Yes

The study is based on a new approach on how Swedish healthcare is supposed to be controlled and organized. There is a renowned administration problem within Swedish healthcare, which seems to be an obstacle to exploit the resources to the fullest. The latest venture within the healthcare system is patient involvement, where the patients become co-producers of their own care, which aims to both improve and make healthcare more efficient. A few wards in Sweden have implemented this new approach whereupon the study intends to discuss the effectiveness and efficiency in some of these. The study is restricted to three wards, whereof two of these are inpatient wards and the other one is an outpatient ward, within the medical clinic in Jönköping County Council, which has implemented the patient involvement approach in their daily work. The methodology for this study is qualitative in its nature where a time study of personnel time allocation and supplementary interviews with managing nurses on the wards have been conducted. A thematic analysis was then conducted to analyse the generated data, which is connected and supported by the theoretical framework. The theoretical framework consists of theories regarding opportunities and assessing effectiveness and theories on what creates the quality and value of service organizations to assess the efficiency. The results show that all the investigated departments have a relatively high efficiency potential and the utilization of the resources of the department is acceptable. It is found that some efficiency is possible from both an inner and outer effectiveness perspective. The physicians were found to spend least time with patients, while nurses and assistant nurses spend more time with patients, who are linked with their potential for knowledge of what is perceived value for the patient. All wards are working with patient involvement in a way that seeks to increase patient knowledge about their own care, and the personnel’s knowledge of the patient's requests, which contributes to an external efficiency. It is finally found that the patient involvement approach does not directly lead to a high external efficiency. Much of the patient involvement that takes place has the goal of creating value for the patient, which it can do. Though, researchers argue that it is rather the interaction with the patient that provides knowledge of what exactly creates value, suggesting that the time spent with the patient is important. / Studien grundar sig i en förändrad syn på hur sjukvården i Sverige ska styras och organiseras. Det finns en omtalad administrationsproblematik inom svensk hälso- och sjukvård vilket tycks vara ett hinder för att kunna utnyttja resurserna till fullo. Den senaste satsningen inom hälso- och sjukvård är patientinvolvering, där patienterna blir samproducenter av sin egen vård, vilken syftar både förbättra och effektivisera sjukvården. Ett fåtal vårdavdelningar i Sverige har implementerat detta nya arbetssätt varpå studien ämnar diskutera hur effektiviteten ser ut på några av dessa Studien är avgränsad till tre vårdavdelningar, varav två slutenvårdsavdelningar och en öppenvårdsavdelning, inom medicinkliniken i Jönköpings Läns Landsting, vilka implementerat arbetssättet med patientinvolvering i deras dagliga arbete. Metoden för studien är av kvalitativ karaktär där både en tidsstudie över personalens arbetstidfördelning genomförts samt kompletterande intervjuer med ansvariga sjuksköterskor på vårdavdelningarna. En tematisk analys genomfördes sedan för att analysera genererade data vilket kopplas och hämtar stöd från den teoretiska referensramen. Den teoretiska referensramen består av teorier gällande möjligheter till och bedömning av effektivitet samt teorier om vad som skapar kvalitet och värde inom tjänsteorganisationer för att kunna bedöma den yttre effektiviteten. Resultatet visar att samtliga undersökta avdelningar har en relativt hög effektivitetspotential och att utnyttjandet av resurserna på avdelningarna är godtagbart. Det konstateras att viss effektivisering är möjlig både utifrån ett inre- och yttre effektivitetsperspektiv. Läkarna visar sig spendera minst tid med patienterna medan sjuksköterskor och undersköterskor spenderar mer tid med patienterna vilket kopplas samman med deras möjligheter till kunskap om vad som upplevs vara värde för patienten. Samtliga avdelningar arbetar med patientinvolvering på ett sätt som syftar ökar patientens kunskap om sin egen vård, samt personalens kunskap om patientens önskemål, vilket bidrar till en yttre effektivitet. Till sist konstateras att patientinvolvering som arbetssätt inte direkt leder till en hög yttre effektivitet. Mycket av den patientinvolvering som sker har målet att skapa värde för patienten, vilket det kan göra. Forskarna menar dock att det snarare är interaktionen med patienten som ger kunskap om vad som skapar värde, vilket tyder på att tiden som spenderas med patienten är viktig.

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Treating chronic health conditions consumes a significant portion of the health care resource. Two–thirds of UK hospital admissions consist of people with chronic conditions (Singh, 2005). To date, health management has tended to focus on service redesign, rather than focusing on the patients, as a way to facilitate improved outcomes and control costs. Typically, these management approaches are premised on the patient as a consumer/end user. An alternative view to the patient being a consumer is that of the patient being a co–producer of the service. Co–production recognises the client (patient) as a resource, in that value cannot easily be created or delivered, unless the patient actively contributes to the service (Alford, 1998). Patients gain health value when they are well and are independent of the health care system and its costs. Health care organisations gain economic value, when chronic patients require less health care. This thesis examines co–production, in the context of contemporary patient involvement and heath services management. ‘Knowing the People Planning’ (KPP), an innovative health management method, is evaluated for its patient management co–production potential. KPP is based on ten key features of service provision. Four of the key features relate to the patient, whilst the remaining six features relate to the organisation. It is the management of these patient and organisation features that better facilitates chronic long-term mental health patients as co–producers. The empirical findings, from this evaluation of KPP provide evidence for the efficacy of co–productive health management theory and practice. Patient health value and health care organisation economic value are created, when both the organisation and the patient co–produce the health service. KPP was initially implemented by eight of New Zealand’s 21 District Health Boards. Socio-ecological action research methodology was used to evaluate KPP — by taking a ‘people-in-environments’ approach. The evaluation covers fourteen action research cycles for 2,021 chronic long-term patients over four years. Measurements include the amount of time these long-term patients spent in hospital and employment rates. The integration of the action research cycles, using the socio-ecological method supported the generation of (what I have called) ‘co–productive health management theory’. Analyses of secondary data, across organisational and patient domains, supplement the action research findings, in order to assess for confounding factors. The organisation outcomes relate to costs and staff turnover. Patient outcomes relate to service utilisation measures, for approximately 60,000 adult patients per year, who access New Zealand’s secondary mental health services. A pivotal finding of this research was that, as the rate of patients with treatment plans increased from 50% to 90%, inpatient bed use decreased by 26%. However, increased funding for mental health services had only a minor impact on decreasing inpatient bed use. Patient employment rates increased, whilst the number of patients who required access to general practitioners and changes to their housing situation, decreased. The patient management co–production view offers a significant opportunity for health care managers and researchers to significantly improve both patient and organisation value. Co–production views the patient as a resource, who contributes to her/his health outcome, rather than a person who simply consumes services. The better patients can co–produce their health outcome the better their health, and the lower their demand for health services.

Background Recent conflicts have seen an increase in trauma related military amputees who incur complex injuries which result in varied residual limbs. In many cases these amputees have been provided with state of the art (SOTA) components with the expectation that they will transfer into NHS care after military discharge. However, there is a lack of knowledge around how prosthetic prescriptions are made in both the MOD and NHS, including patient involvement. It is important to explore prosthetic prescription decisions to enhance the quality, consistency and equity of care delivery for trauma amputees. This thesis explores decision making in prosthetic care for trauma amputees in the UK during this period of change. Aims To explore aspects of prosthetic care provision in the UK including clinical decision making, patient experience and the transition of prosthetic care from the MOD to the NHS. Design An exploratory qualitative project informed by decision making and patient involvement theory. Semi-structured interviews were carried out with nineteen clinical staff involved in prosthetic provision, six civilian and five veteran trauma amputees. Thematic analysis was used to analyse the data. Findings Prosthetists used a wide range of factors in making prescription decisions, including physical characteristics, patients’ goals, and predicted activity levels. Prescription decision making varied depending on the prosthetists’ level of experience and the different ‘cues’ identified. In some cases there was a lack of transparency about drivers for the prescription choice. Prescription decisions are influenced by long term relationships between prosthetist and patient, allowing a trial and error approach with increasing patient involvement over time. Patient experiences of their trauma amputation influenced their approach to rehabilitation. Patients reported wanting different levels of involvement in their prosthetic care, however, communication was essential for all. Veteran amputees benefited from peer support opportunities which NHS services were less conducive to. However, NHS amputees were more likely to have been ‘involved’ in care decisions. The expectations that MOD patients had of inferior care in the NHS were not realised in the majority of veteran cases. Recommendations Research is needed to support prosthetists’ decisions to become more consistent and transparent. The NHS should consider introducing a peer support model for trauma patients, and particularly in the early stages of rehabilitation.

BakgrundTrycksår är en komplikation till sjukdom, vård och behandling. Såren kan bli en källa till ett lidande. Mer än hundra riskfaktorer för uppkomst av trycksår har identifierats och därför kan inte enskilda faktorer leda till uppkomst av trycksår. Evidensbaserad vård innebär att vid utformning av vård för patienten ska dennes unika egenskaper och preferenser utifrån främsta till buds stående vetenskapliga stöd, vägas samman för nyttan av olika insatser.SyfteSyftet var att beskriva evidensbaserade omvårdnadsåtgärder som minskar förekomsten av trycksår hos patienten.MetodLitteraturstudien har genomförts som en litteraturöversikt genom systematisk sökning av artiklar, som baserades på nitton artiklar från Pubmed och CINAHL.ResultatRådande metoder som ompositionering och olika tryckavlastande stödytor har inte något starkt stöd i inkluderade artiklar gällande trycksårsprevention. Ny teknik som skanning och mätning av hudtemperatur ger positiva resultat, men kan inte ensamt förhindra uppkomst av trycksår utan bör kombineras med andra evidensbaserade omvårdnadsåtgärder. Preventionsprogram ger positiva resultat och utförs i flera fall multiprofessionellt och med patienters delaktighet.SlutsatsEvidensbaserade strategier är nyckeln till framgångsrika förebyggande program. Här behöver flera faktorer samverka för att uppnå en synergisk effekt och verka optimalt. Skanning och annan ny teknik, som SEM Scanner och MiS som är objektiva hjälpmedel och kan komplettera trycksårsvården. / BackgroundPressure ulcers are a complication of disease, care and treatment. The wounds can become a source of suffering. More than one hundred risk factors have been identified to cause pressure ulcer therefore a single risk factor cannot cause the onset of pressure ulcers. Evidence-based care means that when planning the care for the patient, their unique characteristics and preferences should be weighed together for the benefit of different interventions based on the latest scientific knowledge.AimThe aim was to describe evidence-based nursing measures that reduce the incidence of pressure ulcers in the patient.MethodThe literature study has been conducted as a literature review through systematic search of articles, which were based on nineteen articles from Pubmed and CINAHL.ResultsCurrent methods such as repositioning and various pressure-relieving support surfaces do not have strong support in included articles regarding pressure ulcer prevention. New technology such as scanning and measuring skin temperature have favorable outcomes but cannot alone prevent the onset of pressure ulcers but should be combined by other evidence based nursing measures. Prevention programs contributes to promising results and are in many cases carried out multiprofessionally and with the participation of patients.ConclusionsEvidence based strategies are key to successful prevention programs. Several factors need to work together to achieve a synergistic effect and operate optimally. Scanning and other new technologies, such as SEM Scanner and MiS, are objective aids and can complement pressure ulcer care.

Medication safety and improving communication at care transitions are an international priority. There is vast evidence on the scale of error associated with medicines reconciliation and some evidence of successful interventions to improve reconciliation. However, there is insufficient evidence on the factors that contribute towards medication error at transitions, or the roles of those involved. This thesis examined current UK medicines reconciliation practice within primary and secondary care, and the role of HCPs and patients. Using a mixed-method, multi-centre design, the type and severity of discrepancies at admission to hospital were established and staff undertaking medicines reconciliation across secondary and primary care were observed, using evidence-informed framework, based on a narrative literature review. The overall processes used to reconcile medicines were similar; however, there was considerable inter and intra-organisational variation within primary and secondary care practice. Patients were not routinely involved in discussions about their medication, despite their capacity to do so. Various human factors in reconciliation-related errors were apparent; predominantly inadequate communication, individual factors e.g. variation in approach by HCP, and patient factors e.g. lack of capacity. Areas of good practice which could reduce medicines reconciliation-related errors/discrepancies were identified. There is a need for increased consistency and standardisation of medicines reconciliationrelated policy, procedures and documentation, alongside communication optimisation. This could be achieved through a standardised definition and taxonomy of error, the development of a medicines reconciliation quality assessment framework, increased undergraduate and post-graduate education, improved patient engagement, better utilisation of information technology and improved safety culture.

Bakgrund. Att få en allvarlig bristning i samband med förlossning kan ge kvinnor smärta, lidande, och låg livskvalitet under lång tid. Syfte. Syftet med förbättringsarbetet har varit att förbättra eftervården genom att införa strukturerad uppföljning, öka kvalitén i bedömning och diagnostik, förbättra informationen till patienten och utveckla former för patientdelaktighet i förbättringsarbetet. Syftet med studien har varit att ur ett verksamhetsperspektiv beskriva erfarenheterna av patientdelaktigheten i förbättringsarbetet. Metod. Förbättringsarbetet har designats med hjälp av Förbättringstrappan och utgått från ett patientprocessorienterat perspektiv. Metod för studien var kvalitativ i form av en fallstudie. Resultat. Genom förbättringsarbetet följs kvinnorna upp via bristningsregistret, uppföljningsbesök med 3D- ultraljud görs på en specialinrättad mottagning. Vidare får kvinnorna individuell fysioterapeutinformation innan hemgång, en vårdkedja har införts och former för patientdelaktighet har utformats och använts. Dessa är frågeformulär, intervjuer, workshops och patientföreträdare i förbättringsnätverket. Resultatet från studien visar att formerna för patientdelaktighet ger skilda förutsättningar för delaktigheten. Resultatet visar på betydelsen av organisatoriska förutsättningar, värdet av patientdelaktighet, utmaningar vid införande och vilket reellt inflytande som patientdelaktigheten haft under processen och för resultaten av förbättringsarbetet. Slutsatser. Patientdelaktighet skapar värde i flera dimensioner. Patientdelaktighet behöver designas, anpassas till kontexten och förbättringsarbetets mål och dess syfte behöver vara tydligt uttryckt. / Background. Perineal tears during childbirth can lead to after-delivery complications that leads to great suffering and low quality of life for a long time. Purpose. The purpose has been to improve after-delivery care by systematic follow-up, increasing the quality of diagnostics and management of these women, improving the information for the patient and developing new ways of improving including patients in the improvement work. The purpose of the study has been to study the effect of patient participation in the improvement work. Method. "The improvement ramp" and patient process-oriented perspective has been used to design the improvement work. The method of the study was qualitative in the form of a case study. Results. Follow-up using 3D-ultrasound is introduced. A care chain has been introduced and ways of patient participation have been designed and used. These are questionnaires, interviews, workshops and patient representatives in the improvement network. The results of the study show that the ways of patient participation provide different conditions for participation. The result shows the importance of organizational conditions, the value of patient participation, challenges in the introduction and the real influence that patient participation has had during the process and on the results of the improvement work. Conclusions. Patient-participation in QI creates values in several dimensions. Patient-participation needs to be carefully designed in compliance with context, goals and purpose.

Purpose. To systematically develop and field test an intervention to engage families and healthcare teams in the decision-making process about life support for critically ill patients in the Intensive Care Unit (ICU). Setting. Adult medical-surgical ICU at a Canadian academic teaching hospital. Methods. The International Patient Decision Aid Standards (IPDAS) criteria and the Interprofessional Shared Decision Making (SDM) model guided the study of families facing decisions about life support for their relative in ICU that involved:1) systematic review; 2) qualitative descriptive study; 3) mixed methods field test of a novel patient decision aid (DA). Systematic review findings. Of 3162 citations, four trials evaluated interventions to improve communication between health professionals and patients/families. One intervention met eight of nine criteria for SDM but did not evaluate its effect on the benefit to communication. Qualitative study findings. Six family members and nine health professionals identified two options (life support or comfort care) and values associated with these options. Values included maintaining quality of life, surviving critical illness, minimizing pain and suffering, not being attached to machines, giving the family enough time to adapt emotionally to the patient’s health situation, and the judicious use of healthcare resources. Families were unlikely to become engaged without healthcare professionals making the decision explicit and minimizing other barriers across the decision-making process. Field test findings. Family members and health professionals for eight patients indicated that the DA was feasible to use, acceptable to users, had the potential to do what was intended, and did not seem to present adverse consequences to users. An enhanced delivery strategy is needed for future evaluation of its effect on facilitating patient/family involvement in decisions. Conclusions. Limited involvement of families in the process of decision-making about life support in the ICU reinforced the need for effective interventions to facilitate SDM. These studies validated the operationalization of the IPDAS criteria, as part of a systematic process for developing and field testing DAs. However, IPDAS criteria stop short of elements necessary to consider when implementing the DA in the processes of care.

Bakgrund: Kvalitetsutveckling inom vården pågår i hela världen. Internationell forskning indikerar att förbättringscoacher kan vara en framgångsfaktor i förbättringsarbetet. Det är i dag oklart hur man kan utveckla interna coacher till att stödja kontinuerliga förbättringar. Studien utvärderar ett lokalt, tvärprofessionellt coachprogam inom vård och omsorg i ett geografiskt område i Sverige med en etablerad samverkanskultur. För att främja ökad kundcentrering ingick en pensionär i programmets planeringsgrupp. Deltagarna introducerades i grundläggande förbättringskunskap och i lösningsfokuserat arbetssätt som ett sätt att bättre kunna hantera komplexiteten i vård och omsorg. Programmet utformades med åtta gemensamma träffar under perioden mars till oktober 2011.   Syfte: Att identifiera faktorer i ett lokalt coachprogram som framstår som mest väsentliga för att medarbetare i vård och omsorg ska kunna gå in i rollen som förbättringscoacher. Metod: Studien är en observerande fallstudie med inslag av aktionsforskning och en induktiv kvalitativ ansats. Deltagare i studien var blivande coacher, pensionärer, planeringsgruppen och erfarna coacher. Sju semistrukturerade intervjuer med totalt 17 personer genomfördes, samt analys av lokala dokument och fyra enkäter. Data analyserades genom en manifest kvalitativ innehållsanalys och triangulering. Resultatet validerades av samtliga deltagare i studien. Resultat: Involvering av pensionärer ansågs vara en viktig faktor eftersom det förstärkte kundfokuseringen. Deltagarna i studien poängterade att kundfokus, ett lösningsfokuserat förhållningssätt, nätverk och systemförståelse var grundläggande för utvecklingen av coachrollen. Dessa faktorer bedömdes som viktigare än de specifika förbättringsverktygen. Diskussion: De mest väsentliga faktorerna kan delas in i det som uppmuntrade till idéer, vilja, görande och uthållighet. Pensionärsinvolveringen förstärkte kundfokuseringen, och det lösningsfokuserade arbetssättet framstod som ett bra komplement till de sedvanliga förbättringsverktygen. Det vore intressant att jämföra detta program med förbättringsprogram i andra kontexter. / Background: Internal improvement coaches can support quality improvement efforts. The study is about a local interprofessional coach training program in a region in Sweden with an established culture of collaboration. The program included participants from different health care disciplines and was organized over eight days between March and October 2011. A senior citizen was involved in faculty and participated during all training sessions. The participants were introduced to basic improvement knowledge and a solution focused approach.Purpose: To explore essential elements of a local coach training program and what appears to be crucial in moving into the role of being an improvement coach.Method: The study is a mix methods case study with elements of action research and an inductive qualitative approach. Participants in the study were prospective coaches, senior citizens, the program team, and experienced coaches. Data were collected through seven semi-structured group interview sessions with a total of 17 individuals, document analysis and 4 questionnaires. Data were analyzed using a manifest content analysis and triangulation. The results were validated by all participants in the study.Results: The data suggest that the involvement of a senior citizen was essential for strengthening customer focus. Participants in the study pointed out that customer focus, developing a value base, networking skills with a solution focused approach and systems thinking were fundamental to the development of the coaching role. These factors were assessed as more important than improvement tools.Discussion: The results can be divided into those which encouraged ideas, will, execution, and endurance. Senior citizen involvement enhanced customer focus and the solution-focused approach seems to be a valuable addition to the usual improvement tools. It would be interesting to compare this program with other improvement programs or in other contexts.