Action researchers as "orchestrators" of co-innovation: a theoretical and methodological framework.

BACKGROUND: With the increasing complexity of health care services, more comprehensive and integrated services need to be designed. Action researchers are encouraged to facilitate multiactor participation and user-centered approaches to initiate service development. However, "orchestrating" co-innovation, in which actors have diverse attitudes, agendas, positions of power, and horizons of understanding, is challenging, and a framework that supports action researchers in co-innovation studies lack. The purpose of this article was to explore how action researchers can facilitate multiactor engagement and handle possible challenges and stimulate creativity among diverse stakeholders. METHODS: We have studied and discussed two Scandinavian cases of rehabilitation innovation (for cancer patients and persons with acquired brain injury) where two research teams with action research approaches have acted in an orchestrating role to create co-innovation. RESULTS: We identified four themes that are essential for action researchers to facilitate collaborative and creative co-innovation processes: (1) relational power reflexibility, (2) resource integration, (3) joint understanding, and (4) the facilitation of creativity. These mutually dependent themes constitute a theoretical and methodological framework for of co-innovation. CONCLUSIONS: This paper offers a contribution that supports action researchers in orchestrating diverse actors and their contributions in co-innovation processes.

User involvement and value co-creation in well-being ecosystems.

PURPOSE: This article aims to examine how users' involvement in value co-creation influences the development and orchestration of well-being ecosystems to help tackle complex societal challenges. This research contributes to the public management literature and answers recent calls to investigate novel public service governances by discussing users' involvement and value co-creation for novel well-being solutions. DESIGN/METHODOLOGY/APPROACH: The authors empirically explore this phenomenon through a case study of a complex ecosystem addressing increased well-being, focussing on the formative evaluation stage of a longitudinal evaluation of Sweden's first support centre for people affected by cancer. Following an abductive reasoning and action research approach, the authors critically discuss the potential of user involvement for the development of well-being ecosystems and outline preconditions for the success of such approaches. FINDINGS: The empirical results indicate that resource reconfiguration of multi-actor collaborations provides a platform for value co-creation, innovative health services and availability of resources. Common themes include the need for multi-actor collaborations to reconfigure heterogeneous resources; actors' adaptive change capabilities; the role of governance mechanisms to align the diverse well-being ecosystem components, and the engagement of essential actors. RESEARCH LIMITATIONS/IMPLICATIONS: Although using a longitudinal case study approach has revealed stimulating insights, additional data collection, multiple cases and quantitative studies are prompted. Also, the authors focus on one country but the characteristics of users' involvement for value co-creation in innovative well-being ecosystems might vary between countries. PRACTICAL IMPLICATIONS: The findings of this study demonstrate the value of cancer-affected individuals, with "lived experiences", acting as sources for social innovation, and drivers of well-being ecosystem development. The findings also suggest that participating actors in the ecosystem should utilise wider knowledge and experience to tackle complex societal challenges associated with well-being. SOCIAL IMPLICATIONS: Policymakers should encourage the formation of well-being ecosystems with diverse actors and resources that can help patients navigate health challenges. The findings especially show the potential of starting from the user's needs and life situation when the ambition is to integrate and innovate in fragmented systems. ORIGINALITY/VALUE: The proposed model proposes that having a user-led focus on innovating new solutions can play an important role in the development of well-being ecosystems.

From "Invented here" to "Use it everywhere!": A Learning health system from bottom and/or top?

Introduction: Departing from a practical problem of how to use digitalization to improve care quality and efficiency, this paper investigates how the concept of Learning Health Systems (LHSs) can be applied to an existing organization. LHSs offer a vision for how healthcare can accelerate both scale-up of innovations and quality improvements at all levels. However, aligning stakeholders at different levels to convergent development is challenging and translation and adaptation of the LHS concept to fit with the existing organization is essential. Methods: A one-year longitudinal action research (AR) study was conducted within five psychiatric departments at the Sahlgrenska University Hospital in Gothenburg, Sweden. Translation of the LHS concept to the local circumstances within the organization was set as the aim, to both improve practice and further scientific understanding. An AR group led the practical and scholarly work and holistic data were collected, including field notes, documents, recordings, and workshops. Data were analyzed by an insider-outsider approach. Results: The one-year study is described to provide insights into the process of designing a locally adapted LHS using an AR approach. Practical needs were identified and iteratively matched with theory to form a local LHS model. A conflict between top-down and bottom-up views on development emerged, where higher-level management tended to prioritize uniform solutions and developers local learning. An adapted solution to balance these approaches was negotiated, consisting of a technical and an organizational part. Conclusions: The conflict between top-down and bottom-up approaches for how to implement LHSs needs to be considered both in practical work to transform care organizations and in scientific studies of LHSs. The approach to translate, rather than instrumentally implement, LHSs to real-world settings is suggested as advantageous. Furthermore, designing such endeavors as AR projects can provide excellent conditions to create LHSs that work in practice.

Exploring the meaning, role and experiences of a patient-led social innovation for people affected by cancer: a new collaborative care model complementing traditional cancer rehabilitation in Sweden.

OBJECTIVE: Kraftens Hus is the first support centre in Sweden designed by and for people affected by cancer, including patients, family, friends, staff members and local community representatives (collectively 'stakeholders'). The purpose of this study was to explore the meaning, role and experiences of Kraftens Hus stakeholders using a patient and public involved methodology. METHODS: To understand and map the experiences of visitors to Kraftens Hus, we applied concept mapping (CM), a mixed methods approach where data are collected and analysed in four structured steps designed to capture the diverse perspectives of multiple stakeholders. Qualitative interviews with relevant stakeholders supplemented the CM findings. RESULTS: The final concept map contained six clusters of ideas. Within the clusters, there was a recurring theme that cancer-affected people value accessible and long-term psychosocial support (PSS). The intended emotional, social and practical needs identified in a previous design process seem to have been addressed and appreciated by Kraftens Hus visitors. CONCLUSION: Kraftens Hus is an example of a new patient-led social innovation based on a life-event perspective and integration of resources from different sectors in society. By focusing on life, not the disease, the care continuum expands, and long-term PSS is provided alongside cancer treatment. The evaluation confirms that PSS should focus on health and well-being in the broadest sense.

Value configurations for balancing standardization and customization in chronic care: a qualitative study.

BACKGROUND: Demands for both customization and standardization are increasing in healthcare. At the same time, resources are scarce, and healthcare managers are urged to improve efficiency. A framework of three value configurations - shop, chain, and network - has been proposed for how healthcare operations can be designed and organized for efficient value creation. In this paper, use of value configurations for balancing of standardization and customization is explored in the context of care for chronic mental conditions. METHODS: A typical case is presented to illustrate the manifestations of conflicting demands between customization and standardization, and the potential usefulness of the value configurations framework. Qualitative data were collected from managers and care developers in two focus groups and six semi-structured interviews, completed by a national document describing a care pathway. Data were coded and analysed using an insider-outsider approach. RESULTS: Operationalization of the balance between standardization and customization were found to be highly delegated and ad hoc. Also, the conflict between the two demands was often seen as aggravated by scarce resources. Value configurations can be fruitful as a means of discussing and redesigning care operations if applied at a suitable level of abstraction. Applied adequately, all three value configurations were recognized in the care operations for the patient group, with shop as the overarching configuration. Some opportunities for improved efficiency were identified, yet all configurations were seen as vital in the chronic care process. CONCLUSIONS: The study challenges the earlier proposed organizational separation of care corresponding to different value configurations. Instead, as dual demand for customization and standardization permeates healthcare, parallel but explicated value configurations may be a path to improved quality and efficiency. Combined and intermediate configurations should also be further investigated.

Fourteen years of quality improvement education in healthcare: a utilisation-focused evaluation using concept mapping.

Background: The need for training in quality improvement for healthcare staff is well acknowledged, but long-term outcomes of such training are hard to evaluate. Behaviour change, improved organisational performance and results are sought for, but these variables are complex, multifactorial and difficult to assess. Aim: The purpose of this article is to explore the personal and organisational outcomes identified by participants over 14 years of university-led QI courses for healthcare professionals. Method: Inspired by the Kirkpatrick model for evaluation, we used concept mapping, a structured mixed method that allows for richness of data to be captured and visualised by inviting stakeholders throughout the process. In total, 331 previous course participants were included in the study by responding to two prompts, and 19 stakeholders taking part in the analysis process by doing the sorting. Result: Two maps, one for personal outcomes and one for organisational outcomes, show clusters of the responses from previous course participants and how the outcomes relate to each other in meta-clusters. Both maps show possible long-term outcomes described by the previous course participants. Conclusion: The results of this study indicate that it is possible that training in quality improvement with a strong experiential pedagogical approach fosters a long-term improvement capability for the course participants and, even more important, a long-term improvement capability (and increased improvement skill) in their respective organisations.

Value-based healthcare translated: a complementary view of implementation.

BACKGROUND: Interest in the implementation of various innovations (e.g. medical interventions and organizational approaches) has increased rapidly, and management innovations (MIs) are considered particularly complex to implement. In contrast to a traditional view that innovations are implemented, some scholars have promoted the view that innovations are translated into contexts, a view referred to as translation theory. The aim of this paper is to investigate how a translation theory perspective can inform the Consolidated Framework of Implementation Research (CFIR) to increase understanding of the complex process of putting MIs into practice. The empirical base is a two-year implementation of the MI Value-Based Health Care (VBHC) to a psychiatric department in a large Swedish hospital. METHODS: In this longitudinal case study, a qualitative approach was applied using an insider researcher with unique access to data, who followed the implementation starting in 2015. Data sources includes field notes, documents, and audio recordings of meetings and group reflections which were abridged into an event data file structured by CFIR domains. In a joint analysis, an outsider researcher was added to strengthen the analysis and mitigate potential bias. RESULTS: Two themes were identified, for which CFIR did not satisfactorily explain the findings. First, the intervention characteristics (i.e. the content of the MI) were modified along the process and, second, the process did not follow predefined plans. However, the project was still perceived to be successful by internal and external stakeholders. CONCLUSIONS: The paper proposes three ways in which translation theory can inform CFIR when applied to MIs: 1) strength of evidence is not as important for MIs as for medical and technical innovations; 2) adaptability of the MI can be emphasized more strongly, and 3) it can be more fruitful to view implementation as a dynamic process rather than seeing it as a matter of planning and execution. For managers, this implies encouragement to seize the opportunity to translate MIs to fit their organization, rather than to aim to be true to an original concept.

Whole System in the Room: Toward Systems Integration in Healthcare.

How might systems integration be furthered in healthcare? The paper addresses this by exploring critically the potentials of appreciative inquiry for accelerating systems integration through a large group intervention. We analyze a one-day dialog workshop to get "the whole system in the room" to improve cancer care in a regional health authority in south west Sweden. Seeing systems integration as socialization and enhanced common understandings, we suggest that discourse may play a crucial role in bringing together the various stakeholders in the system. Our analysis of the group discussions of the event demonstrates however that the degree of shared understanding can vary considerably across the discussion themes of appreciative inquiry. We argue that the "patient," as a linguistic artifact, can act as a boundary signifier that enables those present to interact in a meaningful and coherent way but that this stops short of systems integration.

A value-based taxonomy of improvement approaches in healthcare.

Purpose The concept of value is becoming increasingly fashionable in healthcare and various improvement approaches (IAs) have been introduced with the aim of increasing value. The purpose of this paper is to construct a taxonomy that supports the management of parallel IAs in healthcare. Design/methodology/approach Based on previous research, this paper proposes a taxonomy that includes the dimensions of view on value and organizational focus; three contemporary IAs - lean, value-based healthcare, and patient-centered care - are related to the taxonomy. An illustrative qualitative case study in the context of psychiatric (psychosis) care is then presented that contains data from 23 interviews and focuses on the value concept, IAs, and the proposed taxonomy. Findings Respondents recognized the dimensions of the proposed taxonomy and indicated its usefulness as support for choosing and combining different IAs into a coherent management model, and for facilitating dialog about IAs. The findings also suggested that the view of value as "health outcomes" is widespread, but healthcare professionals are less likely than managers to also view value as a process. Originality/value The conceptual contribution of this paper is to delineate some important characteristics of IAs in relation to the emerging "value era". It also highlights the coexistence of different IAs in healthcare management practice. A taxonomy is proposed that can help managers choose, adapt, and combine IAs in local management models.

When they talk about motherhood: a qualitative study of three groups' perceptions in a Swedish child health service context.

BACKGROUND: In light of the growing emphasis on individualization in healthcare, it is vital to take the diversity of inhabitants and users into consideration. Thus, identifying shared perceptions among group members may be important in improving healthcare that is relevant to the particular group, but also perceptions of the staff with whom interactions take place. This study investigates how motherhood is perceived among three groups: Somali-born mothers; Swedish-born mothers; and nurses at Swedish child health centers. Inequities in terms of access and satisfaction have previously been identified at the health centers. METHODS: Participants in all three groups were asked to finalize two statements about motherhood; one statement about perfect motherhood, another about everyday motherhood. The responses were analyzed using qualitative coding and categorization to identify differences and similarities among the three groups. RESULTS: The responses to both statements by the three groups included divergences as well as convergences. Overall, biological aspects of motherhood were absent, and respondents focused almost exclusively on social matters. Working life was embedded in motherhood, but only for the Somali-born mothers. The three groups put emphasis on different aspects of motherhood: Somali-born mothers on the community; the Swedish-born mothers on the child; and the nurses on the mother herself. The nurses - and to some extent the Swedish-born mothers - expected the mother to ask for help with the children when needed. However, the Somali-born mothers responded that the mother should be independent, not asking for such help. Nurses, more than both groups of mothers, largely described everyday motherhood in positively charged words or phrases. CONCLUSION: The findings of this paper suggest that convergences and divergences in perceptions of motherhood among three groups may be important in equitable access and utilization of healthcare. Individualized healthcare requires nuance and should avoid normative or stereotypical encounters by recognizing social context and needs that are relevant to specific groups of the population.

Degradation of phytate by Pichia kudriavzevii TY13 and Hanseniaspora guilliermondii TY14 in Tanzanian togwa.

The fermented cereal-based gruel togwa is used as weaning food for children in Tanzania. Togwa is rich in minerals but these are often not available for uptake in the human intestine due to natural inhibitors, such as phytate (IP(6)). The yeasts Pichia kudriavzevii TY13, Hanseniaspora guilliermondii TY14 and TY20, isolated from Tanzanian togwa, and selected for high phytase activity in complex yeast medium YPD, were now studied regarding their ability to degrade IP(6) in maize-based model togwa. A modified constitutively high-phytase producing Saccharomyces cerevisiae BY80 and commercial Aspergillus ficuum phytase were included for comparison. In addition, a strain of Lactobacillus plantarum was included in the model-togwa set-up. All yeasts in the study grew and reached final cell density 1.5-2 log units higher than the start value. S. cerevisiae BY80 degraded 85% of the IP(6) in 48 h; the same degradation level as with A. ficuum phytase (89%). Of the togwa-isolated yeasts, P. kudriavzevii TY13 and H. guilliermondii TY14 showed strong phytate degradation in the model-togwa; 95% or more of the initial IP(6) was degraded after 48 h. This corresponds to a remaining level of 0.4 and 0.3µmol IP(6)/g dw. Co-inoculation with L. plantarum did not increase IP(6) degradation. Moreover, fermentation with P. kudriavzevii TY13 yielded a successive increase in inorganic phosphate (P(i)), from 0.7 to 5.4 mM, suggesting a phytase production in TY13 which is fairly insensitive to P(i) repression. The study shows that phytate in a model togwa is available for yeast phytase enzymes, and addresses the importance of strain selection for effectively degrading the phytate. Certain yeasts originating from togwa seem to have developed a natural high phytase production, and P. kudriavzevii TY13 and H. guilliermondii TY14 seem particularly well adapted to phytate degradation in togwa, and is our choice for further studies and strain improvement.

Biodiversity and phytase capacity of yeasts isolated from Tanzanian togwa.

The focus of the present investigation was on the Tanzanian fermented food togwa as a source for dietary iron and zinc, and the potential for mineral availability improvements using selected yeasts. To establish the content of target minerals and main inhibitor for intestinal uptake, iron and zinc as well as the mineral chelating phytic acid, (IP(6) or phytate) were determined in naturally fermented togwa. Yeasts were isolated from sorghum, maize and cassava based togwa, and identified by sequencing the D1/D2 region of the LSU rRNA gene. The isolated yeasts were subsequently screened for phytase activity. The total iron content in sorghum, maize and cassava based togwa were 41.5 (+/-7.2), 85.4 (+/-31.9) and 28.6 (+/-3.8) microg/g dw (dry weight) respectively. The zinc content was 12.3 (+/-3.1), 11.0 (+/-1.1) and 6.4 (+/-4.5) microg/g dw in sorghum, maize and cassava based togwa, and the phytate content in the three varieties were 2.6+/-1.2, 4.7+/-0.8 and 0.4+/-0.4 micromol/g dw respectively. The phytate levels in the sorghum and maize based togwa are expected to substantially reduce the availability of iron. The molar ratio phytate to iron for these two varieties were estimated to be 3.5:1 and 3.1:1 respectively. In general, a phytate to iron molar ratio below 1 is needed to increase the availability of iron. Among 26 isolates, 9 different species could be distinguished: Issatchenkia orientalis, Pichia anomala, Pichia norvegensis, Pichia burtonii, Pichia guilliermondii, Kluyveromyces marxianus, Saccharomyces cerevisiae, Hanseniaspora guilliermondii and Candida glabrata. The strains were screened for phytase activity in YPD supplemented with 0.5 mM IP(6). Of 26 screened strains, the phytase activity was most prominent in strains of I. orientalis and H. guilliermondii. The strains and data constitute a basis for further improvements of iron and zinc bioavailability in togwa.

Production of folates by yeasts in Tanzanian fermented togwa.

We have investigated the impact of different yeasts and fermentation time on folate content and composition in a fermented maize-based porridge, called togwa, consumed in rural areas in Tanzania. The yeasts studied, originally isolated from indigenous togwa, belong to Issatchenkia orientalis, Pichia anomala, Saccharomyces cerevisiae, Klyveromyces marxianus and Candida glabrata. The main folate forms found, detected and quantified by HPLC during the fermentations were 5-methyl-tetrahydrofolate (5-CH(3)-H(4)folate) and tetrahydrofolate (H(4)folate). The content of H(4)folate, per unit togwa, remained fairly stable at a low level throughout the experiment for all strains, whereas the 5-CH(3)-H(4)folate concentration was highly dependent on yeast strain as well as on fermentation time. The highest folate concentration was found after 46 h of fermentation with C. glabrata (TY26) (6.91+/-0.14 microg 100 mL(-1)), corresponding to a 23-fold increase compared with unfermented togwa. The cell concentration per se could not predict the togwa folate level, as shown by the much higher specific folate content (g folate CFU(-1)) in the S. cerevisiae strain (TY08) compared with the other species tested. This study provides useful data when trying to maximize folate content in togwa as well as in other yeast-fermented products.

Perceptions of improvement work in Swedish health care: implications for improvement practices.

This study explored perceptions of improvement work in Swedish health care. The article discusses effects that these perceptions may have on improvement processes. As part of a broader study surveying managers' (n = 2313) view of improvement work in Swedish health care, this study focused on those 845 managers who regarded their improvement work as bringing about benefits. Three underlying factors that may characterize the managers' perceptions are exposed. More than 50% of the respondents perceive a complexity in the practices and techniques associated with improvement work. Furthermore, approximately 50% of the managers recognize a conflict in the meeting between the improvement work and the organization. This indicates that adaptation is a primary concern in this work. The managers' perceptions also reveal that the experience of improvement work in Swedish health care may be positive, although the perception is that it does not necessarily generate more health care per monetary unit.