Interactive Interventions Can Improve Hand Hygiene and Aseptic Techniques During Perioperative Care-Experience From the "Safe Hands" Project.

PURPOSE: This paper evaluates a theory-driven, interactive hand hygiene (HH) intervention, the Safe Hands project, based on theories of organizational learning and culture including leadership support, dialogue and co-creation. DESIGN: This prospective quasi-experimental study used unobtrusive overt observations to evaluate adherence to HH recommendations after implementing an infection-prevention intervention. METHODS: The primary outcome was differences in HH practices "Before aseptic/clean procedure" (WHO moment 2), "After body fluid exposure risk" (WHO moment 3) and performance of aseptic techniques. One operating room (OR) department served as the study hospital and the other as the control hospital, both at Swedish university hospitals. Adherence to HH guidelines was measured 4 times during 2015 to 2017. FINDINGS: The intervention site displayed a significant improvement in adherence to HH guidelines and aseptic techniques. WHO 2; from 23.8% to 36.2%, (P = .014), WHO 3; from 22.2% to 42.3%, (P = .002), and aseptic techniques; from 17.5% to 31.6%, (P = .003). No changes in adherence were identified at the control site. The use of contaminated gloves decreased post intervention at the study operating department. CONCLUSIONS: This study shows that implementing tailored interventions that are underpinned by theories from organizational learning and culture can improve adherence to hand hygiene in a complex setting as the OR up to 6 months post-intervention. The interprofessional co-creation of standards operating procedures addressing specific care procedures and emphasizing the importance of aseptic techniques can be an acceptable and feasible way to reduce the risks of contaminating medical devices and patients during perioperative care.

A co-created nurse-driven catheterisation protocol can reduce bladder distension in acute hip fracture patients - results from a longitudinal observational study.

BACKGROUND: Urinary retention is common in elderly patients undergoing acute hip fracture surgery. Avoiding overfilling the urinary bladder is important to avoid detrusor muscle damage and associated motility problems. The aim of this study was to analyse associations between the co-creation of a nurse-driven urinary catheterisation protocol and the incidence of bladder distension in patients undergoing hip fracture surgery. METHODS: This is a single-centre implementation intervention with a retrospective longitudinal observation design, using five measures points, spanning from June 2015 to March 2020. The intervention was theory driven and the participants, together with the facilitators and researcher, co-created a nurse-driven urinary catheterisation protocol. Data were retrieved from the hip fracture register. Uni- and multivariable logistic regressions were used for analyses of changes in bladder distension and urinary volume of ≥500 ml over the years. RESULTS: A total of 3078 patients were included over a five-year period. The implementation intervention was associated with a reduction in the proportion of patients with bladder distension of 31.5% (95% confidence interval 26.0-37.0), from year 1 to year 5. The multivariable analysis indicated a 39% yearly reduction in bladder distension, OR 0.61 (95% confidence interval 0.57-0.64, p <  0001). There was a reduction in the proportion of patients with a bladder volume of ≥500 ml of 42.8% (95% confidence interval 36.2-49.4), from year 1 to year 5. The multivariable analysis found a 41% yearly reduction in patients with a bladder volume of ≥500 ml, OR 0.59 (95% confidence interval 0.55-0.64, p <  0.0001). The intervention was associated with improved documentation of both catheter indications and removal plans. CONCLUSION: The use of predefined catheter indications and a tighter bladder scanning schedule were associated with a reduction in the incidence of both bladder distension and urine volume ≥ 500 ml in hip fracture patients. Registered nurses can play an active role in the facilitation of timely and appropriate catheter treatment in patients with hip fractures. TRIAL REGISTRATION: Clinical Trial Registry ISRCTN 17022695 registered retrospectively on 23 December 2021, in the end of the study, after data collection.

Iterative co-creation for improved hand hygiene and aseptic techniques in the operating room: experiences from the safe hands study.

BACKGROUND: Hand hygiene and aseptic techniques are essential preventives in combating hospital-acquired infections. However, implementation of these strategies in the operating room remains suboptimal. There is a paucity of intervention studies providing detailed information on effective methods for change. This study aimed to evaluate the process of implementing a theory-driven knowledge translation program for improved use of hand hygiene and aseptic techniques in the operating room. METHODS: The study was set in an operating department of a university hospital. The intervention was underpinned by theories on organizational learning, culture and person centeredness. Qualitative process data were collected via participant observations and analyzed using a thematic approach. RESULTS: Doubts that hand-hygiene practices are effective in preventing hospital acquired infections, strong boundaries and distrust between professional groups and a lack of psychological safety were identified as barriers towards change. Facilitated interprofessional dialogue and learning in "safe spaces" worked as mechanisms for motivation and engagement. Allowing for the free expression of different opinions, doubts and viewing resistance as a natural part of any change was effective in engaging all professional categories in co-creation of clinical relevant solutions to improve hand hygiene. CONCLUSION: Enabling nurses and physicians to think and talk differently about hospital acquired infections and hand hygiene requires a shift from the concept of one-way directed compliance towards change and learning as the result of a participatory and meaning-making process. The present study is a part of the Safe Hands project, and is registered with ClinicalTrials.gov (ID: NCT02983136 ). Date of registration 2016/11/28, retrospectively registered.

Experiences from implementing value-based healthcare at a Swedish University Hospital - an longitudinal interview study.

BACKGROUND: Implementing the value-based healthcare concept (VBHC) is a growing management trend in Swedish healthcare organizations. The aim of this study is to explore how representatives of four pilot project teams experienced implementing VBHC in a large Swedish University Hospital over a period of 2 years. The project teams started their work in October 2013. METHODS: An explorative and qualitative design was used, with interviews as the data collection method. All the participants in the four pilot project teams were individually interviewed three times, with interviews starting in March 2014 and ending in November 2015. All the interviews were transcribed and analyzed using qualitative analysis. RESULTS: Value for the patients was experienced as the fundamental drive for implementing VBHC. However, multiple understandings of what value for patients' means existed in parallel. The teams received guidance from consultants during the first 3 months. There were pros and cons to the consultant's guidance. This period included intensive work identifying outcome measurements based on patients' and professionals' perspectives, with less interest devoted to measuring costs. The implementation process, which both gave and took energy, developed over time and included interventions. In due course it provided insights to the teams about the complexity of healthcare. The necessity of coordination, cooperation and working together inter-departmentally was critical. CONCLUSIONS: Healthcare organizations implementing VBHC will benefit from emphasizing value for patients, in line with the intrinsic drive in healthcare, as well as managing the process of implementation on the basis of understanding the complexities of healthcare. Paying attention to the patients' voice is a most important concern and is also a key towards increased engagement from physicians and care providers for improvement work.

The policy process for health promotion.

AIMS: The paper aims to contribute to our understanding of the policy process in health promotion by addressing the following questions: What are the characteristics of the policy process in health promotion? How do policy entrepreneurs influence project implementation? METHODS: This is a qualitative study with an explorative case study design that uses three different data sources: qualitative interviews, written documents and observations. RESULTS: The paper examines several factors (determinants) that influence the policy process and that, to a lesser extent, are addressed by current models in health policy research. Legitimacy, financial capacity, available structure and political timing are all important determinants that influence the policy process. Policy entrepreneurs, with established networks and knowledge of the environment and its procedures, create legitimacy and provide opportunities for action; however, indistinct organizational boundaries among roles and poorly defined individual responsibilities create policy process uncertainty. As a result, there are lengthy discussions and few decisions, both of which delay the progress of a project. CONCLUSIONS: This paper's theoretical contribution is its analysis of the relationship of policy-making to linear models, via a discussion of policy entrepreneurs, and their importance in the policy process. The paper concludes that we need to consider the influence of policy entrepreneurs, whom build legitimacy and seize action opportunities by coupling the three streams in the policy process, as they help bring projects to fruition. Furthermore, the study points to the importance of policy entrepreneurs throughout the policy process. The paper has practical implications for practitioners whom work with the implementation of community policies.

Constructing accountability in inter-organisational collaboration: the implications of a narrow performance-based focus.

PURPOSE: The purpose of this paper is to analyse how accounts of collaboration practice were made and used to construct accountability in the empirical context of coordination associations, a Swedish form of collaboration between four authorities in health and social care. They feature pooled budgets, joint leadership and joint reporting systems, intended to facilitate both collaboration and (shared) accountability. DESIGN/METHODOLOGY/APPROACH: Empirical data were collected in field observations in local, regional and national settings. In addition, the study is based on analysis of local association documents such as evaluations and annual reports, and analysis of national agency reports. FINDINGS: Accountability is constructed hierarchically with a narrow focus on performance, and horizontal (shared) accountability as well as outcomes are de-emphasised. Through this narrow construction of accountability the coordination associations are re-created as hierarchical and accountability is delegated rather than shared. RESEARCH LIMITATIONS/IMPLICATIONS: Features such as pooled budgets, joint leadership and joint reporting systems can support collaboration but do not necessarily translate into shared accountability if accountability is interpreted and constructed hierarchically. PRACTICAL IMPLICATIONS: When practice conforms to what is counted and accounted for, using the hierarchical and narrow construction of accountability, the result may be that the associations become an additional authority. That would increase rather than decrease fragmentation in the field. ORIGINALITY/VALUE: This research derives from first-hand observations of actor-to-actor episodes complemented with the analysis of documents and reports. It provides critical analysis of the construction and evaluation of accounts and accountability related to practice and performance in collaboration. The main contribution is the finding that despite the conditions intended to facilitate inter-organisational collaboration and horizontal accountability, the hierarchical accountability persisted.

Untangling the perception of value in value-based healthcare - an interview study.

PURPOSE: Value-based health care (VBHC) argues that health-care needs to re-focus to maximise value creation, defining value as the quota when dividing the outcomes important for the patient, by the cost for health care to deliver such outcomes. This study aims to explore the perception of value among different stakeholders involved in the process of implementing VBHC at a Swedish hospital to support leaders to be more efficient and effective when developing health care. DESIGN/METHODOLOGY/APPROACH: Participants comprised 19 clinicians and non-clinicians involved in the implementation of VBHC. Semi-structured interviews were conducted and content analysis was performed. FINDINGS: The clinicians described value as a dynamic concept, dependent on the patient and the clinical setting, stating that improving outcomes was more important than containing costs. The value for non-clinicians appeared more driven by the interplay between the outcome and the cost. Non-clinicians related VBHC to a strategic framework for governance or for monitoring different continuous improvement processes, while clinicians appreciated VBHC, as they perceived its introduction as an opportunity to focus more on outcomes for patients and less on cost containment. ORIGINALITY/VALUE: There is variation in how clinicians and non-clinicians perceive the key concept of value when implementing VBHC. Clinicians focus on increasing treatment efficacy and improving medical outcomes but have a limited focus on cost and what patients consider most valuable. If the concept of value is defined primarily by clinicians' own assumptions, there is a clear risk that the foundational premise of VBHC, to understand what outcomes patients value in their specific situation in relation to the cost to produce such outcome, will fail. Health-care leaders need to ensure that patients and the non-clinicians' perception of value, is integrated with the clinical perception, if VBHC is to deliver on its promise.

Effectiveness of implementing a preventive urinary catheter care bundle in hip fracture patients.

Background: Urinary catheter (UC)-associated infections are one of the most common preventable healthcare-associated infections (HAIs) and they frequently occur in older, frail populations. Aim: The study aim was to describe the incidence of UC-associated infection in elderly patients undergoing hip fracture surgery after implementing a preventive care bundle. Methods: A longitudinal prospective study using a before-and-after design. The bundle was theory driven and involved the co-creation of a standard operational procedure, education and practical training sessions. Prospectively collected registry data were analysed. Univariable statistics and multivariable logistic regressions were used for analyses. Results: 2,408 patients with an acute hip fracture were included into the study. There was an overall reduction in UC catheter associated-associated urinary tract infections, from 18.5% (n = 75/406) over time to 4.2% (n = 27/647). When adjusting for all identified confounders, patients in phase 4 were 74% less likely to contract an UC-associated infection (OR, 0.26; 95% CI, 0.15-0.45, p < 0.0001). Discussion: Bundled interventions can reduce UC-associated infections substantially, even in elderly frail patients. Partnership and co-creation as implementation strategies appear to be promising in the fight against HAI.

Reduction of early surgical site and other care related infections in 3553 hip fracture patients: lessons learned from the 5-year Safe Hands project.

BACKGROUND: Surgical site infection (SSI) after acute hip fracture surgery is a devastating complication associated with increased suffering and mortality. The aim of the study was to investigate early SSI, sepsis, pneumonia and urinary tract infections over five years, before and after the implementation of the Safe Hands project. METHODS: This was a single-centre observational study with a 5-year longitudinal design, investigating the effects of an infection-prevention intervention targeting the clinical care pathway of individuals with acute hip fracture. Statistical analyses were based on routinely collected patient outcome data comprising 3553 patients. The study conforms to the criteria of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). RESULTS: The incidence of early SSIs decreased from 2.5% in years 1-2 to 1.1% in years 4-5. Similar results were observed for sepsis (2.7% to 1.3%) and urinary tract infections (14.2% to 4.2%). The multivariable regression results suggest that, for every observed year, the odds of early SSIs decreased. Male gender, procedure time, sepsis and preoperative skin damage increased the odds significantly. CONCLUSIONS: Our preventive bundle, based on partnership between researchers, managers and clinicians and a strong commitment to change from the involved professions, appear to be effective in reducing the frequency of potentially devastating SSIs and other hospital acquired infections after hip fracture surgery. The use of external and internal facilitators was crucial to enable individual and organisational learning and overcoming barriers to improvements. TRIAL REGISTRATION: Clinical Trials.gov ID: NCT02983136 Registered 6 December 2016-Retrospectively registered.

Regulating time commitments in healthcare organizations: managers' boundary approaches at work and in life.

PURPOSE: The purpose of this paper is to explore managers' boundary setting in order to better understand their handling of time commitment to work activities, stress, and recovery during everyday work and at home. DESIGN/METHODOLOGY/APPROACH: The paper has qualitatively-driven, mixed method design including observational data, individual interviews, and focus group discussions. Data were analyzed according to Charmaz' view on constructivist grounded theory. FINDINGS: A first step in boundary setting was to recognize areas with conflicting expectations and inexhaustible needs. Second, strategies were formed through negotiating the handling of managerial time commitment, resulting in boundary-setting, but also boundary-dissolving, approaches. The continuous process of individual recognition and negotiation could work as a form of proactive coping, provided that it was acknowledged and questioned. RESEARCH LIMITATIONS/IMPLICATIONS: These findings suggest that recognition of perceived boundary challenges can affect stress and coping. It would therefore be interesting to more accurately assess stress, coping, and health status among managers by means of other methodologies (e.g. physiological assessments). PRACTICAL IMPLICATIONS: In regulating managers' work assignments, work-related stress and recovery, it seems important to: acknowledge boundary work as an ever-present dilemma requiring continuous negotiation; and encourage individuals and organizations to recognize conflicting perspectives inherent in the leadership assignment, in order to decrease harmful negotiations between them. Such awareness would benefit more sustainable management of healthcare practice. ORIGINALITY/VALUE: This paper highlights how managers can handle ever-present boundary dilemmas in the healthcare sector by regulating their time commitments in various ways.

Lower-status experts' influence on health-care managers' decision-making.

PURPOSE: The purpose of this paper is to investigate and theoretically explain how line managers and lower-status experts work together in public health-care organizations. Hence, this study explores how lower-status experts influence line managers' decision-making and task prioritizing in order to guide staff experts' cooperation and performance improvements. DESIGN/METHODOLOGY/APPROACH: The authors used a qualitative method for data collection and analysis of the experts' and line managers' explanations about their cooperation. A theoretical approach of experts' identity positioning, in terms of differences and similarities, was used in analyzing the interaction between managers and experts. FINDINGS: This study shows that similarities and differences in positioning acts exist simultaneously. Similarity is constructed by way of strategic and professional alignment with the line managers' core tasks. Differences stem from the distinction between knowledge-grounded skills and professional attributes such as language, analytical tools, and jargon. Lower-status experts need to leave their entrenched positions and match the professional status of line managers in both knowledge aspirations and appearance to reach a respected approach of experts' identity positioning. ORIGINALITY/VALUE: Unlike many previous studies, this study demonstrates that similarities and differences in positioning acts exist simultaneously.

Process facilitators shifting between the support and expert roles in a complex work environment intervention in the Swedish healthcare sector.

PURPOSE: Process facilitation as part of a complex intervention for changing or improving practices within workplaces is becoming a common work method. The aim of this study was to investigate what characterizes the process-facilitating role in a complex intervention. DESIGN/METHODOLOGY/APPROACH: The present study focuses on a complex work environment intervention targeting eight organizational units (workplaces) in the Swedish healthcare sector. The study applies a mixed-method approach and has been carried out in two steps. First, a qualitative process evaluation was performed. Secondly, an evaluation was conducted to see to what extent these identified conditions and mechanisms affected the quantitative intervention effect in term of sickness absence. FINDINGS: The analysis shows that the facilitating role consisted of three overlapping and partially iterative phases. These phases involved different activities for the facilitating role. Depending on how the facilitating role and the intervention were designed, various supporting conditions were found to significantly affect the outcome of the intervention measured as the total sickness absence. RESEARCH LIMITATIONS/IMPLICATIONS: It is concluded that the facilitation is not static or fixed during the change process. Instead, the facilitation role develops and emerges through the process of support during the different implementation phases. PRACTICAL IMPLICATIONS: The facilitative role of performing support is based on a combination of support role activities and expert role activities. The support role focuses on support activities, while the expert role includes capacity building through knowledge- and legitimacy-oriented activities. ORIGINALITY/VALUE: This study contributes to earlier research by developing a methodological approach for carrying out process facilitation in complex interventions.

Managing complex workplace stress in health care organizations: leaders' perceived legitimacy conflicts.

AIM: To conceptualize how health care leaders' strategies to increase their influence in their psychosocial work environment are experienced and handled, and may be supported. BACKGROUND: The complex nature of the psychosocial work environment with increased stress creates significant challenges for leaders in today's health care organizations. METHOD: Interviews with health care leaders (n = 39) were analysed in accordance with constructivist grounded theory. RESULTS: Compound identities, loyalty commitments and professional interests shape conditions for leaders' influence. Strategies to achieve legitimacy were either to retain clinical skills and a strong occupational identity or to take a full leadership role. Ethical stress was experienced when organizational procedural or consequential legitimacy norms were in conflict with the leaders' own values. Leadership support through socializing processes and strategic support structures may be complementary or counteractive. CONCLUSIONS: Support programmes need to have a clear message related to decision-making processes and should facilitate communication between top management, human resource departments and subordinate leaders. Ethical stress from conflicting legitimacy principles may be moderated by clear policies for decision-making processes, strengthened sound networks and improved communication. IMPLICATIONS FOR NURSING MANAGEMENT: Supportive programmes should include: (1) sequential and strategic systems for introducing new leaders and mentoring; (2) reflective dialogue and feedback; (3) team development; and (4) decision-making policies and processes.

What health care managers do: applying Mintzberg's structured observation method.

Aim The aim of the present study was to explore and describe what characterizes first- and second-line health care managers' use of time. Background Many Swedish health care managers experience difficulties managing their time. Methods Structured and unstructured observations were used. Ten first- and second-line managers in different health care settings were studied in detail from 3.5 and 4 days each. Duration and frequency of different types of work activities were analysed. Results The individual variation was considerable. The managers' days consisted to a large degree of short activities (<9 minutes). On average, nearly half of the managers' time was spent in meetings. Most of the managers' time was spent with subordinates and <1% was spent alone with their superiors. Sixteen per cent of their time was spent on administration and only a small fraction on explicit strategic work. Conclusions The individual variations in time use patterns suggest the possibility of interventions to support changes in time use patterns. Implications for nursing management A reliable description of what managers do paves the way for analyses of what they should do to be effective.

Contemporary leadership in healthcare organizations: fragmented or concurrent leadership.

PURPOSE: The purpose of this paper is to gain a deeper understanding of the main contemporary challenges for healthcare leaders in their everyday work practice, and the support they need to master their experienced dilemmas. DESIGN/METHODOLOGY/APPROACH: Qualitative in-depth interviews (n=52), and focus-group interviews (n=6) with 31 first-line and 45 second-line healthcare leaders are analysed in line with constructivist grounded theory. FINDINGS: In this paper, two leadership models are proposed for defining and differentiating ways of meeting different logics and demands made on leaders in the healthcare sector. The first model is leadership by separating different logics and fragmentation of time. Here, leaders express a desire for support in defining, structuring, dividing, and allocating tasks. The second model is leadership by integrating different logics and currentness of solutions. In this case, leaders want support in strengthening proactive leadership and shaping the basis for participative employeeship. RESEARCH LIMITATIONS/IMPLICATIONS: This research is designed to describe what people experience rather than to assess the frequency of that experience in the studied settings. However, it would be interesting to elaborate on the findings of this study using other research methodologies. PRACTICAL IMPLICATIONS: The findings contribute to contextual knowledge that is of relevance in supporting healthcare leaders. This is helpful in identifying important conditions that support the establishment of leadership and employeeship, leading to improvements in healthcare practice. ORIGINALITY/VALUE: The paper describes how contemporary leadership in the healthcare sector is constituted through different strategies for meeting multiple logics.

The Safe Hands Study: Implementing aseptic techniques in the operating room: Facilitating mechanisms for contextual negotiation and collective action.

BACKGROUND: Even though hand hygiene and aseptic techniques are essential to provide safe care in the operating room, several studies have found a lack of successful implementation. The aim of this study was to describe facilitative mechanisms supporting the implementation of hand hygiene and aseptic techniques. METHODS: This study was set in a large operating room suite in a Swedish university hospital. The theory-driven implementation process was informed by the literature on organizational change and dialogue. Data were collected using interviews and participant observations and analyzed using a thematic approach. The normalization process theory served as a frame of interpretation during the analysis. RESULTS: Three facilitating mechanisms were identified: (1) commitment through a sense of urgency, requiring extensive communication between the managers, operating room professionals, and facilitators in building commitment to change and putting the issues on the agenda; (2) dialogue for co-creation, increasing and sustaining commitment and resource mobilization; and (3) tailored management support, including helping managers to develop their leadership role, progressively involving staff, and retaining focus during the implementation process. CONCLUSIONS: The facilitating mechanisms can be used in organizing implementation processes. Putting the emphasis on help and support to managers seems to be a crucial condition in complex implementation processes, from preparation of the change process to stabilization of the new practice.

Organizing person-centred care in paediatric diabetes: multidisciplinary teams, long-term relationships and adequate documentation.

BACKGROUND: Type 1 diabetes is one of the most frequent long-term endocrine childhood disorders and the Swedish National Diabetes Register for children states that adolescents (12-18 years) constitute the most vulnerable patient group in terms of metabolic control. The aim of this study was to examine how a multidisciplinary team functions when caring for adolescents with type 1 diabetes. METHODS: Qualitative interviews were performed with 17 health professionals at a Paediatric Diabetes Care Unit in a Swedish university hospital. The interviews were analysed to gain insight into a multidisciplinary care team's experiences of various organizational processes and circumstances related to the provision of person-centred paediatric diabetes care. RESULTS: Building long-term relationships with adolescents, the establishment of a multidisciplinary care team and ensuring adequate documentation are vital for the delivery of person-centred care (PCC). Furthermore, a PCC process and/or practice requires more than the mere expression of person-centred values. The contribution of this study is that it highlights the necessity of facilitating and safeguarding the organization of PCC, for which three processes are central: 1. Facilitating long-term relationships with adolescents and their families; 2. Facilitating multi-professional teamwork; and 3. Ensuring adequate documentation. CONCLUSION: Three processes emerged as important for the functioning of the multidisciplinary team when caring for adolescents with type 1 diabetes: building a long-term relationship, integrating knowledge by means of multidisciplinary team work and ensuring adequate documentation. This study demonstrates the importance of clearly defining and making use of the specific role of each team member in the paediatric diabetes care unit (PDCU). Team members should receive training in PCC and a PCC approach should form the foundation of all diabetes care. Every adolescent suffering from type 1 diabetes should be offered individual treatment and support according to her/his needs. However, more research is required to determine how a PCC approach can be integrated into adolescent diabetes care, and especially how PCC education programmes for team members should be implemented.

Environmental and capacity requirements are critical for implementing and sustaining a drug prevention program: a multiple case study of "Clubs against drugs".

BACKGROUND: "Clubs against drugs" (CAD) is a comprehensive program with a systems approach to prevention with the intention of preventing drug use in nightclub environment. In 2001 CAD was developed and implemented in Stockholm and was disseminated to 20 other municipalities in Sweden up until 2010. This study investigates the factors related to the implementation and compares Stockholm to the rest of the municipalities. METHODS: A sequential exploratory method was used which consisted of three steps including a questionnaire and two rounds of interviews. Questionnaires included all communities and the interviews included twelve respondents from three example municipalities in the first phase and four respondents from Stockholm in the second phase. The interviews were analyzed using content analysis. RESULTS: In Stockholm the program was described as having been implemented and sustained over time. The implementation in the example municipalities was perceived as difficult with many obstacles and achieving sustainability was also described as difficult. Two of three municipalities were not active at the time of this study, illustrating that the program only lasted a few years. Factors identified as being related to implementation outcomes were need assessments, participation, support, collaboration and local enthusiasts. CONCLUSIONS: The capacity to implement and sustain CAD differed substantially between Stockholm and the other municipalities. If the prerequisites and capacity are not sufficient the implementation is not likely to be successful, even when the activities are promoted on a national level like CAD. The needs of the interventions and the capacity to implement the program should be examined before adopting the program. This was not done, probably because the drive to spread the activity was not sufficiently questioned.

Towards network and citizen: collaborative care for drug abusers.

In Sweden like in many other countries, inter-organizational collaboration has been introduced to co-ordinate the care for clients. Even so, the knowledge of how inter-organizational collaboration is developed over time is limited today. This study focuses on how the inter-organizational collaboration was conducted in the care for drug abusers over a period of 5 years. The study sought to answer the following questions: Which effect does inter-organizational collaboration have on ways-of-working among professionals and which effect does inter-organizational collaboration have on the services provided by the clients?We argue that inter-organizational collaboration is developed through three processes. First, the professionals redefine 'areas of responsibilities' in the different organizations. Second, the professionals 'reconstruct their ways of working' with clients. Third, the professionals 'organize a networking model with the client as citizen in the centre'. This paper describes how the three processes appeared in the studied inter-organizational collaboration project 'SANNA' (Collaborative Care for drug abusers).