Measuring competition in primary care-Evidence from Sweden.

INTRODUCTION: In many tax-based healthcare systems, policymakers have introduced reforms that promote provider competition with the intention of improving the quality and efficiency. Healthcare competition is usually defined spatially, with local markets often being identified as a circle around each provider. We argue that existing local market definitions can be improved to better capture actual local markets. For pro-competition reforms to potentially lead to the gains envisioned by policymakers, a crucial condition is the actual emergence of competitive markets. However, limited research has been conducted on competition in primary care markets, despite primary care constituting a vital part of a healthcare system. AIM: The study aims to contribute to the debate on how to define local markets geographically and to examine provider competition in Swedish primary care. METHODS: A cross-sectional study was conducted using data on all individuals and all primary care providers in Sweden. Local markets were defined as: fixed radius (1 km and 3 km); variable radius; and variable shape-our new local market definition that allows markets to vary in both size and shape. Competition was measured using the Herfindahl-Hirschman index and a count of the number of competitors within the local market. RESULTS: Fixed radius markets fail to capture variation within and across geographical areas. The variable radius and variable shape markets are similar but do not always identify the same competitors or level of competition. Furthermore, competition levels vary significantly in Swedish primary care. Many providers operate in monopoly markets, whereas others face high competition. CONCLUSIONS: While the variable shape approach has the potential to better capture actual markets and more accurately identify competitors, further analyses are needed. Moreover, Swedish policymakers are advised to decide whether to still pursue competition and if so, take measures to improve local market conditions in monopolies.

Tracing the refinement of policy tools for disability rights: a content analysis of how the granting process of state-funded personal assistance in Sweden is aligned with the LSS Act.

PURPOSE: According to the Swedish Act concerning Support and Service for Persons with Certain Functional Impairments (The LSS Act), personal assistance (PA) aims to enhance good living conditions for people with disability. The Act is operationalised by a policy tool, an instruction developed and refined by the Swedish Social Insurance Agency (SSIA) to grant PA. The study explores how this instruction is aligned with the LSS rationale and goals. MATERIAL AND METHOD: Qualitative content analysis was applied on the material i.e., a government bill preceding the LSS Act and the policy tool, i.e., the SSIA instruction, versions 1994 and 2019. RESULTS: The result shows that the instruction has deviated from the LSS Act over time, by decreasing users' access to community life, a shift towards health care activities, lack of support for the PA user, increased control and service-granting criteria. CONCLUSION: This paper emphasises that the selection of policy tools goes beyond mere pragmatism, as they are subject to refinement procedures that have significant impacts over time. The deviations observed in fulfilling the objectives of the LSS Act highlights the importance of ongoing adjustments to policy tools to align with the original policy goals in order to promote disability rights.

The study explored how policy tools, which serve as compulsory guidance by outlining the personal assistance granting process for local caseworkers, align with the rationale and policy goals of the Swedish Disability Act and policy goals, aiming to enhance good living conditions for people with disabilities.The designs of policy tools are frequently revised and adjusted and consequently influence policy outcome over time.Since policy tools are important for the implementation of government policy they need to be reviewed and monitored in order to secure original policy goals with the ultimate aim of enhancing good living conditions and advancing disability rights.

Vertical policy coordination of COVID-19 testing in Sweden: an analysis of policy-specific demands and institutional barriers.

PURPOSE: The build-up of large-scale COVID-19 testing required an unprecedented effort of coordination within decentralized healthcare systems around the world. The aim of the study was to elucidate the challenges of vertical policy coordination between non-political actors at the national and regional levels regarding this policy issue, using Sweden as our case. DESIGN/METHODOLOGY/APPROACH: Interviews with key actors at the national and regional levels were analyzed using an adapted version of a conceptualization by Adam et al. (2019), depicting barriers to vertical policy coordination. FINDINGS: Our results show that the main issues in the Swedish context were related to parallel sovereignty and a vagueness regarding responsibilities and mandates as well as complex governmental structures and that this was exacerbated by the unfamiliarity and uncertainty of the policy issue. We conclude that understanding the interaction between the comprehensiveness and complexity of the policy issue and the institutional context is crucial to achieving effective vertical policy coordination. ORIGINALITY/VALUE: Many studies have focused on countries' overall pandemic responses, but in order to improve the outcome of future pandemics, it is also important to learn from more specific response measures.

'Nurses are seen as general cargo, not the smart TVs you ship carefully': the politics of nurse staffing in England, Spain, Sweden, and the Netherlands.

Nurse workforce shortages put healthcare systems under pressure, moving the nursing profession into the core of healthcare policymaking. In this paper, we shift the focus from workforce policy to workforce politics and highlight the political role of nurses in healthcare systems in England, Spain, Sweden, and the Netherlands. Using a comparative discursive institutionalist approach, we study how nurses are organised and represented in these four countries. We show how nurse politics plays out at the levels of representation, working conditions, career building, and by breaking with the public healthcare system. Although there are differences between the countries - with nurses in England and Spain under more pressure than in the Netherlands and Sweden - nurses are often not represented in policy discourses; not just because of institutional ignorance but also because of fragmentation of the profession itself. This institutional ignorance and lack of collective representation, we argue, requires attention to foster the role and position of nurses in contemporary healthcare systems.

A New Way of Thinking and Talking About Economy: Clinic Managers' Perspectives on the Sustainable Implementation of a Decommissioning Programme in Sweden.

Healthcare systems may run into economic problems that may require 'active' decommissioning by policy-makers and managers. The aim of this study was to investigate, from a sustainability perspective, the implementation of an extensive decommissioning programme in one of the Swedish regions. Interviews were performed with 26 clinic managers 3 years after initial implementation. Those were analysed inductively, and then discussed based on a model of potential influences on sustainability. Although the programme was only 'partly sustained', the result point to a sustained attention to the health system's poor economy, visible in a great effort by the clinics to maintain their budgets. The most important influences were intervention fit and modifications made at the clinic level (i. innovation characteristics), clinic and health system leadership (ii. context), champions (iii. capacity) and shared decision-making and relationship building (iv. processes and interactions). When implementing decommissioning, it is particularly important to engage managers responsible for the care of patients and clinic budgets from an early stage and to allow them to design approaches based on the staff's and managers' detailed knowledge of the situation at their clinics and of the disease area, that is, to achieve fit at the clinics. In this way, the decommissioning approaches can more likely get the character of quality improvement efforts, which increases sustainability and may lead to positive quality outcomes. Despite being unpopular, the study suggests that decommissioning can have positive effects as well, such as creating opportunities to make difficult but necessary changes and fostering increased collegial support during the centralisation of services.

The Impact of the Swedish Care Coordination Act on Hospital Readmission and Length-of-Stay among Multi-Morbid Elderly Patients: A Controlled Interrupted Time Series Analysis.

Coordinating follow-up care after discharge from hospital is critical to ensuring good outcomes for patients, but is difficult when multiple care providers are involved. In 2018, Sweden adopted the Care Coordination Act, which modified economic incentives to reduce discharge delays and mandated a discharge planning process for patients requiring post-discharge social- or primary care services. This study evaluates the impact of this reform on hospital length-of-stay and unplanned readmissions among multi-morbid elderly patients. Interrupted time series analysis of all in-patient care episodes involving multi-morbid elderly patients in Sweden from 2015 - 2019 (n = 2 386 039) was performed. Secondary analyses using case-mix adjustment and controlled interrupted time series analysis were employed to assess for bias. Average length of stay decreased during the post-reform period, corresponding to 248 521 saved care days. Unplanned readmissions meanwhile increased, corresponding to 7 572 excess unplanned readmissions. While reductions in length-of-stay were concentrated among patients targeted by the reform, increases in readmission rates were similar in patients not targeted by the reform, indicating potential confounding. The reform thus appears to have achieved its goal of decreasing in-patient length of stay, but a robust effect on readmissions, outpatient visits, or mortality was not found. This may be due to lackluster implementation or an ineffective mandated intervention.

Any lessons to learn? Pathways and impasses towards health system resilience in post-pandemic times.

The COVID-19 pandemic has been an ultimate challenge for health systems as a whole rather than just single sectors (e.g. hospital care). Particularly, interface management between health system sectors and cooperation among stakeholders turned out to be crucial for an adequate crisis response. Dealing with such interfaces, it is argued in the literature, demands from health care systems to become resilient. One way to analyse this is to focus on the ways in which bottlenecks in health systems are dealt with during the pandemic. This paper investigates six bottlenecks, including overburdened public health agencies, neglected nursing homes and insufficient testing capacities that have been encountered in the health systems of Germany, Sweden and the Netherlands during the pandemic. Based on empirical findings we identify and critically discuss preliminary lessons in terms of health system resilience, an increasingly popular theoretical concept that frames crises as an opportunity for health system renewal. We argue that in practice health system resilience is hindered by path dependencies of national health systems and, owed to the crisis, interim policies that lack ambition for broader reforms.

Soft law and individual responsibility: a review of the Swedish policy response to COVID-19.

Sweden's coronavirus disease 2019 (COVID-19) response, initially based largely on voluntary measures, has evoked strong reactions nationally and internationally. In this study, we describe Sweden's national policy response with regard to the general public, the community and the health care system, with a focus on how the response changed from March 2020 to June 2021. A number of factors contributed to Sweden's choice of policy response, including its existing legal framework, independent expert agencies and its decentralized, multi-level health care governance system. Challenges to the health- and elder care system during the pandemic, such as the need to increase intensive care- and testing capacity, and to ensure the safety of the elderly were addressed largely at the regional and local levels, with national authorities assuming a primarily coordinative role. Although the overall response based on voluntary compliance has persisted, the national government started to take a more prominent role in public messaging, and in enacting legally binding restrictions during subsequent waves of the pandemic. This study illustrates that not only policy responses, but also the fundamental structure of the health- and elder care system and its governance should be considered when evaluating the impact of the COVID-19 pandemic.

Better safe than sorry: Registered nurses' strategies for handling difficult calls to emergency medical dispatch centres - An interview study.

AIMS AND OBJECTIVES: To describe strategies employed by registered nurses for handling difficult calls to emergency medical dispatch centres. BACKGROUND: At emergency medical dispatch centres, registered nurses encounter a range of difficult calls in their clinical practice. They often use clinical decision support systems, but these may be of limited help if the caller is for instance abusive or has limited language proficiency. Much can be learnt from strategies developed by registered nurses for handling difficult calls. DESIGN: A descriptive qualitative study was conducted. METHODS: A purposeful sample of 24 registered nurses from three different emergency medical dispatch centres were interviewed. The transcribed interviews were analysed using qualitative content analysis. The COREQ checklist was applied. RESULTS: An overarching theme was established: "Using one's nursing competence and available resources for a safe outcome", based on three sub-themes: Use one's own professional and personal resources, Use resources within the organisation and Use external resources. The themes in turn consist of ten categories. CONCLUSIONS: Registered nurses employed a range of strategies to deal with difficult calls, often in combination. They used their personal resources, resources within their own organisation, and collaboration partners to make safe triage decisions and use resources wisely. The effectiveness of these strategies, however, remains unknown. When registered nurses were unable to rule out a high-acuity condition, they used safety-netting and sent an ambulance. Evaluating current strategies and making strategies explicit could further improve the ability of nurses to handle difficult calls. RELEVANCE TO CLINICAL PRACTICE: The strategies described by registered nurses for handling difficult calls to EMDCs included using a consecutive set of strategies. Some of the strategies seemed to be used deliberately, while others seemed tacit and applied in a routinised way. These strategies could potentially be useful for RNs working with telephone triage in different contexts.

Do personal assistance activities promote participation in society for persons with disabilities in Sweden? A five-year longitudinal study.

PURPOSE: To explore whether the personal assistance (PA) activities provided by the Swedish Act concerning Support and Service for Persons with Certain Functional Impairment in 2010 and 2015 promote participation in society according to Article 19 of the United Nations' Convention on the Rights of Persons with Disabilities (UNCRPD). METHODS: Register data and data from two questionnaires were used (N = 2565). Descriptive statistics and chi-square (McNemar's test) were used to describe the basic features of the data. Mixed binominal logistic regression was used to examine correlation between gender and hours of PA between 2010 and 2015. RESULTS: Despite an increase in the number of PA hours, more care activities and a reduction of most PA activities representing an active life were found. The result was especially evident for women, older people, and for a particular person category. CONCLUSIONS: The results offer evidence of a shift to a medical model and indicate a risk of social exclusion due to fewer activities representing an active life. An increase on average of 16 h of PA over the period studied does not guarantee access to an active life and may indicate a marginal utility. The noted decline of PA for participation in society enhances the importance of monitoring content aspects to fulfil Article 19 of the UNCRPD.Implications for RehabilitationPersonal assistance (PA) in Sweden is a supportive measure for persons with disabilities; however, there are few studies to show whether PA activities are fulfilling disability rights of participation in society.The results show that PA activities are used more for medical care and home-based services over the five-year period.The study highlights the importance of monitoring aspects of content to ensure that the activities of PA comply with the policy objectives of the LSS legislation and Article 19 of the United Nations' Convention on the Rights of Persons with Disabilities (UNCRPD), i.e., full participation in society. Monitoring efforts should include individualised planning and follow-up, moreover, ensure compliance with social service capacity at PA providers.

Does voluntary health insurance reduce the use of and the willingness to finance public health care in Sweden?

Voluntary private health insurance (VHI) has generally been of limited importance in national health service-type health care systems, especially in the Nordic countries. During the last decades however, an increase in VHI uptake has taken place in the region. Critics of this development argue that voluntary health insurance can undermine support for public health care, while proponents contend that increased private funding for health services could relieve strained public health care systems. Using data from Sweden, this study investigates empirically how voluntary health insurance affects the public health care system. The results of the study indicate that the public Swedish health care system is fairly resilient to the impact of voluntary health insurance with regards to support for the tax-based funding. No difference between insurance holders and non-holders was found in willingness to finance public health care through taxes. A slight unburdening effect on public health care use was observed as VHI holders appeared to use public health care to a lesser extent than those without an insurance. However, a majority of the insurance holders continued to use the public health care system, indicating only a modest substitution effect.

Balancing Pragmatism and Sustainability: A Case Study of an Interorganisational Network to Improve Integrated Care for the Elderly.

INTRODUCTION: Networks constitute a promising strategy for interorganisational collaboration, but may fail due to network tensions. By investigating the activities and internal dynamics of a voluntary meso-level network operating in the intersection of health and social care, this study aims to enhance the understanding of the relationship between pragmatism and sustainability and the role network governance plays in this respect. METHODS: In this descriptive case study, 2-3 researchers observed 3 three-hour long network meetings during the course of a year, and four complementary interviews were performed. Data were analysed based on the literature on network functioning and effectiveness. RESULTS: Pragmatism (a focus on 'getting things done') was more emphasised than sustainability although the network meetings also contained elements of relationship- and trust-building. The network leadership (a Network Administrative Organisation, NAO) created structure and concretized the participants' ideas while remaining flexible and perceptive, and also carried out tasks which would otherwise not have been performed. DISCUSSION: The emphasis on pragmatism did not seem to influence sustainability negatively which has been pointed out as a potential risk in previous literature. Rather, the focus on pragmatism reinforced sustainability in a way that is similar to what has been described in prior research as a "trust-building loop" and discussed further in terms of a "perception of progress" mechanism. However, it was unclear what future the voluntary network would have without the NAO. CONCLUSION: Network governance is instrumental to success, and should be carefully considered when initiating interorganisational network initiatives for integrated care.

Factors that shape the successful implementation of decommissioning programmes: an interview study with clinic managers.

BACKGROUND: As a response to many years of repetitive budget deficits, Region Dalarna in Sweden started a restructuring process in 2015, and implemented a decommissioning programme to achieve a balanced budget until 2019. Leading politicians and public servants took the overall decisions about the decommissioning programme, but the clinical decision-making and implementation was largely run by the clinic managers and their staff. As the decommissioning programme improved the finances, met relatively little resistance from the clinical departments, and neither patient safety nor quality of care were perceived to be negatively affected, the initial implementation could be considered successful. The aim of this study was to investigate clinic managers' experience of important factors enabling the successful implementation of a decommissioning programme in a local healthcare organization. METHODS: Drawing on a framework of factors and processes that shape successful implementation of decommissioning decisions, this study highlights the most important factors that enabled the clinic managers to successfully implement the decommissioning programme. During 2018, an interview study was conducted with 26 clinic managers, strategically selected to represent psychiatry, primary care, surgery and medicine. A deductive content analysis was used to analyze the interviews. By applying a framework to the data, the most important factors were illuminated. RESULTS: The findings highlighted factors and processes crucial to implementing the decommissioning programme: 1) create a story to get a shared image of the rationale for change, 2) secure an executive leadership team represented by clinical champions, 3) involve clinic managers at an early stage to ensure a fair decision-making process, 4) base the decommissioning decisions on evidence, without compromising quality and patient safety, 5) prepare the organisation to handle a process characterised by tensions and strong emotions, 6) communicate demonstrable benefits, 7) pay attention to the need of cultural and behavioral change and 8) transparently evaluate the outcome of the process. CONCLUSIONS: From these findings, we conclude that in order to successfully implement a decommissioning programme, clinic managers and healthcare professions must be given and take responsibility, for both the process and outcome.

The perspectives of Swedish registered nurses about managing difficult calls to emergency medical dispatch centres: a qualitative descriptive study.

BACKGROUND: Telephone triage at emergency medical dispatch centres is often challenging for registered nurses due to lack of visual cues, lack of knowledge about the patient, and time pressure - and making the right decision can be a matter of life and death. Some calls may be more difficult to handle, and more knowledge is needed about these calls to develop education and coping strategies. Therefore, the aim of this study was to describe the perspectives of registered nurses' views about managing difficult calls to emergency medical dispatch centres. METHODS: A descriptive design with a qualitative inductive approach was used. Three dispatch centers in mid-Sweden were investigated, covering about 950,000 inhabitants and handling around 114,000 calls per year. Individual interviews were carried out with a purposeful sample of 24 registered nurses. Systematic text condensation was conducted. RESULTS: Seven themes were generated: calls with communication barriers, calls from agitated or rude callers, calls about psychiatric illness, calls from third parties, calls about rare or unclear situations, calls with unknown addresses and calls regarding immediate life-threatening conditions. There was a strong consensus among the registered nurses about which calls were experienced as difficult, with the exception of calls about immediate life-threatening conditions. Some registered nurses thought calls about immediate life-threatening conditions were easy to handle as they simply adhered to protocol, while others described these calls as difficult and were emotionally affected. CONCLUSION: The registered nurses' descriptions of difficult calls focused on the callers, while their own role, the organisational framework, and leadership were not mentioned. Many types of calls included difficulties, which could be related to the caller, their symptoms, or different circumstances. The registered nurses pointed to language barriers and rude, agitated callers as increasing problems. An investigation of actual emergency calls is warranted to examine the extent and nature of such calls.

How do people choose to be informed? A survey of the information searched for in the choice of primary care provider in Sweden.

BACKGROUND: To stimulate quality through choice of provider, patients need to seek and base their decisions on both relevant and reliable information describing providers' clinical quality. The purpose of this study was first to investigate what types of information and information sources patients turned to in the active choice of primary care provider. Second, it investigated whether a sub-group of patients considered more likely to actively seek information, also sought more advanced information about the clinical quality of providers. METHODS: Data collection was performed through a web-based survey to the general adult (18+) Swedish population, for a net sample of 3150 respondents. Descriptive statistics were used to study what types of information and information sources respondents used prior to their choice. Multiple regression analysis was employed to examine predictors for seeking relevant and reliable information describing providers' clinical quality. RESULTS: Patients in active choice situations searched for a median of four information types and used a median of one information source. The information searched for was primarily basic information, for instance, how to switch providers and their geographical location. Information sources used were mainly partisan sources, such as providers themselves, and family and acquaintances. The sub-group of individuals more likely to seek information were not found to seek more advanced forms of information. CONCLUSIONS: Not even the patients considered most likely to seek information prior to their choice of primary care provider, searched for information deemed necessary to make well-informed choices. Thus, patients did not act according to the theoretical assumptions underlying the patient choice reforms, i.e., making informed choices based on clinical quality in order to promote the best providers over inferior ones. The results call for governments and health care authorities to actively assess and develop primary care providers' clinical quality by means other than patient choice.

Registered nurses' understandings of emergency medical dispatch center work: A qualitative phenomenographic interview study.

Non-urgent and urgent telephone nursing services are increasing globally, and phenomenographic research has shown that how work is understood may influence work performance. This descriptive study makes a qualitative inductive investigation of understandings of emergency medical dispatch center work among registered nurses. Twenty-four registered nurses at three mid Swedish emergency medical dispatch centers were interviewed. Analysis based on phenomenographic principles identified five categories in the interviews: (i) Assess, prioritize, direct, or refer; (ii) Facilitate ambulance nursing work; (iii) Perform nursing care; (iv) Always be available for the public; and (v) Have the person behind the patient in mind. The first constitutes the basis of the work. The second emphasizes cooperation with and support for the ambulance staff. The third entails remotely providing nursing care, whilst the fourth stresses serving the entire population. The fifth and most comprehensive way of understanding work involves having a holistic view of the person in need, including person-centered care. Provision of high-quality emergency medical dispatch center work involves all categories. Combined, they constitute a "work map," valuable for reflection, competence development, and introduction of new staff.

Money matters - primary care providers' perceptions of payment incentives.

PURPOSE: Payments to healthcare providers create incentives that can influence provider behaviour. Research on unit-level incentives in primary care is, however, scarce. This paper examines how managers and salaried physicians at Swedish primary healthcare centres perceive that payment incentives directed towards the healthcare centre affect their work. DESIGN/METHODOLOGY/APPROACH: An interview study was conducted with 24 respondents at 13 primary healthcare centres in two cities, located in regions with different payment systems. One had a mixed system comprised of fee-for-service and risk-adjusted capitation payments, and the other a mainly risk-adjusted capitation system. FINDINGS: Findings suggested that both managers and salaried physicians were aware of and adapted to unit-level payment incentives, albeit the latter sometimes to a lesser extent. Respondents perceived fee-for-service payments to stimulate production of shorter visits, up-coding of visits and skimming of healthier patients. Results also suggested that differentiated rates for patient visits affected horizontal prioritisations between physician and nurse visits. Respondents perceived that risk-adjustments for diagnoses led to a focus on registering diagnosis codes, and to some extent, also up-coding of secondary diagnoses. PRACTICAL IMPLICATIONS: Policymakers and responsible authorities need to design payment systems carefully, balancing different incentives and considering how and from where data used to calculate payments are retrieved, not relying too heavily on data supplied by providers. ORIGINALITY/VALUE: This study contributes evidence on unit-level payment incentives in primary care, a scarcely researched topic, especially using qualitative methods.

Is it possible to influence ability, willingness and understanding among nursing home care staff to implement nutritional guidelines? A comparison of a facilitated and an educational strategy.

BACKGROUND: Translating nutrition knowledge into care practice is challenging since multiple factors can affect the implementation process. This study examined the impact of two implementation strategies, that is external facilitation (EF) and educational outreach visits (EOVs), on the organisational context and individual factors when implementing nutritional guidelines in a nursing home (NH) setting. METHODS: The EF strategy was a one-year, multifaceted (including support, guidance, a practice audit and feedback) intervention given to four NH units. The EOV strategy was a three-hour lecture about the nutritional guidelines given to four other NH units. Both strategies were directed at selected NH teams, consisting of a unit manager, a nurse and 5-10 care staff. A questionnaire was distributed, before and after the interventions, to evaluate the prerequisites for the staff to use the guidelines. Three conditions were used to examine the organisational context and the individual factors: the staff's ability and willingness to implement the nutritional guidelines and their understanding of them. Confirmatory factor analysis and structural equation models were used for the data analysis. RESULTS: The results indicated that on average, there was a significant increase in the staff's ability to implement the nutritional guidelines in the EF group. The staff exposed to the EF strategy experienced better resources to implement the guidelines in terms of time, tools and support from leadership and a clearer assignment of responsibility regarding nutrition procedures. There was no change in staff's willingness and understanding of the guidelines in the EF group. On average, no significant changes were observed for the staff's ability, willingness or understanding in the EOV group. CONCLUSIONS: A long-term, active and flexible implementation strategy (i.e. EF) affected the care staff's ability to implement the nutritional guidelines in an NH setting. No such impact was observed for the more passive, educational approach (i.e. EOV).

Malpractice claimed calls within the Swedish Healthcare Direct: a descriptive - comparative case study.

BACKGROUND: Medical errors are reported as a malpractice claim, and it is of uttermost importance to learn from the errors to enhance patient safety. The Swedish national telephone helpline SHD is staffed by registered nurses; its aim is to provide qualified healthcare advice for all residents of Sweden; it handles normally about 5 million calls annually. The ongoing Covid-19 pandemic have increased call volume with approximate 30%. The aim of the present study was twofold: to describe all malpractice claims and healthcare providers' reported measures regarding calls to Swedish Healthcare Direct (SHD) during the period January 2011-December 2018 and to compare these findings with results from a previous study covering the period January 2003-December 2010. METHODS: The study used a descriptive, retrospective and comparative design. A total sample of all reported malpractice claims regarding calls to SHD (n = 35) made during the period 2011-2018 was retrieved. Data were analysed and compared with all reported medical errors during the period 2003-2010 (n = 33). RESULTS: Telephone nurses' failure to follow the computerized decision support system (CDSS) (n = 18) was identified as the main reason for error during the period 2011-2018, while failure to listen to the caller (n = 12) was the main reason during the period 2003-2010. Staff education (n = 21) and listening to one's own calls (n = 16) were the most common measures taken within the organization during the period 2011-2018, compared to discussion in work groups (n = 13) during the period 2003-2010. CONCLUSION: The proportion of malpractice claims in relation to all patient contacts to SHD is still very low; it seems that only the most severe patient injuries are reported. The fact that telephone nurses' failure to follow the CDSS is the most common reason for error is notable, as SHD and healthcare organizations stress the importance of using the CDSS to enhance patient safety. The healthcare organizations seem to have adopted a more systematic approach to handling malpractice claims regarding calls, e.g., allowing telephone nurses to listen to their own calls instead of having discussions in work groups in response to events. This enables nurses to understand the latent factors contributing to error and provides a learning opportunity.

Readmission Reduction Strategies for Patients Discharged to Skilled Nursing Facilities: A Case Study From 2 Hospital Systems in 1 City.

BACKGROUND: Some hospitals seek integration with skilled nursing facilities (SNFs) to reduce readmissions while others focus more on patients discharged home. PURPOSE: Our objective was to understand different approaches for readmission reduction for patients discharged to SNFs based on contrasting strategies from 2 competing hospital systems. METHODS: Employing a case study methodology, we compared 1 hospital system that integrated with SNFs to a competing system that did not. We compared interview data from clinical and administrative staff and publicly reported rehospitalization rate changes from the 2 systems. RESULTS: Analysis of integrating hospital system interviews noted providing patients detailed discharge information and educating SNF staff regarding care protocols. Integrated hospital system all-cause readmission rates declined by nearly 1 percentage point more than the nonintegrated hospital system (coefficient, -0.008; 95% confidence interval, -0.003 to -0.012) between 2014 and 2017. CONCLUSION: As hospitals explore care transition improvements to SNFs, developing more embedded relationships highlights one approach to improve value.