"What it really takes" - A qualitative study of how professionals coproduce healthcare service with immigrant patients.

Background: The concept of coproduction shows great promise for meaningful partnerships between patients and health professionals. This is particularly relevant for immigrant patients who are less inclined to take an active role in consultations. The present study described health professionals' practices and experiences of coproducing healthcare service with immigrant and refugee patients in clinical encounters. Methods: We conducted a three-phase qualitative study with immigrant and refugee patients and health professionals at an interdisciplinary outpatient clinic for immigrants and refugees with complex long-standing health problems at a Danish university hospital. First, we conducted 25 observations of consultations between seven professionals (three doctors, three nurses, one social worker) and 24 patients with varied backgrounds and health problems. Findings were discussed in a focus group and individual interviews with the migrant clinic's staff. Finally, the themes were discussed with co-researchers and revised in a member check with experienced clinicians. Data were analyzed through meaning condensation, supported by the NVivo software. Results: We identified four themes characterizing the work of health professionals in creating coproduced healthcare service: a team effort of sense-making, disentangling the chaos first, when everything fails - listen to the patient, and continuity - becoming part of the patient's story. Conclusion: Interdisciplinary work fostering values of doing what makes sense to form a positive partnership with the patient allows health professionals to act autonomously, flexibly, and creatively. Using communication tools designed around patient needs, create optimal conditions for coproduction as health professionals empathically validate and integrate patient experiences. Professionals need advanced listening and relational skills and tolerance of ambiguity and insecurity. Relational continuity facilitates long-term coproduction but also bears risks of emotional dependency.

"When I feel safe, I dare to open up": immigrant and refugee patients' experiences with coproducing healthcare.

OBJECTIVE: Interest in the coproduction concept in healthcare is increasing. According to coproduction, services are, unlike goods, always coproduced by a user and a service provider. This study explored how immigrants and refugees perceive the coproduction of their healthcare service in clinical encounters. METHODS: We conducted semi-structured interviews with thirteen patients with varied backgrounds and health problems. Participants were purposefully recruited in an interdisciplinary clinic for immigrants and refugees at a Danish University Hospital. Interviews were transcribed, anonymized, and analyzed using meaning condensation. RESULTS: Patients emphasized the importance of a safe space where they could be themselves and feel supported. This encouraged them to be open and assume an active role in the coproduction of their health. A stable therapeutic alliance based on kindness and kinship helped them find strength and take responsibility for their own health. CONCLUSIONS: This study improves our understanding of how immigrants and refugees experience the coproduction of healthcare services. Further studies, evaluating long-term outcomes of coproduction efforts, are required. PRACTICE IMPLICATIONS: Providing a safe space in which health professionals have time to listen and empathically validate immigrant and refugee patients' lived realities, can enable patients to open up and become agents of their own health.

Initial development of a self-assessment approach for coproduction value creation by an international community of practice.

BACKGROUND: Coproduction offers a new way of conceptualizing healthcare as a service that is co-created by people (health professionals and people seeking health services) rather than a product that is generated by providers or health systems and delivered to patients. This offers new possibilities for those introducing and testing changes, and it enables additional ways of creating value. Fjeldstad and colleagues describe the architecture of several kinds of value creating systems: (i) Chain; (ii) Shop; (iii) Network and (iv) Access. An international Value Creating Business Model Community of practice (VCBM CoP) was formed by the International Coproduction of Health Network and explored these types of systems and developed a self-assessment guide for health systems to use to assess value. METHODS: An international community of practice comprising leaders, clinicians, patients and finance specialists representing 12 health systems from four countries (USA, UK, Israel and Sweden) met monthly for 1 year and used a semi-structured process to iteratively refine and adapt Fjeldstad's model for use in healthcare and develop a draft self-assessment guide. The process concluded with initial focus group user experience sessions with six health systems. RESULTS: The community of practice successfully completed a 1-year journey of discovery, development and learning, resulting in two products: (1) a full-version self-assessment guide (detailed) and (2) an abbreviated 'short-form' of the guide. Initial focus-group results suggest that there is initial perceived feasibility, acceptability and utility of the guides and that further development and research is reasonable to pursue. Results suggest significant variation and context specificity in the use of the guide, simple and complex knowledge transfer applications in use, and the need for the development of simple and technology supported versions for use in the future. CONCLUSION: The VCBM CoP has successfully completed a 1-year collaborative learning cycle, resulting in the development of a self-assessment guide that is now ready for additional investigation using formal research methods. The CO-VALUE study has been designed to build on the work of the CoP and includes qualitative and quantitative assessment phases and a concept mapping study.

A starter's guide to learning and teaching how to coproduce healthcare services.

BACKGROUND: There has been insufficient attention paid to the role of learning in co-production-both how service users and professional service providers learn to co-produce effectively and how the lessons of co-production are captured at a service level. OBJECTIVE: We aimed to develop and test a curriculum to support healthcare professionals' interest in learning how to co-produce health and healthcare services with patients. METHODS: We developed a co-production curriculum that was tested iteratively in multiple in-person and virtual teaching sessions and short courses. We conducted a formative evaluation of the co-production curriculum and teaching tools to tailor the curriculum. RESULTS: Several theories underpin our approach to learning and teaching how to co-produce healthcare services. The co-production curriculum is grounded in systems theory and shares elements of educational theories, namely, the postmodern curriculum matrix, the actor network theory and situated learning in communities of practice. Learning participants valued the sense of community, the experiential learning environment, and the practical methods to support their exploration of co-production. CONCLUSION: This paper summarizes the educational theories that underpin our efforts to develop and implement the curriculum, reports on a formative assessment conducted with learners, and makes recommendations for creating an environment for learning how health professionals can co-produce health and healthcare with patients.

From assurance to coproduction: a century of improving the quality of health-care service.

BACKGROUND: Over the last century, the invitation to improve health-care service quality has taken many different forms: questions, observations, methods, tools and actions have emerged and evolved to create relevant 'improvement work.' In this paper we present three phases of this work. The basic frameworks used in these phases have not supplanted each other, but they have been layered one upon the next over time. Each brought important new thinking, new change opportunities and a new set of limits. The important messages of each need to be carried together into the future, as must the sense of curiosity and possibility about the commonalities that has driven this evolution. METHODS: Literature, personal experience and other artifacts were reviewed to develop this description of how the focus on quality work has evolved (and continues to evolve) over the last century. RESULTS: We describe three phases. Quality 1.0 seeks to answer the question 'How might we establish thresholds for good healthcare services?' It described certain 'basic' standards that should be used to certify acceptable performance and capability. This led to the formation of formal processes for review, documentation and external audits and a system for public notice and recognition. Over time, the limits and risks of this approach also became more visible: a 'micro-accounting compliance' sometimes triumphed over what might be of even greater strategic importance in the development and operations of effective systems of disease prevention and management to improve outcomes for patients and families. Quality 2.0 asked 'How might we use enterprise-wide systems for disease management?' It added a focus on the processes and systems of production, reduction of unwanted variation, the intrinsic motivation to take pride in work, outcome measurement and collaborative work practices as ways to improve quality, modeled on experiences in other industries. Quality 3.0 asks 'How might we improve the value of the contribution that healthcare service makes to health?' It requires careful consideration of the meaning of 'service' and 'value', service-creating logic, and prompts us to consider both relationships and activities in the context of the coproduction of health-care services. CONCLUSION: Efforts to improve the quality and value of health-care services have evolved over the last century. With each success have come new challenges and questions, requiring the addition of new frames and approaches.

The role of co-production in Learning Health Systems.

BACKGROUND: Co-production of health is defined as 'the interdependent work of users and professionals who are creating, designing, producing, delivering, assessing, and evaluating the relationships and actions that contribute to the health of individuals and populations'. It can assume many forms and include multiple stakeholders in pursuit of continuous improvement, as in Learning Health Systems (LHSs). There is increasing interest in how the LHS concept allows integration of different knowledge domains to support and achieve better health. Even if definitions of LHSs include engaging users and their family as active participants in aspects of enabling better health for individuals and populations, LHS descriptions emphasize technological solutions, such as the use of information systems. Fewer LHS texts address how interpersonal interactions contribute to the design and improvement of healthcare services. OBJECTIVE: We examined the literature on LHS to clarify the role and contributions of co-production in LHS conceptualizations and applications. METHOD: First, we undertook a scoping review of LHS conceptualizations. Second, we compared those conceptualizations to the characteristics of LHSs first described by the US Institute of Medicine. Third, we examined the LHS conceptualizations to assess how they bring four types of value co-creation in public services into play: co-production, co-design, co-construction and co-innovation. These were used to describe core ideas, as principles, to guide development. RESULT: Among 17 identified LHS conceptualizations, 3 qualified as most comprehensive regarding fidelity to LHS characteristics and their use in multiple settings: (i) the Cincinnati Collaborative LHS Model, (ii) the Dartmouth Coproduction LHS Model and (iii) the Michigan Learning Cycle Model. These conceptualizations exhibit all four types of value co-creation, provide examples of how LHSs can harness co-production and are used to identify principles that can enhance value co-creation: (i) use a shared aim, (ii) navigate towards improved outcomes, (iii) tailor feedback with and for users, (iv) distribute leadership, (v) facilitate interactions, (vi) co-design services and (vii) support self-organization. CONCLUSIONS: The LHS conceptualizations have common features and harness co-production to generate value for individual patients as well as for health systems. They facilitate learning and improvement by integrating supportive technologies into the sociotechnical systems that make up healthcare. Further research on LHS applications in real-world complex settings is needed to unpack how LHSs are grown through coproduction and other types of value co-creation.

The History of Quality: From an Eye for an Eye, Through Love, and Towards a Multidimensional Concept for Patients, Kin, and Professionals.

In ancient civilizations, poor quality was dealt with according to the principle of "an eye for an eye." In the modern era we have learned from industry what quality really is. Quality includes standards, protocols, system thinking, and an understanding of variation to ensure good outcomes. In the post-COVID era, quality is not all about predefined specifications but rather about relationships and even love. Quality can now be defined as multidimensional, including person-centered care for patients, kin, and providers. Care should be safe, efficient, effective, timely, equitable, and eco-friendly. High quality is only possible if we include core values of dignity and respect, holistic care, partnership, and kindness with compassion in our daily practice for every stakeholder at every managerial and policy level. PATIENT SUMMARY: Quality of care is a multidimensional concept in which person-centered care is central. The care a patient receives should be safe, efficient, effective, timely, equitable, and eco-friendly. Attention should be given to dignity, respect, kindness, and compassion. There should be a holistic approach that includes partnership with all stakeholders. The only acceptable level of quality a professional should provide is the level they would accept if their loved one were to be the next patient.

COproduction VALUE creation in healthcare service (CO-VALUE): an international multicentre protocol to describe the application of a model of value creation for use in systems of coproduced healthcare services and to evaluate the initial feasibility, utility and acceptability of associated system-level value creation assessment approaches.

INTRODUCTION: Coproduction introduces a fundamental shift in how healthcare service is conceptualised. The mechanistic idea of healthcare being a 'product' generated by the healthcare system and delivered to patients is replaced by that of a service co-created by the healthcare system and the users of healthcare services. Fjeldstad et al offer an approach for conceptualising value creation in complex service contexts that we believe is applicable to coproduction of healthcare service. We have adapted Fjeldstad's value creation model based on a detailed case study of a renal haemodialysis service in Jonkoping, Sweden, which demonstrates coproduction characteristics and key elements of Fjeldstad's model. METHODS AND ANALYSIS: We propose a five-part coproduction value creation model for healthcare service: (1) value chain, characterised by a standardised set of processes that serve a commonly occurring need; (2) value shop, which offers a customised response for unique cases; (3) a facilitated value network, which involves groups of individuals struggling with similar challenges; (4) interconnection between shop, chain and network elements and (5) leadership. We will seek to articulate and assess the value creation model through the work of a community of practice comprised of a diverse international workgroup with representation from executive, financial and clinical leaders as well as other key stakeholders from multiple health systems. We then will conduct pilot studies of a qualitative self-assessment process in participating health systems, and ultimately develop and test quantitative measures for assessing coproduction value creation. ETHICS AND DISSEMINATION: This study has been approved by the Dartmouth-Hitchcock Health Institutional Review Board (D-HH IRB) as a minimal risk research study. Findings and scholarship will be disseminated broadly through continuous engagement with health system stakeholders, national and international academic presentations and publications and an internet-based electronic platform for publicly accessible study information.

Under what circumstances can immigrant patients and healthcare professionals co-produce health? - an interpretive scoping review.

PURPOSE: Immigrant patients run a risk of receiving lower quality of care. Co-production, as the concept of how to collaboratively create valuable healthcare service for the patient, offers a new perspective that might help. The scoping review aimed at identifying and analysing factors facilitating co-production between immigrant patients and healthcare professionals. METHODS: We searched seven scientific databases for peer-reviewed publications of all study designs. Two reviewers independently screened the publications for eligibility and performed data extraction. Data were analysed by applying an inductive, interpretive approach for data synthesis. RESULTS: Fifteen publications were included for analysis. We identified six factors hat facilitate co-production: 1) prioritizing co-production in the organization, 2) providing a safe environment that promotes trust and patience, 3) using a language the patient understands, 4) respecting the patient's knowledge and priorities, 5) improvising with knowledge and courage, and 6) engaging in self-reflection. CONCLUSIONS: The scoping review illustrated that co-production with immigrant patients can be successful if the system and professionals are interested and prepared. Immigrant patients could be a valuable source of information and powerful co-producers of their own health. The study contributed to a growing body of research on patient-professional co-production in healthcare and might also prove relevant for other disadvantaged patient groups.

An international comparison of factors affecting quality of life among patients with congestive heart failure: A cross-sectional study.

OBJECTIVE: To explore associations among twenty formal and informal, societal and individual-level factors and quality of life (QOL) among people living with congestive heart failure (CHF) in two settings with different healthcare and social care systems and sociocultural contexts. SETTING AND PARTICIPANTS: We recruited 367 adult patients with CHF from a single heart failure clinic within two countries with different national social to healthcare spending ratios: Minneapolis, Minnesota, United States (US), and Nijmegen, Netherlands (NL). DESIGN: Cross-sectional survey study. We adapted the Social Quality Model (SQM) to organize twenty diverse factors into four categories: Living Conditions (formal-societal: e.g., housing, education), Social Embeddedness (informal-societal: e.g., social support, trust), Societal Embeddedness (formal-individual: e.g., access to care, legal aid), and Self-Regulation (informal-individual: e.g., physical health, resilience). We developed a survey comprising validated instruments to assess each factor. We administered the survey in-person or by mail between March 2017 and August 2018. OUTCOMES: We used Cantril's Self-Anchoring Scale to assess overall QOL. We used backwards stepwise regression to identify factors within each SQM category that were independently associated with QOL among US and NL participants (p<0.05). We then identified factors independently associated with QOL across all categories (p<0.05). RESULTS: 367 CHF patients from the US (32%) and NL (68%) participated. Among US participants, financial status, receiving legal aid or housing assistance, and resilience were associated with QOL, and together explained 49% of the variance in QOL; among NL participants, financial status, perceived physical health, independence in activities of daily living, and resilience were associated with QOL, and explained 53% of the variance in QOL. CONCLUSIONS: Four formal and informal factors explained approximately half of the variance in QOL among patients with CHF in the US and NL.

Networked health care: Rethinking value creation in learning health care systems.

Creating better value in health care service today is very challenging. The social pressure to do so is real for every health care system and its leadership. Real benefit has been achieved in manufacturing sector work by the use of "value-chain" thinking, which assumes that the work is a series of linked processes necessary to make a product. For those activities in health care systems that are similar, this model may be very helpful. Attempts to "install" the value chain widely in health care systems have, however, been frustrating. As a result, well-meaning leaders seeking better value have resorted to programs of cost reduction, rather than service redesign. Professionals have not been very happy or willing participants. The work of health care service invites an expanded model of value creation, one that better matches the work. This paper proposes a networked architecture that can mobilize and integrate the resources of health care professionals, interested patients, family, and other community members in the delivery and improvement of health care systems. It also suggests how this value-creation architecture might contribute to research and the development of new knowledge. Two cases illustrate the proposed architecture and its implications for system design and practice, technology development, and roles and responsibilities of all actors involved in health care systems. We believe that this model better fits the need of making and improving health care services. This expanded understanding of how value is created invites attention by senior leaders, by those attempting to facilitate the improvement of current systems, by patients and clinicians involved in the daily work of health care service coproduction, by those charged with the preparation and formation of future professionals, by those who measure and conduct research in health care services, and by those leading policy, payment, and reimbursement systems.

A multidimensional quality model: an opportunity for patients, their kin, healthcare providers and professionals to coproduce health.

Background: It is twenty years since the US Institute of Medicine (IOM) defined quality in healthcare, as comprising six domains: person-centredness, timeliness, efficiency, effectiveness, safety and equity. Since then, a new quality movement has emerged, with the development of numerous interventions aimed at improving quality, with a focus on accessibility, safety and effectiveness of care. Further gains in equity and timeliness have proven even more challenging. The challenge: With the emergence of "service-oriented" systems, complexity science, the challenges of climate change, the growth of social media and the internet and the new reality of COVID-19, the original domains proposed by the IOM invite reflection on their relevance and possibility for improvement. The possible solution: In this paper, we propose a revised model of quality that is built on never-ending learning and includes new domains, such as Ecology and Transparency, which reflect the changing worldview of healthcare. We also introduce the concept of person- or "kin-centred care" to emphasise the shared humanity of people involved in the interdependent work. The change of Person Centred Care to Kin Centred Care introduces a broader concept of the person and ensures that Person Centred Care is included in every domain of quality rather than as a separate domain. The concentration on the technological aspects of quality is an example of the problem in the past. This is a more expansive view of what "person-centredness" began. The delivery of health and healthcare requires people working in differing roles, with explicit attention to the lived realities of the people in the roles of professional and patient. The new model will provide a construct that may make the attainment of equity in healthcare more possible with a focus on kindness for all.

Coproducing Health Professions Education: A Prerequisite to Coproducing Health Care Services?

In 2016, Batalden et al proposed a coproduction model for health care services. Starting from the argument that health care services should demonstrate service-dominant rather than goods-dominant logic, they argued that health care outcomes are the result of the intricate interaction of the provider and patient in concert with the system, community, and, ultimately, society. The key notion is that the patient is as much an expert in determining outcomes as the provider, but with different expertise. Patients come to the table with expertise in their lived experiences and the context of their lives.The authors posit that education, like health care services, should follow a service-dominant logic. Like the relationship between patients and providers, the relationship between learner and teacher requires the integrated expertise of each nested in the context of their system, community, and society to optimize outcomes. The authors then argue that health professions learners cannot be educated in a traditional, paternalistic model of education and then expected to practice in a manner that prioritizes coproductive partnerships with colleagues, patients, and families. They stress the necessity of adapting the health care services coproduction model to health professions education. Instead of asking whether the coproduction model is possible in the current system, they argue that the current system is not sustainable and not producing the desired kind of clinicians.A current example from a longitudinal integrated clerkship highlights some possibilities with coproduced education. Finally, the authors offer some practical ways to begin changing from the traditional model. They thus provide a conceptual framework and ideas for practical implementation to move the educational model closer to the coproduction health care services model that many strive for and, through that alignment, to set the stage for improved health outcomes for all.

Coproduction of healthcare service with immigrant patients: protocol of a scoping review.

INTRODUCTION: Immigrant patients often meet barriers to patient-centred healthcare in their new host countries. Given the heterogeneity of patients from ethnic minorities, established strategies for patient centredness might not work in their case. The concept of coproduction provides a new perspective on how to collaboratively create the highest possible value for both the patient and the healthcare system. The concept acknowledges that all service is coproduced and directs attention to the relationship between patient and care provider. Coproduction is still a new concept in healthcare and its use with vulnerable groups of patients requires further study. This protocol outlines a scoping review to be conducted on the current knowledge on coproduction of service by immigrants and their service providers in the healthcare sector. METHODS AND ANALYSIS: We will use Joanna Briggs methodology for scoping reviews. The data will stem from the following databases: PubMed, Scopus, Ovid EMBASE, EBSCO CINAHL, EBSCO PsycINFO, Cochrane Library and Web of Science. We will also screen the websites of national authorities and research organisations for publications and review the literature lists of the identified articles for relevant references. We will include all types of literature on coproduction of healthcare or social service by immigrants and service providers, including their relationship with one another, communication and collaboration. Two reviewers will independently screen eligible publications and extract data using a checklist developed for this scoping review. ETHICS AND DISSEMINATION: The results of the study will provide an innovative perspective on the coproduction of value in healthcare service by immigrant patients and care providers. We will present the results at national and international conferences, seminars and other events with relevant stakeholders and immigrant patients, and publish them in a peer-reviewed journal.

'Reframing Healthcare Services through the Lens of Co-Production' (RheLaunCh): a study protocol for a mixed methods evaluation of mechanisms by which healthcare and social services impact the health and well-being of patients with COPD and CHF in the USA and The Netherlands.

INTRODUCTION: The USA lags behind other high-income countries in many health indicators. Outcome differences are associated with differences in the relative spending between healthcare and social services at the national level. The impact of the ratio and delivery of social and healthcare services on the individual patient's health is however unknown. 'Reframing Healthcare Services through the Lens of Co-Production' (RheLaunCh) will be a cross-Atlantic comparative study of the mechanisms by which healthcare and social service delivery may impact patient health with chronic conditions. Insight into these mechanisms is needed to better and cost-effectively organise healthcare and social services. METHODS: We designed a mixed methods study to compare the socioeconomic background, needs of and service delivery to patients with congestive heart failure and chronic obstructive pulmonary disease in the USA and the Netherlands. We will conduct: (1) a literature scan to compare national and regional healthcare and social service systems; (2) a retrospective database study to compare patient's socioeconomic and clinical characteristics and the service use and spending at the national, regional and hospital level; (3) a survey to compare patient perceived quality of life, receipt and experience of service delivery and ability of these services to meet patient needs; and (4) multiple case studies to understand what patients need to better govern their quality of life and how needs are met by services. ETHICS AND DISSEMINATION: Ethics approval was granted by the ethics committee of the Radboud University Medical Center (2016-2423) in the Netherlands and by the Human Subjects Research Committee of the Hennepin Health Care System, Inc. (HSR #16-4230) in the USA. Multiple approaches will be used for dissemination of results, including (inter)national research presentations and peer-reviewed publications. A website will be established to support the development of a community of practice.

SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process.

Since the publication of Standards for QUality Improvement Reporting Excellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this manuscript, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) semistructured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) two face-to-face consensus meetings to develop interim drafts and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasises the reporting of three key components of systematic efforts to improve the quality, value and safety of healthcare: the use of formal and informal theory in planning, implementing and evaluating improvement work; the context in which the work is done and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve healthcare, recognising that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (http://www.squire-statement.org).