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  • 151.
    Restom, Fadia
    Jönköping University, School of Health Science, HHJ, Quality Improvement and Leadership in Health and Welfare.
    Hälsobokslutet för att ge chefer stöd i att främja personalens Välbefinnande  _ utvärdering av ett förbättringsinitiativ inom hälso- och sjukvården: _ utvärdering av ett förbättringsinitiativ inom hälso- och sjukvården2013Independent thesis Advanced level (degree of Master (Two Years)), 20 credits / 30 HE creditsStudent thesis
    Abstract [en]

    Introduction: Work environment and employee´s health are not new studied areas as it characterizes the production and quality of the labor market, and especially in the public sector as the county council. A new mindset, to measure the health effects and to follow them up, started to appear. Consequently, a new concept arrived and began to get a foothold, called health accounts. It is believed that the visibility of the relationship between health and economy is crucial to succeed in reducing ill health.

    Aim: The purpose is to study and understand the possibility of introducing health accounts in health care and to study its benefits. The purpose is answered by the following questions: - What are the manager’s attitudes to health care on health promotion projects and how do they monitor their results? – To what use will health accounts give the managers? - How do health accounts support the evaluation of health promotion actions?

    Method: The study has an interaction research approach as well as an inductive and qualitative approach with descriptive design. Two clinics in the HighlandHospital were included in the study because they both had ongoing health promotion actions directed towards its employees. Knowledge from these actions improvement results were used in the implementation of health accounts. Seven managers from these two clinics were interviewed in semi-structured interviews and the data then analyzed thru qualitative content analysis with the above questions in aim.

    Results: A dialogue was made with the managers where I reported some key data that both already existed and were developed during the study. The managers experienced health accounts as information longed for and therefore wanted to continue on the same track.

    Conclusions and Discussion: In order to create a workplace that promotes it requires a serious and long-term work, such as the work based health accounts model. Support in the form of a dialogue with the managers, plays an important role. The result also indicates that using health accounts can support managers with their leadership promoting health, but it can’t get health leadership.

    Keywords: Health accounting, workplace health promotion, health promotion leadership, human health, improvement of knowledge, improvement efforts.

  • 152.
    Robert, Glenn
    et al.
    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). Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom.
    Cornwell, Jocelyn
    Point of Care Foundation, London, United Kingdom.
    Black, Nick
    London School of Hygiene and Tropical Medicine, London, United Kingdom.
    Friends and family test should no longer be mandatory2018In: BMJ. British Medical Journal (International Ed.), ISSN 0959-8146, E-ISSN 0959-535X, Vol. 360, article id k367Article in journal (Other academic)
  • 153.
    Robert, Glenn
    et al.
    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). Florence Nightingale Faculty of Nursing and Midwifery, Kings College London, London, United Kingdom.
    Macdonald, Alastair S.
    School of Design, Glasgow School of Art, Glasgow, United Kingdom.
    Co-design, organisational creativity and quality improvement in the healthcare sector: 'designerly' or 'design-like'?2017In: Designing for service: key issues and new directions / [ed] D. Sangiorgi & A. Prendiville, London: Bloomsbury Academic, 2017Chapter in book (Refereed)
  • 154.
    Robert, Glenn
    et al.
    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). Florence Nightingale, Faculty of Nursing and Midwifery, King's College, London, London, United Kingdom.
    Philippou, J.
    Leamy, M.
    Reynolds, E.
    Ross, S.
    Bennett, L.
    Taylor, C.
    Shuldham, C.
    Maben, J.
    Exploring the adoption of Schwartz Center Rounds as an organisational innovation to improve staff well-being in England, 2009-20152017In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, no 1, article id e014326Article in journal (Refereed)
    Abstract [en]

    Objectives: Schwartz Center Rounds ('Rounds') are a multidisciplinary forum in which healthcare staff within an organisation discuss the psychological, emotional and social challenges associated with their work in a confidential and safe environment. Implemented in over 375 North American organisations, since 2009, they have been increasingly adopted in England. This study aimed to establish how many and what types of organisations have adopted Rounds in England, and to explore why they did so.

    Setting: Public healthcare organisations in England.

    Participants: Secondary data analysis was used to map and profile all 116 public healthcare organisations that had adopted Rounds in England by July 2015. Semistructured telephone interviews were conducted with 45 Round coordinators within adopting organisations.

    Results: The rate of adoption increased after a major national report in 2013. Rounds were typically adopted in order to improve staff well-being. Adopting organisations scored better on staff engagement than non-adopters; among adopting organisations, those performing better on patient experience were more likely to adopt earlier. Most adoption decision-making processes were straightforward. A confluence of factors-a generally favourable set of innovation attributes (including low cost), advocacy from opinion leaders in different professional networks, active dissemination by change agents and a felt need to be seen to be addressing staff well-being-initially led to Rounds being seen as 'an idea whose time had come'. More recent adoption patterns have been shaped by the timing of charitable and other agency funding in specific geographical areas and sectors, as well as several forms of 'mimetic pressure'.

    Conclusions: The innate attributes of Rounds, favourable circumstances and the cumulative impact of a sequence of distinct informal and formal social processes have shaped the pattern of their adoption in England.

  • 155.
    Rodriguez, Rocío
    et al.
    Kristiania University College, Oslo, Norway.
    Svensson, Göran
    Kristiania University College, Oslo, Norway.
    Eriksson, David
    Jönköping University, School of Engineering, JTH, Supply Chain and Operations Management.
    Comparing and contrasting the evolution through time of organizational sustainability initiatives2018In: International Journal of Quality and Service Sciences, ISSN 1756-669X, E-ISSN 1756-6703, Vol. 10, no 3, p. 296-315Article in journal (Refereed)
    Abstract [en]

    Purpose: The purpose of this study is to compare private and public hospitals’ sustainability actions, as well as to contrast their organizational evolution over time (i.e. past, present and expected future) in the Spanish health-care sector. Sustainability initiatives refer to organizations’ economic, social and environmental actions.

    Design/methodology/approach: This study applies an inductive approach based on judgmental sampling and in-depth interviews of key informants at private and public hospitals in the Spanish health-care sector. Data were gathered from the executive in charge of corporate social responsibility in public hospitals and the directors of communication at private hospitals.

    Findings: Although the private and public hospitals studied are in the same health-care industry and run similar operations, their organizational sustainability initiatives in the past, present and expected future differ. The scope of sustainability initiatives between private and public hospitals is different, compared through time. Who was and who is promoting, as well as who is going to promote sustainability initiatives, also differs between private and public hospitals.

    Research limitations/implications: One limitation of this study is that it was undertaken exclusively in Spanish organizations from one industry, but this is also a benefit, as it enables a comparison and contrast of the evolution between private and public hospitals. Future research could focus on the evolution of organizational sustainability initiatives in other industries and countries.

    Practical implications: The reported comparison of empirical findings between private and public hospitals, as well as the subsequent discussion contrasting these findings, yields various managerial implications in terms of the scope and promotor of sustainable actions.

    Originality/value: This study differs from previous ones by exploring the evolutionary details of the organizational sustainability initiatives through time in both private and public hospitals. This study also makes a contribution by revealing common denominators and differentiators between private and public hospitals that operate in the same health-care industry. 

  • 156.
    Rotter, Thomas
    et al.
    College of Pharmacy and Nutrition/ University of Saskatchewan.
    Bath, Brenna
    University of Saskatchewan, Saskatoon, Kanada.
    Dobson, Roy
    University of Saskatchewan, Saskatoon, Kanada.
    Harrison, Liz
    University of Saskatchewan, Saskatoon, Kanada.
    Jeffery, Cathy
    University of Saskatchewan, Saskatoon, Kanada.
    Sari, Nazmi
    University of Saskatchewan, Saskatoon, Kanada.
    Stevenson, Katherine
    Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare. University of Saskatchewan, Saskatoon, Kanada.
    Kinsman, Leigh
    University of Tasmania, Australia.
    Ronellenfitsch, Ulrich
    Universitätsklinikum Heidelberg.
    Westhorp, Gill
    Community Matters, Unley, South Australia, Australia.
    Kanadischer Kraftakt2015In: F & W - Fuehren und Wirtschaften im Krankenhaus, ISSN 0175-4548, no 6Article in journal (Other (popular science, discussion, etc.))
  • 157.
    Rämgård, Margareta
    et al.
    Department of Care Science, Malmö University, Malmö, Sweden.
    Forsgren, Annika
    R&D Elderly Care, Scania Association of Local Authorities, Lund, Sweden.
    Avery, Helen
    Jönköping University, School of Education and Communication, HLK, Learning Practices inside and outside School (LPS), Communication, Culture & Diversity @ JU (CCD@JU).
    PHR in health and social care for older people – regional development through learning within and across organisations2017In: Educational action research, ISSN 0965-0792, E-ISSN 1747-5074, Vol. 25, no 4, p. 506-524Article in journal (Refereed)
    Abstract [en]

    The study draws on findings from a series of seven participatory action research projects in community care for older people carried out over a period of eight years in 20 municipalities in southern Sweden. The analysis here looks at social impact across administrative levels and geographical scales. Different professional groups and care workers in community care participated, crossing divides between social work and health care. The participatory methods all involved a phase of individual reflection, a phase of reflection in practice with colleagues and mixed groups at the regional level, including unit managers and directors in some stages. Impacts concerned interprofessional learning and improved conditions for collaboration in care for older people across institutional boundaries as well as organisational learning across the municipalities. The action research approach was characterised by intensive work with values, empowering low-status professional groups. Social impacts were achieved beyond each project by benefitting from the multi-stakeholder design, using the structure of the organisations and the regional R&D department of the Association of Local Authorities. Over time, the different projects thus contributed to regional development ‘from below’. Nevertheless, employer perspectives tended to determine which conclusions from the projects were eventually implemented and prioritised. Continued reflective dialogue meetings between professional groups are therefore, needed as part of regular work processes. Local and regional structures need forms of autonomy that allow them to implement recommendations from participatory projects. Finally, employee perspectives need to be reflected in decision-making at all levels, particularly including low-status groups of care staff. 

  • 158.
    Sandström, Emma
    Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare.
    Att genomföra venös kärlaccessplanering innan problem uppstår - lärdomar från ett förbättringsarbete och dess spridning av kunskap och information2016Independent thesis Advanced level (degree of Master (Two Years)), 20 credits / 30 HE creditsStudent thesis
    Abstract [sv]

    Bakgrund:

    Av de patienter som vårdas inom slutenvården bedöms 90 % behöva venös kärlaccess. För att gå från det idag förhärskande reaktiva arbetssättet till ett proaktivt har förbättringskunskap applicerats på venös kärlaccessplanering. En framgångsfaktor för förbättringsarbete är kommunikation vilket i detta arbete har belysts extra.

    Syfte:

    Syftet med förbättringsarbetet är att samtliga patienter som vårdas på KAVA får/har en behovsanpassad infart för att undvika onödiga stick.  

    Syftet med studien av förbättringsarbetet är att beskriva förbättringsgruppens erfarenheter av att sprida kunskap och information samt ge en bild av hur dess mottagare har nåtts av budskapet.

    Metod:

    Nolans förbättringsmodell har applicerats på förbättringsarbetet. För studien har en mixad metod använts, innehållande intervjuer och enkät som analyserats med kvalitativ innehållsanalys respektive deskriptiv statistik.

    Resultat:

    Förbättringsarbetet resulterade i att merparten av patienterna får en individuell kärlaccessplan inom 24 timmar. Studien av förbättringsarbetet visar på att den interpersonella kommunikationen har stor vikt och att förbättringsgruppen är den enskilt största källan till spridning av budskapet vilket stämmer väl överrens med tidigare forskning.

    Slutsats:

    Ett proaktivt arbetssätt kan implementeras för planering av venös kärlaccess genom Nolans förbättringsmodell. Den interpersonella kommunikationen är av stor vikt för spridning av kunskap och bör tas i beaktande vid planering och utförande av förbättringsarbeten.

  • 159.
    Schön, Per
    et al.
    Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden; Stockholm Gerontology Research Center, Stockholm, Sweden.
    Lagergren, Mårten
    Stockholm Gerontology Research Center, Stockholm, Sweden.
    Kåreholt, Ingemar
    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). Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden.
    Rapid decrease in length of stay in institutional care for older people in Sweden between 2006 and 2012: results from a population-based study2016In: Health & Social Care in the Community, ISSN 0966-0410, E-ISSN 1365-2524, Vol. 24, no 5, p. 631-638Article in journal (Refereed)
    Abstract [en]

    There is limited knowledge about older people’s length of stay (time untildeath) in institutional care and how it has changed over time. The aim ofthis study was to analyse changes in the length of stay for older peoplein institutional care between 2006 and 2012. All persons 65+ living inKungsholmen (an urban area of Stockholm), who moved to an institutionbetween 2006 and 2012, were included (N = 1103). The data source wasthe care system part of a longitudinal database, the Swedish NationalStudy on Aging and Care. The average length of stay was analysed usingLaplace regression for the 10th to the 50th percentile for the years 2006–2012. The regressions showed that in 2006, it took an average of 764 daysbefore 50% of those who had moved into institutional care had died. Thecorresponding figure for 2012 was 595 days, which amounts to a 22.1%decrease over the period studied (P = 0.078). For the lower percentiles,the decrease was even more rapid, for example for the 30th percentile,the length of stay reduced from 335 days in 2006 to 119 days in 2012, adecrease of 64.3% (P < 0.001). The most rapid increase was found in theproportion that moved to an institution and died within a short timeperiod. In 2006, the first 10% had on average died after 85 days, in 2012after only 8 days; a decrease in the length of stay of 90.5% (P = 0.002). Ingeneral, there was a significant decrease in the length of stay ininstitutional care between 2006 and 2012. The most dramatic change overthe period studied was an increase in the proportion of people whomoved into an institution and died shortly afterwards.

  • 160.
    Sjöstrand, Håkan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Region Kronoberg.
    Erfarenheter från införande av personcentrerad vård på en hjärtavdelning: En studie om effekter och upplevelser av ett förbättringsarbete med syftet att öka patientdelaktighet på hjärtavdelningen vid medicinkliniken i Växjö2017Independent thesis Advanced level (degree of Master (Two Years)), 80 credits / 120 HE creditsStudent thesis
    Abstract [en]

    Introduction: A recent published report shows that patient involvement in Sweden is in several ways low compared with other comparable countries. Person-centering is an attitude aimed at increasing patient involvement and which in studies has shown positive health effects. The need for care can be reduced especially for patients with chronic diseases such as heart failure, which is the single most common cause of inpatient care in Sweden.

    Purpose: The purpose of the improvement work aimed at introducing a person-centered approach and thereby increase the patient's involvement in a cardiac care department. The purpose of the study of the improvement work was to investigate the staff's experience of this. The findings could facilitate further implementation of this method of work.

    Method: Improvement work was conducted in a project form and implemented according to Nolan's improvement model. The round was replaced with an in-depth enrollment interview, and a written care plan was established. Patients were asked to rate their perceived involvement at time for discharge. The staff's experience was studied with inductive qualitative approach through focus group interviews.

    Result: According to the surveys, the experience of involvement was high both before and after the introduction of person-centered work methods, but the variation was high. All occupational categories thought the person-centered approach had added value, both for patients and staff. The main emphasis was on increased patient participation, better understanding of the context, increased team spirit and better advancement.

    Conclusion: The experience of introducing person-centered care was generally positive and did not differ between the different occupational groups. The staff saw value of increased patient involvement, better long term planning and increased coherence and sense of togetherness with a person-centered approach.

  • 161.
    Sjöström, Katarina
    Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare. TioHundra AB.
    Att förbättra för patienten med patienten: Aktionsforskning med syftet att studera effekterna av en utbildningsinsats ”Förbättringsarbete med fokus på patientsamverkan” på sjukhus och i primärvård i vårdbolaget TioHundra AB2017Independent thesis Advanced level (degree of Master (Two Years)), 80 credits / 120 HE creditsStudent thesis
    Abstract [en]

    Background: Patient partnership in care is important to deliver high quality of care. Citizens are invited to participate in improving care, but it is often unclear how this can work in practice. TioHundra AB: s (THAB) strategy is to partnership with citizens and to increase the number of quality improvement work (QI) with patient partnership. A training program, "QI focusing on patient partnership" was conducted in THAB in collaboration with Quality Register Center Stockholm (QRC).

    Purpose: To provide knowledge about methods and tools for patient partnership in QI and to produce experiences for the creation of a company-wide patient partnership guideline. The purpose of the study was to study the effects of the training program.

    Methods: In the study, deductive action research has been used. Qualitative and quantitative data from position reports, focus groups and questionnaires were collected and analyzed based on a theoretical framework, Kirkpatrick's model for evaluation of education. A number of process- and result measures were followed during the training program.

    Results: The number of patient partnership in QI has increased and all participants have tested several different methods/tools. They describe increased knowledge, multiple lessons learned and behavioral changes regarding patient partnership in QI.

    Conclusions: The result indicates that it is possible to bring about a change in behavior when working with and thinking about patient partnership in QI, even in a relatively short period of time. How the training program has been tailored to fit the context and adapted during the program is likely to be a success factor, as well as how it was embedded and communicated in the leadership and in the operational plan.

  • 162.
    Skarstedt, Marita
    et al.
    Klinisk mikrobiologi, Medicinsk diagnostik, Landstinget i Jönköpings län.
    Keller, Christina
    Jönköping University, Jönköping International Business School, JIBS, Business Informatics.
    Henriks, Göran
    Qulturum, Landstinget i Jönköpings län.
    Löfgren, Sture
    Klinisk mikrobiologi, Medicinsk diagnostik, Landstinget i Jönköpings län.
    Matussek, Andreas
    Klinisk mikrobiologi, Medicinsk diagnostik, Landstinget i Jönköpings län.
    Minskad TAT för blododling: Erfarenheter från en förbättringsprocess2013Conference paper (Other academic)
    Abstract [sv]

    Kundnöjdhet är en viktig faktor för kliniska laboratorier. En betydelsefull värdemätare är turnaround tid för prover. I ett samarbetsprojekt mellan klinisk mikrobiologi och kemi ändrades rutinerna för omhändertagandet av blododlingar under kvällar och nätter. Ny teknik för bakterietypning och snabb resistensbestämning infördes. Medeltid från provtagning till resistensbestämning för cefotaximresistenta enterobacteriaceae minskades från 55 till 43 timmar. För att undersöka personalen upplevelser genomfördes intervjuer vilka visade att personalen kan hantera förändringar väl.

  • 163. Smirthwaite, Goldina
    et al.
    Tengelin, Ellinor
    Kunskapscentrum för Jämlik vård i Västra Götalandsregionen.
    Borrman, Therese
    Sveriges Kommuner och Landsting.
    (O)jämställdhet i hälsa och vård: reviderad upplaga 20142014Report (Other academic)
    Abstract [sv]

    Mellan kvinnor och män finns det många olikheter i hälsa, vårdtillgång och vårdkvalitet. Fortfarande drabbas kvinnor i större utsträckning än män av kvalitetsbrister och problem i vården – till exempel rapporterar kvinnor mer än dubbelt så ofta som män att de blivit kränkta av vården. Men det finns också områden där vården misslyckas med att möta mäns behov. Denna reviderade och utvidgade upplaga av (O)jämställdhet i hälsa och vård belyser utifrån uppdaterade siffror medicinskt omotiverade könsskillnader som görs inom vården och analyserar skillnader i kvinnors och mäns livslängd och hälsa ur ett genusperspektiv.

  • 164.
    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.

  • 165.
    Stefansson, Ulrika
    Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare.
    Med fokus på det sannolika: En fallstudie av ett analytiskt förbättringsarbete för att minska återinskrivning inom 30 dagar på sjukhus2016Independent thesis Advanced level (degree of Master (Two Years)), 20 credits / 30 HE creditsStudent thesis
  • 166.
    Stenström, Nils
    et al.
    Jönköping University, School of Health and Welfare, HHJ, Dep. of Behavioural Science and Social Work.
    Deogan, Charlotte
    Institutionen för folkhälsovetenskap, Karolinska Institutet.
    Månsdotter, Anna
    Institutionen för folkhälsovetenskap, Karolinska Institutet.
    Cannabisprevention i skolor – kostnadseffektivt?2015In: BestPractice, no 15, p. 19-21Article in journal (Refereed)
    Abstract [sv]

    Cannabisanvändning kan få negativa konsekvenser för ungdomars hälsa och mentala förmåga samt medföra ekonomiska kostnader för samhället.

    I denna studie exemplifieras kostnader för en typ av förebyggande insats, för besparingar inom olika samhällssektorer samt för hälsorelaterade risker i form schizofreni, psykos, depression, trafikolyckor och amotivationssyndrom. Med hjälp av hälsoekonomisk modellering skattas kostnadseffektivitet i form av kostnader (i EUR) per enhet vunnen hälsa mätt i kvalitetsjusterade levnadsår (QALY) av skolbaserad cannabisprevention i relation till traditionell ANDT-undervisning (alkohol, narkotika, dopning och tobak).

    Resultaten visar att det amerikanska programmet Project ALERT skulle kunna vara en kostnadseffektiv strategi för cannabisprevention efter rimlig anpassning till svenska förhållanden (cirka 22 000 EUR/ QALY), och kostnadsbesparande om det riktas mot pojkar 14–15 år från socioekonomiskt svaga områden (relationen kostnad:besparing cirka 1:3). Utifrån bland annat den diskussion om legalisering av cannabis som pågår på många håll i världen rekommenderar vi fortsatt arbete med det hälsoekonomiska perspektivet för utvärdering av preventiva strategier.

  • 167.
    Sterwin, Carl
    Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare.
    Kortare väntan för patienter som behöver käkkirurgisk operation: En fallstudie av införande av kapacitets- och produktionsstyrning inom käkkirurgisk verksamhet2018Independent thesis Advanced level (degree of Master (Two Years)), 20 credits / 30 HE creditsStudent thesis
    Abstract [en]

    Background:

    The waiting time for oral surgery in the form of wisdom teeth and dental implant operations at Jönköping department for oral and maxillofacial surgery was too long and was a driver for improvement project with the aim of improving accessibility.

     

    Purpose:

    The global aim of the improvement project was to reduce the suffering for patients by shortening the waiting time for oral surgery.

    The specific purpose of the improvement project was to increase efficiency and reduce lead times in the processes involved in wisdom and dental implant surgery by increasing production volume by 50% to April 2018. The aim of the improvement work was to provide care when the need arises without unwanted waiting time. The purpose of the study of the improvement work was to clarify the experiences as evidenced by capacity and production management in order to improve accessibility to oral surgery.

     

    Method:

    Introduction of improvement knowledge in a systematic improvement work together with the method capacity and production management were used to increase production volume. Ideas for increasing production were tested in PDSA wheels and evaluated with quantitative measurements of results. The study used qualitative methods in the form of semi structured interviews with individual staff and focus group interviews with the improvement team.

     

    Results:

    Production volume increased for third molar surgery by 73% ​​and for dental implant surgery 54% without increased resources in the form of more staff or premises. The waiting time for the patients was reduced from 30 months to 21 months.

    The study showed that capacity and production management experienced by employees and management work well in oral and maxillofacial units with mixed funding.

  • 168.
    Stevenson, Katherine
    et al.
    Jönköping University, School of Health Science, HHJ, Dep. of Rehabilitation.
    Keller, Christina
    Jönköping University, Jönköping International Business School, JIBS, Business Informatics.
    Andersson-Gäre, Boel
    Jönköping University, School of Health Science, HHJ. Quality improvements, innovations and leadership in health care and social work. Jönköping University, The Jönköping Academy for Improvement of Health and Welfare.
    Gäre, Klas
    Jönköping University, Jönköping International Business School, JIBS, Business Informatics.
    Thor, Johan
    Jönköping University, School of Health Science, HHJ, Dep. of Rehabilitation.
    Professionals learning to lead improvement efforts in health and social care: A realist evaluation of an interprofessional practice-based masters program2011Conference paper (Other academic)
  • 169.
    Storm, Kent
    Jönköping University, School of Health and Welfare.
    Standardiserade mätverktyg inom slutenvården – om möjligt, med betoning på röntgenverksamheter: En analys2017Independent thesis Advanced level (degree of Master (One Year)), 10 credits / 15 HE creditsStudent thesis
    Abstract [en]

    Measuring and documenting clinical care work has not been prioritized in radiology operations. Access to comparative data would allow for different forms of standardization for improved quality of care and patient safety. That SPC charts (statistical process control charts) are not noticed affects patient safety work. This study aims to increase knowledge about measurement tools available, what answers they can provide and their usefulness. The purpose was to compare and analyze various standardized measuring tools that can be used in somatic in-patients care, to increase the quality of care and patient safety. If possible, with emphasis on radiology operations. A synthesizing (integrative) literature review, of the type systematic literature review, in absence of meta-analysis, was chosen. Method is qualitative inductive approach, mixed with quantitative method. Fourteen different measuring tools are presented in this study. Shewhart (control) charts, flow charts and cause-and-effect charts are most frequently described. All measurement tools, included in the study, improves the accuracy at decision making processes. Shewhart (control) chart shows variation (waste) over time and whether a process is stable or unstable. Flow charts and cause-and-effect charts show where improvement efforts should be focused primarily. The Lean measurement tools, WMS (workflow management system), RFMEA (radiology failure mode and effect analysis) are unique through their versatility. Using standardized measurement tools provides access to qualitative and meaningful information that improves quality of care, patient safety, and simplifies data analysis.

  • 170.
    Ström, Anna
    Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare.
    Samverkan för trygg hemgång: Ett förbättringsarbete om övergången mellan geriatrik, ASIH och primärvård för den multisjuka patienten2018Independent thesis Advanced level (degree of Master (Two Years)), 20 credits / 30 HE creditsStudent thesis
    Abstract [en]

    Introduction: Patients with multiple illnesses are individuals with complex needs of care. For this group of patients, continuity of care and their sense of security is is of great importance.

    Improvement work objective: To create secure and accessible ASIH for elders with multiple illnesses by¨develop ways of working to enable re-admittance and secure discharges for this group of patients.

    Case study objective: To Investigate and analyze team members’ common experiences.

    Method: Implementation using Nolan’s improvement model. A case study using qualitative contents analysis.

    Result: The improvement work resulted in an even flow of referrals and shortened admission times to ASIH. Patients’ sense of security were rated to 76%. Seven Seven patients had the possibility towere be  re-admitted 1-7 times 1-7 times during the project.

    Casestudy summary: ”Conditions for cooperationfor a common goal”. A clear pattern with the following significant conditions emerged from the focusgroups interviews: continuity, learning, cooperation, and communication.

    Discussion: ASIH can be an option to facilitate the transition home for elderly patients with multiple illnesses. ASIH provides a sense of security and may prevent re-hospitalization. This model of cooperation requires clear, common goals and opportunities for feedback to enable learning contributes to measurable results.

  • 171.
    Stålne, Kristian
    et al.
    Malmö University, Malmö, Sweden.
    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).
    Törnblom, Oskar
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. KTH Royal Institute of Technology, Stockholm, Sweden.
    Assumptions and distinctions on leadership development in complex roles in the context of more advanced and complex organizational design2018Conference paper (Refereed)
  • 172.
    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)
  • 173.
    Tennstedt, Frida
    et al.
    Jönköping University, School of Health and Welfare, HHJ. Prosthetics and Orthotics.
    Mastoraki Karlsson, Linnea
    Jönköping University, School of Health and Welfare, HHJ. Prosthetics and Orthotics.
    Barns intryck av omgivningen på en ortopedteknisk avdelning: -      En kvalitativ studie om hur barn uppfattar miljön och mötet på en ortopedteknisk avdelning2016Independent thesis Basic level (degree of Bachelor), 10 credits / 15 HE creditsStudent thesis
    Abstract [en]

    Background: To achieve good child centered care in the field of prosthetics/orthotics, information about how children perceive a meeting with a prosthetist/orthotist is needed. Knowing children’s thoughts, opinions and suggestions about the situation can help increase knowledge about how to set up the environment and meetings. Aim: The aim of this study is to investigate how children experience the interactions with health professionals and the environment when meeting a prosthetist or orthotist. Method: A qualitative method called “draw and tell” was used. Eight children aged between 6 to 12 years were interviewed after a meeting with a prosthetist/orthostist. The interviews were transcribed and a content analysis was performed. Result: Too much talk without engaging the child and long waiting times were found as negative factors and activities such as books and toys and that the prosthetist/orthotist was kind were found as positive factors during the meeting. Multiple suggestions were given about what kinds of activity could be available to children when waiting these included computer games and books. Conclusion:  This study shows that it is important for a prosthetist/orthoptist to engage children in the meetings and that possibilities for activities are available when children are waiting to see the clinician.

     

    Keywords: Children’s experience, Prosthetics, Orthotics,  Enviroment, Consultation

  • 174.
    Tenvert, Carl
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Ökad tillgänglighet med multipla interventioner: -Identifiering av motivationsfaktorer i ett förbättringsarbete utifrån self-determination theory2016Independent thesis Advanced level (degree of Master (Two Years)), 20 credits / 30 HE creditsStudent thesis
    Abstract [en]

    Background

    The population of Sweden and most of the world are becoming larger and older. This will mean more people seeking care. Health care today is already strained by waiting lists for outpatient care and operation. Public healthcare purchasing private healthcare or expands with additional clinics has not proven to be successful alternatives. Motivation based on self-determination theory (SDT) has been studied during the project. An important part of SDT is that external motivation is divided into four different degrees; external regulation, introjected regulation, identified regulation and integrated regulation. SDT also argues that the required nutrition to motivation is  autonomy, competence and relatedness.

    Purpose

    The improvement work aims to increase access to healthcare in an orthopedic clinic without extra appointments or buying private care. The study highlights the factors that feed motivation based on SDT.

    Method

    A pilot study identified that balance, registration of patients and controls were keys for availability. These three elements were processed through PDSA in a project. The study is based on a mixed approach with survey and focus interviews.

    Results

    The result shows that the queues at the outpatient unit can be reduced with the initiatives implemented (control, balance and right registration). The difficulty, however, is to find balance between the various capacities and balance seasonal variation. The study shows clearly the importance of autonomy for motivating employees. Having the power or being powerless affect the autonomy greatly.

  • 175.
    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)
  • 176.
    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)
  • 177.
    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)
  • 178.
    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] Paul Batalden, Tina Foster, London: Radcliffe Publishing, 2012, p. 175-192Chapter in book (Other academic)
  • 179.
    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, ISSN 1472-6920, 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.

  • 180.
    Thor, Johan
    et al.
    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).
    Peterson, A.
    Lindahl, Bertil
    The role of quality registries in health care improvement2016In: National quality registries in Swedish health care / [ed] Gunilla Jacobsson Ekman, Bertil Lindahl, Annika Nordin, Karolinska Institutet University Press , 2016, p. 53-67Chapter in book (Other academic)
  • 181.
    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)
  • 182.
    Thörne, Karin
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Futurum, Academy for Health and Care, Region Jönköping County.
    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).
    Hult, Håkan
    Abrandt-Dahlgren, Madeleine
    Co-producing interprofessional round work: Designing spaces for patient partnership2017In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 26, no 2, p. 70-82Article in journal (Refereed)
    Abstract [en]

    Within wide-ranging quality improvement agendas, patient involvement in health care is widely accepted as crucial. Ward rounds that include patients' active participation are growing as an approach to involve patients, ensure safety, and improve quality. An emerging approach to studying quality improvement is to focus on "clinical microsystems," where patients, professionals, and information systems interact. This provides an opportunity to study ward rounds more deeply. A new model of conducting ward rounds implemented through quality improvement work was studied, using the theory of practice architectures as an analytical tool. Practice architecture focuses on the cultural-discursive, social-political, and material-economic conditions that shape what people do in their work. Practice architecture is a sociomaterial theoretical perspective that has the potential to change how we understand relationships between practice, learning, and change. In this study, we examine how changes in practices are accomplished. The results show that practice architecture formed co-productive learning rounds, a possible model integrating quality improvement in daily work. This emerged in the interplay between patients through their "double participation" (as people and as information on screens), and groups of professionals in a ward round room. However, social interplay had to be renegotiated in order to accomplish the goals of all ward rounds.

  • 183.
    Tyrstrup, Mia
    et al.
    Department of Clinical Sciences, General Practice, Lund University, Lund, Sweden.
    van der Velden, Alike
    Department of Clinical Sciences, General Practice, Lund University, Lund, Sweden.
    Engström, Sven
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Primary Care Research and Development Unit, Jönköping, Sweden.
    Goderis, Geert
    Katholieke Universiteit Leuven, Academic Center for General Practice, Leuven, Belgium.
    Molstad, Sigvard
    Department of Clinical Sciences, General Practice, Lund University, Lund, Sweden.
    Verheij, Theo
    Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands.
    Coenen, Samuel
    Department of Primary and Interdisciplinary Care (ELIZA), Center for General Practice, University of Antwerp, Antwerp, Belgium.
    Adriaenssens, Niels
    Department of Primary and Interdisciplinary Care (ELIZA), Center for General Practice, University of Antwerp, Antwerp, Belgium.
    Antibiotic prescribing in relation to diagnoses and consultation rates in Belgium, the Netherlands and Sweden: use of European quality indicators2017In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 35, no 1, p. 10-18Article in journal (Refereed)
    Abstract [en]

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

    DESIGN: A retrospective observational database study.

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

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

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

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

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

  • 184.
    Törnquist, Louise
    Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare. Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Näringsriktiga mellanmål och tätare viktkontroller minskade ofrivilligviktnedgång: En kvalitativ studie om ett förbättringsarbete på ett äldreboende2018Independent thesis Advanced level (degree of Master (Two Years)), 20 credits / 30 HE creditsStudent thesis
    Abstract [sv]

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

  • 185.
    Ulhassan, Waqar
    et al.
    Karolinska Institutet.
    Sandahl, Christer
    Karolinska Institutet.
    Westerlund, Hugo
    Stockholm University.
    Henriksson, Peter
    Karolinska Institutet.
    Bennermo, Marie
    Karolinska Institutet.
    von Thiele Schwarz, Ulrica
    Karolinska Institutet.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare. Karolinska Institutet.
    Antecedents and Characteristics of Lean Thinking Implementation in a Swedish Hospital: A Case Study2013In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 22, no 1, p. 48-61Article in journal (Refereed)
    Abstract [en]

    Despite the reported success of Lean in health care settings, it is unclear why and how organizations adopt Lean and how Lean transforms work design and, in turn, affects employees' work. This study investigated a cardiology department's journey to adopt and adapt Lean. The investigation was focused on the rationale and evolution of the Lean adoption to illuminate how a department with a long quality improvement history arrived at the decision to introduce Lean, and how Lean influenced employees' daily work. This is an explanatory single case study based on semistructured interviews, nonparticipant observations, and document studies. Guided by a Lean model, we undertook manifest content analysis of the data. We found that previous improvement efforts may facilitate the introduction of Lean but may be less important when forecasting whether Lean will be sustained over time. Contextual factors seemed to influence both what Lean tools were implemented and how well the changes were sustained. For example, adoption of Lean varied with the degree to which staff saw a need for change. Work redesign and teamwork were found helpful to improve patient care whereas problem solving was found helpful in keeping the staff engaged and sustaining the results over time.

  • 186.
    Ulhassan, Waqar
    et al.
    Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden.
    Schwarz, Ulrica von Thiele
    Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Westerlund, Hugo
    Stress Research Institute, Stockholm University, Stockholm, Sweden.
    Interactions between lean management and the psychosocial work environment in a hospital setting - a multi-method study2014In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, p. 480-Article in journal (Refereed)
    Abstract [en]

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

  • 187.
    Ulhassan, Waqar
    et al.
    Medical Management Centre, Karolinska Institutet.
    Schwarz, Ulrica von Thiele
    Medical Management Centre, Karolinska Institutet.
    Westerlund, Hugo
    Stress Research Institute, Stockholm University.
    Sandahl, Christer
    Medical Management Centre, Karolinska Institutet.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Medical Management Centre, Karolinska Institutet.
    How visual management for continuous improvement might guide and affect hospital staff: A case study2015In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 24, no 4, p. 222-228Article in journal (Refereed)
    Abstract [en]

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

  • 188.
    Ulhassan, Waqar
    et al.
    Karolinska Institutet.
    Westerlund, Hugo
    Stockholm University.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare. Karolinska Institutet.
    Sandahl, Christer
    Karolinska Institutet.
    von Thiele Schwarz, Ulrica
    Karolinska Institutet.
    Does Lean Implementation interact with group functioning?2014In: Journal of Health Organisation & Management, ISSN 1477-7266, E-ISSN 1758-7247, Vol. 28, no 2, p. 196-213Article in journal (Refereed)
    Abstract [en]

    Purpose: As healthcare often is studied in relation to operational rather than socio-technical aspects of Lean such as teamwork, this study aims to explore how a Swedish hospital Lean intervention related to changes in teamwork over time.

    Design/methodology/approach: Teamwork was measured with the Group Development Questionnaire (GDQ) employee survey during Lean implementation at three units, in 2010 (n=133) and 2011 (n=130). Qualitative data including interviews, observations and document analysis were used to characterize the Lean implementation and context. Based on this, expected teamwork change patterns were documented and tested with GDQ-data through linear regression analysis.

    Findings: At Ward-I, Lean implementation was successful and teamwork improved. At Ward-II, Lean was partially implemented and teamwork improved slightly, while both Lean and teamwork deteriorated at the emergency department (ED). The regression analysis was significant at Ward-II (p=.02) and the ED (p=.04), but not at Ward-I (p=.11).

    Practical implications: Developing expected changes based on theoretically derived assumptions and qualitative data may make it possible to detect the results of a complex change. Overall, Lean may have some impact on teamwork, if properly implemented. However, this impact may be more prominent in relation to structural and productivity issues of teamwork than group members’ relational issues. Also, effects of Lean on teamwork may differ depending on the teams’ initial stage of teamwork. Practitioners should note that, with groups struggling with initial stages of teamwork, Lean may be very challenging.

    Originality/value: This study focused specifically on implications of Lean for nurse teamwork in hospital setting using both qualitative and quantitative data.

  • 189.
    Ulin, Kerstin
    et al.
    Institute of Health and Care Science, Sahlgrenska Academy, University of Gothenburg.
    Malm, Dan
    Jönköping University, School of Health and Welfare, HHJ, Dep. of Nursing Science. Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare.
    Nygårdh, Annette
    Jönköping University, School of Health and Welfare, HHJ, Dep. of Nursing Science. Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    What is known about the benefits of patient-centered care in patients with heart failure2015In: Current Heart Failure Reports, ISSN 1546-9530, E-ISSN 1546-9549, Vol. 12, no 6, p. 350-359Article, review/survey (Refereed)
    Abstract [en]

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

  • 190.
    Unbeck, Maria
    et al.
    Karolinska Institutet.
    Sterner, Eila
    Karolinska Institutet.
    Elg, Mattias
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Linköping University.
    Fossum, Bjöörn
    Sophiahemmet University College.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare. Karolinska Institutet.
    Pukk Härenstam, Karin
    Karolinska Institutet.
    Design, application and impact of quality improvement 'theme months' in orthopaedic nursing: A mixed method case study on pressure ulcer prevention2013In: International Journal of Nursing Studies, ISSN 0020-7489, E-ISSN 1873-491X, Vol. 50, no 4, p. 527-535Article in journal (Refereed)
    Abstract [en]

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

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

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

    Setting: An orthopaedic department at a Swedish university hospital.

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

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

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

  • 191.
    Unné, Anna
    Jönköping University, School of Health Science, HHJ, Quality Improvement and Leadership in Health and Welfare.
    Smärtskattning 0 -ett värde i sig.: Ett förbättringsarbete som synliggör skillnad mellan det som sägs och görs utifrån evidensbaserade smärthanteringsrutiner inom palliativ vård.2013Independent thesis Advanced level (degree of Master (Two Years)), 20 credits / 30 HE creditsStudent thesis
  • 192.
    Vackerberg, Nicoline
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Levander, Märta Sund
    Department of Medical and Health Sciences, Division of Nursing, Faculty of Medicine and Health Sciences, Linköping University, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    What is best for Esther? Building improvement coaching capacity with and for users in health and social Care-A case study2016In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 25, no 1, p. 53-60Article in journal (Refereed)
    Abstract [en]

    While coaching and customer involvement can enhance the improvement of health and social care, many organizations struggle to develop their improvement capability; it is unclear how best to accomplish this. We examined one attempt at training improvement coaches. The program, set in the Esther Network for integrated care in rural Jonkoping County, Sweden, included eight 1-day sessions spanning 7 months in 2011. A senior citizen joined the faculty in all training sessions. Aiming to discern which elements in the program were essential for assuming the role of improvement coach, we used a case-study design with a qualitative approach. Our focus group interviews included 17 informants: 11 coaches, 3 faculty members, and 3 senior citizens. We performed manifest content analysis of the interview data. Creating will, ideas, execution, and sustainability emerged as crucial elements. These elements were promoted by customer focusembodied by the senior citizen trainershared values and a solution-focused approach, by the supportive coach network and by participants' expanded systems understanding. These elements emerged as more important than specific improvement tools and are worth considering also elsewhere when seeking to develop improvement capability in health and social care organizations.

  • 193.
    Vackerberg, Nicoline
    et al.
    Jönköping University, The Jönköping Academy for Improvement of Health and Welfare.
    Norman, AnnCharlott
    Jönköping University, The Jönköping Academy for Improvement of Health and Welfare. Linnéuniversitetet.
    Jutterdal, Stefan
    Thor, Johan
    Jönköping University, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health Science, HHJ, Quality Improvement and Leadership in Health and Welfare. Karolinska Institutet.
    Utveckling och förbättringsarbete är ömsesidigt beroende och berikande2015In: Att lära och utvecklas i sin profession / [ed] Gabriele Biguet, Ingrid Lindquist, Cathrin Martin, Anna Pettersson, Lund: Studentlitteratur AB, 2015, p. 169-185Chapter in book (Other academic)
  • 194.
    Vale, Maria do Carmo
    et al.
    Pediatric Neurodevelopment Unit, Hospital Dona Estefânia, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.
    Pereira-da-Silva, Luıs
    Woman, Children and Adolescent’s Medicine Teaching and Research Area, NOVA Medical School of Lisbon, Universidade Nova de Lisboa, Lisbon, Portugal.
    Pimentel, Maria João
    Pediatric Neurodevelopment Unit, Hospital Dona Estefânia, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.
    Marques, Teresa Nunes
    Early Intervention Program Regional Lisbon Area, Ministry of Social Security and Solidarity, Portugal.
    Rodrigues, Helena
    Department of Special Education, Ministry of Education and Science, Portugal.
    Cunha, Gilda
    Department of Exact Science, Lisbon School of Health Technology, Lisbon, Portugal.
    Machado, Maria do Céu
    Department of Pediatrics, Faculty of Medicine, Universidade de Lisboa, Lisbon, Portugal.
    Sanches-Ferreira, Manuela
    Special Education Department, School of Education, Porto Polytechnic, Porto, Portugal.
    Simeonsson, Rune J.
    Jönköping University, School of Education and Communication, HLK, CHILD. School of Education, University of North Carolina, Chapel Hill, NC, USA.
    Classifying Functioning of Children and Adolescents with Intellectual Disability: The Utility of the International Classification of Functioning, Disability and Health for Children and Youth2017In: Journal of Policy and Practice in Intellectual Disabilities, ISSN 1741-1122, E-ISSN 1741-1130, Vol. 14, no 4, p. 285-292Article in journal (Refereed)
    Abstract [en]

    Observational cross-sectional study carried out in a pediatric neurodevelopment unit of a tertiary-care hospital. A sample of 355 children with median ((min.–max.) 1.0–17.3) years with intellectual disability (30.4% borderline, 43.1% mild, 19.7% moderate, 5.1% severe, and 1.7% profound disability) was seen over a period of 3 years. Based on clinical observation and psychological evaluation, a neurodevelopmental pediatrician selected ICF-CY body functions codes, and respective qualifiers, to effectively describe functioning of children. Based on evaluation reports, a psychologist and a special educator assigned the previously chosen ICF-CY body functions codes to 139 and 67 children, respectively. Inter-rater agreement was estimated using simple and weighted Cohen's kappa coefficients and Gwet's AC1 statistic and Gwet's weighted kappa coefficient statistic. A set of eight ICF-CY codes was identified as efficiently describing impairments of body functions of children with intellectual disability: global mental functions b117 and b122; specific mental functions b147, b163, b164, and b167; and voice and speech functions b320 and b330. Results indicate a correspondence between the level of severity of qualifiers assigned to ICF-CY codes and the level of intellectual disability. Inter-rater agreement was variable among raters, with the best agreements found for qualifying intellectual functions (b117) and psychomotor functions (b122). A profile of eight ICF-CY codes effectively describes functioning of children with intellectual disability, providing an alternative to medically based classification, based on diagnoses with functionally based classification of children's characteristics. The findings contribute to define a comprehensive set of codes to reliably record individual differences of functioning in this population.

  • 195. Vilaseca, J
    et al.
    Dedeu, T
    de Graaf, P
    Hobbs, R
    Muth, C
    Mårtensson, Jan
    Jönköping University, School of Health Science, HHJ, Dep. of Nursing Science.
    López-Alcázar, M
    Scherer, M
    Chronic heart failure: the role of primary care: position paper of the European Forum for Primary Care2008In: Quality in Primary Care, ISSN 1479-1072, E-ISSN 1479-1064, Vol. 16, no 5, p. 351-362Article in journal (Refereed)
  • 196.
    Vimarlund, Vivian
    Jönköping University, Jönköping International Business School, JIBS, Informatics. Jönköping University, Jönköping International Business School, JIBS, Centre for Information Technology and Information Systems (CenITIS). Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Linköping University, Linköping, Sweden.
    E-health two-sided markets: Implementation and business models2016Collection (editor) (Refereed)
    Abstract [en]

    E-health two-side Markets: Implementation and Business Models presents empirical models and suggestions that focus on how to remove barriers to deliver online services across borders and how actual barriers affect business models in a two-sided market with regard to eHealth. Technological innovation and business developments in online trade result in fast-evolving markets with the continuous emergence of new products and services, thus requiring a specific approach. This book discusses how to develop innovative and cost-effective implementation strategies for complex organizations, the importance of barriers and facilitators for two-sided markets when implementing e-health services and/or IT based innovations, which pre-requisites have to be achieved in complex organizations that act in two-sided markets when implementing e-services, the ecosystem for implementation of services and innovations in complex organizations, and its effects for business models. This book is a valuable source for researchers in medical informatics, and is also ideal for stakeholders, consultants, advisors, and product designers involved in eHealth services. Presents guidelines that can be used as examples of pros and cons in two-side markets. Provides knowledge that enables readers to identify the changes that need to be considered in budget proposals for eHealth implementation. Includes examples of business models applied in two-side markets, diminishing external effects and failures.

  • 197.
    Vimarlund, Vivian
    Jönköping University, Jönköping International Business School, JIBS, Informatics. Jönköping University, Jönköping International Business School, JIBS, Centre for Information Technology and Information Systems (CenITIS). Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Linköping University, Linköping, Sweden.
    The future of two-sided e-health markets2016In: E-health two-sided markets: Implementation and business models / [ed] Vivian Vimarlund, Elsevier, 2016, p. 189-195Chapter in book (Refereed)
    Abstract [en]

    The two-sided e-health market is rapidly becoming fundamental for health and social care. Worldwide many different steps have been taken to increase the engagement of consumers with e-health, mainly focusing in the development of novel digital services that increase well-being or tackle some social challenges, such as the lack of qualified personnel, or dwindling resources. At the same time, some effort is also spent on establishing a market in which both sides-e-health consumers and providers-can interact and benefit from with each other (Connell and Young, 2007). In this sideline, there has been a great ambition to introduce "service innovation," "design thinking," and other tenors of the service-dominant logic (Vargo and Lusch, 2008) to open up for new collaborations between private and public actors. Intermediary platforms, provided by regional or national authorities (Aanestad and Jensen, 2011) or private actors such as insurance companies (Scott et al., 2006), become a key coordination infrastructure that allows information to flow within and between the two sides of the market, regulating nontransaction activities and making decisions that determine which group receives support and in which manner, and which kind of price structure will exist to stimulate the two sides to become an active actor of the market.

  • 198.
    Vimarlund, Vivian
    et al.
    Jönköping University, Jönköping International Business School, JIBS, Informatics. Jönköping University, Jönköping International Business School, JIBS, Centre for Information Technology and Information Systems (CenITIS). Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Linköping University, Linköping, Sweden.
    Mettler, T.
    University of Lausanne, Lausanne, Switzerland.
    Business models in two-sided markets (analysis of potential payments and reimbursement models that can be used)2016In: E-health two-sided markets: Implementation and business models / [ed] Vivian Vimarlund, Elsevier, 2016, p. 173-185Chapter in book (Refereed)
    Abstract [en]

    Business models play an important role in establishing sustainable intermediary platforms for e-health services in two-sided markets. In this chapter, we describe different types of business models and potential revenue and reimbursement schemes based on the Swedish HealthForMe platform. In doing so, we also discuss many of today's open questions and challenges to be addressed by intermediaries operating in two-sided e-health markets. We conclude this chapter by providing an overview of key implications and success factors for owners of such intermediary platforms, and offer an outlook to focal research areas within the context of business models for two-sided markets.

  • 199.
    Vimarlund, Vivian
    et al.
    Jönköping University, Jönköping International Business School, JIBS, Informatics. Jönköping University, Jönköping International Business School, JIBS, Centre for Information Technology and Information Systems (CenITIS). Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Linköping University, Linköping, Sweden.
    Mettler, T.
    University of Lausanne, Lausanne, Switzerland.
    Introduction to the ecosystem for two-sided markets, barriers and facilitators2016In: E-health two-sided markets: Implementation and business models / [ed] Vivian Vimarlund, Elsevier, 2016, p. 3-15Chapter in book (Other academic)
    Abstract [en]

    Two-sided markets arise in situations in which there are externalities and in which transaction costs, broadly considered, prevent the two sides from solving this externality directly. In the e-health market, the expansion of the Internet economy has shown to be significant in stimulating the entry of business organizations, many of which are already in two-sided markets.An e-health two-sided market needs to offer sustainable structures, i.e., an ecosystem to support a flexible model that must meet unexpected demand and at the same time be able to handle high demand peaks and long periods if needed. In this chapter we introduce key concepts and factors that are of relevance in two-sided markets. We further discuss the fundamental role of two-side market ecosystem in enabling parties to realize gains from trade or other interactions by reducing the transactions costs of finding each other and interacting. Hence, e-health market ecosystems first and foremost need to be designed for adaptability and network effects. We discuss issues that influence the sustainability and further development of a two-sided e-health market.

  • 200.
    von Plessen, Christian
    et al.
    Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Syddansk universitet.
    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).
    Säkrare vård - från teori till praktik i det kliniska mikrosystemet2017In: Kvalitetsarbete för bättre och säkrare vård / [ed] Anne-Marie Boström, Gun Nordström, Bodil Wilde Larsson, Lund: Studentlitteratur AB, 2017, 2, p. 57-77Chapter in book (Other academic)
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