Background: Persons who require services from multiple care providers often struggle to navigate between them. Coordinating and connecting various health and social care providers presents a common global challenge for all parties involved. This thesis was based on the experiences of a local quality improvement project called ESTHER, which started in Sweden and has since spread to other countries. ESTHER aimed to create a seamless structure between municipalities and inpatient and outpatient care providers. This coordinated approach was designed to bridge the gaps between different care services and ensure that care was delivered based on Esther's perspective. Research suggests that involving persons in need of care in the improvement process can lead to more effective solutions. However, the literature does not clearly define the prerequisites for this involvement. This thesis aimed to enhance our understanding of the roles of power and psychological safety in co-produced improvement work. The studies conducted for this thesis explored the experiences of developing ESTHER and co-production practices within that context.
Methods: Two studies were conducted in a health and social care setting in the Highland area of Jönköping County. A case study design was used with a practice-oriented and interactive approach, framed by improvement science including co-production. Qualitative methodology was employed, incorporating interviews, blended focus groups discussions, document analysis, and modelling. Data collection included contributions from managers, frontline health and social care professionals, persons receiving care, and project-related documents.
The data was analysed using inductive thematic analysis and deductive modelling. Throughout the research process, Franzen’s Power Triangle and Gustavsson´s extended knowledge model for continual improvement, were applied to provide theoretical and analytical grounding.
Findings: Both studies demonstrate the importance of collaboration, openness, and shared commitment in improving care. This involves promoting partnerships between care providers and with persons in need of care, grounded in the creation of a respectful and permissive climate in which power is shared.
Study I demonstrated how a person-centered quality improvement project evolved into a mindset, emphasizing the role of co-production in enhancing services for persons with care needs. This transformation was guided by systems thinking and the integration of change psychology into multidisciplinary improvement dialogues. Essential factors included trust in frontline staff, simple rules, and support from senior management, along with ongoing learning, local improvement coaches, and the co-production of improvements, all of which helped integrate these practices into daily work.
Study II emphasized the need to reflect on various power-related factors regarding co-produced improvements in health and social care. Resources were found to be crucial and context-dependent, similarly attitudes and perceptions among professionals and persons in need of care played a key role. To achieve co-production, the power dimension should be considered. This study introduced the power triangle of co-production which recognizes different power dimensions and their interconnections.
Conclusions: The development of ESTHER was guided by the unifying question, "What is best for Esther?" which summarized the shared purpose of the initiative. This simple yet powerful question flattened hierarchies, promoted collaboration, and maintained a focus on co-production with persons in need of care. Psychological safety and power-sharing emerged as essential elements in this quality improvement initiative in health and social care. Sustainable collaboration and co-production are supported by a shared vision, willingness to share power, promote mutual trust, and engage in continuous reflection to ensure a power balance.