Implementation of a national policy for improving health and social care: a comparative case study using the Consolidated Framework for Implementation Research.

BACKGROUND: Comprehensive policies are becoming common for addressing wicked problems in health and social care. Success of these policies often varies between target organizations. This variation can often be attributed to contextual factors. However, there is a lack of knowledge about the conditions for successful policy implementation and how context influences this process. The aim of this study was to investigate county-level actors' perspectives on the implementation of a comprehensive national policy in three Swedish counties. The policy focused on developing quality of care for elderly based on the use of national quality registries (NQRs) and to improve coordination of care. METHODS: A comparative case study approach was used. Data was collected longitudinally through documents and interviews. The Consolidated Framework for Implementation Research (CFIR) guided the analysis. RESULTS: All three counties shared the view that the policy addressed important issues. Still, there was variation regarding how it was perceived and managed. Adaptable features-i.e., NQRs and improvement coaches-were perceived as relevant and useful. However, the counties differed in their perceptions of another policy component-i.e., senior management program-as an opportunity or a disturbance. This program, while tackling complex issues of collaboration, fell short in recognizing the counties' pre-existing conditions and needs and also offered few opportunities for adaptations. Performance bonuses and peer pressure were strong incentives for all counties to implement the policy, despite the poor fit of policy content and local context. CONCLUSIONS: Comprehensive health policies aiming to address wicked problems have better chances of succeeding if the implementation includes assessments of the target organizations' implementation capacity as well as the implicit quid pro quos involved in policy development. Special attention is warranted regarding the use of financial incentives when dealing with wicked problems since the complexity makes it difficult to align incentives with the goals and to assess potential consequences. Other important aspects in the implementation of such policies are the use of collaborative approaches to engage stakeholders with differing perspectives, and the tailoring of policy communication to facilitate shared understanding and commitment.

Enhancing policy implementation to improve healthcare practices: The role and strategies of hybrid national-local support structures.

BACKGROUND: In this study, we followed a national initiative to enhance the use of quality indicators gathered in national quality registries (NQRs) for improvement of clinical practices in Swedish healthcare, more specifically by investigating the support strategies of regional support centers with national and local missions. The aim was to increase knowledge on the role, challenges, and strategies of support structures with mixed and complex missions in the healthcare system. METHODS: Documents and 25 semistructured interviews with staff at 6 regional support centers, ie, quality registry centers, formed this multiple case study. Data were analyzed using conventional content analysis. RESULTS: The centers' strategies varied from developing the NQRs to become more suitable for improvement to supporting healthcare's use of NQRs, from the use of task to process-oriented support strategies, and from taking on national responsibilities to responding to local initiatives. All quality registry centers engaged in initiatives inspired by the Breakthrough Series approach. Some used preexisting change concepts or collaborated with local development units. A main challenge was to overcome a lack of formal mandate to act in the healthcare organizations they served. CONCLUSIONS: Support functions with mixed and complex missions have to use a variation of strategies to reach relevant actors and achieve changes. This study provides valuable input for policy and decision-makers on the support strategies used and challenges of support functions with complex missions situated in-between national and local levels of the healthcare system, here denoted hybrid national-local support structures.

Reaching beyond the review of research evidence: a qualitative study of decision making during the development of clinical practice guidelines for disease prevention in healthcare.

BACKGROUND: The judgment and decision making process during guideline development is central for producing high-quality clinical practice guidelines, but the topic is relatively underexplored in the guideline research literature. We have studied the development process of national guidelines with a disease-prevention scope produced by the National board of Health and Welfare (NBHW) in Sweden. The NBHW formal guideline development model states that guideline recommendations should be based on five decision-criteria: research evidence; curative/preventive effect size, severity of the condition; cost-effectiveness; and ethical considerations. A group of health profession representatives (i.e. a prioritization group) was assigned the task of ranking condition-intervention pairs for guideline recommendations, taking into consideration the multiple decision criteria. The aim of this study was to investigate the decision making process during the two-year development of national guidelines for methods of preventing disease. METHODS: A qualitative inductive longitudinal case study approach was used to investigate the decision making process. Questionnaires, non-participant observations of nine two-day group meetings, and documents provided data for the analysis. Conventional and summative qualitative content analysis was used to analyse data. RESULTS: The guideline development model was modified ad-hoc as the group encountered three main types of dilemmas: high quality evidence vs. low adoptability of recommendation; insufficient evidence vs. high urgency to act; and incoherence in assessment and prioritization within and between four different lifestyle areas. The formal guideline development model guided the decision-criteria used, but three new or revised criteria were added by the group: 'clinical knowledge and experience', 'potential guideline consequences' and 'needs of vulnerable groups'. The frequency of the use of various criteria in discussions varied over time. Gender, professional status, and interpersonal skills were perceived to affect individuals' relative influence on group discussions. CONCLUSIONS: The study shows that guideline development groups make compromises between rigour and pragmatism. The formal guideline development model incorporated multiple aspects, but offered few details on how the different criteria should be handled. The guideline development model devoted little attention to the role of the decision-model and group-related factors. Guideline development models could benefit from clarifying the role of the group-related factors and non-research evidence, such as clinical experience and ethical considerations, in decision-processes during guideline development.

Strategies to facilitate implementation and sustainability of large system transformations: a case study of a national program for improving quality of care for elderly people.

BACKGROUND: Large-scale change initiatives stimulating change in several organizational systems in the health and social care sector are challenging both to lead and evaluate. There is a lack of systematic research that can enrich our understanding of strategies to facilitate large system transformations in this sector. The purpose of this study was to examine the characteristics of core activities and strategies to facilitate implementation and change of a national program aimed at improving life for the most ill elderly people in Sweden. The program outcomes were also addressed to assess the impact of these strategies. METHODS: A longitudinal case study design with multiple data collection methods was applied. Archival data (n = 795), interviews with key stakeholders (n = 11) and non-participant observations (n = 23) were analysed using content analysis. Outcome data was obtained from national quality registries. RESULTS: This study presents an approach for implementing a large national change program that is characterized by initial flexibility and dynamism regarding content and facilitation strategies and a growing complexity over time requiring more structure and coordination. The description of activities and strategies show that the program management team engaged a variety of stakeholders and actor groups and accordingly used a palate of different strategies. The main strategies used to influence change in the target organisations were to use regional improvement coaches, regional strategic management teams, national quality registries, financial incentives and annually revised agreements. Interactive learning sessions, intense communication, monitor and measurements, and active involvement of different experts and stakeholders, including elderly people, complemented these strategies. Program outcomes showed steady progress in most of the five target areas, less so for the target of achieving coordinated care. CONCLUSIONS: There is no blue-print on how to approach the challenging task of leading large scale change programs in complex contexts, but our conclusion is that more attention has to be given to the multidimensional strategies that program management need to consider. This multidimensionality comprises different strategies depending on types of actors, system levels, contextual factors, program progress over time, program content, types of learning and change processes, and the conditions for sustainability.

Concurrent implementation of quality improvement programs.

PURPOSE: Competing activities and projects can interfere with implementing new knowledge and approaches. The purpose, therefore, was to investigate processes and impact related to implementing two concurrent quality initiatives in a Swedish hospital. These were a regionally initiated, system-wide organizational learning programme called the Dynamic and Viable Organization (DVO) and a national initiative on stopping healthcare-associated and hospital-acquired infections (SHAI). Both undertakings aspired to increase staff competence in systematic improvement approaches. DESIGN/METHODOLOGY/APPROACH: Multiple methods were applied including surveys, observations, interviews, process diaries, documents and organizational measurements. Respondents were unit managers, change facilitators and improvement team members. FINDINGS: Even though both initiatives shared the same improvement approach, there was no strong indication that they were strategically combined to benefit each other. The initiatives existed side by side with some coordination and some conflict. Despite absent management strategies to utilize the national SHAI initiative, positive developments in QI culture and communication were reported. The current study illustrates the inherent difficulties coordinating change initiatives, even in favourable circumstances. ORIGINALITY/VALUE: This article addresses the lesser studied but common situation of coinciding and competing projects in organizations.

Quality improvement in large healthcare organizations.

PURPOSE: The purpose of this paper is to investigate the obstacles and challenges associated with organizational monitoring and follow-up (M & F) processes related to health care quality improvement (QI) and development. DESIGN/METHODOLOGY/APPROACH: A longitudinal case study of a large health care organization during a system-wide QI intervention. Content analysis was conducted of repeated interviews with key actors and archival data collected over a period of four years. FINDINGS: The demand for improved M & F strategies, and what and how to monitor were described by the respondents. Obstacles and challenges for achieving M & F strategies that enables system-wide and coherent development were found in three areas: monitoring, processing, and feedback and communication. Also overarching challenges were found. PRACTICAL IMPLICATIONS: A model of important aspects of M & F systems is presented that can be used for analysis and planning and contribute to shared cognition of such systems. Approaches for systematic analysis and follow-up of identified problems have to be developed and fully incorporated in the organization's measurement systems. A systematic M & F needs analytic and process-oriented competence, and this study highlights the potential in an organizational function with capacity and mandate for such tasks. ORIGINALITY/VALUE: Most health care systems are flooded with a vast amount of registers, records, and measurements. A key issue is how such data can be processed and refined to reflect the needs and the development process of the health care system and how rich data can be used for improvement purposes. This study presents key organizational actor's view on important factors to consider when building a coherent organizational M & F strategy.

Kaizen practice in healthcare: a qualitative analysis of hospital employees' suggestions for improvement.

OBJECTIVES: Kaizen, or continuous improvement, lies at the core of lean. Kaizen is implemented through practices that enable employees to propose ideas for improvement and solve problems. The aim of this study is to describe the types of issues and improvement suggestions that hospital employees feel empowered to address through kaizen practices in order to understand when and how kaizen is used in healthcare. METHODS: We analysed 186 structured kaizen documents containing improvement suggestions that were produced by 165 employees at a Swedish hospital. Directed content analysis was used to categorise the suggestions into following categories: type of situation (proactive or reactive) triggering an action; type of process addressed (technical/administrative, support and clinical); complexity level (simple or complex); and type of outcomes aimed for (operational or sociotechnical). Compliance to the kaizen template was calculated. RESULTS: 72% of the improvement suggestions were reactions to a perceived problem. Support, technical and administrative, and primary clinical processes were involved in 47%, 38% and 16% of the suggestions, respectively. The majority of the kaizen documents addressed simple situations and focused on operational outcomes. The degree of compliance to the kaizen template was high for several items concerning the identification of problems and the proposed solutions, and low for items related to the test and implementation of solutions. CONCLUSIONS: There is a need to combine kaizen practices with improvement and innovation practices that help staff and managers to address complex issues, such as the improvement of clinical care processes. The limited focus on sociotechnical aspects and the partial compliance to kaizen templates may indicate a limited understanding of the entire kaizen process and of how it relates to the overall organisational goals. This in turn can hamper the sustainability of kaizen practices and results.

Improving treatment of depression in primary health care: a case study of obstacles to perform a clinical trial designed to implement practice guidelines.

AIM: The aim of this study is to investigate factors contributing to the failure of a randomized clinical trial designed to implement and test clinical practice guidelines for the treatment of depression in primary health care (PHC). BACKGROUND: Although the occurrence of depression is increasing globally, many patients with depression do not receive optimal treatment. Clinical practice guidelines for the treatment of depression, which aim to establish evidence-based clinical practice in health care, are often underused and in need of operationalization in and adaptation to clinical praxis. This study explores a failed clinical trial designed to implement and test treatment of depression in PHC in Sweden. METHOD: Qualitative case study methodology was used. Semi-structured interviews were conducted with eight participants from the clinical trial researcher group and 11 health care professionals at five PHC units. Additionally, archival data (ie, documents, email correspondence, reports on the clinical trial) from the years 2007-2010 were analysed. FINDINGS: The study identified barriers to the implementation of the clinical trial in the project characteristics, the medical professionals, the patients, and the social network, as well as in the organizational, economic and political context. The project increased staff workload and created tension as the PHC culture and the research activities clashed (eg, because of the systematic use of questionnaires and changes in scheduling and planning of patient visits). Furthermore, there was a perception that the PHC units' management did not sufficiently support the project and that the project lacked basic incentives for reaching a sustainable resolution. Despite efforts by the project managers to enhance and support implementation of the innovation, they were unable to overcome these barriers. The study illustrates the complexity and barriers of performing clinical trials in the PHC.