Practice-based Improvements in Healthcare

A central problem for the healthcare sector today is how to manage change and improvements. In recent decades the county councils in Sweden have started various improvement initiatives and programs in order to improve their healthcare services. The improvement program of the Kalmar county council, which constitutes the empirical context for this thesis, is one of those initiatives. The purpose of this thesis is to contribute to a broader understanding of large-scale improvement program in a healthcare setting. This is done by analyzing practitioner’s improvement ideas, describing participants in the improvement projects, revising and testing a survey to measure the development of improvement ideas and describing the improvement program from a theoretical perspective. The theoretical change model used looks at change from two opposing directions in six dimensions; Goals, Leadership, Focus, Process, Reward system and Use of consultants. The aims of the county council improvement program are to become a learning organization, disseminate improvement methodologies and implement continuous quality improvements in the organization. All healthcare administrations and departments in the county council were invited to apply for funds to accomplish improvement projects. Another initiative invited staff teams to work with improvement ideas in a program with support from facilitators, using the breakthrough methodology. Now almost all ongoing developments, improvements, patient safety projects, manager and leader development initiatives are put together under the county council improvement program umbrella. In the appended papers both qualitative and quantitative research approach were used. The first study (paper I) analyzed which types of improvement projects practitioners are engaged in using qualitative content analysis. Five main categories were identified: Organizational Process; Evidence and Quality; Competence Development; Process Technology; and Proactive Patient Work. Most common was a focus on organizational changes and process, while least frequent was proactive patient work. Besides these areas of focus, almost all aimed to increase patient safety and increase effectiveness and availability. Paper II described the participants in two of the initiatives, the categorized improvement projects in paper I and the team members in the methodology guided improvement programs. Strong professions like physicians and nurses were well represented, but other staff groups were not as active. Managers were responsible for a majority of the projects. The gender perspective reflected the overall mix of employees in the county council. Paper III described a revision and test of a Minnesota Innovation Survey (MIS) that will be used to follow and measure how quality improvement ideas develop and improve over time. Descriptive statistics were presented. The respondents were satisfied with their work and what they had accomplished. The most common comment was about time, not having enough time to work with the improvement idea and the difficulty of finding time because of regular tasks. This was the first test of the revised survey and the high use of the answer alternative “Do not know” showed that the survey did not fit the context very well in its present version. Trying to connect the county council improvement program and the initiatives studied in papers I and II with the change model gave rise to some considerations. The county council improvement program has an effort to combine organizational changes and a culture that encourages continuous improvements. Top-down and bottom-up management approaches are used, through setting out strategies from above and at the same time encouraging practitioners to improve their day-to-day work. Whether this will be a successful way to implement and achieve a continuous improvement culture in the whole organization is one of the main issues remaining to find out in further studies. Acknowledgments First of all, for the fact that this thesis exists I have to thank my supervisors — without your advice and guidance I never would have pulled this off! Mattias, thanks for your calm patience and encouragement, and for our discussions forcing me to reflect and consider. Ewa, your persistent attempts to get me to understand the importance of accuracy, thanks for being persistent and always positive. Kent-Inge, thanks for your ideas and comments, together with encouraging calls and useful readings. Supervisors from different disciplines are an advantage but sometimes confusing. To all my colleagues at the Division of Quality Technology and Management at Linköping University, for always making me feel welcome on those (few) occasions I am there. Lillian, thank you for your indispensable help when I am in Kalmar being kicked out of the university computer system and for all your help with this thesis. My colleagues at the development department at the Kalmar county council, Stefan, Anna, Lena and Viktoria for being there from the beginning, always caring and sharing time at coffee breaks. There are a lot of other colleagues and people at the county council who gave their support in different ways, thank you, all of you! I would also like to thank the steering committee in the improvement program for having the idea of hiring a PhD student, and giving me the opportunity to make this work a reality. There has been almost two years of weekly commuting between Lund, Kalmar and sometimes Linköping. I am most grateful to my husband Jonny for putting up with this and for your support when times were rough. Lund, November 2010 Ann-Christine Andersson