Publications by authors named "John Ovretveit"

82 Publications

Implementation researchers can improve the responses of services to the COVID-19 pandemic.

Authors:
John Øvretveit

Implement Res Pract 2020 2;1:2633489520949151. Epub 2020 Sep 2.

Medical Management Center (LIME), Karolinska Institutet, Stockholm, Sweden.

This article describes a rapid implementation research project with the Stockholm health care system to assist the system to respond to the COVID-19 pandemic. It uses this example to illustrate some ways in which implementation research and knowledge can contribute to improving service responses to the pandemic and its consequences as these evolve over the coming months. A sub-specialty of rapid implementation science is proposed to provide practical assistance and as one way to develop implementation research.

Plain Language Abstract: This article describes a rapid implementation research project with the Stockholm health care system to assist the system to respond to the COVID-19 pandemic. It uses this example to illustrate some ways in which implementation research and knowledge can contribute to improving service responses to the pandemic and its consequences as these evolve over the coming months. A sub-specialty of rapid implementation science is proposed to provide practical assistance and as one way to develop implementation research.
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http://dx.doi.org/10.1177/2633489520949151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7468666PMC
September 2020

The hospital bed is broken: beds don't wear out, staff do.

Authors:
John Øvretveit

BMJ 2021 01 26;372:n223. Epub 2021 Jan 26.

Department of Learning, Informatics, Management, and Ethics, Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18A, SE-171 77 Stockholm, Sweden.

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http://dx.doi.org/10.1136/bmj.n223DOI Listing
January 2021

Management of the emergency response to the SARS-CoV-2 (COVID-19) outbreak in Stockholm, Sweden, and winter preparations.

J Prim Health Care 2020 Sep;12(3):207-214

Stockholm Health Care Services, Region Stockholm (SLSO), Torsplan, Stockholm, Sweden.

INTRODUCTION Sweden is unique in adopting a 'no-lockdown' public health approach to the SARS-CoV-2 (COVID-19) outbreak. There were fears that health services would not be able to care for high numbers of COVID-19 patients. AIM To describe and review the emergency response of a public primary and community health-care organisation in Stockholm, Sweden, to the demand for care for COVID-19 and non-COVID-19 patients during March-July 2020, and summarise preparations for the months to follow. METHODS This was a rapid implementation action research case study, which also draws on one author's experience as Chief Executive Officer and other members' experience in an emergency management group. RESULTS Sweden experienced similar mortality per million population to the UK, despite the different public health strategy used to address the COVID-19 outbreak. The Stockholm-integrated public primary and community health-care service, serving a population of 2.3 million, made many changes quickly. One change included coordinating non-acute private health-care services, following the local government emergency directive to do so. DISCUSSION It is possible that the fast and effective response by management and services in primary and community health care reduced infection and hospital demand, which contributed to a lower mortality than otherwise expected. The actions and preparations described for Stockholm's response may provide ideas for other health-care systems. The partnership research approach between the Karolinska Medical University and the Region Stockholm health-care system used in this project shows that rapid research methods have advantages for both partners in an emergency situation.
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http://dx.doi.org/10.1071/HC20082DOI Listing
September 2020

Can management decentralisation resolve challenges faced by healthcare service delivery organisations? Findings for managers and researchers from a scoping review.

Int J Health Plann Manage 2021 Jan 29;36(1):30-41. Epub 2020 Aug 29.

Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden.

Purpose: Decentralisation of decision-making from central to lower level organisation has been proposed as a way to increase innovation and make services more responsive to local needs. The purpose of this study was to discover research that can contribute to understanding decentralisation as one strategy for resolving challenges in healthcare service delivery organisations. This scoping review provides examples and research-informed guidance for decentralisation research, planning and implementation.

Findings: There is limited empirical research into management decentralisation within primary and community care, but some useful frameworks for assessing and planning decentralisation. Rapid changes are being made to workforce redesign, substitution and patient co-production. Research into such 'micro-decentralisation' is not considered in the decentralisation literature. Neither is how the context of culture, systems and regulations affects implementation of this type of decentralisation. Our recent experience suggests that management decentralisation can enable fast and effective local changes to respond to the evolving Severe acute respiratory syndrome coronavirus 2 (SARS COV-2) pandemic.

Conclusions: Decentralisation can create conditions that support innovation and improvement locally to develop primary and community care. Managers and policy makers can use an appropriate decentralisation strategy to address challenges in workforce retention and recruitment, rising care demands and expectations of patients. There are opportunities for researchers to provide actionable knowledge about changes in organisations and management which could address current challenges in healthcare.
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http://dx.doi.org/10.1002/hpm.3058DOI Listing
January 2021

Patient health records usage in patients admitted to hospital - a workshop by the Royal College of Physicians' Health Informatics Unit.

Future Healthc J 2019 Mar;6(Suppl 1):33

Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institute, Stockholm, Sweden.

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http://dx.doi.org/10.7861/futurehosp.6-1-s33DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6616736PMC
March 2019

DIGITAL TECHNOLOGY: Opportunities and barriers for usage of personal health records in hospital - report from a -workshop of the Health Informatics Unit at the Royal -College of Physicians.

Future Healthc J 2019 Feb;6(1):52-56

Wessex Institute of Health & Research, Faculty of Medicine, University of Southampton, Southampton, UK.

Personal health records (PHRs) are thought to offer benefits and are promoted by health policy makers and some healthcare systems. Evidence for usage by patients in hospital is limited.  This article reports a one-day workshop hosted by the Royal College of Physicians that considered the evidence of the value to patients and others, the challenges to adoption and use of PHRs and sought to identify the practical and research questions that need to be answered.  The purpose of this article is to provide readers with an overview of the issues and possible future for hospital application of PHRs in the UK's NHS, especially for supporting self-care, family carers and advancing person-centred care. It aims to share the experience and ideas of those taking part in the workshop and reference resources that we have found useful while highlighting areas for future research.
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http://dx.doi.org/10.7861/futurehosp.6-1-52DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6520086PMC
February 2019

Adapting improvements to context: when, why and how?

Int J Qual Health Care 2018 Apr;30(suppl_1):20-23

New York State Department of Health AIDS Institute.

There is evidence that practitioners applying quality improvements often adapt the improvement method or the change they are implementing, either unknowingly, or intentionally to fit their service or situation. This has been observed especially in programs seeking to spread or 'scale up' an improvement change to other services. Sometimes their adaptations result in improved outcomes, sometimes they do not, and sometimes they do not have data make this assessment or to describe the adaptation. The purpose of this paper is to summarize key points about adaptation and context discussed at the Salzburg Global Seminar in order to help improvers judge when and how to adapt an improvement change. It aims also to encourage more research into such adaptations to develop our understanding of the when, why and how of effective adaptation and to provide more research informed guidance to improvers.The paper gives examples to illustrate key issues in adaptation and to consider more systematic and purposeful adaptation of improvements so as to increase the chances of achieving improvements in different settings for different participants. We describe methods for assessing whether adaptation is necessary or likely to reduce the effectiveness of an improvement intervention, which adaptations might be required, and methods for collecting data to assess whether the adaptations are successful. We also note areas where research is most needed in order to enable more effective scale up of quality improvements changes and wider take up and use of the methods.
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http://dx.doi.org/10.1093/intqhc/mzy013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5909662PMC
April 2018

Learning about improvement to address global health and healthcare challenges-lessons and the future.

Authors:
John Ovretveit

Int J Qual Health Care 2018 Apr;30(suppl_1):37-41

Department Leaning Informatics Management and Education (LIME/MMC), 17a Tomtebodavägen 18A. Karolinska Institutet, Stockholm 17177, Sweden.

This perspectives' paper highlights some of the learning from the seminar that the author considers to have particular relevance for improvement practitioners and for investigators seeking to maximize the usefulness of their investigations. The paper discusses the learning under four themes and also notes the future learning needed to enable faster and lower-cost improvement and innovative methods for this learning. The four themes are: describing and reporting improvement interventions; the theme of increasing our certainty about attributing effects to implemented improvement changes; the theme of generalizing the learning from one investigation or improvement and the theme of learning for sustainment and scale-up. The paper suggests ways to build on what we learned at the seminar to create and enable faster take up of proven improvements by practitioners and healthcare services so as to benefit more patients more quickly in a variety of settings.
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http://dx.doi.org/10.1093/intqhc/mzy015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5909655PMC
April 2018

Digital Technologies Supporting Person-Centered Integrated Care - A Perspective.

Authors:
John Øvretveit

Int J Integr Care 2017 Sep 25;17(4). Epub 2017 Sep 25.

Karolinska Institutet Stockholm, SE.

Shared electronic health and social care records in some service systems are already showing some of the benefits of digital technology and digital data for integrating health and social care. These records are one example of the beginning "digitalisation" of services that gives a glimpse of the potential of digital technology and systems for building coordinated and individualized integrated care. Yet the promise has been greater than the benefits, and progress has been slow compared to other industries. This paper describes for non-technical readers how information technology was used to support integrated care schemes in six EU services, and suggests practical ways forward to use the new opportunities to build person-centered integrated care.
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http://dx.doi.org/10.5334/ijic.3051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5854142PMC
September 2017

Factors influencing early stage healthcare-academia partnerships.

Int J Health Care Qual Assur 2018 Feb;31(1):28-40

Department of Learning Informatics Management and Ethics (LIME) and Medical Management Centre (MMC), Karolinska Institutet, Stockholm, Sweden.

Purpose The purpose of this paper is to explore factors influencing early implementation and intermediate outcomes of a healthcare-academia partnership in a primary healthcare setting. Design/methodology/approach The Academic Primary Healthcare Network (APHN) initiative was launched in 2011 in Stockholm County, Sweden and included 201 primary healthcare centres. Semi-structured interviews were conducted in 2013-2014 with all coordinating managers ( n=8) and coordinators ( n=4). A strategic change model framework was used to collect and analyse data. Findings Several factors were identified to aid early implementation: assignment and guidelines that allowed flexibility; supportive management; dedicated staff; facilities that enabled APHN actions to be integrated into healthcare practice; and positive experiences from research and educational activities. Implementation was hindered by: discrepancies between objectives and resources; underspecified guidelines that trigger passivity; limited research and educational activities; a conflicting non-supportive reimbursement system; limited planning; and organisational fragmentation. Intermediate outcomes revealed that various actions, informed by the APHN assignment, were launched in all APHNs. Practical implications The findings can be rendered applicable by preparing stakeholders in healthcare services to optimise early implementation of healthcare-academia partnerships. Originality/value This study increases understanding of interactions between factors that influence early stage partnerships between healthcare services and academia in primary healthcare settings.
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http://dx.doi.org/10.1108/IJHCQA-11-2016-0178DOI Listing
February 2018

Salzburg Global Seminar Session 565-'Better Health Care: how do we learn about improvement?'

Int J Qual Health Care 2018 Apr;30(suppl_1):1-4

Common Knowledge Associates, 3050 Tamarron Blvd. #7301, Austin, Texas 78746, USA.

A fundamental question for the field of healthcare improvement is the extent to which the results achieved can be attributed to the changes that were implemented and whether or not these changes are generalizable. Answering these questions is particularly challenging because the healthcare context is complex, and the interventions themselves tend to be complex and multi-dimensional. The Salzburg Global Seminar Session 565-'Better Health Care: How do we learn about improvement?' was convened to address questions of attribution, generalizability and rigor, and to think through how to approach these concerns in the field of quality improvement. The Salzburg Global Seminar Session 565 brought together 61 leaders in improvement from 22 countries, including researchers, evaluators and improvers. The primary conclusion that resulted from the session was the need for evaluation to be embedded as an integral part of the improvement. We have invited participants of the seminar to contribute to writing this supplement, which consists of eight articles reflecting insights and learning from the Salzburg Global Seminar. This editorial serves as an introduction to the supplement. The supplement explains results and insights from Salzburg Global Seminar Session 565.
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http://dx.doi.org/10.1093/intqhc/mzy020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5909659PMC
April 2018

Scaling up improvements more quickly and effectively.

Int J Qual Health Care 2017 Dec;29(8):1014-1019

Health Services Research and Implementation Science, Kaiser Permanente Southern California, Department of Research & Evaluation, 100S. Los Robles Ave., 3rd Floor, Pasadena, CA 91101, USA.

Faster and more widespread implementation could help more patients to benefit more quickly from known effective treatments. So could more effective implementation of better assessment methods, service delivery models, treatments and services. Implementation at scale and 'descaling' are ways for hospitals and health systems to respond to rising demands and costs. The paper proposes ways to provide leaders with the information that would help them to decide whether and how to scale up a proven improvement. We draw on our knowledge of the improvement and implementation literature on the subject and on our experience of scale up programs in Kaiser Permanente, in Swedish county health systems, and in international health. We describe a '3S' scale up infrastructure and other ingredients that appear necessary for successful widespread improvement, and list the resources that we have found useful for developing scale up programs. The paper aims to encourage more actionable research into scale up, and shows the opportunities for researchers to both advance implementation and improvement science and contribute to reducing suffering and costs in a more timely and effective way.
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http://dx.doi.org/10.1093/intqhc/mzx147DOI Listing
December 2017

Using patient-reported outcome measurement to improve patient care.

Int J Qual Health Care 2017 Oct;29(6):874-879

Shebva Medical Center, Tel Hashomer, Israel.

Patients at the center of care is often the stated focus of clinicians and healthcare services. The quality and safety movement has shown that effective organization of care is needed, in addition to professional skills. This movement has provided professionals and others with methods to improve both organization and practice for patients. These methods include measurement to give those carrying out improvement feedback about the effects of their changes. New types of measures that enable patients to report treatment outcomes can now be use in quality improvement and quality reporting to bring a renewed focus on making care more patient-centered. Although used for some time in research, these measures are relatively new tools for quality improvement and not all research measures are suitable for everyday feedback or improvement projects. The purpose of the paper is to provide an introduction to the use and value of patient-reported outcome measures in quality improvement and to give practical guidance and resources for using PROMs for quality improvement. It draws on the authors' experiences using patient reported outcomes measures for quality research and improvement and their workshop at the 2016 Tokyo ISQUA conference, as well as on reviews and guidance documents about the use of PROMs. It does not provide a comprehensive and systematic review of research, but an overview and introduction to PROMs for quality improvement.
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http://dx.doi.org/10.1093/intqhc/mzx108DOI Listing
October 2017

Using implementation tools to design and conduct quality improvement projects for faster and more effective improvement.

Int J Health Care Qual Assur 2017 Oct;30(8):755-768

Veterans Health Administration, Los Angeles, California, USA.

Purpose The purpose of this paper is to enable improvers to use recent knowledge from implementation science to carry out improvement changes more effectively. It also highlights the importance of converting research findings into practical tools and guidance for improvers so as to make research easier to apply in practice. Design/methodology/approach This study provides an illustration of how a quality improvement (QI) team project can make use of recent findings from implementation research so as to make their improvement changes more effective and sustainable. The guidance is based on a review and synthesis of improvement and implementation methods. Findings The paper illustrates how research can help a quality project team in the phases of problem definition and preparation, in design and planning, in implementation, and in sustaining and spreading a QI. Examples of the use of different ideas and methods are cited where they exist. Research limitations/implications The example is illustrative and there is little limited experimental evidence of whether using all the steps and tools in the one approach proposed do enable a quality team to be more effective. Evidence supporting individual guidance proposals is cited where it exists. Practical implications If the steps proposed and illustrated in the paper were followed, it is possible that quality projects could avoid waste by ensuring the conditions they need for success are in place, and sustain and spread improvement changes more effectively. Social implications More patients could benefit more quickly from more effective implementation of proven interventions. Originality/value The paper is the first to describe how improvement and implementation science can be combined in a tangible way that practical improvers can use in their projects. It shows how QI project teams can take advantage of recent advances in improvement and implementation science to make their work more effective and sustainable.
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http://dx.doi.org/10.1108/IJHCQA-01-2017-0019DOI Listing
October 2017

Bridging the discursive gap between lay and medical discourse in care coordination.

Sociol Health Illn 2017 09 28;39(7):1019-1034. Epub 2017 Mar 28.

School of Government, Plymouth University, UK.

For older people with multiple chronic co-morbidities, strategies to coordinate care depend heavily on information exchange. We analyse the information-sharing difficulties arising from differences between patients' oral narratives and medical sense-making; and whether a modified form of 'narrative medicine' might mitigate them. We systematically compared 66 general practice patients' own narratives of their health problems and care with the contents of their clinical records. Data were collected in England during 2012-13. Patients' narratives differed from the accounts in their medical record, especially the summary, regarding mobility, falls, mental health, physical frailty and its consequences for accessing care. Parts of patients' viewpoints were never formally encoded, parts were lost when clinicians de-coded it, parts supplemented, and sometimes the whole narrative was re-framed. These discrepancies appeared to restrict the patient record's utility even for GPs for the purposes of risk stratification, case management, knowing what other care-givers were doing, and coordinating care. The findings suggest combining the encoding/decoding theory of communication with inter-subjectivity and intentionality theories as sequential, complementary elements of an explanation of how patients communicate with clinicians. A revised form of narrative medicine might mitigate the discursive gap and its consequences for care coordination.
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http://dx.doi.org/10.1111/1467-9566.12553DOI Listing
September 2017

Using and choosing digital health technologies: a communications science perspective.

J Health Organ Manag 2017 Mar;31(1):28-37

Center for the Advancement of Healthcare Quality and Patient Safety (CAHQS), Faculty of Communication Sciences, Università della Svizzera italiana (USI) , Lugano, Switzerland.

Purpose The purpose of this paper is to explore a non-technical overview for leaders and researchers about how to use a communications perspective to better assess, design and use digital health technologies (DHTs) to improve healthcare performance and to encourage more research into implementation and use of these technologies. Design/methodology/approach Narrative overview, showing through examples the issues and benefits of introducing DHTs for healthcare performance and the insights that communications science brings to their design and use. Findings Communications research has revealed the many ways in which people communicate in non-verbal ways, and how this can be lost or degraded in digitally mediated forms. These losses are often not recognized, can increase risks to patients and reduce staff satisfaction. Yet digital technologies also contribute to improving healthcare performance and staff morale if skillfully designed and implemented. Research limitations/implications Researchers are provided with an introduction to the limitations of the research and to how communications science can contribute to a multidisciplinary research approach to evaluating and assisting the implementation of these technologies to improve healthcare performance. Practical implications Using this overview, managers are more able to ask questions about how the new DHTs will affect healthcare and take a stronger role in implementing these technologies to improve performance. Originality/value New insights into the use and understanding of DHTs from applying the new multidiscipline of communications science. A situated communications perspective helps to assess how a new technology can complement rather than degrade professional relationships and how safer implementation and use of these technologies can be devised.
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http://dx.doi.org/10.1108/JHOM-07-2016-0128DOI Listing
March 2017

Perspectives: answering questions about quality improvement: suggestions for investigators.

Authors:
John Øvretveit

Int J Qual Health Care 2017 Feb;29(1):137-142

LIME/MMC, Karolinska Institutet Medical University, Stockholm, Sweden.

'Does it work?' is not the only question that practical improvers have of those investigating of quality improvements. They also want to know, 'Will it work here? What conditions do we need to implement and sustain it? Can we adapt it? How much will it cost and save? Is there enough evidence to spread it?'This perspectives article describes methods that investigators can use to answer these questions about improvement changes and improvement methods. It suggests that one reason why research is underused by improvers is because there is little research that answers these questions that would enable improvers to decide whether or how to implement an improvement in their local setting. It shows improvers that answers are possible and where improvers might find research and reports which answer these questions. It is based on reviews of research and reports about methods for producing valid and actionable knowledge to answer these questions. It describes a new 'quality improvement investigation movement' which is uniting applied researchers and improvers to use innovative methods to answer these questions. These investigators recognize the strengths of the randomized controlled trail method, and how easy it is to draw the wrong conclusions from data generated using lower cost and more timely methods. It emphasizes how investigators can choose a method suited to each question, describe the limitations of the method and communicate to improvers the degree of certainty of their answers to the questions.
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http://dx.doi.org/10.1093/intqhc/mzw136DOI Listing
February 2017

Building a learning health system using clinical registers: a non-technical introduction.

J Health Organ Manag 2016 Oct;30(7):1105-1118

Institute for Healthcare Delivery Research, Intermountain Healthcare, Salt Lake City, Utah, USA.

Purpose The purpose of this paper is to describe how clinical registers were designed and used to serve multiple purposes in three health systems, in order to contribute practical experience for building learning healthcare systems. Design/methodology/approach Case description and comparison of the development and use of clinical registries, drawing on participants' experience and published and unpublished research. Findings Clinical registers and new software systems enable fact-based decisions by patients, clinicians, and managers about better care, as well as new and more economical research. Designing systems to present the data for users' daily work appears to be the key to effective use of the potential afforded by digital data. Research limitations/implications The case descriptions draw on the experience of the authors who were involved in the development of the registers, as well as on published and unpublished research. There is limited data about outcomes for patients or cost-effectiveness. Practical implications The cases show the significant investments which are needed to make effective use of clinical register data. There are limited skills to design and apply the digital systems to make the best use of the systems and to reduce their disadvantages. More use can be made of digital data for quality improvement, patient empowerment and support, and for research. Social implications Patients can use their data combined with other data to self-manage their chronic conditions. There are challenges in designing and using systems so that those with lower health and computer literacy and incomes also benefit from these systems, otherwise the digital revolution may increase health inequalities. Originality/value The paper shows three real examples of clinical registers which have been developed as part of their host health systems' strategies to develop learning healthcare systems. The paper gives a simple non-technical introduction and overview for clinicians, managers, policy-advisors and improvers of what is possible and the challenges, and highlights the need to shape the design and implementation of digital infrastructures in healthcare services to serve users.
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http://dx.doi.org/10.1108/JHOM-06-2016-0110DOI Listing
October 2016

Patient focused registries can improve health, care, and science.

BMJ 2016 Jul 1;354:i3319. Epub 2016 Jul 1.

Medical Management Centre, Karolinska Institutet, Stockholm, Sweden Quality Register Center Stockholm, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367618PMC
http://dx.doi.org/10.1136/bmj.i3319DOI Listing
July 2016

Comparing and improving chronic illness primary care in Sweden and the USA.

Int J Health Care Qual Assur 2016 Jun;29(5):582-95

LIME/MMC, Karolinska Institutet, Stockholm, Sweden.

Purpose - The purpose of this paper is to identify opportunities for improving primary care services for people with chronic illnesses by comparing how Sweden and US services use evidence-based practices (EBPs), including digital health technologies (DHTs). Design/methodology/approach - A national primary healthcare center (PHCC) heads surveys in 2012-2013 carried out in both countries in 2006. Findings - There are large variations between the two countries. The largest, regarding effective DHT use in primary care centers, were that few Swedish primary healthcare compared to US heads reported having reminders or prompts at the point of care (38 percent Sweden vs 84 percent USA), despite Sweden's established electronic medical records (EMR). Swedish heads also reported 30 percent fewer centers receiving laboratory results (67 percent Sweden vs 97 percent USA). Regarding following other EBPs, 70 percent of Swedish center heads reported their physicians had easy access to diabetic patient lists compared to 14 percent in the USA. Most Swedish PHCC heads (96 percent) said they offered same day appointment compared to 36 percent in equivalent US practices. Practical implications - There are opportunities for improvement based on significant differences in effective practices between the countries, which demonstrates to primary care leaders that their peers elsewhere potentially provide better care for people with chronic illnesses. Some improvements are under primary care center control and can be made quickly. There is evidence that people with chronic illnesses in these two countries are suffering unnecessarily owing to primary care staff failing to provide proven EBP, which would better meet patient needs. Public finance has been invested in DHT, which are not being used to their full potential. Originality/value - The study shows the gaps between current and potential proven effective EBPs for services to patients with chronic conditions. Findings suggest possible explanations for differences and practical improvements by comparing the two countries. Many enhancements are low cost and the proportionate reduction in suffering and costs they bring is high.
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http://dx.doi.org/10.1108/IJHCQA-02-2016-0014DOI Listing
June 2016

Guidance for research-practice partnerships (R-PPs) and collaborative research.

J Health Organ Manag 2014 ;28(1):115-26

Purpose: The purpose of this paper is to provide evidence based guidance to researchers and practice personnel about forming and carrying out effective research partnerships.

Design/methodology/approach: A review of the literature, interviews and discussions with colleagues in both research and practice roles, and a review of the authors' personal experiences as researchers in partnership research.

Findings: Partnership research is, in some respects, a distinct "approach" to research, but there are many different versions. An analysis of research publications and of their research experience led the authors to develop a framework for planning and assessing the partnership research process, which includes defining expected outcomes for the partners, their roles, and steps in the research process.

Practical Implications: This review and analysis provides guidance that may reduce commonly-reported misunderstandings and help to plan more successful partnerships and projects. It also identifies future research which is needed to define more precisely the questions and purposes for which partnership research is most appropriate, and methods and designs for specific types of partnership research.

Originality/value: As more research moves towards increased participation of practitioners and patients in the research process, more precise and differentiated understanding of the different partnership approaches is required, and when each is most suitable. This article describes research approaches that have the potential to reduce "the research-practice gap". It gives evidence- and experience-based guidance for choosing and establishing a partnership research process, so as to improve partnership relationship-building and more actionable research.
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http://dx.doi.org/10.1108/JHOM-08-2013-0164DOI Listing
June 2014

A patient-centered primary care practice approach using evidence-based quality improvement: rationale, methods, and early assessment of implementation.

J Gen Intern Med 2014 Jul;29 Suppl 2:S589-97

VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, VA Greater Los Angeles, 16111 Plummer Street, North Hills, CA, 91343, USA,

Background: Healthcare systems and their primary care practices are redesigning to achieve goals identified in Patient-Centered Medical Home (PCMH) models such as Veterans Affairs (VA)'s Patient Aligned Care Teams (PACT). Implementation of these models, however, requires major transformation. Evidence-Based Quality Improvement (EBQI) is a multi-level approach for supporting organizational change and innovation spread.

Objective: To describe EBQI as an approach for promoting VA's PACT and to assess initial implementation of planned EBQI elements.

Design: Descriptive.

Participants: Regional and local interdisciplinary clinical leaders, patient representatives, Quality Council Coordinators, practicing primary care clinicians and staff, and researchers from six demonstration site practices in three local healthcare systems in one VA region.

Intervention: EBQI promotes bottom-up local innovation and spread within top-down organizational priorities. EBQI innovations are supported by a research-clinical partnership, use continuous quality improvement methods, and are developed in regional demonstration sites.

Approach: We developed a logic model for EBQI for PACT (EBQI-PACT) with inputs, outputs, and expected outcomes. We describe implementation of logic model outputs over 18 months, using qualitative data from 84 key stakeholders (104 interviews from two waves) and review of study documents.

Results: Nearly all implementation elements of the EBQI-PACT logic model were fully or partially implemented. Elements not fully achieved included patient engagement in Quality Councils (4/6) and consistent local primary care practice interdisciplinary leadership (4/6). Fourteen of 15 regionally approved innovation projects have been completed, three have undergone initial spread, five are prepared to spread, and two have completed toolkits that have been pretested in two to three sites and are now ready for external spread.

Discussion: EBQI-PACT has been feasible to implement in three participating healthcare systems in one VA region. Further development of methods for engaging patients in care design and for promoting interdisciplinary leadership is needed.
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http://dx.doi.org/10.1007/s11606-013-2703-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4070240PMC
July 2014

Suffering in silence: a qualitative study of second victims of adverse events.

BMJ Qual Saf 2014 Apr 15;23(4):325-31. Epub 2013 Nov 15.

Department of Learning, Informatics, Management and Ethics (LIME), Medical Management Centre (MMC), Karolinska Institutet, , Stockholm, Sweden.

Introduction: The term 'second victim' refers to the healthcare professional who experiences emotional distress following an adverse event. This distress has been shown to be similar to that of the patient-the 'first victim'. The aim of this study was to investigate how healthcare professionals are affected by their involvement in adverse events with emphasis on the organisational support they need and how well the organisation meets those needs.

Methods: 21 healthcare professionals at a Swedish university hospital who each had experienced an adverse event were interviewed. Data from semi-structured interviews were analysed by qualitative content analysis using QSR NVivo software for coding and categorisation.

Results: Our findings confirm earlier studies showing that emotional distress, often long-lasting, follows from adverse events. In addition, we report that the impact on the healthcare professional was related to the organisation's response to the event. Most informants lacked organisational support or they received support that was unstructured and unsystematic. Further, the formal investigation seldom provided adequate and timely feedback to those involved. The insufficient support and lack of feedback made it more difficult to emotionally process the event and reach closure.

Discussion: This article addresses the gap between the second victim's need for organisational support and the organisational support provided. It also highlights the need for more transparency in the investigation of adverse events. Future research should address how advanced support structures can meet these needs and provide learning opportunities for the organisation. These issues are central for all hospital managers and policy makers who wish to prevent and manage adverse events and to promote a positive safety culture.
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http://dx.doi.org/10.1136/bmjqs-2013-002035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963543PMC
April 2014

Improvement research priorities: USA survey and expert consensus.

Nurs Res Pract 2013 18;2013:695729. Epub 2013 Aug 18.

Academic Center for Evidence-Based Practice, School of Nursing, University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA ; Steering Council Member, Improvement Science Research Network, USA.

The purpose of this study was to identify stakeholder views about national priorities for improvement science and build agreement for action in a national improvement and implementation research network in the USA. This was accomplished using three stages of identification and consensus. (1) Topics were identified through a multipronged environmental scan of the literature and initiatives. (2) Based on this scan, a survey was developed, and stakeholders (n = 2,777) were invited to rate the resulting 33-topic, 9-category list, via an online survey. Data from 560 respondents (20% response) were analyzed. (3) An expert panel used survey results to further refine the research priorities through a Rand Delphi process. Priorities identified were within four categories: care coordination and transitions, high-performing clinical systems and microsystems improvement approaches, implementation of evidence-based improvements and best practices, and culture of quality and safety. The priorities identified were adopted by the improvement science research network as the research agenda to guide strategy. The process and conclusions may be of value to quality improvement research funding agencies, governments, and research units seeking to concentrate their resources on improvement topics where research is capable of yielding timely and actionable answers as well as contributing to the knowledge base for improvement.
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http://dx.doi.org/10.1155/2013/695729DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3759273PMC
September 2013

Psychometric properties of the Hospital Survey on Patient Safety Culture, HSOPSC, applied on a large Swedish health care sample.

BMC Health Serv Res 2013 Aug 22;13:332. Epub 2013 Aug 22.

Medical Management Centre, Karolinska Institutet, SE 171 77 Stockholm, Sweden.

Background: A Swedish version of the USA Agency for Healthcare Research and Quality "Hospital Survey on Patient Safety Culture" (S-HSOPSC) was developed to be used in both hospitals and primary care. Two new dimensions with two and four questions each were added as well as one outcome measure. This paper describes this Swedish version and an assessment of its psychometric properties which were tested on a large sample of responses from personnel in both hospital and primary care.

Methods: The questionnaire was mainly administered in web form and 84215 forms were returned (response rate 60%) between 2009 and 2011. Eleven per cent of the responses came from primary care workers and 46% from hospital care workers. The psychometric properties were analyzed using both the total sample and the hospital and primary care subsamples by assessment of construct validity and internal consistency. Construct validity was assessed by confirmatory (CFA) and exploratory factor (EFA) analyses and internal consistency was established by Cronbachs's α.

Results: CFA of the total, hospital and primary care samples generally showed a good fit while the EFA pointed towards a 9-factor model in all samples instead of the 14-dimension S-HSOPSC instrument. Internal consistency was acceptable with Cronbach's α values above 0.7 in a major part of the dimensions.

Conclusions: The S-HSOPSC, consisting of 14 dimensions, 48 items and 3 single-item outcome measures, is used both in hospitals and in primary care settings in Sweden for different purposes. This version of the original American instrument has acceptable construct validity and internal consistency when tested on large datasets of first-time responders from both hospitals and primary care centres. One common instrument for measurements of patient safety culture in both hospitals and primary care settings is an advantage since it enables comparisons between sectors and assessments of national patient safety improvement programs. Future research into this version of the instrument includes comparing results from patient safety culture measurements with other outcomes in relation to safety improvement strategies.
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http://dx.doi.org/10.1186/1472-6963-13-332DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3765335PMC
August 2013

[Staff who have been involved in adverse events is left without help. Systematic support from colleagues and managers is desirable, according to interview study].

Lakartidningen 2013 Mar 13-19;110(11):550-2

Institutionen för lärande, informatik, management och etik, Medical Management Centre, Karolinska institutet.

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July 2013

Simulation team training for improved teamwork in an intensive care unit.

Int J Health Care Qual Assur 2013 ;26(2):174-88

Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.

Purpose: This study aims to describe implementation of simulator-based medical team training and the effect of this programme on inter-professional working in an intensive care unit (ICU).

Design/methodology/approach: Over a period of two years, 90 percent (n = 152) of the staff of the general ICU at Karolinska University Hospital, Huddinge, Sweden, received inter-professional team training in a fully equipped patient room in their own workplace. A case study method was used to describe and explain the planning, formation, and results of the training programme.

Findings: In interviews, the participants reported that the training had increased their awareness of the importance of effective communication for patient safety. The intervention had even had an indirect impact by creating a need to talk, not only about how to communicate efficaciously, but also concerning difficult care situations in general. This, in turn, had led to regular reflection meetings for nurses held three times a week. Examples of better communication in acute situations were also reported. However, the findings indicate that the observed improvements will not last, unless organisational features such as staffing rotas and scheduling of rounds and meetings can be changed to enable use of the learned behaviours in everyday work. Other threats to sustainability include shortage of staff, overtime for staff, demands for hospital beds, budget cuts, and poor staff communication due to separate meetings for nurses and physicians.

Originality/value: The present results broaden our understanding of how to create and sustain an organizational system that supports medical team training.
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http://dx.doi.org/10.1108/09526861311297361DOI Listing
May 2013

Contemporary quality improvement.

Authors:
John Øvretveit

Cad Saude Publica 2013 Mar;29(3):424-6

Medical Management Centre, The Karolinska Institutet, Stockholm, Sweden.

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http://dx.doi.org/10.1590/s0102-311x2013000300002DOI Listing
March 2013
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