Yes / Background: Evidence suggests that patients can meaningfully feed back to healthcare providers about the safety of their care. The PRASE (Patient Reporting and Action for a Safe Environment) intervention provides a way to systematically collect feedback from patients to support service improvement. The intervention is being implemented in acute care settings with patient feedback collected by hospital volunteers for the first time. Objective: To undertake a formative evaluation which explores the feasibility and acceptability of the PRASE intervention delivered in collaboration with hospital volunteers from the perspectives of key stakeholders. Design: A qualitative evaluation design was adopted across two acute NHS Trusts in the UK between July 2014 and November 2015. We conducted five focus groups with hospital volunteers (n = 15), voluntary services and patient experience staff (n = 3) and semistructured interviews with ward staff (n = 5). Data were interpreted using framework analysis. Results: All stakeholders were positive about the PRASE intervention as a way to support service improvement, and the benefits of involving volunteers. Volunteers felt adequate training and support would be essential for retention. Staff concentrated on the infrastructure needed for implementation and raised concerns around sustainability. Findings were fed back to the implementation team to support revisions to the intervention moving into the subsequent summative evaluation phase. Conclusion: Although there are concerns regarding sustainability in practice, the PRASE intervention delivered in collaboration with hospital volunteers is a promising approach to collect patient feedback for service improvement. / The Health Foundation (Closing the Gap in Patient Safety Programme).

Den svenska hälso- och sjukvården står inför utmaningen med en ökande och åldrande befolkning. Överdiagnostisering och under-, över- och felanvändning av diagnostisk service bidrar till de ekonomiska utmaningarna. Utilization management kan bidra till att komma tillrätta med användningen. I ett samarbetsprojekt mellan Rådet för värdeskapande användning av Medicinsk diagnostik i Region Jönköpings län och en vårdcentral genomfördes ett förbättringsarbete för att minska förbrukningen av laboratorieanalyser; målet var att komma till rätta med över-, under och felanvändning. Parallellt genomfördes en studie med syftet att utvärdera effekter av fem insatser rådet gjort. Studien genomfördes med en mixad metod med förklarande sekventiell design. Då förbättringsarbetet aldrig tog fart i verksamheten, på grund av chefsomsättning, kan inga resultat redovisas. Studien påvisar få förändringar i beställningsmönster. I intervjuerna med remittenterna framkommer temat att vilja arbeta med beställningsmönster och förändringar nära verksamheten. Remittenterna efterfrågar tekniska lösningar och dialog med de diagnostiska specialiteterna. Litteraturen stödjer hittills gjorda insatser men i studien ses få resultat. Tidigare insatser har varit engångsföreteelser. Genom att nyttja förbättringskunskapen och arbeta med frågorna närmare remittenternas vardag kan engagemang skapas varpå förändringen lättare anammas. Kombinationen av förbättringsarbeten på mikrosystemnivå med stöd och förbättringar på mesonivå kommer sannolikt att bidra till framgång med värdeskapande användning. / Swedish healthcare is facing the challenge of an increasing and aging population making cost reductions necessary. Some of the challenges are based around the over diagnosis and the misutilisation of laboratory analysis. Utilisation management could contribute to proper use. A quality improvement project was performed as a collaboration between a primary care centre and the Council of Value-creating use of Medical Diagnosis. The aim was to reduce the number of analyses and misuse of laboratory analysis. A mixed method study was conducted with the aim to evaluate five interventions made by the Council. Because the improvement project never really started, results are limited. Interviews with physicians revealed that the studied units are open for dialogue with the diagnostic specialties and willing to change ordering patterns but few changes were detected. The literature supports the interventions made so far but few results are shown. One reason might be that previous efforts have been isolated events. By using the knowledge of quality improvement and bringing the questions closer to the units’, change might be easier to embrace. The combination of quality improvement in the microsystems with support and improvements in mesosystems will probably contribute to success.

The research reported in this dissertation investigates the impact that accountability systems have on the design and development of student centered learning environments. The nature of student-centered learning environments (SCLEs) in this study is framed theoretically by cultural historical activity theory (CHAT). The investigation itself occurred within a specific practice context: an urban charter school serving elementary-aged children. The efforts to design and develop SCLEs in the school focused on the use of improvement inquiry by groups of stakeholders organized into a developing human ecology in educational contexts called networked improvement communities. The research sought to determine (1) how accountability systems influenced instructional practices within the school and (2) how practicing teachers perceived the assessments embedded within the accountability systems. Data were collected via surveys, interviews, and a focus group. The data from the surveys and interviews informed the work for the focus group. The work from the focus group generated a stakeholder-generated “theory of practice improvement” in the form of an illustrative driver diagram. The driver diagram contributed an empirically generated proposal for how improved instructional practices might be pursued at the school. The investigation concluded with recommendations for implementing the plan within the school and recommendations to the broader field of education to engage more deeply in improvement inquiry. / School of Education; / Professional Doctorate in Educational Leadership (ProDEL) / EdD; / Dissertation;

Inom Jönköpingssocialtjänst genomfördes ett förbättringsarbete som syftade till ökad säkerhet  för  barn  och  unga  samt  förbättrat  stöd  till  barn  och  familjer. Målet  var färre sammanbrott vid placeringar och mer ändamålsenliga insatser i barnets hemmiljö. För att nå syftet genomfördes ett projekt som handlade om att implementera Signs of Safety på ett av Jönköpings socialkontor. Förbättringsarbetet använde Hållbarhetstriangeln och dess tre hörnstenar som struktur; styrning, stöd och störning. Förbättringsarbetet studerades med hjälp av fallstudiedesign som byggde på intervjuer med deltagare i förbättringsprojektet samt dokument. Studiens syfte var att utöka kunskapen kring vilka påverkande faktorer som förekommer kopplat till förbättringsarbete inom socialtjänstens barnavård. Resultatet av förbättringsarbetet visar ingen tydlig förbättring i förhållande till förbättringsarbetets mål, dock indikerar processmätningar att föräldrarna upplever starkare samarbetsallians med socialtjänsten under och efter projektet än före. Studiens resultat tyder på att genomförandet av förbättringsarbetet påverkat förutsättningen att lyckas med implementeringen av Signs of Safety. Följande påverkansfaktorer identifierades: förståelsen, viljan, möjligheten att lära samt fördelningen av resurser. En av studiens slutsatser är att fördelning av resurser verkar vara viktigt men faktorer som är av god kvalitet, såsom metodstöd, kan kompensera för de som saknas vilket styrker tidigare forskning inom området. / The child welfare service in Jönköping municipality carried out an improvement project aimed for increased safety for children and improved support for children and families. The goal was fewer breakdowns in out-of-home placements and more effective interventions in the child's home environment. An improvement project about implementing Signs of Safety in one of Jönköping's offices was conducted.The improvement project was based on the Sustainability Triangle and its three pillars; governance, support and disturbance.The improvement project was studied by case-study design including interviews with participants and document analysis. The aim of the study was to increase the knowledge of influencing factors linked to improvements in the context of child welfare. The goals of the improvement project were not reached though the results indicate that the parents experienced increased collaborative alliance with the social services during and after the project than before.The process of the improvement project influenced the premise of successful implementation of Signs of Safety. Understanding, will, ability to learn and allocation of resources appeared as influencing factors. The conclusion is that allocation of resources seems to be important, but that factors, such as method support, which are of good quality can compensate for missing resources. This reinforces earlier research in the field.

Unexplained variations in organisational performance in healthcare are a continued focus of research, political, and public interest. Regulatory agencies are always seeking new ways to reduce variation and improve performance, and the use of approaches to develop improvement capability is increasingly encouraged. However, the regulatory perspective on improvement capability is under researched. This research study seeks to understand how regulatory agencies in the United Kingdom (UK) assess improvement capability within healthcare organisations. It explores how improvement capability is conceptualised, compares the regulatory arrangements across the UK, and examines assessment and enforcement policies and practices, before developing a conceptual framework for improvement capability. The research study uses data from 48 interviews, 90 regulatory policy documents and 30 assessment reports. Regulatory conceptualisations of improvement capability are explored through cross-case comparison and qualitative analysis. A review of 70 instruments and frameworks for the assessment of improvement capability from the literature identifies that there are plural conceptualisations of improvement capability. The findings from the review are synthesised into eight dimensions of improvement capability which are used to analyse the empirical data and to develop a conceptual framework. The analysis finds an emergent trend towards responsive regulatory models which aim to develop improvement capability. However, the analysis identifies ambiguity in regulatory agencies' conceptualisation of improvement capability with two dimensions of improvement capability used more frequently than others in regulatory assessments. Regulatory agencies need to clarify their conceptualisation of improvement capability and supplement their assessment processes to further understand local circumstances. This can be used to inform more flexible regulatory responses, including the tailored provision of improvement support to develop improvement capability. This requires greater regulatory effort and resources, and the analysis finds there are three areas of tension, linked to regulatory roles, resources and relationships. The research study proposes a conceptual framework of improvement capability that can be used to clarify regulatory conceptualisation and assessment of improvement capability. Greater conceptual clarity will strengthen regulatory agencies' assessment, diagnosis and prediction of organisational performance trajectories, and support the advancement of more appropriate, effective and responsive regulatory interventions, including the development of improvement capability.

<p>  </p> <p>Education reforms aimed at improving student outcomes often fail because they are top-down and do not successfully scale to wider use. Over the past two decades, improvement science, which uses disciplined inquiry to solve district problems at scale, has emerged as a solution. This multi-case study investigated the question: What are the profiles and lived experiences of superintendents who use improvement science? Data for this study were collected through semi-structured interviews with three superintendents who were part of a superintendent network that focused on improvement science. The superintendents were from diverse districts: A regional Education Services District, an urban school district, and a suburban school district. Data were analyzed through themes that emerged in the literature and data. Four key findings were gleaned: Superintendents need to 1) prioritize a positive workplace culture, 2) shift ownership to staff, 3) support staff in sharing and risk taking, and 4) shift to the use of measurements at the team-level. Three recommendations stemmed from the findings and literature: Superintendents should 1) foster a workplace culture emphasizing ownership and vulnerability, 2) ensure implementation is user-centered, and 3) focus on solving the most pressing problems connected to student outcomes. Action steps for each recommendation are provided. Superintendent profiles showed them to be leaders who improve the workplace culture, are equity-driven, are vulnerable and reflective, are instructional leaders and system thinkers, and are collaborative. Yet they are still working toward staff taking ownership of improvement efforts. In essence, staff implementation has not caught up to superintendent vision. This study suggests if superintendents build capacity around a positive workplace culture and a user-centered, problem-specific approach, districts will be able to solve the most pressing student equity gap problems at scale.</p>

Introduktion Medicinsk vetenskap och sjukvårdens möjligheter att hjälpa utvecklas ständigt. Sjukvården idag kan i många fall ställa rätt diagnos och ge en effektiv behandling för att bota den som drabbats av ohälsa. Radiologiska undersökningar är ett viktigt hjälpmedel men innebär också risker i form av strålning samt felaktigt resursanvändande. Syfte Syftet med förbättringsarbetet var att skapa en bättre användning av radiologi och följsamhet till medicinska riktlinjer så att patienten får rätt undersökning utifrån sitt behov samt att resur-ser nyttjas mer optimalt. Målsättningen var att öka andelen berättigade undersökningar. Syftet med studien av förbättringsarbetet var att få en förståelse för vilka faktorer som påverkar remittentens val av radiologisk undersökning och därmed berättigandegraden vilka aktiviteter i förbättringsarbetet påverkar berättigandegraden och på vilket sätt Metod Interventioner i form av utbildning och mätningar användes för att höja berättigandegraden. Bedömning av berättigandegraden gjordes av en ST-läkare. En fallstudie med kvalitativ ansats genomfördes och fokusgruppintervju användes för att stu-dera förbättringsarbetet. Resultat Studien visar att berättigandegraden ökar något som ett resultat av de valda interventionerna. Utbildningen på plats gav också upplevda positiva effekter i form av bättre kunskap och lä-rande för deltagare. Analysen visade att osäkerhet som läkare upplever i sitt arbete med patienten kan härledas till kategorierna kunskap och krav. Diskussion/Slutsats Utbildning genomförd av radiologispecialist har visat sig vara framgångsrikt koncept. Mät-ningar som metod för lärande och förändring uppfattades istället som mätning för uppföljning. Förbättrad kunskap kring vilka faktorer som styr läkares val av undersökning har uppnåtts och områden för fortsatt förbättring har identifierats / Introduction Medical science and medical facilities and clinical possibilities to help patients evolve con-stantly. Healthcare today can often make the diagnosis and provide effective treatment to cure the victim of ill health. Radiological surveys are an important tool but also provide risks in the form of radiation, and improper use of resources. Purpose The purpose of the improvement work was to create a better use of radiology and adherence to medical guidelines so that the patient gets the right for increase based on their needs and resources will be used more optimally. The goal was to increase the proportion of eligible studies. The purpose of the study of the improvement was to gain an understanding of what factors affect physicians choice of radiological investigation and thereby provide entitlement degree which activities in the improvement process affects eligibility degree and in what way Method Interventions in the form of education and measurements used to improve eligibility rate. As-sessment of the eligibility rate was made by a resident physician. A case study with a qualitative approach was implemented and focus-group interviews were used to study the improvement process. Results Results indicates that the eligibility rate increased slightly as a result of the selected interven-tions. Education in place, however, gave perceived benefits in terms of improved knowledge and learning for participants. The analysis showed that the uncertainty that physicians experience in their work with pa-tients can be attributed to the categories of knowledge and requirements. Discussion / Conclusion Education conducted by a radiology specialist has is shown to be a successful concept. Meas-urements as a method of learning and change were perceived as measurement for monitoring. Improved knowledge about the determinants of physician choice of survey has been achieved and areas for further improvement are identified.

This thesis is anchored in improvement science, the research field of improvement. Improvement science describes and explores improvement in real-life contexts and “system of profound knowledge” (Deming, 2000) is a cornerstone. Performance measures, including their variation over time, are fundamental in the research and evaluation of outcomes of continuous quality improvement efforts (CQI efforts). However, the strong emphasis on operationalisations and measurements risks overshadowing other kinds of outcomes to which CQI efforts can lead. Research has shown that it is advantageous that those performing change have some kind of “sharedness”, e.g. shared cognitions, understanding, knowledge, interpretations or frame of reference. Despite the diversity of concepts and scientific studies, “sharedness” is mainly described as a prerequisite for change. This thesis addresses the call to broaden the scientific approach in improvement science and to take advantage of knowledge developed since Deming's time. It has a point of departure in the presumption that CQI efforts also lead to intangible outcomes; qualitative effects that are not easily captured with traditional performance measures. The concept “Expressions of shared interpretations” is used to study “sharedness” as intangible outcomes. The overall aim with this thesis is to explore Expressions of shared interpretations as intangible outcomes of CQI efforts from the perspective of clinical microsystems and healthcare professionals. The specific aims are to examine and establish how Expressions of shared interpretations develop, influence CQI efforts and change over time. Using a qualitative approach, this thesis comprises four papers, based on three studies. The empirical context is healthcare and welfare organizations providing care: hospital clinics in county councils/regions and nursing homes in municipalities. The studies include time periods from one to three and a half years, totalling six years. Expressions of shared interpretations inherently mean that the methods for data analysis need to be based on commonalities or patterns in the data. In this thesis three methods are used: qualitative content analysis, thematic analysis and directed content analysis. To examine time-related changes, year-to-year comparative analyses of themes and categories are done. To explore Expressions of shared interpretations, different theoretical frameworks are used: team cognitions (Paper 1), sensemaking theory (Paper 2), cognitive shifts (Paper 3) and programme theories (Paper 4). A directed content analysis is applied in a meta-analysis of the results presented in the four papers. The results indicate that Expressions of shared interpretations develop as intangible outcomes of CQI efforts and a general programme theory of CQI efforts in health- and elderly care is developed, illuminating how Expressions of shared interpretations change and influence CQI efforts. The general programme theory incorporates the PDSA cycle and describes the complex, interconnected and continuous development of Expressions of shared interpretations. It also illuminates how Expressions of shared interpretations provide change performers with momentum to engage in forthcoming PDSA cycles and how sensemaking is a central activity. CQI efforts in health- and elderly care are characterised by a “just get on with it” attitude, while in this thesis, thoughtfulness is emphasized. Existing improvement tools support collaboration, creativity and analysis of critical aspects of the operations, yet none of the improvement tools help change performers gain understanding of the CQI effort as such. To address this, this thesis suggests that change performers complement the use of improvement tools with an inquiring mind, that they collaborate in thoughtful dialogues and that leaders function as inquirers. To support this posture, the widely used Model for improvement is complemented with a fourth question: What are our assumptions? The question pinpoints the need to be thoughtful in every step of the CQI effort, not just in the analysis of the problem at hand.

abstract: The most common approach to improvement of educational systems has been the adoption of episodic initiatives and short-lived improvement programs. In recent years, a continuous improvement (CI) approach has made it onto the education scene, but the effects of continuous improvement in education remain largely unstudied. This study addressed the need to examine the long term impacts of CI in educational organizations. Using a CI framework, this mixed methods action research (MMAR) study was conducted to examine the impact of CI on one school district’s measures of quality, stakeholder satisfaction, and cost savings, as well as to determine the value of CI leadership coaching, according to district leaders. Qualitative data included interviews with and observations of school district leaders and the CI leadership coach. Quantitative data included stakeholder surveys, district scorecards, and state data dashboard reports. Results indicated improvement from a CI approach was slow to occur, though CI positively impacted some quality outcomes, primarily in the area of math. CI positively impacted student satisfaction, though it had minimal impact on employee and parent satisfaction. The district experienced cost savings as a result of CI, and CI leadership coaching was reported as highly valued by district leaders. The results of the study suggest a systematic CI approach and coaching support can impact change over time, but requires patience and a within district executive leader champion. / Dissertation/Thesis / Doctoral Dissertation Leadership and Innovation 2019

The increased prevalence rate of childhood obesity in Saudi Arabia is a nationwide health issue. The doctoral project was instituted in the pediatric out-patient clinic (POPC) of a tertiary university hospital in Riyadh, Saudi Arabia. Child obesity clinic and clinical practice guideline (CPG) for primary prevention were not available in the pediatric outpatient clinic with a high incidence of newly diagnose obese children. The focus of this doctoral project was to improve the clinical nursing practice of POPC nurses through the adoption of CPG on primary prevention of childhood obesity. The knowledge translation into action framework provided a summary of descriptive series of ideal CPG implementation steps in POPC. The search for published CPGs was taken from DynaMed, National Guideline Clearinghouse, Guideline International Network, Pubmed, and Google Scholar. There were 2 tools applied for analysis and synthesis. First, the appraisal of guidelines for research and evaluation II instrument was used to assess the quality of the guidelines. Second, the BARRIERS' scale was used to assess the extent of nurses' perception of barriers in CPG utilization. The 1st findings from this study revealed that RNAO CPG was the best and high-quality CPG over the Endocrine Society and the Institute for Clinical Systems Improvement CPGs. The 2nd findings showed that most of the nurses perceived BARRIERS to utilization towards on the unclear implications of the CPG in their daily nursing practice. Hence, one of the vital recommendations was to have CPG awareness and education before the implementation. Overall, the doctoral project contributed to positive social change through guidelines, policies, and protocol provision for childhood obesity prevention in similar settings.