceptive methods post-partum. Methods: This Quality Improvement Collaborative (QIC) on contraceptive services and use will combine a cluster randomized controlled trial (cRCT) with a process evaluation. The cRCT will be conducted at 28 maternal health clinics (MHCs) in Sweden, that are the clusters and unit of randomization, and include women attending regular post-partum visits within 16 weeks post birth. Utilizing the Breakthrough Series Collaborative model, the study’s intervention strategies include learning sessions, action periods, and workshops informed by joint learning, co-design, and evidence-based practices. The primary outcome, women’s choice of an effective contraceptive method within 16 weeks after giving birth, will be measured using the Swedish Pregnancy Register (SPR). Secondary outcomes regarding women’s experiences of contraceptive counselling, use and satisfaction of chosen contraceptive method will be evaluated using questionnaires completed by participating women at enrolment, 6 and 12 months post enrolment. The outcomes including readiness, motivation, competence and confidence will be measured through project documentation and questionnaires. The project’s primary outcome involving women’s choice of contraceptive method will be estimated by using a logistic regression analysis. A multivariate analysis will be performed to control for age, sociodemographic characteristics, and reproductive history. The process evaluation will be conducted using recordings from learning sessions, questionnaires aimed at participating midwives, intervention checklists and project documents. Discussion: The intervention’s co-design activities will meaningfully include immigrants in implementation research and allow midwives to have a direct, immediate impact on improving patient care. This study will also provide evidence as to what extent, how and why the QIC was effective in post-partum contraceptive services. Trial registration: NCT05521646, August 30, 2022.

  • 25.
    Lim, E. L. P.
    et al.
    Jönköping University, School of Health and Welfare.
    Khee, G. Y.
    Department of Pharmacy, Singapore General Hospital, Singapore.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Andersson-Gäre, Boel
    Jönköping University, School of Health and Welfare, HHJ, Dept. for Quality Improvement and Leadership. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping). Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Thumboo, J.
    SingHealth Office of Regional Health, Singapore Health Services, Singapore.
    Allgurin, Monika
    Jönköping University, School of Health and Welfare, HHJ, Dept. of Social Work. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping). Jönköping University, School of Health and Welfare, HHJ. SALVE (Social challenges, Actors, Living conditions, reseach VEnue).
    How the Esther Network model for coproduction of person-centred health and social care was adopted and adapted in Singapore: a realist evaluation2022In: BMJ Open, E-ISSN 2044-6055, Vol. 12, no 12, article id e059794Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The Esther Network (EN) model, a person-centred care innovation in Sweden, was adopted in Singapore to promote person-centredness and improve integration between health and social care practitioners. This realist evaluation aimed to explain its adoption and adaptation in Singapore. DESIGN: An organisational case study using a realist evaluation approach drawing on Greenhalgh et al (2004)'s Diffusion of Innovations in Service Organisations to guide data collection and analysis. Data collection included interviews with seven individuals and three focus groups (including stakeholders from the macrosystem, mesosystem and microsystem levels) about their experiences of EN in Singapore, and field notes from participant observations of EN activities. SETTING: SingHealth, a healthcare cluster serving a population of 1.37 million residents in Eastern Singapore. PARTICIPANTS: Policy makers (n=4), EN programme implementers (n=3), practitioners (n=6) and service users (n=7) participated in individual interviews or focus group discussions. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcome data from healthcare institutions (n=13) and community agencies (n=59) were included in document analysis. RESULTS: Singapore's ageing population and need to transition from a hospital-based model to a more sustainable community-based model provided an opportunity for change. The personalised nature and logic of the EN model resonated with leaders and led to collective adoption. Embedded cultural influences such as the need for order and hierarchical structures were both barriers to, and facilitators of, change. Coproduction between service users and practitioners in making care improvements deepened the relationships and commitments that held the network together. CONCLUSIONS: The enabling role of leaders (macrosystem level), the bridging role of practitioners (mesosystem level) and the unifying role of service users (microsystem level) all contributed to EN's success in Singapore. Understanding these roles helps us understand how staff at various levels can contribute to the adoption and adaptation of EN and similar complex innovations systemwide.

  • 26.
    Lim, Esther Li Ping
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Ong, R. H. S.
    Health Services Research, Changi General Hospital, Singapore.
    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, Department for Quality Improvement and Leadership.
    Wilińska, Monika
    Jönköping University, School of Health and Welfare, HHJ, Department of Social Work. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping). Jönköping University, School of Health and Welfare, HHJ. SALVE (Social challenges, Actors, Living conditions, reseach VEnue).
    Andersson-Gäre, Boel
    Jönköping University, School of Health and Welfare, HHJ, Department for Quality Improvement and Leadership. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping). Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Thumboo, J.
    SingHealth Office of Regional Health, Singapore Health Services, Singapore.
    An Evaluation of the Relationship between Training of Health Practitioners in a Person-Centred Care Model and their Person-Centred Attitudes2023In: International Journal of Integrated Care, E-ISSN 1568-4156, Vol. 23, no 4, article id 11Article in journal (Refereed)
    Abstract [en]

    Introduction: The Esther Network (EN) person-centred care (PCC) advocacy training aims to promote person-centred attitudes among health practitioners in Singapore. This study aimed to assess the relationship between the training and practitioners’ PCC attributes over a 3-month period, and to explore power sharing by examining the PCC dimensions of “caring about the service user as a whole person” and the “sharing of power, control and information”. Methods: A repeated-measure study design utilising the Patient-Practitioner Orientation Scale (PPOS), was administered to 437 training participants at three time points – before training (T1), immediately after (T2) and three months after training (T3). A five-statement questionnaire captured knowledge of person-centred care at T1 and T2. An Overall score, Caring and Sharing sub-scores were derived from the PPOS. Scores were ranked and divided into three groups (high, medium and low). Ordinal Generalised Estimating Equation (GEE) model analysed changes in PPOS scores over time. Results: A single, short-term training appeared to result in measurable improvements in person-centredness of health practitioners, with slight attenuation at T3. There was greater tendency to “care” than to “share power” with service users across all three time points, but the degree of improvement was larger for sharing after training. The change in overall person-centred scores varied by sex and profession (females score higher than males, allied health showed a smaller attenuation at T3). Conclusion: Training as a specific intervention, appeared to have potential to increase health practitioners’ person-centredness but the aspect of equalising power was harder to achieve within a hierarchical structure and clinician-centric culture. An ongoing network to build relationships, and a supportive system to facilitate individual and organisational reflexivity can reinforce learning.

  • 27. Mazzocato, Pamela
    et al.
    Holden, Richard
    Brommels, Mats
    Aronsson, Håkan
    Bäckman, Ulrika
    Elg, Mattias
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren Children's Hospital, Stockholm, Sweden2012In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 12, no 1, p. 28-Article in journal (Refereed)
    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).

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

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

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

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

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

  • 29.
    Mazzocato, Pamela
    et al.
    Karolinska Institutet.
    Unbeck, Maria
    Karolinska Institutet.
    Elg, Mattias
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Linköping University.
    Sköldenberg, Olof Gustaf
    Karolinska Institutet.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Karolinska Institutet.
    Unpacking the key components of a programme to improve the timeliness of hip-fracture care: a mixed-methods case study2015In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 23, p. 1-12, article id 93Article in journal (Refereed)
    Abstract [en]

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

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

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

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  • 30.
    Nilsen, Per
    et al.
    Linköping University, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Bender, Miriam
    Sue & Bill Gross School of Nursing, University of California, Irvine, CA, USA.
    Leeman, Jennifer
    University of North Carolina, USA.
    Andersson-Gäre, Boel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    Sevdalis, Nick
    King's College, London, UK.
    Improvement science2020In: Handbook on implementation science / [ed] P. Nilsen & S. A. Birken, Cheltenham: Edward Elgar Publishing, 2020, p. 389-408Chapter in book (Other academic)
  • 31.
    Nordenström, Jörgen
    et al.
    Karolinska institutet.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Karolinska institutet.
    Bästa praxis - en nyckel till bättre vårdkvalitet och mer effektiv vård2016In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 113, p. 34-37, article id DWYWArticle in journal (Other academic)
    Abstract [sv]

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

  • 32.
    Odhagen, Erik
    et al.
    University of Gothenburg, Gothenburg, Sweden.
    Sunnergren, Ola
    Ryhov County Hospital Jönköping, Jönköping, Sweden.
    Söderman, Anne-Charlotte Hessén
    Karolinska Institutet, Stockholm, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Stalfors, Joacim
    University of Gothenburg, Gothenburg, Sweden.
    Reducing post-tonsillectomy haemorrhage rates through a quality improvement project using a Swedish National quality register: a case study2018In: European Archives of Oto-Rhino-Laryngology, ISSN 0937-4477, E-ISSN 1434-4726, Vol. 275, no 6, p. 1631-1639Article in journal (Refereed)
    Abstract [en]

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

  • 33.
    Persson, Sofia
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Andersson, Ann-Christine
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Kvarnefors, Annmargreth
    Region Jönköping, Jönköping, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Andersson-Gäre, Boel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    Quality as strategy, the evolution of co-production in the Region Jönköping health system, Sweden: A descriptive qualitative study2021In: International Journal for Quality in Health Care, ISSN 1353-4505, E-ISSN 1464-3677, Vol. 33, no Supplement 2, p. II15-II22Article in journal (Refereed)
    Abstract [en]

    Background: Pursuing the vision 'for a good life in an attractive region,' the Region Jönköping County (RJC) in Sweden oversees public health and health-care services for its 360 000 residents. For more than three decades, RJC has applied 'quality as strategy,' which has included increasing involvement of patients, family and friends and citizens. This practice has evolved, coinciding with the growing recognition of co-production as a fundamental feature in health-care services. This study views co-production as an umbrella term including different methods, initiatives and organizational levels. When learning about co-production in health-care services, it can be helpful to approach it as a dynamic and reflective process.

    Objective: This study aims to describe the examples of key developmental steps toward co-production as a system property and to highlight 'lessons learned' from a Swedish health system's journey.

    Method: This qualitative descriptive study draws on interviews with key stakeholders and on documents, such as local policy documents, project reports, meeting protocols and presentations. Co-production initiatives were defined as strategies, projects, quality improvement (QI) programs or other efforts, which included persons with patient experience and/or their next of kin (PPE). We used directed manifest content analysis to identify initiatives, timelines and methods and inductive conventional content analysis to capture lessons learned over time.

    Results: The directed content analyses identified 22 co-production initiatives from 1997 until today. Methods and approaches to facilitate co-production included development of personas, storytelling, person-centered care approaches, various co-design methods, QI interventions, harnessing of PPEs in different staff roles, and PPE-driven improvement and networks. The lessons learned included the following aspects of co-production: relations and structure; micro-, meso-And macro-level approaches; attitudes and roles; drivers for development; diversity; facilitating change; new perspectives on current work; consequences; uncertainties; theories and outcomes; and regulations and frames.

    Conclusions: Co-production evolved as an increasingly significant aspect of services in the RJC health system. The initiatives examined in this study provide a broad overview and understanding of some of the RJC co-production journey, illustrating a health system's approach to co-production within a context of long-standing application of QI and microsystem theories. The main lessons include the constancy of direction, the strategy for improvement, engaged leaders, continuous learning and development from practical experience, and the importance of relationships with national and international experts in the pursuit of system-wide health-care co-production.

  • 34.
    Peterson, Anette
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Healthcare Department, Region of Jönköping, Jönköping, Sweden.
    Gudbjörnsdottir, Soffia
    Center of Registers in Region Västra Götaland, Gothenburg, Sweden.
    Löfgren, Ulla-Britt
    Center of Registers in Region Västra Götaland, Gothenburg, Sweden.
    Schiöler, Linus
    Sahlgrenska Academy, University of Gothenburg, Sweden.
    Bojestig, Mats
    Healthcare Department, Region of Jönköping, Jönköping, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Andersson-Gäre, Boel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Collaboratively improving diabetes care in Sweden using a National Quality Register: Successes and challenges-A Case Study2015In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 24, no 4, p. 2012-221Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Since 1996, the Swedish National Diabetes Register (NDR) enabled health care providers to monitor their clinical performance over time and compare it with the national average. All health systems of Swedish county councils report data. By 2014, the NDR included data from 360 000 patients. Comparisons among county councils show significant variations in clinical outcomes and in adherence to evidence-based national guidelines. The purpose of this study was to evaluate whether and how a quality improvement collaborative could influence clinical practice and outcomes.

    METHODS: Twenty-three diabetes teams from all over Sweden, both primary care units and internal medicine departments, joined a quality improvement collaborative. The project was inspired by the Breakthrough Collaborative Model and lasted for 20 months. Evaluation data were collected from the teams' final reports and the NDR throughout the study period.

    RESULTS AND CONCLUSION: The teams reported improved patient outcomes significantly compared with the national average for systolic blood pressure and low-density lipoprotein levels. In contrast, glycated hemoglobin A1c levels deteriorated in the whole NDR population. Five themes of changes in practice were tested and implemented. Success factors included improved teamwork, with active use of register data, and testing new ideas and learning from others.

  • 35.
    Peterson, Anette
    et al.
    Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare.
    Hanberger, L.
    Samuelsson, U.
    Åkesson, K.
    Andersson Gäre, Boel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Hedberg, Berit
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Learning from a successful Quality ImprovementCollaborative. Why did it work? – Experience from teams and team coacheswho improved their care for children with diabetesManuscript (preprint) (Other academic)
  • 36.
    Schmidt, Ingrid
    et al.
    Socialstyrelsen National Board of Health and Welfare, Department of Evaluation and Analysis, Stockholm, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Davidson, Thomas
    Linkopings universitet, Department of Management and Engineering, Linkoping, Sweden.
    Nilsson, Fredrik
    Lunds Universitet, Department of Design Sciences, Lund, Sweden.
    Carlsson, Christina
    Lunds Universitet, Department of Clinical Sciences, Lund, Sweden.
    The national program on standardized cancer care pathways in Sweden: Observations and findings half way through2018In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 122, no 9, p. 945-948Article in journal (Refereed)
    Abstract [en]

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

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

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

  • 38.
    Stevenson, Katherine
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ, Department for Quality Improvement and Leadership.
    D'Eon, M.
    College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada and Director, Educational Innovation Institute, Medical College of Georgia, Augusta University, Augusta, GA.
    Headrick, L.
    School of Medicine, University of Missouri, Columbia, MO.
    Andersson-Gäre, Boel
    Jönköping University, School of Health and Welfare, HHJ, Department for Quality Improvement and Leadership. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping). Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    From Theory to Practice: The Enacted Curriculum of a Successful Master's Program in Quality Improvement and Leadership2023In: Journal of Continuing Education in the Health Professions, ISSN 0894-1912, E-ISSN 1554-558X, Vol. 43, no 4, p. 234-240Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Blended learning has taken on new prominence in the fields of higher and continuing education, especially as programs have shifted in response to teaching in a global pandemic. The faculty at the Jönköping Academy's Masters in Quality Improvement and Leadership program has been offering a blended learning curriculum, based on four core design principles, since 2009. We studied key features of the enacted curriculum to understand conditions that can support an effective blended learning model. METHODS: We used a case study approach underpinned by interactive research. Document analysis, a focus group, individual interviews, and stimulated recall interviews were used for data collection. Themes were identified through qualitative content analysis and data reduction, data display, and conclusion drawing. RESULTS: We grouped data into six emergent themes that clarify the enacted curriculum of an established Master's program: focusing on a common purpose, developing technical and relational knowledge and skills, linking theory and practice in the workplace, leveraging collaboration for mutual benefit, concentrating on leadership and coaching, and applying a blended and interprofessional learning model. CONCLUSION: Educators faced with increased demands to be flexible and to offer opportunities for distance education can learn from this case example of effective teaching of quality improvement and leadership in a blended format.

  • 39.
    Suutari, Anne-Marie
    et al.
    Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Department of Internal Medicine and Geriatrics, the Highland Hospital (Höglandssjukhuset), Eksjö, Region Jönköping County, Sweden.
    Areskoug Josefsson, Kristina
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Kjellström, Sofia
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Nordin, Annika
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Promoting a sense of security in everyday life—A case study of patients and professionals moving towards co-production in an atrial fibrillation “learning café”2019In: Health Expectations, ISSN 1369-6513, E-ISSN 1369-7625, Vol. 22, no 6, p. 1240-1250Article in journal (Refereed)
    Abstract [en]

    Background

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

    Objective

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

    Design

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

    Setting

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

    Improvement activities

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

    Results

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

    Conclusions

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

  • 40.
    Suutari, Anne-Marie
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Department of Internal Medicine and Geriatrics, the Highland Hospital (Höglandssjukhuset), Region Jönköpings län, Eksjö, Sweden.
    Nordin, Annika
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Kjellström, Sofia
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Health Services Department, Stockholm County Council, Stockholm, Sweden.
    Areskoug Josefsson, Kristina
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Faculty of Health Studies, VID Specialized University, Oslo, Akershus, Norway.
    Using stakeholders' experiences to redesign health services for persons living with heart failure: a case study protocol in a Swedish cardiac care setting [Protocol]2022In: BMJ Open, E-ISSN 2044-6055, Vol. 12, no 3, article id e058469Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Clinical guidelines promote recognising persons with heart failure (referred to as PWHF) as coproducers of their own care. Coproduction of healthcare-involving PWHF, families and professionals in care processes-aims to promote the best possible health. Still, it is unclear how to coproduce heart failure (HF) care. This study explores whether and how Experience-Based Co-Design (EBCD) involving PWHF, family members and professionals can be undertaken online, in a Swedish cardiac care setting, to codesign improved experiences of HF care.

    METHODS AND ANALYSIS: In EBCD, stakeholders' experiences are solicited to redesign healthcare services. First, we will undertake a thematic analysis of field notes from consultations and filmed/audio-recorded interviews with PWHF (n=10-12). This analysis will identify 'touchpoints' (emotionally positive/negative events that shape overall service experiences), edited into a 'trigger film'. Next, a thematic analysis of family members' (n=10-12) and professionals' (n=10-12) interviews will identify key themes mirroring their experiences. Separate feedback events with each stakeholder group will confirm identified touchpoints and key themes and identify areas for HF care improvement. At a joint event, prompted by the 'trigger film', stakeholders will agree on one area for HF care improvement. A team including PWHF, family members and professionals, led by an improvement adviser, will then plan, design, implement and evaluate an improvement activity addressing the identified problem area. A deductive thematic analysis of field notes, project documentation and stakeholder focus group interviews, underpinned by MUSIQ, will identify how organisational conditions influence the process. Quantitative measurements, describing the results of the improvement activity, will be integrated with qualitative data to strengthen the case. To reduce resource intensity, we will use online tools during the process.

    ETHICS AND DISSEMINATION: The Swedish Ethical Review Authority approved the study in May 2021. The results will be disseminated through seminars, conference presentations and publications.

  • 41.
    Suutari, Anne-Marie
    et al.
    Jönköping University, School of Health and Welfare. The Highland Hospital (Höglandssjukhuset), Eksjö, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    ‘Learning Café’ group education program with atrial fibrillation patients – a model for co-production2018Conference paper (Other academic)
  • 42.
    Suutari, Anne-Marie
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Nordin, Annika
    Jönköping University, School of Health and Welfare, HHJ, Department for Quality Improvement and Leadership. Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Areskoug Josefsson, Kristina
    Jönköping University, School of Health and Welfare, HHJ, Department for Quality Improvement and Leadership. Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Section for health promotion and care sciences, University West, Trollhättan, Sweden; Faculty of Health Studies, VID Specialized University, Oslo, Akershus, Norway.
    Experiences of and conditions for re-designing heart failure care – a qualitative evaluation of an Experience-Based Co-Design case in a Swedish cardiac care settingManuscript (preprint) (Other academic)
  • 43.
    Suutari, Anne-Marie
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Department of Internal Medicine and Geriatrics, the Highland Hospital (Höglandssjukhuset), Region Jönköping County, Eksjö, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Nordin, Annika
    Jönköping University, School of Health and Welfare, HHJ, Department for Quality Improvement and Leadership. Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Areskoug Josefsson, Kristina
    Jönköping University, School of Health and Welfare, HHJ, Department for Quality Improvement and Leadership. Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. The Department of Health Sciences, University West, Trollhättan, Sweden; Department of Behavioral Science, Oslo Metropolitan University, Oslo, Norway.
    Improving heart failure care with an Experience-Based Co-Design approach: what matters to persons with heart failure and their family members?2023In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 23, no 1, article id 294Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Heart failure is a chronic heart condition. Persons with heart failure often have limited physical capability, cognitive impairments, and low health literacy. These challenges can be barriers to healthcare service co-design with family members and professionals. Experience-Based Co-Design is a participatory healthcare quality improvement approach drawing on patients', family members' and professionals' experiences to improve healthcare. The overall aim of this study was to use Experience-Based Co-Design to identify experiences of heart failure and its care in a Swedish cardiac care setting, and to understand how these experiences can translate into heart failure care improvements for persons with heart failure and their families.

    METHODS: A convenience sample of 17 persons with heart failure and four family members participated in this single case study as a part of an improvement initiative within cardiac care. In line with Experienced-Based Co-Design methodology, field notes from observations of healthcare consultations, individual interviews and meeting minutes from stakeholders' feedback events, were used to gather participants' experiences of heart failure and its care. Reflexive thematic analysis was used to develop themes from data.

    RESULTS: Twelve service touchpoints, organized within five overarching themes emerged. The themes told a story about persons with heart failure and family members struggling in everyday life due to a poor quality of life, lack of support networks, and difficulties understanding and applying information about heart failure and its care. To be recognized by professionals was reported to be a key to good quality care. Opportunities to be involved in healthcare varied, Further, participants' experiences translated into proposed changes to heart failure care such as improved information about heart failure, continuity of care, improved relations, and communication, and being invited to be involved in healthcare.

    CONCLUSIONS: Our study findings offer knowledge about experiences of life with heart failure and its care, translated into heart failure service touchpoints. Further research is warranted to explore how these touchpoints can be addressed to improve life and care for persons with heart failure and other chronic conditions.

  • 44.
    Suutari, Anne-Marie
    et al.
    Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Department of Internal Medicine and Geriatrics, The Highland Hospital, Eksjö, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Nordin, Annika
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Kjellström, Sofia
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Areskoug Josefsson, Kristina
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Faculty of Health Studies, VID Specialized University, Oslo, Norway; Department of Behavioral Science, Oslo Metropolitan University, Oslo, Norway.
    Improving Health for People Living With Heart Failure: Focus Group Study of Preconditions for Co-Production of Health and Care2021In: Journal of Participatory Medicine, ISSN 2152-7202, Vol. 13, no 2, article id e27125Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Co-production of health and care involving patients, families of patients, and professionals in care processes can create joint learning about how to meet patients' needs. Although barriers and facilitators to co-production have been examined previously in various health care contexts, the preconditions in Swedish chronic cardiac care contexts are yet to be explored. This study is set in the health system of the Swedish region of Jönköping County and is part of system-wide efforts to promote better health for persons with heart failure (HF).

    OBJECTIVE: The objective of this study was to test the usefulness of the Capability, Opportunity, and Motivation Behavior (COM-B) model when assessing the barriers to and facilitators of co-production of health and care perceived by patients with HF, family members of patients with HF, and professionals in a Swedish chronic cardiac care context as a guide for subsequent initiatives.

    METHODS: Data collection involved 1 focus group interview (FGI) with patients with HF (n=5), 1 FGI with family members of patients with HF (n=5), 1 FGI with professionals in primary care (n=7), and 1 FGI with professionals in cardiac care (n=4). In addition, patients with HF kept diaries of their thoughts regarding co-production. Using a deductive approach to content analysis, underpinned by the COM-B model, barriers and facilitators were categorized into capabilities, opportunities, and motivations to co-produce health and care.

    RESULTS: The participants showed limited understanding of co-production as a practice. They appeared to view it as a privilege to be offered to patients on top of traditional care and rarely as an approach for improving health care processes. The interviews revealed the limited health literacy among patients and the struggle of professionals to convey health information to these patients. Co-production was considered to be more resource-intensive than traditional care. Different expectations of stakeholders' roles were revealed: professionals expected older patients not to want to co-produce health and care, and all participants expected professionals to be in charge of health care services. The family members' position involved trying to balance their desire to support their relatives with understanding when, how, and with whom to co-produce. Presumed benefits motivated stakeholders: co-production was recognized to motivate patients to improve self-care. However, the participants recognized that motivation to get involved in health and care decisions varies over time among stakeholders.

    CONCLUSIONS: Co-production can be facilitated by the stakeholders' motivation. However, varying levels of understanding of co-production, patients' limited health literacy, unease with power sharing between patients and professionals, and resource constraints are barriers that need to be managed to promote co-produced care and better health for persons living with HF. Further research is warranted to explore how to co-produce health care services with patients with HF and how leaders can facilitate the inevitable cultural change it requires and represents.

  • 45.
    Thor, Johan
    Jönköping University, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health Science, HHJ, Quality Improvement and Leadership in Health and Welfare. Karolinska Institutet.
    Förbättringsarbete och förändringsprocessen2012In: Kvalitetsarbete för bättre och säkrare vård / [ed] Gun Nordström, Bodil Wilde Larsson, Lund: Studentlitteratur AB, 2012, 1, p. 89-109Chapter in book (Other academic)
  • 46.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Karolinska Institutet.
    Förbättringsarbete och förändringsprocessen2017In: Kvalitetsarbete för bättre och säkrare vård / [ed] Anne-Marie Boström, Gun Nordström, Bodil Wilde Larsson, Lund: Studentlitteratur AB, 2017, 2, p. 107-126Chapter in book (Other academic)
  • 47.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Kvalitet och förbättringsarbete i hemsjukvård2019In: Hemsjukvård: olika perspektiv på trygg och säker vård / [ed] Mirjam Ekstedt & Maria Flink, Stockholm: Liber, 2019, 1 uppl., p. 282-293Chapter in book (Other academic)
  • 48.
    Thor, Johan
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Region Stockholm.
    Andersson, Ann-Christine
    Jönköping University, School of Health and Welfare, HHJ, Department for Quality Improvement and Leadership. Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Andersson-Gäre, Boel
    Jönköping University, School of Health and Welfare, HHJ, Department for Quality Improvement and Leadership. Jönköping University, School of Health and Welfare, HHJ. Studies on Integrated Health and Welfare (SIHW). Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Förbättringskunskap behöver fortsatt tillämpas i vården [Improvement knowledge has been applied when changing health services - and continues to be needed]2023In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 120, article id 22154Article in journal (Refereed)
    Abstract [en]

    In 2002, Läkartidningen published a call to apply improvement knowledge in efforts to change health services. Looking back over the past 20 years, we highlight many scientifically documented examples of such application. Many efforts, often within »breakthrough collaboratives«, have included Swedish national quality registries, with documented health outcome improvements related to application of Improvement Knowledge. Applications have been evaluated through improvement science studies. A literature review documented 32 PhD theses addressing healthcare improvement published by Swedish universities. Increasingly, improvement knowledge definitions and applications include - and harness - the experiences and knowledge among patients and their families. To meet challenges in the future, all health care stakeholders will need to master and apply improvement knowledge.

  • 49.
    Thor, Johan
    et al.
    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.
    Lundgren, Charlotte
    Batalden, Paul B.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Andersson-Gäre, Boel
    Jönköping University, School of Health and Welfare, 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.
    Henriks, Göran
    Sjödahl, Rune
    Gabrielsson-Järhult, Felicia
    Jönköping University, School of Health and Welfare, HHJ, Institute of Gerontology. Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare.
    Collaborative improvement of cancer services in Southeastern Sweden – striving for better patient and population health, better care, and better professional development2012In: Sustainably Improving Health Care: Creatively linking care outcomes, system performance, and professional development / [ed] P. Batalden & T. Foster, London: Radcliffe Publishing, 2012, p. 175-192Chapter in book (Other academic)
  • 50.
    Thor, Johan
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Karolinska institutet.
    Olsson, Daniel
    Karolinska institutet.
    Nordenström, Jörgen
    Karolinska institutet.
    The design, fate and impact of a hospital-wide training program in evidence-based medicine for physicians: An observational study2016In: BMC Medical Education, E-ISSN 1472-6920, Vol. 16, article id 86Article in journal (Refereed)
    Abstract [en]

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

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

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

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

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