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.

Background Customer satisfaction is important for clinical microbiology laboratories and the most important service aspect is the reliability of responses. One important indicator of the quality of care is turnaround time for a sample referred to a laboratory. Aim This study describes and evaluates an improvement of the blood culture process and evaluates the staff’s experiences of the changes brought by the improvement project. Methods The blood culture process during evenings and nights was re-designed in a cooperation project between the laboratories of clinical microbiology and clinical chemistry in a mid-size Swedish county council. Typing with matrix-assisted laser desorption/ionization time of flight (MALDI ToF) and rapid antibiotic susceptibility testing were also introduced. To describe staff experi-ences semi-structured interviews were performed with twelve of the staff involved. Results The time from sampling to susceptibility testing and typing, for patients with cefotaxime resistant enterobacteriaceae, was before the improvement project on average 55 hours compared to 43 hours after closure of the project. In the qualitative content analysis four categories were found which represented the experience of the staff: patient focus, changed knowledge, cooperation and driving forces. Discussion The study of the implementation of the improvement showed that laboratory staff could handle the change well. The change from traditional biochemical typing, used for over 50 years, to MALDI ToF is indeed a paradigm shift. Nevertheless, nobody was disappointed over the fact that some of the fundamental previous microbiological laboratory work routines were laid to rest.

In the early 2010s, competitive market logic was introduced into healthcare systems so as to achieve rapid improvements. This took place as improvement policies began to emphasize the notion of collaboration as a method of ensuring patient safety across organizational boundaries. This thesis addresses how staff, in their practical improvement work, balance economic values, on the one hand, against meaningful solutions for the patient, on the other. The research interest focuses on the particular interpretations about improvements that emerge in negotiations about change. These interpretations are foundational to the learning that simultaneously takes place. The aim of the thesis is to analyse and explain the pedagogical conditions that take place in improvement practices in a healthcare system in the 2010s. The thesis takes its theoretical point of departure in a pedagogical theory that describes how contextual conditions influence learning processes in a specific practice where communication is foundational for learning. The thesis uses critical discourse analysis as a methodological point of departure and builds on a model of improvement work, namely, the clinical microsystem. The first study consists of a literature review of the microsystem framework. Subsequently, three case studies were conducted at Jönköping county council, Sweden. Discussions of improvements at clinical meetings and improvement coaches’ reflections over their pedagogical approaches provide the empirical data for the case studies. The findings show that market logic gives rise to a number of displacement effects with respect to learning processes. Short-term profits are shown to supersede goals of a more profound development of knowledge. The composition of an improvement practice is of critical importance to the nature of the negotiation that takes place, and thus how the practice comes to successfully challenge things that are taken for granted and the power structures that exist within the practice. Improvement coaches themselves become pedagogical prerequisites under the influence of the prevailing conditions, as they promote different learning organizations. This thesis develops the conceptual framework that is instantiated by the clinical microsystem, and it also contributes to the social constructionist field of improvement science by establishing pedagogical and discursive perspectives on improvement and change. / Bridging the Gaps

In the early 2010s, competitive market logic was introduced into healthcare systems so as to achieve rapid improvements. This took place as improvement policies began to emphasize the notion of collaboration as a method of ensuring patient safety across organizational boundaries. This thesis addresses how staff, in their practical improvement work, balance economic values, on the one hand, against meaningful solutions for the patient, on the other. The research interest focuses on the particular interpretations about improvements that emerge in negotiations about change. These interpretations are foundational to the learning that simultaneously takes place. The aim of the thesis is to analyse and explain the pedagogical conditions that take place in improvement practices in a healthcare system in the 2010s. The thesis takes its theoretical point of departure in a pedagogical theory that describes how contextual conditions influence learning processes in a specific practice where communication is foundational for learning. The thesis uses critical discourse analysis as a methodological point of departure and builds on a model of improvement work, namely, the clinical microsystem. The first study consists of a literature review of the microsystem framework. Subsequently, three case studies were conducted at Jönköping county council, Sweden. Discussions of improvements at clinical meetings and improvement coaches’ reflections over their pedagogical approaches provide the empirical data for the case studies. The findings show that market logic gives rise to a number of displacement effects with respect to learning processes. Short-term profits are shown to supersede goals of a more profound development of knowledge. The composition of an improvement practice is of critical importance to the nature of the negotiation that takes place, and thus how the practice comes to successfully challenge things that are taken for granted and the power structures that exist within the practice. Improvement coaches themselves become pedagogical prerequisites under the influence of the prevailing conditions, as they promote different learning organizations. This thesis develops the conceptual framework that is instantiated by the clinical microsystem, and it also contributes to the social constructionist field of improvement science by establishing pedagogical and discursive perspectives on improvement and change. / Bridging the Gaps

Förväntad effekt av vårdens elektroniska IT-system är ökad patientsäkerhet, vårdkvalitet och tillgänglighet. Ett första villkor för att kunna uppnå detta är att IT-systemet används. I denna studie granskas ett underutnyttjat IT-system, använt för informationsöverföring mellan olika huvudmän vid samordnad vård- och omsorgsplanering. Granskningen baseras på teorier om hur individers intention och vilja till att använda ett IT-system initieras eller upprätthålls genom omgivningens påverkan. Resultatet visar att IT-användare i den patientnära vården (mikrosystemet) saknar adekvat tekniskt, organisatoriskt (mesosystemet) och ledningsstöd (makrosystemet), vilket kan förklara underutnyttjandet. / Expected impact of electronic healthcare systems is increasing patient safety, care quality and availability. Using the system is essential to achieve this. This study explain the assimilation gap in an electronic healthcare system used in coordinated care planning by theories how individuals’ intentions and willingness to use electronic systems is affected by environmental influences. The result shows that the end users lack technical, organizational, and management support, which can explains the assimilation gap.