Trust-based service innovation of municipal home care. A longitudinal mixed methods study

Background: In Scandinavia, various public reforms are initiated to enhance trust in the healthcare services and the public sector in general. This study explores experiences from a two-step service innovation project in municipal home care in Norway, coined as the Trust Model (TM), aiming at developing an alternative to the purchaser-provider split (PPS) and enhancing employee motivation, user satisfaction, and citizen trust. The PPS has been the prevalent model in Norway since the 1990s. There is little empirical research on trust-based alternatives to the PPS in health- care. The overall objectives of this study were to explore facilitators and barriers to trust-based service innovation of municipal homecare and to develop a framework for how to support the implementation of the TM. Methods: The TM elements were developed through a comprehensive participatory process, resulting in the deci- sion to organize the home care service in small, self-managed and multidisciplinary teams, and trusting the teams with full responsibility for care decisions and delivery within a limited area. Through a longitudinal mixed methods case study design a) patients’ expressed values and b) factors facilitating or preventing the service innovation process were explored through two iterations. The first included three city districts, three teams and 80 patients. The second included four districts, eight teams and 160 patients. Results: The patient survey showed patients valued and trusted the service. The team member survey showed increased motivation for work aligned with TM principles. Both quantitative and qualitative methods revealed a series of facilitators and barriers to the innovation process on different organizational levels (teams, team leaders, system). The key message arising from the two iterations is to keep patients’ values in the centre and recognize the multilevelled organizational complexity of successful trust-based innovation in homecare. Synthesizing the results, a framework for how to support trust-based service innovation was constructed. Conclusions: Trust-based innovation of municipal homecare is feasible. The proposed framework may serve as a tool when planning trust-based innovation, and as a checklist for implementation and improvement strategies. Further research is needed to explore the validity of the framework and its replicability in other areas of healthcare

Tillitsmodellen – hovedpilotering i Oslo kommune 2017-18

Bakgrunn, prosess og antagelser For å møte fremtidens utfordringer når det gjelder hjemmebaserte helsetjenester på en god måte er det behov for innovasjon og fornyelse. Formålet med prosjekt Tillitsmodellen har vært å utvikle et tillitsbasert alternativ til bestiller/utfører-modellen som • tar utgangspunkt i hva en enkelte tjenestemottager opplever som viktig, • gir økt ansvar og myndighet til fagpersonene, og • forenkler og forbedrer kontroll- og rapporteringsrutiner. Tillitsmodellen for de hjemmebaserte tjenestene i form av selvstyrende tverrfaglige team ble utviklet gjennom en omfattende nedenfra-og-opp-prosess i fire bydeler, med medvirkning fra representanter for brukere, fagorganisasjoner og medarbeidere i bydelene. Resultatet ble et nytt tjenestedesign og en ny forvaltningsmodell med saksbehandling i lokale team, med helhetlig ansvar for et avgrenset geografisk område. Man ønsket å oppnå følgende resultater med den nye forvaltningsmodellen: • økt trygghet, tilfredshet og selvbestemmelse for brukerne •økt motivasjon og arbeidsglede for fagpersonalet • økt fleksibilitet, effektivitet og kvalitet i tjenestene. Denne nye forvaltningsmodellen, «Tillitsmodellen», ble forpilotert i tre bydeler høsten 2017 og deretter videreutviklet og hovedpilotert i fire bydeler 2017-18

Co-creating digital transformation in care of older persons: A longitudinal mixed-methods study

Norwegian authorities emphasize use of welfare technology in order to meet the increasing demand for healthcare services to the population of older persons. Implementation of welfare technology is considered beneficial to increase the quality of municipal care services, support the independence of persons receiving care services and improve the care providers’ workflow. However, welfare technologies challenge established workflows and competence, as well as perceptions of good care. Furthermore, recommended implementation strategies such as co-creation of services and outcome measurements such as benefit - and value realization represent novelties in the care services. Digital transformation of the care services thus calls for innovative approaches, as well as research. This thesis had a longitudinal mixed-methods design, and explored and evaluated implementation of digital monitoring services based on welfare technologies that promoted safety in municipal residential care facilities. The thesis belonged to a person-centred healthcare PhD program, and theories on innovation, implementation, co-creation, resistance and networks guided the research. Three sub-studies were included, presented by four research papers. In the first sub-study, paper 1 aimed to identify and describe forms of resistance that emerged during the first year (2013-2014) of the digital monitoring implementation in five residential care facilities. Paper 2 aimed to identify the facilitators and barriers during the full four-year (2013-2017) implementation of digital monitoring in eight residential care facilities, and to explore co-creation as implementation strategy and practice. Both were longitudinal qualitative case studies where we observed and elicited the experiences of care providers, healthcare managers and vendors. Paper 2 also included managers and staff in information technology (IT) support services. Data analyses in paper 2 started with a deductive analysis based on a determinants of innovation framework, and both papers included inductive content analysis of interviews, process- and observation data. Four main categories of resistance could be identified in paper 1: Organizational, cultural, technological and ethical. Each included several subcategories, which emerged as the participants perceived threats to stability and predictability in their workflow; to their role and group identity; and to their basic healthcare values. The resistance was primarily subtle, and changed over time. IT infrastructure and –support was identified as the most prominent resisting factor. Importantly, resistance contributed as a productive force during co-creation processes. Paper 2 identified five categories of facilitators and barriers: Pre-implementation preparations, implementation strategy, technology stability and usability, building competence and organisational learning, and service transformation and quality management. Each category encompassed several subcategories that affected the early-, mid and late phases of the implementation to varying degrees. The implementation resulted in a sustained digital monitoring service in all the residential care facilities, indicating success. The co-creation methodology was in itself identified as the most prominent facilitator. The reluctance of the IT support service to contribute in the co-creation activities, in combination with persistent IT infrastructure instability, was the principle barrier. In the second sub-study, paper 3 aimed to describe how a measurement instrument for determinants of innovation could be contextually adapted to evaluate welfare technology implementation in municipal care services. We performed an iterative evaluation of our adaptations of the instrument (questionnaire) during 2013-2019 and identified the chronological order of the most relevant informants and settings to adapt and verify the instrument. We described the operationalization of items detailing the 29 instrument determinants and linked the determinants to a sequence of welfare technology implementation strategies used in municipal care services. In the third sub-study, paper 4 aimed to evaluate facilitators for and barriers to implementation of wireless nurse call systems as measured by the adapted determinant instrument. Paper 4 had a quantitative cross-sectional descriptive design and we collected questionnaire data from care providers (n=98) during the first year of wireless nurse call system implementations in five residential care facilities (2017-2019). The greatest facilitators were the normative belief of unit managers and the care providers’ perceptions of the nurse call systems contributing to prompter call responses and increased safety for residents and families. The care providers’ lack of prior knowledge, and how they initially found the systems difficult to learn, constituted the most prominent barriers, rapidly solved through training and skill acquisition. The major finding of the thesis is that digital transformation in the form of successful implementation of digital monitoring is a complex, resource intensive and time-consuming process in municipal residential care facilities, and more so when it represents radical innovation with respect to technology novelty, disruption of care relationships and workflows, moral values, and the need for competency. All the implementations studied were successful in establishing new services that are still sustained, even though the implementations represented a high degree of complexity. Alignment of actors and agencies’ self-efficacy, their trust in the technology, and in other actors’ competence and support represented a tipping-point in the implementation processes, where the resistance decreased and safe, person-centred practices were established. Co-creation had a strong facilitating effect on resource-integration between actors, as well as on the development of competency and new workflows. However, both the implementations and co-creation represented novelty and depended on facilitation. The findings point to the importance of how the implementation of digital monitoring was conceptualized; as a straightforward “just do it” process, or as a complex and innovative endeavor. The thesis contributed with substantial empirical evidence for digital monitoring implementations, including resistance, co-creation, facilitators and barriers, implementation strategies, complexity, conceptualization of digital monitoring implementation, and development of competency, capacity and capability for digital monitoring in residential care facilities. Further, it contributed methodologically with detailed descriptions of co-creation practices for dual implementation and research projects, as well as an adapted version of a measurement instrument for determinants of innovation for welfare technology implementation. Clinical implications are in line with the major findings: Digital monitoring implementation will be safer if conceptualized as digital transformation, rather than incremental change. The implementations benefit from good planning and persistent management focus. The prior level of digital competency among care managers and care providers needs to be addressed appropriately. Practical training and co-creation processes facilitate implementation efforts and contribute to competence building and an implementation climate characterized by benevolence. The measurement instrument offers valuable means to evaluate welfare technology implementation. Moreover, digital transformation of care services challenges the current silo organization of municipal IT support services. This is ultimately a threat to patient safety and will need to change over time. More research is needed into patients’ perspectives, safety aspects and organizational capacity building as more welfare technologies are introduced into the care services, either as new entities or as new parts and functionalities expanding such innovative digital systems as described in this thesis. A compilation of welfare technology implementation strategies has been suggested, and more research is needed into the differentiation and cause effect relationship between barriers, facilitators, implementation strategies, intermediate implementation outcomes and long term service- and patient outcomes, in order to realize benefits and a sustainable digital care service. Keywords: co-creation, digital transformation, welfare technology, digital monitoring, innovation, implementation, facilitators, barriers, service design, residential care, patient safety, competency building, resource integration, ethical resistance, complexit

Helseinnovasjon i Drammensregionen: En forstudie om interesse og grunnlag for samskaping

Bygging av nytt sykehus på Brakerøya i Drammen innebærer en gyllen mulighet for helseinnovasjon og regional utvikling, for å gå sammen om å finne gode svar hvordan ”pasientens helsevesen” kan realiseres i Drammensregionen; svar som også kan bidra til bærekraftig utvikling av helse- og velferdssystemet nasjonalt og internasjonalt. Hensikten med denne forstudien er • Å identifisere aktørenes interesse for og mulighet til å være med og delta aktivt i en helseklynge i Drammensregionen, • Å identifisere hva interesserte aktører selv ønsker og tror de vil få ut av det å delta si en slik klynge og • Å identifisere hva interesserte aktører ser for seg som viktig felles interesse i en slik klynge, og hvordan samspillet i en slik klynge kan koordineres? En spørreundersøkelse med 48 bedrifter og dybdeintervjuer med 9 sentrale aktører ble gjennomført. Spørreundersøkelsen viste at • kjennskapen til eksisterende helseklynger er gjennomgående lav • viktigste motivasjon for klyngedeltakelse er tilgang til ny kunnskap, muligheter for å lære av andre, nye markeder, tettere kontakt med andre virksomheter samt omdømmebygging • respondentene kan bringe inn kunnskap, erfaring og ideer til (felles) prosjekter • viktigste aktiviteter/fasiliteter i et klyngesamarbeid er en dyktig koordinator og felles mål, samt prosjektsamarbeid og kortere mingle-/temamøter • halvparten av respondentene mener det er aktuelt eller svært aktuelt å delta i et klyngesamarbeid, 4 av 10 svarer det samme om en regionavdeling av en nasjonal klynge • for nesten like mange er samlokalisering i forbindelse med helseparken aktuelt eller svært aktuelt. Intervjuundersøkelsen avdekket dilemmaer og utfordringer som det kan bli viktig å utrede og ta stilling til i det videre arbeidet. Dilemmaene knytter seg særlig til: • Felles faglig fundament: Grunnlaget for samarbeid og samskaping må være et felles overordnet mål, som å bidra til å realisere tanken om pasientens helsevesen. Dette vil kreve samarbeid på tvers av fagområder og sektorer, som er krevende. • Behovsdrevet innovasjon: Det er behov for å utvikle ”pasientens helsevesen”, men (de offentlige og private) helsetjenestene har begrenset kapasitet for å gjennomføre utprøvinger av innovasjoner samtidig som tjenestene er i full drift. • Det regionale versus det nasjonale og internasjonale. Ideer som kan bryte gjennom teknologi- og kunnskapsfronten kan utvikles og implementeres regionalt, men vil ofte kreve samarbeid nasjonalt og/eller internasjonalt for å nå sitt fulle potensiale. • Samlokalisering versus regionalt område: Hvor stor bør omkretsen i den geografiske sirkelen være for å skape best mulig dynamikk for samskaping? • Nettverk versus klynge: Hvordan samarbeide med andre gode miljøer som kan gi nye muligheter i det videre arbeidet? Konklusjon: Det synes å være et godt grunnlag for å utvikle videre samarbeid om helseinnovasjon i Drammens-regionen. Det er fortsatt uklart hvem som skal samle næringslivet (og hvordan) som vil bidra til utvikling av helsenæring i regionen. Det trengs også en aktør som tenker «utenfor boksen» som kan heve innovasjonshøyden. Fylkeskommunen og det offentlige partnerskapet har lagt et godt grunnlag for å invitere til prosjektutvikling og samarbeid med næringslivet via det treårige prosjektet «Helsehub – navet i utvikling av person-orienterte helsetjenester»

Nursing staff’s evaluation of facilitators and barriers during implementation of wireless nurse call systems in residential care facilities. A cross-sectional study

Background Traditional nurse call systems used in residential care facilities rely on patients to summon assistance for routine or emergency needs. Wireless nurse call systems (WNCS) offer new affordances for persons unable to actively or consciously engage with the system, allowing detection of hazardous situations, prevention and timely treatment, as well as enhanced nurse workflows. This study aimed to explore facilitators and barriers of implementation of WNCSs in residential care facilities. Methods The study had a cross-sectional descriptive design. We collected data from care providers (n = 98) based on the Measurement Instrument for Determinants of Innovation (MIDI) framework in five Norwegian residential care facilities during the first year of WNCS implementation. The self-reporting MIDI questionnaire was adapted to the contexts. Descriptive statistics were used to explore participant characteristics and MIDI item and determinant scores. MIDI items to which ≥20% of participants disagreed/totally disagreed were regarded as barriers and items to which ≥80% of participants agreed/totally agreed were regarded as facilitators for implementation. Results More facilitators (n = 22) than barriers (n = 6) were identified. The greatest facilitators, reported by 98% of the care providers, were the expected outcomes: the importance and probability of achieving prompt call responses and increased safety, and the normative belief of unit managers. During the implementation process, 87% became familiar with the systems, and 86 and 90%, respectively regarded themselves and their colleagues as competent users of the WNCS. The most salient barriers, reported by 37%, were their lack of prior knowledge and that they found the WNCS difficult to learn. No features of the technology were identified as barriers. Conclusions Overall, the care providers gave a positive evaluation of the WNCS implementation. The barriers to implementation were addressed by training and practicing technological skills, facilitated by the influence and support by the manager and the colleagues within the residential care unit. WNCSs offer a range of advanced applications and services, and further research is needed as more WNCS functionalities are implemented into residential care services

Towards successful digital transformation through co-creation: a longitudinal study of a four-year implementation of digital monitoring technology in residential care for persons with dementia

Background: Implementation of digital monitoring technology systems is considered beneficial for increasing the safety and quality of care for residents in nursing homes and simultaneously improving care providers’ workflow. Co-creation is a suitable approach for developing and implementing digital technologies and transforming the service accordingly. This study aimed to identify the facilitators and barriers for implementation of digital monitoring technology in residential care for persons with dementia and wandering behaviour, and explore co-creation as an implementation strategy and practice. Methods: In this longitudinal case study, we observed and elicited the experiences of care providers and healthcare managers in eight nursing homes, in addition to those of the information technology (IT) support services and technology vendors, during a four-year implementation process. We were guided by theories on innovation, implementation and learning, as well as co-creation and design. The data were analysed deductively using a determinants of innovation framework, followed by an inductive content analysis of interview and observation data. Results: The implementation represented radical innovation and required far more resources than the incremental changes anticipated by the participants. Five categories of facilitators and barriers were identified, including several subcategories for each category: 1) Pre-implementation preparations; 2) Implementation strategy; 3) Technology stability and usability; 4) Building competence and organisational learning; and 5) Service transformation and quality management. The combination of IT infrastructure instability and the reluctance of the IT support service to contribute in co-creating value with the healthcare services was the most persistent barrier. Overall, the co-creation methodology was the most prominent facilitator, resulting in a safer night monitoring service. Conclusion: Successful implementation of novel digital monitoring technologies in the care service is a complex and time-consuming process and even more so when the technology allows care providers to radically transform clinical practices at the point of care, which offers new affordances in the co-creation of value with their residents. From a long-term perspective, the digital transformation of municipal healthcare services requires more advanced IT competence to be integrated directly into the management and provision of healthcare and value co-creation with service users and their relatives

Evaluating Welfare Technology Implementation in Municipal Care Services Contextual Adaptation of the Measurement Instrument for Determinants of Innovation

The Measurement Instrument for Determinants of Innovations (MIDI) was developed to identify facilitators and barriers during implementation processes in healthcare. Thereby the implementation strategies can be better targeted to obtain successful implementation. MIDI is theory- and evidence based, and provides a generic description of 29 determinants with suggested questions that need to be adapted to the specific innovation and implementation context. This paper aims to describe how MIDI can be contextually adapted; using welfare technology implementation in municipal care services as context. Based on this process we suggest operationalization of specific determinants on item-level in the MIDI adapted to the welfare technology context (MIDI-WT)

Towards successful digital transformation through co-creation: a longitudinal study of a four-year implementation of digital monitoring technology in residential care for persons with dementia

Background: Implementation of digital monitoring technology systems is considered beneficial for increasing the safety and quality of care for residents in nursing homes and simultaneously improving care providers’ workflow. Co-creation is a suitable approach for developing and implementing digital technologies and transforming the service accordingly. This study aimed to identify the facilitators and barriers for implementation of digital monitoring technology in residential care for persons with dementia and wandering behaviour, and explore cocreation as an implementation strategy and practice. Methods: In this longitudinal case study, we observed and elicited the experiences of care providers and healthcare managers in eight nursing homes, in addition to those of the information technology (IT) support services and technology vendors, during a four-year implementation process. We were guided by theories on innovation, implementation and learning, as well as co-creation and design. The data were analysed deductively using a determinants of innovation framework, followed by an inductive content analysis of interview and observation data. Results: The implementation represented radical innovation and required far more resources than the incremental changes anticipated by the participants. Five categories of facilitators and barriers were identified, including several subcategories for each category: 1) Pre-implementation preparations; 2) Implementation strategy; 3) Technology stability and usability; 4) Building competence and organisational learning; and 5) Service transformation and quality management. The combination of IT infrastructure instability and the reluctance of the IT support service to contribute in co-creating value with the healthcare services was the most persistent barrier. Overall, the co-creation methodology was the most prominent facilitator, resulting in a safer night monitoring service. Conclusion: Successful implementation of novel digital monitoring technologies in the care service is a complex and time-consuming process and even more so when the technology allows care providers to radically transform clinical practices at the point of care, which offers new affordances in the co-creation of value with their residents. From a long-term perspective, the digital transformation of municipal healthcare services requires more advanced IT competence to be integrated directly into the management and provision of healthcare and value co-creation with service users and their relatives

Implementering av velferdsteknologi i helse- og omsorgstjenester : opplæringsbehov og utforming av nye tjenester – en sluttrapport

De kommunale helse- og omsorgstjenestene står overfor store utfordringer framover tilknyttet nye og yngre brukergrupper, flere eldre med hjelpebehov, knapphet på personell og utfordringer relatert til samhandling mellom kommunehelsetjenesten, primærhelsetjenesten og spesialisthelsetjenesten. Framtidens omsorgsutfordringer kan til dels løses ved å ta i bruk mer teknologi. Mye teknologi er allerede tilgjengelig, men løsningene er til dels fragmenterte, lite brukervennlig og effekten er lite dokumentert. Arena Helseinnovasjon AS har sammen med Høgskolen i Buskerud og Vestfold og flere kommuner utviklet velferdsteknologi som nå implementeres. Gjennom et pilotprosjekt i kommunene Risør, Holmestrand, Lier, Kongsberg, samt Nore og Uvdal har digitalt nattilsyn bidratt til økt trygghet og sikkerhet for mennesker med demens. Dette er også fulgt gjennom dette forskningsprosjektet, som er et kvalifiseringsprosjekt finansiert av Oslofjordfondet (del av Regionale forskningsfond). Forskningsprosjektet har hatt fokus på kunnskapsbehov og organisasjonsendringer ved implementering av velferdsteknologi