SUMMARY This thesis addresses improvement capability at the front lines of healthcare with a focus on interprofessional health care improvement teams who provide care and improve care. The overall aim is to explore high performing clinical microsystems and evaluate interventions to cultivate health care improvement capabilities of frontline interprofessional teams. Methods Descriptive and evaluative study designs were employed in the five studies which comprise this thesis. A total of 495 interprofessional health care providers from a variety of health care contexts in the United States (Study I, II, III & IV) and Sweden (Study V) participated in the studies. The mixed methods research included qualitative observation, interviews, focus groups and surveys analyzed with qualitative manifest content analysis. The quantitative data were analyzed with statistics appropriate for non-parametric data. Findings Study I and II describe how leaders who understand health care improvement can create conditions for interprofessional teams to provide care and simultaneously improve care. Study III evaluates adapted clinical microsystem processes and tools successfully adapted in two different hospitals. Frontline staff reported that they needed help to balance providing care and improving care. Study IV and V explored and tested team coaching to help interprofessional teams to increase their improvement capabilities within improvement collaboratives. The participants perceived team coaching mostly positively and identified supportive coaching actions. In Study V an intervention with “The Team Coaching Model” was tested in Sweden and showed increased acquisition of improvement knowledge in the intervention teams compared to teams who did not receive the coaching model. Conclusions The thesis findings show leaders can help cultivate health care improvement capability by designing structures, processes and outcomes of their organizational systems to support health care improvement activities, setting clear improvement expectations of all staff, developing the knowledge of every staff member in the microsystem to know their operational processes and systems to promote action learning in their daily work, and providing help with team coaching using a Team Coaching Model.

Objectif de l’étude : Identifier les modifications des critères de décision des médecins généralistes et des médecins spécialistes du cancer concernant la prise en charge des personnes âgées atteintes de cancer (Lorraine, France), après mise en place sur une année de mesures correctives des pratiques de soin. Matériel et Méthode : En 2014, 2925 questionnaires évaluant ces critères de décision ont été envoyés par voie postale à l’ensemble des médecins généralistes et des spécialistes du cancer de la région Lorraine. Pendant l’année suivante, ont été mises en place des mesures d’amélioration consistant principalement en des séances de formation et d’information et en la distribution d’outils spécifiques (création d’un guide des idées reçues cancer et personnes âgées). En 2015, 2987 questionnaires ont été envoyés à la même population pour réévaluation. Cette étude quantitative a été complétée par une étude qualitative en 2016 par entretiens semi-dirigés auprès de 56 patients âgés atteints de cancer et 36 médecins généralistes lorrains portant sur leur ressenti concernant le parcours de soins. Résultats : 535 réponses ont été colligées en 2014, et 480 réponses en 2015. On observe une différence significative concernant l’ensemble des critères de décision entre les deux périodes de l’enquête. Pour la plupart de leurs critères de décision listés en 2014, les médecins les considèrent moins important après la période de formation. Les principales difficultés rapportées sont d’ordre organisationnel. L’étude qualitative confirme ces données, avec en particulier un besoin de formation. Les patients expriment une satisfaction importante de leur parcours de soin. Conclusion : Les médecins généralistes et les spécialistes du cancer se rejoignent sur les difficultés rencontrées, plus qu’ils ne s’opposent sur les modalités de prise en charge. La formation des professionnels est un levier majeur d’amélioration des pratiques, notamment par rapport à la perception de la maladie cancéreuse / Objective : To identify changes in the decision-making criteria of general ractitioners and oncologists concerning the care of elderly cancer patients after one year of corrective measures for care practices in the Lorraine region, France. Methods : In 2014, a postal mail questionnaire was sent to all GPs and oncologists in the Lorraine region. This questionnaire was designed to identify physicians decision-making criteria. It was based on the results of a literature review and on existing guidelines. During one year, corrective measures were implemented to improve practices, especially training sessions for physicians and production of specific tools including a guide to the accepted ideas in geriatric oncology. In 2015, the same questionnaire was resent to the same medical population to compare the answers. We also performed a complementary qualitative study of general practitioners and elderly people in charge of oncogeriatric consultation. Results : In 2014, 535 questionnaires were returned out of 2925 sent and in 2015, 480 were returned out of 2987 sent. Our results show for the first time that there exists a significant difference in the overall decision criteria between the two survey periods. Physicians tend to consider the principal decision criteria to be less important after the training period. GPs and oncologists express the importance of the interval before care begins. The qualitative study confirms this data, with a need for training. Patients express significant satisfaction with their care pathway. Conclusion : Training and information sessions for physicians remain the most important tool for improving care practices. The analysis of our data makes it possible to further integrate the patient into the care path, which remains a public health issue in terms of cost and organization

The aim of the study was to examine adolescents’ experiences of having brachial plexus birth palsy, which is impaired arm function due to a birth injury. Psychosocial focal points were how the adolescent’s experience their lives concerning studies, spare time activities and relationships, experiences of limitations in comparison to their peers, and how they experience health care. Eight adolescents who had surgery of the injury were interviewed. Through qualitative phenomenological analysis the following meaning units were identified: ‘Me and others’; ‘Professional medical contacts and experiences’; and ‘Adjustment and strategies to solutions and obstacles’ with essences ‘Disabled or have a disability’; ‘Then and now’ and ‘Lack of references’. The result showed that the adolescents did not identify themselves as disabled, and did not focus on their arm, but wished for improved physical function. They had good support from health care, although wanted more follow-ups and more aimed information. They had adjusted well to their injury, but did not have any comparisons as they had their injury since birth. Understanding the experiences adolescents with BPBP have is essential for advancing the care of these individuals. Further research is necessary regarding the experience people with this injury have. / Syftet med studien var att studera ungdomars erfarenheter av att leva med en plexusskada, det vill säga nedsatt armfunktion på grund av en förlossningsskada, ur ett psykosocialt perspektiv med fokus på hur ungdomarna upplever sina liv beträffande studier, fritid och relationer, upplevelser av begränsningar i jämförelse med generationskamrater på grund av skadan, samt erfarenheter av sjukvården. Åtta ungdomar som opererats för skadan intervjuades. Genom kvalitativ fenomenologisk analys kunde följande meningsbärande enheter urskiljas: ’Jag och andra’; ’Professionella kontakter och erfarenheter’ och ’Anpassningar och strategier till lösningar och hinder’ där ’Funktionshindrad eller ha funktionshinder’; ’Då och nu’ samt ’Brist på referenser’ var gemensamma samtalsämnen. Resultatet visade att ungdomarna inte betraktade sig som handikappade, de fokuserade inte på sin arm i sin vardag, och önskade klara av mer fysiska aktiviteter. De upplevde gott stöd från sjukvården, men önskade uppföljningar och mer riktad information. De hade anpassat sig till skadan, men upplevde att de inte kunde jämföra med andra eftersom de haft skadan sedan födseln. Att kunna förstå ungdomars erfarenheter av att leva med en plexusskada, är nödvändigt för att förbättra vården och bemötandet för dessa individer.