External inspection approaches and involvement of stakeholders' views in inspection following serious incidents - a qualitative mixed methods study from the perspectives of regulatory inspectors.

OBJECTIVE: The objective was to gain knowledge about how external inspections following serious incidents are played out in a Norwegian hospital context from the perspective of the inspectors, and whether stakeholders' views are involved in the inspection. METHODS: Based on a qualitative mixed methods design, 10 government bureaucrats and inspectors situated at the National Board of Health Supervision and three County Governors in Norway, were strategically recruited, and individual semi-structured interviews were conducted. Key official government documents were selected, collected, and thematically analyzed along with the interview data. RESULTS: Our findings overall demonstrate two overarching themes: Theme (1) Perspectives on different external inspection approaches of responding and involving stakeholders in external inspection following serious incidents, Theme (2) Inspectors' internal work practices versus external expectations. Documents and all participants reported a development towards new approaches in external inspection, with more policies and regulatory attention to sensible involvement of stakeholders. Involvement and interaction with patients and informal caregivers could potentially inform the case complexity and the inspector's decision-making process. However, stakeholder involvement was sometimes complex and challenging due to e.g., difficult communication and interaction with patients and/or informal caregivers, due to resource demands and/or the inspector's lack of experience and/or relevant competence, different perceptions of the principle of sound professional practice, quality, and safety. The inspectors considered balancing the formal objectives and expectations, with the expectations of the public and different stakeholders (i.e. hospitals, patients and/or informal caregivers) a challenging part of their job. This balance was seen as an important part of the continuous development of ensuring public trust and legitimacy in external inspection processes. CONCLUSIONS AND IMPLICATIONS: Our study suggests that the regulatory system of external inspection and its available approaches of responding to a serious incident in the Norwegian setting is currently not designed to accommodate the complexity of needs from stakeholders at the levels of hospital organizations, patients, and informal caregivers altogether. Further studies should direct attention to how the wider system of accountability structures may support the internal work practices in the regulatory system, to better algin its formal objectives with expectations of the public.

Next-of-kin involvement in improving hospital cancer care quality and safety - a qualitative cross-case study as basis for theory development.

BACKGROUND: Next-of-kin are an extension of healthcare professionals in all stages of cancer care. They offer care activities such as interpretations of symptoms, and reporting of negative or adverse effects of treatment, without any professional knowledge or skills. Their participation is often expected from healthcare professionals, managers, or the patient. However, there is limited knowledge of next-of-kin's role in and contribution to quality and safety improvement in hospital cancer care. The aim of this study was to explore how managers and healthcare professionals understand the role of next-of-kin in cancer care, and what methods they use for next-of-kin involvement. METHODS: The study design was a comparative multiple embedded case study of cancer departments in two Norwegian university hospitals. Data collection methods consist of qualitative interviews with managers (13) and healthcare professionals (19) collected in 2016, and document analysis of policy documents and regulation. The interviews were analyzed according to a directed content analysis approach guided by the theoretical framework 'Organizing for Quality'. RESULTS: Both hospitals have a strategy to involve next-of-kin in treatment and care but have no formal way of doing so. Managers and healthcare professionals in the two hospitals illuminated nine areas where next-of-kin are important stakeholders in improving quality and safety. These nine areas (e.g. nutrition, observations, transitions, pain treatment, information, palliative and terminal care) are common across the two hospitals. Key challenges in the next-of-kin involvement pertain to insufficient physical working conditions and room facilities, and lack of continuity of experienced nurses and consultants. CONCLUSION: Hospital employees and managers regard next-of-kin as a safety net or a buffer that cannot be replaced by other stakeholders. This study shows a close collaboration between patient, next-of-kin and healthcare professionals in cancer care, but more effort should be invested in more systematic approaches for next-of-kin involvement in quality and safety improvement such as a guide for managers and healthcare professionals on methods and areas of involvement.

Developing Methods to Support Collaborative Learning and Co-creation of Resilient Healthcare-Tips for Success and Lessons Learned From a Norwegian Hospital Cancer Care Study.

BACKGROUND: There is a growing attention on the role of patients and stakeholders in resilience, but there is lack of knowledge and methods on how to support collaborative learning between stakeholders and co-creation of resilient healthcare. The aim of this article was to demonstrate how the methodological process of a consensus process for exploring aspects of next of kin involvement in hospital cancer care can be replicated as an effort to promote resilient healthcare through co-creation with multiple stakeholders in hospitals. METHODS: The study applied a modified nominal group technique process developed by synthesizing research findings across 4 phases of a research project with a mixed-methods approach. The process culminated in a 1-day meeting with 20 stakeholder participants (5 next of kin representatives, 10 oncology nurses, and 5 physicians) from 2 Norwegian university hospitals. RESULTS: The consensus method established reflexive spaces with collective sharing of experiences between the 2 hospitals and between the next of kin and healthcare professionals. The method promoted collaborative learning processes including identification and reflection upon new ideas for involvement, and reduction of the gap between healthcare professionals' and next of kin experiences and expectations for involvement. Next of kin were considered as important resources for resilient performance, if involved with a proactive approach. The consensus process identified both successful and unsuccessful collaborative practices and resulted in a co-designed guide for healthcare professionals to support next of kin involvement in hospital cancer care. CONCLUSIONS: This study expands the body of knowledge on methods development that is relevant for collaborative learning and co-creation of resilient healthcare. This study demonstrated that the consensus methods process can be used for creating reflexive spaces to support collaborative learning and co-creation of resilience in cancer care. Future research within the field of collaborative learning should explore interventions that include a larger number of stakeholders.

Resilience From a Stakeholder Perspective: The Role of Next of Kin in Cancer Care.

OBJECTIVE: The aim of this article was to provide new knowledge on how next of kin are co-creators of resilient performance, as seen from the viewpoint of the healthcare personnel and managers. The following research question guided the study: How are next of kin involved in shaping resilience within cancer care in hospitals? METHODS: The design of the study is a case study of cancer departments in two Norwegian hospitals. Data collection included a total of 32 qualitative semistructured interviews at two organizational levels (managers and staff). The data were analyzed by ways of a directed content analysis according to Hollnagel's Resilience in Health Care framework of resilience potentials (anticipate, monitor, respond, learn). RESULTS: Next of kin are involved in creating and maintaining resilience in cancer care by different kind of activities and in-depth insight into the patient's condition, which strengthen all resilience potentials of responding, anticipation, monitoring, and learning. We have identified nine areas in which next of kin are co-creators in shaping resilience. Next of kin are important stakeholders, both as safety experts and as safety resources, helping healthcare professionals provide quality and safety in the patient care process under difficult conditions. Next of kin's knowledge of the patient's history, their observation of the patient over time within the hospital, at home, and across care transitions are key elements of their contribution. CONCLUSIONS: Next of kin complement healthcare professionals in all four potentials for resilient performance. The study suggests that the Resilience in Health Care framework takes into account the role of next of kin, as a stakeholder potential, because this has not previously been sufficiently considered.