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.

Bakgrund: Personer som behöver insatser från flera vårdgivare har ofta svårt att navigera mellan olika aktörer. Att samordna och skapa en fungerande samverkan mellan hälso- och välfärdsorganisationer är en global utmaning. Denna avhandling bygger på erfarenheter av ett lokalt kvalitets - förbättringsinitiativ vid namn ESTHER. Det startade i Sverige, på småländska höglandet, och har sedan spridit sig bl. a. till andra länder. ESTHER syftar till att skapa en sammanhållen struktur mellan kommuner, slutenvård och öppenvård. Målet är att överbrygga glapp mellan olika vårdgivare och säkerställa att vården utformas utifrån Esthers perspektiv. Forskning visar att involvering av personer i behov av vård, leder till mer effektiva och hållbara lösningar. Syftet med denna avhandling är att fördjupa förståelsen för betydelsen av makt och psykologisk trygghet i samskapande förbättringsprocesser. Studierna undersöker erfarenheter av utvecklingen av ESTHER och samskapande - aktiviteter inom ramen för denna kontext.

Metod: Två studier genomfördes inom hälso- och sjukvård samt vård och omsorg i höglandsområdet i Jönköpings län. Båda är fallstudier som använder ett praktiknära och interaktivt angreppssätt, grundat i förbättringsvetenskap med samskapande som centralt tema. En kvalitativ ansats tillämpades, där datainsamlingen omfattade intervjuer, blandade fokusgruppsdiskussioner, dokumentanalyser och modellering. Empirin inhämtades från chefer, personal inom hälso- och sjukvård samt omsorgen, vårdtagare och projektrelaterade dokument. Data analyserades med hjälp av induktiv tematisk analys och deduktiv modellering. Under hela forskningsprocessen användes Franzéns makttriangel och Gustavsson´s ”extended knowledge model for continual improvement” som teoretisk och analytisk grund.

Resultat: Båda studierna betonar vikten av samarbete, öppenhet och ett gemensamt engagemang för att förbättra vården och omsorgen. En central aspekt är att stärka partnerskap mellan vårdgivare och de personer som behöver vård, med fokus på att skapa ett respektfullt och inkluderande klimat där makt balanseras.

Studie I visade hur ett personcentrerat kvalitetsförbättringsprojekt utvecklades till ett etablerat tankesätt (mindset) och betonade betydelsen av samskapande för att förbättra vård och omsorgen. Övergången från ett projekt till en långsiktig förändring i både tankesätt och praktiskt arbetssätt drevs av ett systemtänkande och en medvetenhet om förändringspsykologi. Bland de centrala faktorerna för att uppnå hållbar förändring framhävdes kontinuerliga multidisciplinära och gränsöverskridande förbättringsdialoger, förtroendet för personalen, tillämpning av enkla regler samt kontinuerligt stöd från ledningen på alla nivåer. Vidare spelade kontinuerligt lärande en avgörande roll i processen, där lokala förbättringscoacher och samskapade förbättringsarbete aktivt bidrog till att integrera tänkesättet i det dagliga arbetet. Detta ledde till en varaktig förändring i organisationens kultur och strukturer.

Studie II betonade behovet av reflektion kring olika maktrelaterade faktorer som var kopplade till samskapande förbättringar inom hälso- och sjukvård samt omsorg. Resurser visade sig vara avgörande och kontextberoende, på samma sätt spelade attityder och uppfattningar bland både professionella och personer i behov av vård en nyckelroll. För att uppnå samskapande bör maktdimensionen beaktas. Studien introducerar en reflektionsmodell som stöd till att balansera makt relaterad till samskapade förbättringar. Modellen lyfter fram och tydliggör de olika maktdimensionerna och deras inbördes samband.

Konklusion: Utvecklingen av ESTHER vägleddes av den centrala frågan: "Vad är bäst för Esther?" som sammanfattade den gemensamma visionen. Denna enkla men kraftfulla fråga bidrog till att bryta ner hierarkier, stärka samarbetet och bibehålla fokus på samskapande med personen som är i behov av vård. Psykologisk trygghet och att adressera maktfaktorer framstod som avgörande faktorer för detta framgångsrika kvalitetsförbättringsinitiativ inom hälso- och sjukvård samt omsorg. Ett hållbart samarbete bygger på en gemensam vision, viljan att dela makt, skapa ömsesidigt förtroende och kontinuerligt reflektera för att upprätthålla en balanserad maktfördelning.

BACKGROUND: Innovations in coproduction are shaping public service reform in diverse contexts around the world. Although many innovations are local, others have expanded and evolved over time. We know very little, however, about the process of implementation and evolution of coproduction. The purpose of this study was to explore the adoption, implementation and assimilation of three approaches to the coproduction of public services with structurally vulnerable groups.

METHODS: We conducted a 4 year longitudinal multiple case study (2019-2023) of three coproduced public service innovations involving vulnerable populations: ESTHER in Jönköping Region, Sweden involving people with multiple complex needs (Case 1); Making Recovery Real in Dundee, Scotland with people who have serious mental illness (Case 2); and Learning Centres in Manitoba, Canada (Case 3), also involving people with serious mental illness. Data sources included 14 interviews with strategic decision-makers and a document analysis to understand the history and contextual factors relating to each case. Three frameworks informed the case study protocol, semi-structured interview guides, data extraction, deductive coding and analysis: the Consolidated Framework for Implementation Research, the Diffusion of Innovation model and Lozeau's Compatibility Gaps to understand assimilation.

RESULTS: The adoption of coproduction involving structurally vulnerable populations was a notable evolution of existing improvement efforts in Cases 1 and 3, while impetus by an external change agency, existing collaborative efforts among community organizations, and the opportunity to inform a new municipal mental health policy sparked adoption in Case 2. In all cases, coproduced innovation centred around a central philosophy that valued lived experience on an equal basis with professional knowledge in coproduction processes. This philosophical orientation offered flexibility and adaptability to local contexts, thereby facilitating implementation when compared with more defined programming. According to the informants, efforts to avoid co-optation risks were successful, resulting in the assimilation of new mindsets and coproduction processes, with examples of how this had led to transformative change.

CONCLUSIONS: In exploring innovations in coproduction with structurally vulnerable groups, our findings suggest several additional considerations when applying existing theoretical frameworks. These include the philosophical nature of the innovation, the need to study the evolution of the innovation itself as it emerges over time, greater attention to partnered processes as disruptors to existing power structures and an emphasis on driving transformational change in organizational cultures.

Older adults have multiple medical and social care needs, requiring a shift toward an integrated person-centered model of care. Our objective was to describe and summarize Swedish experiences of integrated person-centered care by reviewing studies published between 2000 and 2023, and to identify the main challenges and scientific gaps through expert discussions. Seventy-three publications were identified by searching MEDLINE and contacting experts. Interventions were categorized using two World Health Organization frameworks: (1) Integrated Care for Older People (ICOPE), and (2) Integrated People-Centered Health Services (IPCHS). The included 73 publications were derived from 31 unique and heterogeneous interventions pertaining mainly to the micro- and meso-levels. Among publications measuring mortality, 15% were effective. Subjective health outcomes showed improvement in 24% of publications, morbidity outcomes in 42%, disability outcomes in 48%, and service utilization outcomes in 58%. Workshop discussions in Stockholm (Sweden), March 2023, were recorded, transcribed, and summarized. Experts emphasized: (1) lack of rigorous evaluation methods, (2) need for participatory designs, (3) scarcity of macro-level interventions, and (4) importance of transitioning from person- to people-centered integrated care. These challenges could explain the unexpected weak beneficial effects of the interventions on health outcomes, whereas service utilization outcomes were more positively impacted. Finally, we derived a list of recommendations, including the need to engage care organizations in interventions from their inception and to leverage researchers? scientific expertise. Although this review provides a comprehensive snapshot of interventions in the context of Sweden, the findings offer transferable perspectives on the real-world challenges encountered in this field.

Im Alter von 65 Jahren dürfen Schweden auf 16 weitere gesunde Lebensjahre hoffen, Schwedinnen sogar auf 16,5. Im EU-Durchschnitt sind es rund zehn, in Österreich und Deutschland rund acht Jahre weniger. Ein wesentlicher Grund sind bessere Prävention und Nachsorge. Eine schwedische Region konnte innerhalb von zehn Jahren Krankenhauseinweisungen ihrer älteren Einwohnerinnen und Einwohner um zwei Drittel senken und zugleich die Kosten um umgerechnet 3,5 Milliarden Euro senken – im europäischen Gesundheitswesen einzigartige Erfolge. Doch welche Geschichte steckt hinter diesen beeindruckenden Zahlen? Es ist die Geschichte von Esther.

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

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

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

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

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

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.