Distributed leadership in health quality improvement collaboratives.

BACKGROUND AND PURPOSE: Distributed leadership has been suggested for describing patterns of influence in collaborative settings where public services are performed across professions and organizations. This study explores how leadership in health quality improvement collaboratives (QICs) is characterized by aligned distributed leadership practices, and how these practices relate with experienced progress and achievements in the quality improvement (QI) work. METHODS: The analysis relied on a qualitative, multicase study of two nationwide Danish QICs. Data consisted of 12 single-person and 21 group interviews with local QI teams and local and regional QIC coordinators (85 informants in total), participant observations of 34 meetings within the QICs, and a collection of documentary material. The collected data were analyzed thematically with NVivo. RESULTS: Leadership practices in local QI teams are characterized by aligned distributed leadership, with leadership activities being widely distributed based on negotiated, emergent practices regarding the aims, roles, and scope of the QI work. However, local quality coordinators play a pivotal role in driving the QI activities, and hierarchical support from hospital/municipal management is a precondition for the contribution of aligned distributed leadership to experienced progress and QIs. PRACTICE IMPLICATIONS: Emergent distributed leadership should be balanced by thorough consolidation of the practices to provide the best circumstances for robust QI. The active participation of formal managers and local coordinators plays a pivotal role in this consolidation and is decisive for the increased potential for long-term success and sustainability of the QI work, particularly within complex QICs.

Implementation through translation: a qualitative case study of translation processes in the implementation of quality improvement collaboratives.

BACKGROUND: Quality improvement collaboratives (QICs) are used extensively to implement quality improvement in healthcare, and current research is demonstrating positive yet varying evidence. To interpret the effectiveness results, it is necessary to illuminate the dynamics of QIC implementation in specific contexts. Using Scandinavian institutionalist translation theory as a theoretical framework, this study aims to make two contributions. First, we provide insights into the dynamics of the translation processes inherent in QIC implementation. Second, we discuss the implications of the translation processes as experienced by participating actors. METHODS: We used empirical data from a qualitative case study investigating the implementation of QICs as an approach to quality improvement within a national Danish healthcare quality program. We included two diverse QICs to allow for exploration of the significance of organizational complexity for the translation processes. Data comprised qualitative interviews, participant observation and documentary material. RESULTS: Translation was an inherent part of QIC implementation. Key actors at different organizational levels engaged in translation of their implementation roles, and the QIC content and methodology. They drew on different translation strategies and practices that mainly materialized as kinds of modification. The translations were motivated by deliberate, strategic, and pragmatic rationales, contingent on combinations of features of the actors' organizational contexts, and the transformability and organizational complexity of the QICs. The findings point to a transformative power of translation, as different translations led to various regional and local QIC versions. Furthermore, the findings indicate that translation affects the outcomes of the implementation process and the QIC intervention. Translation may positively affect the institutionalization of the QICs and the creation of professional engagement and negatively influence the QIC effects. CONCLUSION: The findings extends the current research concerning the understanding of the dynamics of the translation processes embedded in the local implementation of QICs, and thus constitute a valuable contribution to a more sustainable and effective implementation of QICs in healthcare improvement. For researchers and practitioners, this highlights translation as an embedded part of the QIC implementation process, and encourages detailed attention to the implications of translation for both organizational institutionalization and realisation of the expected intervention outcomes.

Engaging health care professionals in quality improvement: A qualitative study exploring the synergies between projects of professionalisation and institutionalisation in quality improvement collaborative implementation in Denmark.

OBJECTIVE: To examine the projects of professionalisation and institutionalisation forming health care professions' engagement in quality improvement collaborative (QIC) implementation in Denmark, and to analyse the synergies and tensions between the two projects given the opportunities afforded by the QICs. METHODS: This was a cross-sectional interview study with professionals involved in the implementation of two national QICs in Denmark involving 23 individual interviews and focus group discussions with 75 people representing different professional groups. We conducted a reflexive thematic analysis of the data, drawing on institutional contributions to organisational studies of professions. RESULTS: Study participants engaged widely in QIC implementation. This engagement was formed by a constructive interplay between the professions' projects of professionalisation and institutionalisation, with only few tensions identified. The project of professionalisation relates to a self-oriented agenda of contributing professional expertise and promoting professional recognition and development, while the project of institutionalisation focuses on improving health care processes and outcomes and advancing quality improvement. Both projects were largely similar across professional groups. The interplay between the two projects was enabled by the bottom-up approach to implementation, participation of QI specialists, and a clear focus on developing and delivering high-quality patient care. CONCLUSIONS: Future strategies for QIC implementation should position QICs as a framework that promotes the integration of professions' projects of professionalisation and institutionalisation to successfully engage professionals in the implementation process, and thereby optimise the effectiveness of QICs in health care.

The Danish health care quality programme: Creating change through the use of quality improvement collaboratives.

Policy-makers worldwide place quality in health care high on their agendas. Inspired by global trends within health care governance, there has been an increase in patient-oriented and network-based models for quality improvement. In 2015, the Danish Government introduced the Danish Health Care Quality Programme (DHCQP) for the entire Danish health care system in line with this development. For the first time in Denmark, the DHCQP introduced network-based quality improvement collaboratives (QICs) as a model for the implementation of a national quality improvement reform. This article presents the organisational set up and anticipated effects of using QICs within the DHCQP. The Danish set-up is related to the common international use of QICs and the existing evidence for their effectiveness and implementation. The analysis demonstrates a novel organisational set-up embedded in the organisation of the QICs. Furthermore, the article points to two main trends in the DHCQP, namely, centralisation of quality improvement strategies and integration of quality improvement work in clinical practices, and furthermore proposes a need for future research concerning implementation of QICs. Particularly, there is a need to investigate the different activities and organisational mechanisms in the implementation process and how these influence the implementation and functioning of QICs.

Fatty Acid Profiles from Routine Milk Recording as a Decision Tool for Body Weight Change of Dairy Cows after Calving.

Cows mobilize body reserves during early lactation, which is reflected in the milk fatty acid (FA) profile. Milk FA can be routinely predicted by Fourier-transform infrared (FTIR) spectroscopy, and be, thus, used to develop an early indicator for bodyweight change (BWC) in early lactating cows in commercial dairy farms. Cow records from 165 herds in Denmark between 2015 and 2017 were used with bodyweight (BW) records at each milking from floor scales in automatic milking systems. Milk FA in monthly test-day samples was predicted by FTIR. Predictions of BWC were based on a random forest model and included parity, stage of lactation, and test day milk production and components (fat, protein, and FA). Bodyweight loss was mainly explained by decreased short-chain FA (C4:0-C10:0) and increased C18:0 FA. The root mean square error (RMSE) of prediction after cross-validation was 1.79 g/kg of BW (R2 of 0.94). Model evaluation with previously unseen BWC records resulted in reduced prediction performance (RMSE of 2.33 g/kg of BW; R2 of 0.31). An early warning system may be implemented for cows with a large BW loss during early lactation based on milk FA profiles, but model performance should be improved, ideally by using the full FTIR milk spectra.

Dynamics of distributed leadership during a hospital merger.

Purpose Mergers have become an influential part of public hospital development, and the successful implementation of such mergers requires skillful management. Recent studies have pointed to the impact of the distribution of leadership tasks amongst employees for implementing planned radical changes, yet this lacks examination with regard to hospital mergers. The purpose of this paper is to investigate the emergence of distributed leadership and this leadership's influence on the implementation of a hospital merger. Design/methodology/approach The emergence of distributed leadership is examined through a qualitative case study of two Danish hospital units in the context of a large hospital merger. The data consist of 21 interviews and documents collected over a three-year period. Findings The findings suggest dynamics of widened and restricted distributed leadership being influenced by and influencing the merger at hospital and local-unit levels, respectively. Importantly, the perceived purpose of widened and restricted distributed leadership mediated the actual effects of widened and restricted distributed leadership on the implementation of a merger. Moreover, the findings show that mergers on both the hospital and local level lead to variations in top-down and bottom-up distributed leadership across pre-merger organizational boundaries. Practical implications Perceived purposeful widening and restriction of distributed leadership at various hospital levels enables merger integration and collaboration across organizational boundaries and hierarchies. Originality/value The paper addresses the need to understand the complex dynamics of widened and restricted leadership distribution in a merger context.

Only When the Societal Impact Potential Is High? A Panel Study of the Relationship Between Public Service Motivation and Perceived Performance.

Many studies find positive associations between public service motivation (PSM) and performance, but much of this literature is based on cross-sectional data prone to endogeneity and common method bias. Moreover, we know little about potential moderators. In this study, we test the moderating role of societal impact potential (SIP)-the degree to which the job is perceived to provide opportunities to contribute to society. We use cross-sectional data from 13,967 employees in 2010 and 2012 aggregated to construct longitudinal data for 42 organizations. As expected, the association between PSM and individual perceived performance is positive when SIP is high. However, when SIP is low, PSM is only weakly or not at all related to performance. This is an important insight for organizations that try to enhance performance through PSM. Our findings suggest that this can only be done when the employees think that their jobs allow them to contribute to society.

Mortality (including euthanasia) among Danish dairy cows (1990-2001).

Mortality among Danish dairy cows was examined using data from the Danish Cattle Database (DCD) and a questionnaire survey. Mortality risk has increased from approximately 2% in 1990 to approximately 3.5% in 1999. The increased mortality was seen for all dairy breeds and all age groups. Mortality among older dairy cows (parity 3 and older) was approximately twice the mortality among younger cows. 30-40% of deaths were during the first 30 days of the lactation. Approximately, 58% of dead dairy cows had been euthanised. Replies from the questionnaire indicate that the proportion of euthanised cows has increased in the past 5 years. In 86% of all deaths (questionnaire survey) a primary reason could be identified; 25% were for locomotor disorders.