Understanding the conditions for improvement: research to discover which context influences affect improvement success

Context can be defined as all factors that are not part of a quality improvement intervention itself. More research indicates which aspects are ‘conditions for improvement’, which influence improvement success. However, little is known about which conditions are most important, whether these are different for different quality interventions or whether some become less or more important at different times in carrying out an improvement. Knowing more about these conditions could help speed up and spread improvements and develop the science. This paper proposes ways to build knowledge about the conditions needed for different changes, and to create conditional-attribution explanations to provide qualified generalisations. It describes theory-based, non-experimental research designs. It also suggests that ‘practical improvers’ can make their changes more effective by reflecting on and revising their own ‘assumption-theories’ about the conditions which will help and hinder the improvements they aim to implement

Hvordan oppnå markedsmakt i Personal Health Record-bransjen : bransjeutvikling i grenselandet mellom stat og det private næringslivet

I denne oppgaven har vi sett på utviklingen av bransjer innenfor elektronisk utveksling av helseinformasjon. Dette er relativt nye bransjer som har det interessante ved seg at de ligger i grenselandet mellom det offentlige og private næringsliv. Vi har i denne oppgaven mer spesifikt fokusert en bransje som ikke er direkte knyttet til helsevesenet, men fokuserer på individets rett til å ha kontroll på sin egen helseinformasjon, den såkalte Personal Health Record- bransjen (PHR- bransjen). I de siste årene har PHR- bransjen fått stor oppmerksomhet verden over og da spesielt i USA, og mange mener at dette kan bli en av de største nye bransjene i tiden fremover. Det som har medført at en denne bransjen har blitt interessant, er at helsesektorene verden over ikke fullt ut har dratt nytte av den raske utviklingen som har skjedd ellers i samfunnet når det gjelder bruk av ny teknologi. Dette gjelder både i forhold til informasjonsflyt og informasjonskontroll, og da i første rekke gjennom nye medier som mobil, Internett og nyere intelligente systemer. I denne oppgaven har vi sett på hvordan dagens teorier kan benyttes i forhold til denne nye bransjen, og videre hvordan disse teoriene kan videreutvikles for å forstå bransjen bedre. Mer konkret har vi vurdert utviklingen i forhold til en dominant design i bransjen, og i den forbindelse hvordan aktører i bransjen kan påvirke at deres løsning enten blir den dominante designen eller i alle fall er kompatibel med det. I tillegg har vi valgt å inkorporere Michael E. Porter(1980) sin femfaktormodell i et annet analyseverktøy for å beskrive utviklingen mot fastsettelsen av en dominant design. Vi har imidlertid vært nødt til å foreta noen modifikasjoner for at Porters femfaktormodell skal passe til denne bransjen. Samlet sett mener vi at denne gjennomgangen av teoretiske modeller i forhold til PHRbransjen vil gi aktørene mulighet til å kunne analysere markedet og med det bedre posisjonere seg for å oppnå markedsmakt

Driving green growth in pelagic fish capture businesses in the North-East Atlantic A case study developing a sustainable balanced scorecard

Management innovation within sustainability has become increasingly relevant with heightened international focus, demand for sustainable development, and green growth. Still, some industries are falling behind. Typically, the pelagic fishing industry is traditionally managed, financially oriented, and bottom line driven, while being completely dependent on sustainable fish stocks. While policy and regulation are the main causes for sustainable progress in the industry, there is a largely untouched potential for driving green growth on the business level. The balanced scorecard from Kaplan and Norton is a management tool that supports the successful implementation of strategy, and it has been modified to include sustainability measures. The sustainable balanced scorecard links sustainability with the traditional balanced scorecard, and it makes it possible to consider non-monetary strategic success factors to impact green growth. Sustainability management, with the sustainable balanced scorecard, is an attempt to overcome the shortcomings of the traditional approaches to environmental and social management. This is done by integrating the triple bottom line framework into the core processes of a business. In our case study, we gather qualitative data through semi-structured interviews from a pelagic fish capture business. Based on results from our data analysis, we propose a sustainable balanced scorecard for driving green growth in the business. Thus, we create a possible starting point for the development of new strategic tools for driving green growth in the pelagic fishing industry

Integration and Continuity of Primary Care: Polyclinics and Alternatives, a Patient-Centred Analysis of How Organisation Constrains Care Coordination

Background An ageing population, increasingly specialised of clinical services and diverse healthcare provider ownership make the coordination and continuity of complex care increasingly problematic. The way in which the provision of complex healthcare is coordinated produces – or fails to – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational, relational). Care coordination is accomplished by a combination of activities by: patients themselves; provider organisations; care networks coordinating the separate provider organisations; and overall health system governance. This research examines how far organisational integration might promote care coordination at the clinical level. Objectives To examine: 1. What differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical coordination of care. 2. What difference provider ownership (corporate, partnership, public) makes. 3. How much scope either structure allows for managerial discretion and ‘performance’. 4. Differences between networked and hierarchical governance regarding the continuity and integration of primary care. 5. The implications of the above for managerial practice in primary care. Methods Multiple-methods design combining: 1. Assembly of an analytic framework by non-systematic review. 2. Framework analysis of patients’ experiences of the continuities of care. 3. Systematic comparison of organisational case studies made in the same study sites. 4. A cross-country comparison of care coordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics. 5. Analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute in-patient care. Results Starting from data about patients' experiences of the coordination or under-coordination of care we identified: 1. Five care coordination mechanisms present in both the integrated organisations and the care networks. 2. Four main obstacles to care coordination within the integrated organisations, of which two were also present in the care networks. 3. Seven main obstacles to care coordination that were specific to the care networks. 4. Nine care coordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than were care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care coordination because of its impact on GP workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care coordination, and therefore continuities of care, than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings

Driving green growth in pelagic fish capture businesses in the North-East Atlantic - A case study developing a sustainable balanced scorecard

Management innovation within sustainability has become increasingly relevant with heightened international focus, demand for sustainable development, and green growth. Still, some industries are falling behind. Typically, the pelagic fishing industry is traditionally managed, financially oriented, and bottom line driven, while being completely dependent on sustainable fish stocks. While policy and regulation are the main causes for sustainable progress in the industry, there is a largely untouched potential for driving green growth on the business level. The balanced scorecard from Kaplan and Norton is a management tool that supports the successful implementation of strategy, and it has been modified to include sustainability measures. The sustainable balanced scorecard links sustainability with the traditional balanced scorecard, and it makes it possible to consider non-monetary strategic success factors to impact green growth. Sustainability management, with the sustainable balanced scorecard, is an attempt to overcome the shortcomings of the traditional approaches to environmental and social management. This is done by integrating the triple bottom line framework into the core processes of a business. In our case study, we gather qualitative data through semi-structured interviews from a pelagic fish capture business. Based on results from our data analysis, we propose a sustainable balanced scorecard for driving green growth in the business. Thus, we create a possible starting point for the development of new strategic tools for driving green growth in the pelagic fishing industry

Increasing the generalisability of improvement research with an improvement replication programme

If a quality improvement is found effective in one setting, would the same effects be found elsewhere? Could the same change be implemented in another setting? These are just two of the ‘generalisation questions’ which decision-makers face in considering whether to act on reported improvement. In this paper, some of the issues are considered and a programme of research for testing improvements in different settings is proposed to build theory and practical guidance about implementation and results in different settings

Explaining variation in perceived team effectiveness: Results from eleven quality improvement collaboratives

Aims and objectives. Explore effectiveness of 11 collaboratives focusing on 11 different topics, as perceived by local improvement teams and to explore associations with collaborative-, organisational- and team-level factors. Background. Evidence underlying the effectiveness of quality improvement collaboratives is inconclusive and few studies investigated determinants of implementation success. Moreover, most evaluation studies on quality improvement collaboratives are based on one specific topic or quality problem, making it hard to compare across collaboratives addressing different topics. Design. A multiple-case cross-sectional study. Methods. Quality improvement teams in 11 quality improvement collaboratives focusing on 11 different topics. Team members received a postal questionnaire at the end of each collaborative. Of the 283 improvement teams, 151 project leaders and 362 team members returned the questionnaire. Results. Analysis of variance revealed that teams varied widely on perceived effectiveness. Especially, members in the Prevention of Malnutrition and Prevention of Medication Errors collaboratives perceived a higher effectiveness than other groups. Multilevel regression analyses showed that educational level of professionals, innovation attributes, organisational support, innovative culture and commitment to change were all significant predictors of perceived effectiveness. In total, 27·9% of the individual-level variance, 57·6% of the team-level variance and 80% of the collaborative-level variance could be explained. Conclusion. The innovation's attributes, organisational support, an innovative team culture and professionals' commitment to change are instrumental to perceived effectiveness. The results support the notion that a layered approach is necessary to achieve improvements in quality of care and provides further insight in the determinants of success of quality improvement collaboratives. Relevance to clinical practice. Understanding which factors enhance the impact of quality improvement initiatives can help professionals to achieve breakthrough improvement in care delivery to patients on a wide variety of quality problems

Coordination in networks for improved mental health service

<!-- /* Font Definitions */ @font-face {font-family:Times; panose-1:2 2 6 3 5 4 5 2 3 4; mso-font-charset:0; mso-generic-font-family:roman; mso-font-format:other; mso-font-pitch:variable; mso-font-signature:3 0 0 0 1 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:""; margin:0cm; margin-bottom:.0001pt; mso-pagination:widow-orphan; mso-hyphenate:none; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-ansi-language:EN-GB; mso-fareast-language:AR-SA;} @page Section1 {size:612.0pt 792.0pt; margin:70.85pt 70.85pt 70.85pt 70.85pt; mso-header-margin:36.0pt; mso-footer-margin:36.0pt; mso-paper-source:0;} div.Section1 {page:Section1;} --><p class="MsoNormal"><strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB">Background</span></strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB">: Well-organised clinical cooperation between health and social services has been difficult to achieve in Sweden as in other countries.</span></p><p class="MsoNormal"><strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB">Purpose</span></strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB">: This paper presents an empirical study of a mental health coordination network in one area in Stockholm. The aim was to describe the development and nature of coordination within a mental health and social care consortium and to assess the impact on care processes and client outcomes.</span></p><p class="MsoNormal"><strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB">Method</span></strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB">: Data was gathered through interviews with coordina­tors from three rehabilitation units. The interviews focused on coordination activities aimed at supporting the clients’ needs and investigated how the coordinators acted according to the consortium's holistic approach. Data on The Camberwell Assess­ment of Need (CAN-S) showing clients’ satisfaction was used to assess on set of outcomes. </span></p><p class="MsoNormal"><strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB">Findings</span></strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB">: The findings revealed different coordination <span>activities and </span>factors both helping and hindering the network coordination activities. One factor helping was the history of local and personal informal cooperation and shared responsibilities evident. Unclear roles and routines hindered cooperation</span></p><p class="MsoNormal"><strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB">Practical</span></strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB"> <strong>value</strong>: The contribution is an empirical example and a model for organisations establishing structures for network coordination. One l<span>esson for current policy about integrated health care is to adapt and implement ”pair coordinators” where full structural integration is not possible.</span> </span><span style="font-size: 10pt; font-family: Times;" lang="EN-GB">Another lesson, based on the idea of patient quality by coordinated care, is specific to adapt the work of the local psychiatric addictive team – an independent special team in the psychiatric outpatient care serving psychotic clients with complex addictive problems. </span></p

Veien mot suksessfull helårsdrift. En studie av sesongbaserte destinasjoner

Vi har valgt å innlede med oppgavens formål, problemstilling og antagelser. Deretter har vi beskrevet de ulike begrepene som er sentrale for videre lesning. I teorien har vi lagt frem fire utfordringer sesongbaserte destinasjoner står overfor (Butler, 1994). Deretter har vi introdusert Bornhorst et. al. (2009) sine fem kriterier for å drive en suksessfull destinasjon, og gjennomgått forskningen som fant sted i forbindelse med utarbeidelsen av kriteriene. Deretter har vi introdusert en konseptuell modell som vi har utarbeidet med hensikt om å beskrive hvilke faktorer som ligger til grunn for suksessfull helårsdrift ved sesongbaserte destinasjoner, basert på kriteriene til Bornhorst et. al. (2009). Etter teorien har vi beskrevet valg av metode, og gjennomgått de forberedelsene som er gjort i forkant av datainnsamlingen. Deretter har vi introdusert de ulike informantene som ble intervjuet, før vi deretter har analysert funnene. Etterfulgt av analysen drar vi linjer mellom funnene og den teorien som tidligere er gjort rede for. Vi har på grunnlag av dette avgjort om vi kunne støtte opp under de antagelsene som er satt rundt problemstillingen eller ikke. I siste del av oppgaven har vi forsøkt å svare på problemstillingen basert på teorien og forskningen som er gjennomgått tidligere i oppgaven