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  • 1.
    Peterson, Anette
    Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare.
    Learning and understanding for quality improvement under different conditions: An analysis of quality registry-based collaboratives in acute and chronic care2015Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The demands that are placed on healthcare systems continue to increase, but several studies show that patient care and healthcare system outcomes are not as good as they could be. To come to terms with these problems, many stakeholders turn to systematic quality improvement methods. However, research and practice also shows that change in organisations is difficult. Consequently many quality improvement projects fail. Quality Improvement Collaboratives (QICs), introduced through the use of the Breakthrough series model, represent a commonly used approach. Despite their widespread application, uncertainty remains regarding the effectiveness of QICs. In Sweden, a number of national quality registries document healthcare actions and outcomes for different patient-groups and problem-areas. While these registries have long been used for follow-up purposes and for clinical research, they have not been used extensively for systematic clinical improvement purposes. The overall aim of this thesis was to examine if, and how, QICs which are supported by national quality registries can contribute to quality improvement in the provision of healthcare. The aim was also to examine what learning and new understanding occurred in the application of QICs in different settings.

    The empirical material in this thesis comes from three QICs which included participating teams from different hospitals and health centres in Sweden. Each QIC included a national quality registry: the National Quality Registry for Acute Myocardial Infarction Care (RIKS-HIA); the National Diabetes Registry (NDR); and the Swedish Paediatric Diabetes Quality Registry (SWEDIABKIDS).

    The thesis draws on an interactive research approach. The data collection and analysis employed both qualitative and quantitative methods. Data fromthe National Quality Registries, final team reports, focus-group interviews, and team members’ experiences were analysed and triangulated.

    The studies shows that QICs which are supported by national quality registries helped teams to close a number of gaps between ordinary clinical practice and evidence-based guidelines, thereby contributing to the provision of better care and better clinical outcomes (Study I, Study II, and Study III). Important factors for success included stakeholders’ learning andunderstanding of the organisational context; structures that supported improvement efforts; and team members’ and managers’ commitment to improvement (Study IV). Furthermore, support by an internal team coach also promoted success (Study IV).

    This thesis shows how national quality registries can be used in combination with systematic improvement efforts to produce better clinical results. It concludes that different areas of QIC application pose different challenges; for example, addressing care for acute disease versus chronic disease and evaluating professionally influenced process measures versus patient dependent outcome measures. While different organizational contexts and care characteristics can pose challenges to QIC efforts, the formation of “Communities of Practice” during QICs enhanced the learning for improvement with and from others.

  • 2.
    Peterson, Anette
    et al.
    County Council of Jönköping, Sweden.
    Carlhed, Rickard
    Department of Clinical Chemistry, Central Hospital, Karlstad, Sweden.
    Lindahl, Bertil
    Uppsala Clinical Research, Uppsala, Sweden.
    Lindström, Gunilla
    Uppsala Clinical Research, Uppsala, Sweden.
    Åberg, Christina
    Uppsala Clinical Research, Uppsala, Sweden.
    Andersson-Gäre, Boel
    Jönköping University, School of Health and Welfare, HHJ. Quality improvements, innovations and leadership in health care and social work.
    Bojestig, Mats
    County Council of Jönköping, Sweden.
    Improving guideline adherence through intensive quality improvement and the use of a National Quality Register in Sweden for acute myocardial infarction2007In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 16, no 1, p. 25-37Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Data from the Swedish National Register in Cardiac Care have shown over the last 10 years an enduring gap between optimal treatment of acute myocardial infarction (AMI) according to current guidelines and the treatment actually given. We performed a controlled, prospective study in order to evaluate the effects of applying a multidisciplinary team-based improvement methodology to the use of evidence-based treatments in AMI, together with the use of a modified National Quality Register. The project engaged 25% of the Swedish hospitals.

    METHOD: Multidisciplinary teams from 20 hospitals participating in the National Register in Cardiac Care, ranging from small to large hospitals, were trained in continuous quality improvement methodology. Twenty matched hospitals served as controls. Our efforts were focused on finding and applying tools and methods to increase adherence to the national guidelines for 5 different treatments for AMI. For measurement, specially designed quality control charts were made available in the National Register for Cardiac Care.

    RESULTS: To close the gap, an important issue for the teams was to get all 5 treatments in place. Ten of the hospitals in the study group reduced the gap in 5 of 5 treatments by 50%, while none of the control hospitals did so.

    CONCLUSIONS: This first, controlled prospective study of a registry supported by multidisciplinary team-based improvement methodology showed that this approach led to rapidly improved adherence to AMI guidelines in a broad spectrum of hospitals and that National Quality Registers can be helpful tools.

  • 3.
    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.

  • 4.
    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)
  • 5.
    Peterson, Anette
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Hanberger, Lena
    Department of Clinical and Experimental Medicine, Division of Pediatrics and Diabetes. Research Center, Linköping University Hospital, Linköping, Sweden.
    Åkesson, Karin
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Department of Pediatric, County Hospital Ryhov, Jönköping, Sweden.
    Bojestig, Mats
    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.
    Samuelsson, Ulf
    Department of Clinical and Experimental Medicine, Division of Pediatrics and Diabetes. Research Center, Linköping University Hospital, Linköping, Sweden.
    Improved results in paediatric diabetes care using a quality registry in an improvement collaborative: a case study in Sweden2014In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 9, no 5(e97875), p. 1-6Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Several studies show that good metabolic control is important for children and adolescents with type 1 diabetes. In Sweden, there are large differences in mean haemoglobin A1c (HbA1c) in different hospitals and difficulties implementing national guidelines in everyday practice. This study shows how the participation in an improvement collaborative could facilitate improvements in the quality of care by paediatric diabetes teams. The Swedish paediatric diabetes quality registry, SWEDIABKIDS was used as a tool and resource for feedback and outcome measures.

    METHODS:

    Twelve teams at paediatric diabetes centres, caring for 30% (2302/7660) of patients in Sweden, participated in an 18-month quality improvement program. Each team defined treatment targets, areas needing improvement, and action plans. The main outcome was the centre patients' mean HbA1c levels, but other clinical variables and change concepts were also studied. Data from the previous six months were compared with the first six months after starting the program, and the long-term follow up after another eleven months.

    RESULTS:

    All centres reduced mean HbA1c during the second and third periods compared with the first. The mean reduction for all was 3·7 mmol/mol (p<0.001), compared with non-participating centres who improved their mean HbA1c with 1·7 mmol/mol during the same period. Many of the participating centres reduced the frequency of severe hypoglycaemia and/or ketoacidosis, and five centres reached their goal of ensuring that all patients had some sort of physical activity at least once weekly. Change concepts were, for example, improved guidelines, appointment planning, informing the patients, improving teamwork and active use of the registry, and health promotion activities.

    CONCLUSIONS:

    By involving paediatric diabetes teams in a quality improvement collaborative together with access to a quality register, the quality of paediatric diabetes care can improve, thereby contributing to a reduced risk of late complications for children and adolescents with diabetes.

  • 6.
    Samuelsson, Ulf
    et al.
    Division of Pediatrics, Department of Clinical and Experimental Medicine, Linköping University, Sweden.
    Åkesson, Karin
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Department of Pediatrics, County Hospital Ryhov, Jönköping, Sweden.
    Peterson, Anette
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Hanås, Ragnar
    The Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Sweden.
    Hanberger, Lena
    Division of Nursing, Department of Medicine and Health Sciences, Linköping University, Sweden.
    Continued improvement of metabolic control in Swedish pediatric diabetes care.2018In: Pediatric Diabetes, ISSN 1399-543X, E-ISSN 1399-5448, Vol. 19, no 1, p. 150-157Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: To prospectively investigate if the grand mean HbA1c and the differences in mean HbA1c between centers in Sweden could be reduced, thereby improving care delivered by pediatric diabetes teams.

    METHODS: We used an 18-month quality improvement collaborative (QIC) together with the Swedish pediatric diabetes quality registry (SWEDIABKIDS). The first program (IQ-1), started in April 2011 and the second (IQ-2) in April 2012; together they encompassed 70% of Swedish children and adolescents with diabetes.

    RESULTS: The proportion of patients in IQ-1 with a mean HbA1c <7.4% (57 mmol/mol) increased from 26.4% before start to 35.9% at 36 months (P < .001), and from 30.2% to 37.2% (P < .001) for IQ-2. Mean HbA1c decreased in both participating and non-participating (NP) centers in Sweden, thereby indicating an improvement by a spatial spill over effect in NP centers. The grand mean HbA1c decreased by 0.45% (4.9 mmol/mol) during 36 months; at the end of 2014 it was 7.43% (57.7 mmol/mol) (P < .001). A linear regression model with the difference in HbA1c before start and second follow-up as dependent variable showed that QIC participation significantly decreased mean HbA1c both for IQ-1 and IQ-2. The proportion of patients with high HbA1c values (>8.7%, 72 mmol/mol) decreased significantly in both QICs, while it increased in the NP group.

    CONCLUSIONS: The grand mean HbA1c has decreased significantly in Sweden from 2010 to 2014, and QICs have contributed significantly to this decrease. There seems to be a spatial spill-over effect in NP centers.

  • 7.
    Thor, Johan
    et al.
    Jönköping University, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health Science, HHJ, Quality Improvement and Leadership in Health and Welfare. Karolinska Institutet.
    Peterson, Anette
    Jönköping University, School of Health Science, HHJ, Quality Improvement and Leadership in Health and Welfare. Jönköping University, The Jönköping Academy for Improvement of Health and Welfare.
    Lindahl, Bertil
    Kvalitetsregistrens roll i förbättringsarbete2015In: Nationella kvalitetsregister i hälso- och sjukvården / [ed] Gunilla Jacobsson-Ekman, Bertil Lindahl, Annika Nordin, Stockholm: Karolinska Institutet University Press , 2015, p. 50-63Chapter in book (Other academic)
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