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.

Syftet med denna kunskapsöversikt är att belysa hur förbättringskunskapen utvecklats i den svenska hälsovård- och välfärdssektorn, och vilka implikationer förbättringskunskap kan ha för projektet ”Barnens Bästa Gäller! i Kronoberg” (BBGiK). Rapporten avslutas med en diskussion om de möjligheter och utmaningar som påverkar projektet. Förbättringskunskap är nära besläktat med kvalitetsutveckling, och är numer vanligt förekommande i hälso- vård- och välfärdsorganisationer. De lagar och regelverk som styr innefattar skyldigheter att bedriva kvalitetsutveckling, och Ledningssystem för systematiskt kvalitetsarbete (SOSFS 2011:9) gäller för både vård- och omsorgsorganisationer.

Rapporten lyfter fram förbättringskunskapens ursprung, dess forskningsanknytning och evidens och utveckling och övergång till vård- och välfärdsorganisationer. När förbättringskunskap fått fäste i den kunskapsintensiva evidensbaserade vårdsektorn och förbättringsarbeten började bli mera vanligt, uppstod frågor om hur förbättringsmetoder fungerar. Flera av de tidiga aktörerna inom förbättringskunskap var läkare och sjuksköterskor, och därför blev det angeläget att även arbetet med förbättringar kunde betraktas utifrån evidenskrav. Runt sekelskiftet 2000 började de första forskningspublikationerna dyka upp. En av förbättringsforskningens stora utmaningar är att utveckla vetenskaplig robust kunskap, och en vanlig kritik har varit att en svag vetenskaplig och teoretisk grund.

I rapporten har befintlig litteratur producerad i Sverige, i form av böcker och bokkapitel, avhandlingar och artiklar, sammanställts och analyserats avseende publikationsfrekvens över tid och innehåll (tema). Sammanställningen lyfter fram studier som har extra relevans för projektet, såsom samverkansprojekt och olika ansatser att överföra och anpassa förbättringskunskap till den sociala sektorn. Mellan åren 2007–2020 utkom 30 böcker, bokkapitel och enklare skrifter. De flesta är läroböcker i form av antologier skrivna för vårdens professioner och handlar ofta om grundläggande förbättringskunskap. 32 avhandlingar från nio svenska lärosäten identifierades, den första från 2003. Flera avhandlingar intar organisationsperspektiv, men även ledarskap, patientsäkerhet och patientinvolvering/delaktighet förekommer. Totalt 210 artiklar identifierades publicerade mellan 1992 och 2020, med flest antal (n=166) efter 2011. Tematiseringen resulterade i sex olika teman: 1) Systematiskt och värdeskapande förbättringsarbete; 2) Samverkan mellan organisationer och vårdgivare; 3) Användning av förbättringsmetoder och (teoretiska) modeller; 4) Ledarskap och lärande; 5) Mätningar, kvalitetsregister och uppföljning; samt 6) Personinvolvering och patientsäkerhet.

Delaktighet och samskapade är en tydligt ökande trend inom vården. Samtidigt har det inom sociala verksamheter länge ansetts viktigt att beakta personers rättigheter och möjligheter till inflytande. Sammanställningen pekar mot en utveckling där samverkan mellan organisationer och samskapande med dem vård och omsorg är till för blir en allt viktigare faktor. Detta är en viktig aspekt för projektet BBGiK, som spänner över flera olika verksamheter och organisationer. Det är alltid en utmaning när olika verksamheter tillsammans ska hitta fungerande lösningar. Denna utmaning blir inte mindre av att de kommer ifrån olika kunskapstraditioner, men i projektet finns förutsättningar för gemensamt lärande runt en gemensam modell. En förutsättning för att lyckas med förbättringsarbete är ett aktivt ledarskap, och strävan mot samma gemensamma mål: ”att skapa en trygg och säker uppväxt för VARJE barn genom främjande, tidiga och samordnade insatser”.

Purpose: Quality improvement has developed and spread, and today, all Swedish Regions emphasize that their strategies are based on systematic improvement. This paper aims to describe and illuminate the development of Quality Improvement (QI) in Swedish healthcare and welfare organizations by using publications in a Swedish context.

Design/methodology/approach: The overview synthesis is inspired by a scoping literature review approach of relevant literature. All publications relevant to Swedish healthcare and welfare settings between 1992 until 2020 were included.

Findings: In all, 213 papers, 29 books and chapters and 34 dissertations related to QI and research in Swedish healthcare and welfare context were identified. From 2011 to 2020, the publication rate increased rapidly. Six different focus areas emerged: systematic and value-creating improvement work; collaboration between organizations and healthcare providers; use of improvement methods and (theoretical) models; leadership and learning; measurements, quality registers and follow-up; and involvement and patient safety. Further QI development in Swedish healthcare and welfare points to an increased importance of collaboration between organizations and coproduction with beneficiaries for the healthcare and welfare services.

Originality/value: This paper is one of the first to describe and illuminate the QI development in the healthcare and welfare sector in a country. The trajectory also points to a need for coproduction to handle future challenges. 

The aim of this study was to describe health care- and social service professionals' experiences of a quality-improvement program implemented in the south of Sweden. The focus of the program was to develop inter-professional collaboration to improve care and service to people with psychiatric disabilities in ordinary housing. Focus group interviews and a thematic analysis were used. The result was captured as themes along steps in process. (I) Entering the quality-improvement program: Lack of information about the program, The challenge of getting started, and Approaching the resources reluctantly. (II) Doing the practice-based improvement work: Facing unprepared workplaces, and Doing twice the work. (III) Looking backevaluation over 1 year: Balancing theoretical knowledge with practical training, and Considering profound knowledge as an integral part of work. The improvement process in clinical practice was found to be both time and energy consuming, yet worth the effort. The findings also indicate that collaboration across organizational boundaries was broadened, and the care and service delivery were improved.

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.

Under 2015 genomfördes nationella lärandeseminarier för att stärka implementeringen av den lag som ger barn rätt till information, råd och stöd när en förälder plötsligt avlider, är svårt sjuk eller skadad (HSL 2g §). Satsningen var ett förbättringsarbete som omfattade sex landsting som med hjälp av en projektledning träffades vid fyra tillfällen från januari till september. Två av träffarna skedde i Stockholm och två var digitala. Under våren 2015 knöts följeforskning till arbetet med frågeställningar om vilka resultat förbättringsarbetet gav och hur deltagarna upplevde arbetssättet. Syftet var att lyfta fram vad satsningen gav samt att lära inför framtida satsningar – är lärandeseminarier ett användbart arbetssätt för nationella implementeringssatsningar?

Rapporten visar att lärandeseminarier tycks vara en användbar form. Teamen kan redovisa att de uppnått många av de mål som de föresatte sig under projekttiden. Det handlade om kartläggning av kunskapsläge och strukturer, kompetensutveckling samt utveckling av rutiner och material. Teamen uppskattade också att få delta i ett nationellt sammanhang som gav inspiration. Samtidigt framkom det önskemål om fortsatt och ännu mer handfast stöd i fortsatt implementering i klinisk verksamhet.

Breakthrough Collaborative (BC) aims at learning through networking, mainly at micro level, and is used as a tool to improve care and welfare organizations. The aim of this study was to explore and illuminate the challenges when applying BC model at meso and macro level. In 2010, the Swedish Health and Medical Services Act stated the responsibility of healthcare professionals to consider children’s needs as relatives. This study uses an interactive collaborative research model. To support healthcare organizations in the implementation of the regulation, county councils/regions in Sweden were invited to take part in a BC during 2015. Six teams from different county councils/regions participated. Team members were interviewed several times during the project time. Data were analyzed with an explorative and descriptive qualitative content analysis. The result illuminates the challenges faced when applying BC at meso and macro level. Most challenges concern preparation, support structures and system connections. There are similarities with the challenges met at micro level when BC is used at meso and macro level. But it seems even more important to consider how the team is constituted at meso and macro level to make use of the learnings and achieve long-term impact in the home organization.

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

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

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

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

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

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

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

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

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

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

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

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

The purpose of this study was to elucidate conditions at all system levels in a specific health care service to develop practices for identification of children as relatives. An interactive research approach with the intention to create mutual learning between practice and research was used. The participating health care service cared for both clinic in- and outpatients with psychiatric disorders. Health care professionals from different system levels (micro, meso, macro) participated, representing different professions. At the first project meeting, it was obvious that there was no systematic approach to identify children as relatives. At the micro level, activities such as a pilot survey and an open house activity were carried out. At the meso level, it was discussed how to better support collaboration between units. At the management (macro) level, it was decided that all units should appoint at least one child agent, with the aim to increase collaboration throughout the whole health care service. To change focus, in this case from only parents to inclusion of children, is an important challenge faced by health care services when forced to incorporate new policies and regulations. The new regulations contribute to increased complexity in already complex organizations. This study highlights that such challenges are underestimated.

To employ a person-centred approach, it is essential to work with the patient in deciding the important issues that the physiotherapy intervention should target, and to develop and adjust the individual treatment accordingly. Those co-constructive processes of physiotherapy consist of several parts, aiming to improve patient involvement and to optimize intervention outcomes. This paper aims to discuss and bring forward the role of the co-constructive processes in physiotherapy, by using perspectives from learning strategies and quality improvement strategies. The conclusion is that co-constructive learning processes are useful theories, which can be used in unison with quality improvement strategies for optimal co-construction between patients and physiotherapists and thus improve results of physiotherapy interventions.

This paper presents a study on inhabited silence among unaccompanied female minors in Sweden. Silence among unaccompanied minors has often been explained by experienced trauma. Conversely, research also explains silence as a natural way of establishing autonomy during adolescence. By analyzing the narratives of 11 unaccompanied female minors, we aim to problematize and broaden the understanding of silence as a lack of communication. By using Bourdieu’s concept of linguistic capital, we analyze how hegemonic narratives on migration and integration influence how the girls in this study use silence in their everyday interactions. Our findings suggest that silence can be understood as both a rejection of these narratives and a strategy to preserve the girls’ integrity. We also demonstrate how these girls negotiate their linguistic capital in relation to embodiment and othering, thereby pushing boundaries of identity and what it means to be seen as Swedish. The paper concludes that silence itself speaks and shows that what is often perceived as a lack of communication can also be understood as a failure to listen.

BACKGROUND: All children should have the possibility to be healthy during childhood, according to the Convention on the Rights of the Child. In Sweden, the Child Health Services (CHS) support all parents and children from birth until the age of six to promote children's health and development. Some Swedish regions have introduced an extended home-visit programme, with CHS nurses and social workers visiting first-time parents together to provide parental support in collaboration. The programme aims to expand the task of promoting the child's health and increase the possibilities of discovering risk factors in families earlier. The aim of the present study is to describe the professionals' experiences of collaboration when introducing the extended home-visit programme to a broader population within the frame of a family centre.

METHODS: The study used a reflexive thematic qualitative approach with focus group interviews. All staff at the family centre were invited to participate: CHS nurses, social workers, and managers who worked with the extended home-visit programme. Data were collected through focus group interviews with each profession separately and analysed through reflexive thematic analysis.

RESULTS: One overarching theme emerged: A key to facilitating early support. Three connected themes - Ease for everyone on the family's terms, From working alone to becoming a team, and A matter of supporting structures - illuminated the participants' experiences. Their driving force was early detection of risk factors or needs in the family, to be able to provide support. The collaboration was enhanced by the different professional competencies complementing each other. That all were located at the family centre together was also important to facilitate collaboration.

CONCLUSIONS: The extended home-visits were appreciated and experienced as useful by all participants. That a family centre organization already existed was one of the facilitators, functioning as a meeting point to expand the collaboration. The managers' support was essential, and it was experienced as positive that the organization invested resources to allow employees to participate in the development of the extended home-visit programmes. This way of working has the potential to add value for the children and families, and the CHS would benefit from using the extended home-visit programme further.

BACKGROUND: Early support for children and families in need can improve children's health and development. In a Swedish region, a new working model called Safe Environment for Every Kid (SEEK) was introduced in the Child Health Services to facilitate the early identification of psychosocial risk factors.

OBJECTIVE: The aim of this study was to describe the adoption and introduction of the SEEK model in the Child Health Services of Region Jönköping County.

METHODS: Quantitative data were analysed using descriptive statistics, whereas qualitative data were analysed separately by a thematic approach. The results were then interpreted together with documents (including CHS management meeting notes and documents describing planning and training sessions) using an exploratory mixed-methods approach to give a comprehensive description of the adoption and introduction of the SEEK model.

RESULTS: The results show that the SEEK model improved coordination and collaboration, which led to better integrated care for children and families. The structure was regarded as supportive when introducing the SEEK model in Child Health Services. The questionnaire, as part of the SEEK model, was used in 88% of possible health visits. The most reported reason for not using it was a lack of time.

CONCLUSIONS: The desire to make a difference and thereby promote better health and development for children was a crucial factor for the nurses in adopting the SEEK model in their clinical practice. The design using coaches was also appreciated and supported the adoption and introduction of the SEEK model.

PATIENT OR PUBLIC CONTRIBUTION: Parents and healthcare professionals did not contribute to the research process. The results are based on dialogues between CHS nurses and parents after the parents filled in the SEEK questionnaire, providing an understanding of professional relationships when dealing with challenging issues.

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.

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.

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.

A Learning Health System (LHS) promotes the patient being at the very center of his or her care. Patient coproduction of care in an LHS is enabled by a focus on improving outcomes through the use of tools and visualizations that use the harnessed knowledge obtained from every previous treatment of similar patients. Interest in the concept of LHS is growing, and there are promising results in real-world applications. Almost no research has focused on LHSs for severe mental illness (LHS4SMI). By using a user-centered system design approach, a persona and use-case scenarios were created to illustrate how schizophrenia care could be co-produced in an LHS compared to standard care in a non-LHS. The illustration highlight increased participation through decisions informed by all treatments for all similar patients through the use of user interfaces that support continuous evaluation, increased understanding, compensation for cognitive impairment and participation of next of kin in the care process. We propose that an LHS4SMIs like schizophrenia has enormous potential in enabling continuous learning, patient coproduction, and more effective care.

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. 

Aim: To study Swedish pediatric oncologists’ practical and emotional experiences of referring, including and/or treating children in early-phase clinical trials.

Methods: A nationwide study was conducted using a mixed-method approach. Structured interviews based on a study-specific questionnaire and participants’ personal reflections were utilized. Survey responses were analyzed using descriptive statistics, while participants’ comments were analyzed using thematic analysis. All interviews were recorded and transcribed verbatim.

Results: In total, 29 physicians with 4 to 32 years of experience in pediatric oncology participated, with 19 (66%) having > 10 years of experience. Three themes appeared: 1) Optimization-based approach focused on finding the most suitable treatment and care for every child with a refractory/relapsed cancer eligible for an early-phase clinical trial; 2) Team-based approach aimed at establishing local and national consensus in decision-making for treatment options, including early-phase clinical trials and palliative care; 3) Family-based approach in which the physicians provided families with actionable information, listened to their desires, and endeavored to maintain hope in challenging circumstances. Several participants (40% with ≤ 10 years of experience and 58% with > 10 years of experience) viewed the early-phase clinical trial as a potential “chance of cure”. A majority (80%) of physicians with ≤ 10 years of experience, reported that they often or always felt personally and emotionally affected by communication regarding early-phase clinical trials. Delivering difficult news in cases of uncertain prognosis was identified as the major challenge. None of the study participants felt adequately prepared in terms of sufficient knowledge and experience regarding early-phase clinical trials. The physicians expressed a need for guidance and training in communication to address these challenges.

Conclusions: Working with early-phase clinical trials highlight a field where physicians cannot solely rely on their expertise or past experiences, and where they are likely to be deeply emotionally involved. Physicians who care for children eligible for such studies require targeted educational initiatives and supervision.

The aim of the study was to follow up inter-professional experiences of improvement work one year after a completed CII improvement program aiming at improve health care and social services for people with mental disabilities living in ordinary housing. This study was performed with a qualitative descriptive approach which employed six focus group interviews followed by a thematic analysis. The results revealed four themes; Self-awareness and insights; Behavior and actions in daily practice; Organizational cultures and subcultures; and Organizational practices, using Ken Wilbers' integral theory of four quadrants of realities as a holistic frame in the discussion.

Purpose

The purpose of this paper is to address how adult development (AD) theories can contribute to quality improvement (QI).

Design/methodology/approach

A theoretical analysis and discussion on how personal development empirical findings can relate to QI and Deming's four improvement knowledge domains.

Findings

AD research shows that professionals have qualitatively diverse ways of meaning-making and ways to approach possibilities in improvement efforts. Therefore, professionals with more complex meaning-making capacities are needed to create successful transformational changes and learning, with the recognition that system knowledge is a developmental capacity.

Practical implications

In QI and improvement science there is an assumption that professionals have the skills and competence needed for improvement efforts, but AD theories show that this is not always the case, which suggests a need for facilitating improvement initiatives, so that everyone can contribute based on their capacity.

Originality/value

This study illustrates that some competences in QI efforts are a developmental challenge to professionals, and should be considered in practice and research.

Background

Improvement work can be used in preschools to enrich outdoor environment for children’s better health. Effective improvement work can facilitate the necessary changes, but little is known about professionals’ experiences of participation in improvement interventions. The aim was to evaluate how preschool staff experience quality improvement work, using the Breakthrough Series Collaborative improvement programme, to enhance outdoor environments.

Methods

An improvement intervention using a breakthrough collaborative was performed at 9 preschools in Sweden and examined with a longitudinal mixed method design. Staff completed questionnaires on 4 occasions (n=45 participants) and interviews took place after the intervention (n=16 participants).

Results

The intervention was successful in the sense that the staff were content with the learning seminars, and they had triggered physical changes in the outdoor environment. They integrated the quality improvement work with their ordinary work and increasingly involved the children. The staff tested improvement tools but did not find them entirely appropriate for their work, because they preferred existing methods for reflection.

Conclusions

The challenges in quality improvement work seem to be similar across contexts. Using the Breakthrough Series Collaborative in a public health intervention is promising but needs to be integrated with preunderstandings, current reflections and quality tools and models.

INTRODUCTION:

Cocreation, coproduction and codesign are advocated as effective ways of involving citizens in the design, management, provision and evaluation of health and social care services. Although numerous case studies describe the nature and level of coproduction in individual projects, there remain three significant gaps in the evidence base: (1) measures of coproduction processes and their outcomes, (2) mechanisms that enable inclusivity and reciprocity and (3) management systems and styles. By focusing on these issues, we aim to explore, enhance and measure the value of coproduction for improving the health and well-being of citizens.

METHODS AND ANALYSIS:

Nine ongoing coproduction projects form the core of an interactive research programme ('Samskapa') during a 6-year period (2019-2024). Six of these will take place in Sweden and three will be undertaken in England to enable knowledge exchange and cross-cultural comparison. The programme has a longitudinal case study design using both qualitative and quantitative methods. Cross-case analysis and a sensemaking process will generate relevant lessons both for those participating in the projects and researchers. Based on the findings, we will develop explanatory models and other outputs to increase the sustained value (and values) of future coproduction initiatives in these sectors.

ETHICS AND DISSEMINATION:

All necessary ethical approvals will be obtained from the regional Ethical Board in Sweden and from relevant authorities in England. All data and personal data will be handled in accordance with General Data Protection Regulations. Given the interactive nature of the research programme, knowledge dissemination to participants and stakeholders in the nine projects will be ongoing throughout the 6 years. External workshops-facilitated in collaboration with participating case studies and citizens-both during and at the end of the programme will provide an additional dissemination mechanism and involve health and social care practitioners, policymakers and third-sector organisations. 

Rationale, aim, and objective: This study aimed to explore programme theories of a national quality register. A programme theory is a bundle of assumptions underpinning how and why an improvement initiative functions. The purpose was to examine and establish programme theories of a national quality register widely used in Sweden: Senior alert. The paper reports on how programme theories among change recipients emerge in relation to the established programme theory of the initiator.

Methods: A qualitative approach and a longitudinal research design were used. To develop programme theories among change recipients, individual semistructured interviews were conducted. Three sets of interviews were conducted in the period of 2011 to 2013, totalling 22 interviews. In addition, 4 participant observations were made. To develop the initiator's programme theory, an iterative multistage collaboration process between the researchers and the initiator was used. A directed content analysis was used to analyse data.

Findings: The initiator and change recipients described similar programme logics, but differing programme theories. With time, change recipients' programme theories emerged. Their programme theories converged and became more like the programme theory of the initiator.

Conclusions: This study has demonstrated the importance of making both the initiator's and change recipients' programme theories explicit. To learn about conditions for improvement initiatives, comparisons between their programme theories are valuable. Differences in programme theories provide information on how initiators can customize support for their improvement initiatives. Similar programme logics can be underpinned by different programme theories, which can be deceptive. Programme theories emerge over time and need to be understood as dynamic phenomena. 

Purpose

The purpose of this paper is to examine how external change agents (ECAs) engaged to disseminate a national quality register (NQR) called Senior alert nationwide in the Swedish health care and elderly care sectors interpret their work. To study this, sensemaking theories are used.

Design/methodology/approach

This is a qualitative inductive interview study including eight ECAs. To analyze the data, a thematic analysis is carried out.

Findings

Well-disseminated NQRs support health care organizations’ possibility to work with quality improvement and to improve care for patient groups. NQRs function as artifacts that can influence how health care professionals make sense of their work. In this paper, a typology depicting how the ECAs make sense of their dissemination work has been developed. The ECAs are engaged in prospective sensemaking. They describe their work as being about creating future good results, both for patients and affiliated organizations, and they can balance different quality aspects.

Originality/value

The number of NQRs increased markedly in Sweden and elsewhere, but there are few reports on how health care professionals working with the registers interpret their work. The use of ECAs to disseminate NQRs is a novel approach. This paper describes how the ECAs are engaged in prospective sensemaking – an under-researched perspective of the sensemaking theory.

Purpose

The purpose of this study is to examine and establish how sensemaking develops among a group of external change agents (ECAs) engaged to disseminate a national quality register nationwide in Swedish health care and elderly care. To study the emergent sensemaking, the theoretical concept of cognitive shift has been used.

Design/methodology/approach

The data collection method included individual semi-structured interviews, and two sets of interviews (initial sensemaking and renewed sensemaking) have been conducted. Based on a typology describing how ECAs interpret their work, structural analyses and comparisons of initial and renewed sensemaking are made and illuminated in spider diagrams. The data are then analyzed to search for cognitive shifts.

Findings

The ECAs’ sensemaking develops. Three cognitive shifts are identified, and a new kind of issue-related cognitive shift, the outcome-related cognitive shift, is suggested. For the ECAs to customize their work, they need to be aware of how they interpret their own work and how these interpretations develop over time.

Originality/value

The study takes a novel view of the interrelated concepts of sensemaking and sensegivers and points out the cognitive shifts as a helpful theoretical concept to study how sensemaking develops.

Purpose – The study of successful transformational change processes in organizations has been limited. The aim was to understand a change process and the type of change that occurred in a pharmaceutical company in Sweden 2005–2014.

Method – An interactive research design was used, and semi-structured interviews were conducted with 19 individuals, asking about their views on the change journey. Meetings and dialogue with leaders from the organization also took place. Observations from feedback meetings with leaders were included in the analysis. The results were analysed using a time-ordered display identifying key events, interpreted by a theoretical lens determining the type of change over a period of 10 years.

Findings – This was a transformational change caused by external pressure, supported by visionary and transparent leadership, collaborative methods aiming at broad involvement, and systemic understanding. The results indicated a 40% increase in productivity and altered organizational design and culture. Sense-making activities, persistent adoption of quality improvement tools, dispersed power, and sequential change activities underpinned the success.

Practical implications – The results provide insight into the processes of transformational change. Change leaders were provided with knowledge, inspiration and insight when facing transformations.

Social implications – Increased prevalence of transformational change calls for new organizational competencies and altered roles for leaders and employees. There is a need for new ways of developing competence and new recruitment policies for leaders.

Originality/value – This case presents unique empirical evidence of a successful cultural transformation led by a leader using post-conventional principles.

Purpose: The purpose of this paper is to examine people’s experience of a change process and if and how post-conventional leadership principles are expressed in the change process.

Design/methodology/approach: The study used a retrospective exploratory qualitative design. In total, 19 semi-structured interviews and 4 workshops were conducted and analyzed in accordance with a thematic qualitative analysis.

Findings: The post-conventional leadership appears to have facilitated an organizational transformation where explorative work methods aimed at innovation and improvement as well as holistic understanding was used. Dispersed power and mandate to employees, within set frames and with clear goals, created new ways of organizing and working. The leader showed personal consideration, acknowledged the importance of the emotionally demanding aspects of change and admitted the leader’s own vulnerability. Balance between challenge and support created courage to take on new roles and responsibilities. Most employees thrived and grew with the possibilities given, but some felt lack of support and clear directions.

Practical implications: Inspiration from this case on work methods and involvement of employees can be used on other change efforts.

Social implications: This study provides knowledge on leadership capabilities needed for facilitation of transformational change.

Originality/value: Few transformational change processes by post-conventional leaders are thoroughly described, and this study provides in-depth descriptions of post-conventional leadership in transformational change. 

The PICO™ dressing utilizes incisional negative pressure wound therapy in reducing surgical site infection after vascular surgery; however, no patient-reported investigations are available. The objective was to explore patient' experiences wearing the PICO™ dressing for 7 days. Nine men and 6 women were interviewed, and analysis was conducted using qualitative content analysis. The PICO™ dressing system was well accepted by most patients. Most prominent problems were fear of dropping the pump to the floor, lack of information, and initial feelings of uncertainty. Four patients who had the PICO™ and standard dressing in opposite groins simultaneously, preferred the PICO™ dressing.

INTRODUCTION: Multiple sclerosis (MS) is a chronic autoimmune disease with a substantial impact on quality of life and functional capability. The prognosis of MS has changed over time due to the development of increasingly effective therapies. As the knowledge and perceptions of persons living with chronic conditions increasingly have been acknowledged, it has become important to understand lived experiences with a focus on everyday events and experiences as a way of knowing and interpreting the world. Exploring context-specific lived experiences as a source of knowledge about the disease and care may contribute to more precision in designing care services. The aim of this study was to explore the lived experience of persons living with MS in a Swedish context.

MATERIALS AND METHODS: A qualitative interview study was conducted with both purposeful and random sampling strategies, resulting in 10 interviews. Data were analyzed using inductive thematic content analysis.

RESULTS: The analysis generated 4 overarching themes with 12 subthemes, the 4 themes were: perspectives on life and health, influence on everyday life, relations with healthcare, and shared healthcare processes. The themes are concerned with the patients' own perspectives and context as well as medical and healthcare-related perspectives. Patterns of shared experiences were found, for example, in the diagnosis confirmation, future perspectives, and planning and coordination. More diverse experiences appeared concerning relations with others, one's individual requirements, symptoms and consequences, and knowledge building.

CONCLUSION: The findings suggest a need for a more diverse and coproduced development of healthcare services to meet diverse needs in the population with greater acknowledgement of the person's lived experience, including consideration of the complexity of the disease, personal integrity, and different ways of knowing. Findings from this study will be further explored together with other quantitative and qualitative data.

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.

Introduction: Living with a chronic condition such as type 1 diabetes (T1D) affects everyday life and support from others experiencing a similar situation can be helpful. A way to receive such support is to use an online network where people can connect and share experiences. Research has described the benefits of using such tools for connecting patients. The aim of this study was to describe the co-design of a social network for young people with T1D and to describe their experiences when using this network.

Methods: A co-design approach was used, following three steps adapted from Sanders and Stappers (2008). In all, 36 adolescents with T1D participated. Data in the form of recordings and notes from telephone interviews, workshops and focus groups were collected and then analysed using content analysis. Numerical data from the digital platform were also used.

Findings: For the interpersonal values, supporting, learning and relating to emerge, the framework of the network must be appealing and user-friendly. The limits of time and place are eliminated, and there is a possibility for many more to join in.

Conclusion: Co-design ensures that what stakeholders think is important forms the basis for the design. The interpersonal values that are promoted are ones that only the exchange of lived knowledge and experience can generate. It is complementary to the support that healthcare professionals can offer; thus, this kind of social network is important for improved, coproduced care.

Patient or Public Contribution: The participants in the present study were persons living with T1D. They were active co-creators from the start to the end. An adult person with experience of living with T1D was involved as an advisor in the research team when drafting the manuscript.

Background: The Hawthorne Effect is the change in behaviour by subjects due to their awareness of being observed and is evident in both research and clinical settings as a result of various forms of observation. When the Hawthorne effect exists, it is short-lived, and likely leads to increased productivity, compliance, or adherence to standard protocols. This study is a qualitative component of an ongoing multicentre study, examining the role of Incisional Negative Pressure Wound Therapy after vascular surgery (INVIPS Trial). Here we examine the factors that influence hygiene and the role of the Hawthorne effect on the adherence of healthcare professionals to standard hygiene precautions.

Methods: This is a qualitative interview study, investigating how healthcare professionals perceive the observation regarding hygiene routines and their compliance with them. Seven semi-structured focus group interviews were conducted, each interview included a different staff category and one individual interview with a nurse from the Department for Communicable Disease Control. Additionally, a structured questionnaire interview was performed with environmental services staff. The results were analysed based on the inductive qualitative content analysis approach.

Results: The analysis revealed four themes and 12 subthemes. Communication and hindering hierarchy were found to be crucial. Healthcare professionals sought more personal and direct feedback. All participants believed that there were routines that should be adhered to but did not know where to find information on them. Staff in the operating theatre were most meticulous in adhering to standard hygiene precautions. The need to give observers a clear mandate and support their work was identified. The staff had different opinions concerning the patient's awareness of the importance of hygiene following surgery. The INVIPS Trial had mediated the Hawthorne effect.

Conclusion: The results of this study indicate that the themes identified, encompassing communication, behaviour, rules and routines, and work environment, influence the adherence of healthcare professionals to standard precautions to a considerable extent of which many factors could be mediated by a Hawthorne effect. It is important that managers within the healthcare system put into place an improved and sustainable hygiene care to reduce the rate of surgical site infections after vascular surgery.

AIMS: This study is describing newly graduated nurses' experiences of the intervention graduate guidance nurses.

BACKGROUND: Newly graduated nurses need support to become established in the profession. The intervention was initiated to empower and support in the professional role.

METHODS: A qualitative case study was conducted with semi-structured interviews, using a thematic content analysis.

RESULTS: One overarching theme 'Organizational prerequisites', consisting of three themes, occurred: 'Activator' involved that the graduate guidance nurse was the activator creating a clear structure, and the wards became more attractive workplaces. 'Supportive nursing' meant that the graduate guidance nurse constituted an important support function which ensured patient safety. 'Professional development' created the opportunity for professional growth.

CONCLUSION: Newly graduated nurses' experiences show that the creation of an organisational structure enabled the graduate guidance nurses to be an important support and contributed to professional development.

IMPLICATIONS FOR NURSING MANAGEMENT: In health care organisations, strategic decisions, management support and clear goals are important to create the organisational conditions to improve safer care. Support from experienced nurses is a large enabler in supporting newly graduated nurses developing in their profession. The results of the current study can be transferred to other similar health care organisations and can be supporting managers who plan to initiate support to newly graduated nurses.

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.

Background

Sedation of intensive care patients is necessary for comfort and to implement appropriate treatment. The trend of sedation has gone from deep to light sedation. The topic is of interest to intensive care nursing because patients are generally more awake, which requires a different clinical approach than caring for deeply sedated patients.

Purpose

The aim of this study was to describe intensive care unit (ICU) nurses experiences of caring for patients who are lightly sedated during mechanical ventilation.

Methods

A qualitative approach was used. Semi-structured interviews with nine intensive care nurses were conducted. The interview texts were subjected to qualitative content analysis, resulting in the formulation of one main category and six sub-categories.

Findings

The nurses’ experience of lightly sedated patients was described as a challenge requiring knowledge and experience. The ability to communicate with the lightly sedated patient is perceived as important for ICU nurses. Individualised nursing care respecting the patients’ integrity, involvement and participation are goals in intensive care, but might be easier to achieve when the patients are lightly sedated.

Conclusion

The results reinforce the importance of communication in nursing care. It is difficult however to create an inter-personal relationship, encourage patient involvement, and maintain communication with deeply sedated patients. When patients are lightly sedated, the nurses are able to communicate, establish a relationship and provide individualised care. This is a challenge requiring expertise and patience from the nurses. Accomplishing this increases the nurses satisfaction with their care. The positive outcome for the patients is that their experience of their stay in the ICU might become less traumatic.

BACKGROUND: Persons in need of services from different care providers in the health and welfare system often struggle when navigating between them. Connecting and coordinating different health and welfare providers is a common challenge for all involved. This study presents a long-term regional empirical example from Sweden-ESTHER, which has lasted for more than two decades-to show how some of those challenges could be met. The purpose of the study was to increase the understanding of how several care providers together could succeed in improving care by transforming a concept into daily practice, thus contributing with practical implications for other health and welfare contexts.

METHODS: The study is a retrospective longitudinal case study with a qualitative mixed-methods approach. Individual interviews and focus groups were performed with staff members and persons in need of care, and document analyses were conducted. The data covers experiences from 1995 to 2020, analyzed using an open inductive thematic analysis.

RESULTS: This study shows how co-production and person-centeredness could improve care for persons with multiple care needs involving more than one care provider through a well-established Quality Improvement strategy. Perseverance from a project to a mindset was shaped by promoting systems thinking in daily work and embracing the psychology of change during multidisciplinary, boundary-spanning improvement dialogues. Important areas were Incentives, Work in practice, and Integration, expressed through trust in frontline staff, simple rules, and continuous support from senior managers. A continuous learning approach including the development of local improvement coaches and co-production of care consolidated the integration in daily work.

CONCLUSIONS: The development was facilitated by a simple question: "What is best for Esther?" This question unified people, flattened the hierarchy, and reminded all care providers why they needed to improve together. Continuously focusing on and co-producing with the person in need of care strengthened the concept. Important was engaging the people who know the most-frontline staff and persons in need of care-in combination with permissive leadership and embracing quality improvement dimensions. Those insights can be useful in other health and welfare settings wanting to improve care involving several care providers.

The role and position of users in health and welfare has recently changed to become more active in co-production of care. When more co-production is preferred, challenges related to power need to be considered. In this paper, power is seen as the possibility to influence. The paper focuses on power in co-produced improvement work by introducing a reflection model based on Franzén’s power triangle, further developed from improvement coaches’ perceptions. First, empirical data from interviews with improvement coaches were analyzed and then the theoretical model was created. Twelve coaches were included in the interviews, all of them with experience of co-production and improvement work within a region in southeast Sweden. By combining the empirical results with the power triangle, a reflection model concerning power dimensions was developed. The results showed the necessity of reflection regarding several power-related factors. Resources were found to be important and depending on contextual settings. Attitudes and perceptions among personnel and users were also vital. To accomplish co-production, the power dimension must be considered, and the power triangle acknowledges different power dimensions and how they affect each other. The model has a systematic character and allows adjustments to the power dimensions within any other context. It can inspire and be used by improvers working with co-production to promote deeper professional and organizational reflection and thereby contribute to new insights on how to balance power in co-producing health and welfare services.