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The Swiss healthcare system is highly decentralized, making implementation of shared decision making (SDM) and patient and public involvement (PPI) quite slow; nonetheless, change is happening. SDM is now a core communication competency for medical school graduates, as reflected by a dedicated station on the federal exam, and is endorsed by several national societies. Multiple local initiatives are contributing to international best practices, local implementation, and increased capacity. PPI is also gaining momentum, most notably in research, with the development of a national platform for clinical research and inclusion of patients in the evaluation committees for funding. The challenge now is going from example projects by motivated early adopters in academia to making SDM and PPI standard practice.

Introduction: The concept of coproduction holds great promise for meaningful and genuine partnerships between patients and health professionals. Coproduction is especially important for immigrants, who experience limited access and involvement in their healthcare and are at risk of receiving lower quality of care. Insight into how immigrants can use their own experience and expertise to participate in the coproduction of health is scarce. Aim and method: The aim of this research project was to understand how health professionals and immigrant patients coproduce healthcare services to create health. In a systematic scoping review (Study I), we explored faciliators for coproduction of healthcare service with immigrants. Two qualitative studies based on participant observations (n=25), informal conversations, focus groups (n=2), and interviews (n=13) explored health professionals experiences (Study II) and immigrants experiences (Study III) with coproduction in clinical encounters. Data was collected at an interdisciplinary outpatient clinic for immigrants and refugees with long-lasting, complex, and unexplained symptoms. Results: The results of Study are that immigrants can be a valuable source of information and powerful coproducers of their own health if the healthcare organization and frontline health professionals prepare for it. Study II showed that leadership-supported flexibility and interdisciplinary support enabled health professionals to find sensible solutions for each patient. Communication tools designed around patient needs guided health professionals in listening and creating a safe space built on trust and empathy. This safe space was essential for shared decisions about care. Relational continuity strengthened coproduction but also bore risks of emotional dependency. Study III, showed that mutual trust and feeling safe encouraged immigrant patients to open up and take a more active role in the coproduction of their health. A strong therapeutic relationship enabled them to become agents of their own health. Conclusions: Using a coproduction lens, we recognized that creation of a service requires time and that the patient and the health professional to work together. They contribute their resources of lived experience and professional expertise in coproducing healthcare services and thus value for the patient. Implications: Our findings highlight the need for flexibility in daily practice, for compassion and kindness for diverse patient populations, and for accepting vulnerability arising from the complexity of clinical practice and of life. Future research should investigate the validity of findings in different healthcare settings and study long-term effects of coproduction on patients’ health and well-being. Finally, patients should be invited as co-researchers in these studies.

The advent of the electronic health record (EHR) raises many questions regarding its adoption and its added value for patients, clinicians and the entire healthcare system. Based on the results of a participatory project that brought together citizens and experts, we show that the EHR should be understood as a collective and evolving project serving public health objectives, and that both patients and healthcare professionals should contribute to its development. Therefore, this common project represents a significant opportunity to strengthen the patient-professionals partnership.

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ContectWe describe how we developed a monitoring system for community acquired pneumonia (CAP) at North Zealand Regional hospital. We serve 310.000 inhabitants and annually around 3200 patients with CAP are admitted. As part of a program of clinical pathways for common conditions, a pathway for pneumonia was designed and implemented in 2010.ProblemIn spite of our clinical pathway for CAP we found delays in start of treatment, overuse of antibiotics and long length of stay (LOS). Mortality was nearly 20 %.Assessment of problem and analysis of its causes We established an audit group of two nurses and two senior doctors. Direct observations of the clinical processes revealed problems of coordination, complex disease trajectories that did not fit with the pneumonia pathway, unclear guidelines and variation in their interpretation.InterventionWe designed a measurement system to monitor patients with CAP and effects of interventions to improve the quality of their care. Based on current literature we defined and tested a set of indicators and designed an audit form, a database and a dashboard for presenting the results.Two nurses monthly audited randomly selected files of patients with CAP. We started with 34 audit variables. Through repeated cycles of testing, feedback and discussions, we reduced the number of indicators to 22 and time per audit from 20 to 10 minutes.Strategy for changeTo link the monitoring system with our patient pathway for CAP we established an improvement team of clinicians from the emergency department and inpatient units.Measurement of improvementAudit results are presented as a multidimensional dashboard of aggregated baseline data and run charts to monitor changes.Microbiological tests were delayed, often performed after antibiotics were started. Patients received IV antibiotics longer than recommended. Nearly 80 percent of treatment plans were re-evaluated on day three, but only 30 percent shifted to PO. Overall compliance with standards was only around 50 percent and there was great variability of process times and of compliance with recommended steps of the pneumonia pathway.Lessons learntQuality of care for CAP was worse than expected. Defining and agreeing upon a set of indicators was difficult and time consuming but useful to improve our understanding of how care for CAP was in routine clinical practice. Several indicators we initially considered necessary required too tedious data collection or were not useful. So, we could reduce the number of indicators by nearly a third.Important steps from audit to quality dashboard were:Defining and testing audit variablesTesting the audit formDefining indicators based on the audit variablesDesigning a databaseDesigning and testing a dashboard to present indicators in a balanced wayMessages for othersAuditing patients with a common disease as CAP is useful to identify areas for improvement for a large group of patients. The baseline audit can serve as a basis for a monitoring system. Feedback of audit data requires a systematic approach that should include consideration of how best to present and communicate data.

7.von Plessen C, Poulstrup A, Anhøj J

Accepted version, reprinted with permission. Published version, with slightly different title, available at http://dx.doi.org/10.1080/02841860902795240 Introduction Nearly 40% of patients with advanced NSCLC are in performance status (PS) 2. These patients have a shorter life expectancy than PS 0/1 patients and they are underrepresented in clinical trials. Data on how platinum-based combination chemotherapy affects Health Related Quality of Life (HRQOL) of patients with PS 2 are scarce and the treatment of this important group of patients is controversial. Methods A national multicenter phase III study on platinum based chemotherapy to 432 advanced NSCLC patients included 123 patients with PS 2. To explore the treatment impact on HRQOL, the development of HRQOL during the first nine weeks were compared between PS 2 and PS 0/1 patients. We used the EORTC QLQ-C30 and QLQ-LC13 questionnaires. Standardized area under the curve for all HRQOL items, and HRQOL responses classified as better, stable or worse, were compared between the groups. Results Whereas the demographic data at baseline were well balanced between the groups, the PS 2 patients had significantly worse function and more severe symptoms than the PS 0/1 patients. In response to combination chemotherapy, the PS 2 patients had a more profound improvement of global QOL, cognitive function, fatigue, dyspnea, sleeping problems and appetite loss in comparison to the PS 0/1 group. Conclusions PS 2 NSCLC patients seem to achieve valuable HRQOL benefits from platinum-based combination therapy. Prospective clinical studies with predefined HRQOL outcomes in PS 2 patients are needed to confirm these findings.

Background The aim of accreditation is to improve quality of care and patient safety. However, studies on the effectiveness of accreditation on clinical outcomes are limited and inconsistent. Comparative studies have contrasted accredited with non-accredited hospitals or hospitals without a benchmark, but assessments of clinical outcomes of patients treated at hospitals undergoing accreditation are sparse. The Faroe Islands hospitals were accredited for the first time in 2017, making them an ideal place to study the impact of accreditation. Objective We aimed to investigate the association between first-time hospital accreditation and length of stay (LOS), acute readmission (AR) and 30-day mortality in the unique situation of the Faroe Islands. Methods We conducted a before and after study based on medical record reviews in relation to first-time accreditation. All three Faroese hospitals were voluntarily accredited using a modified second version of the Danish Healthcare Quality Programme encompassing 76 standards. We included inpatients 18 years or older treated at a Faroese hospital with one of six clinical conditions (stroke/transient ischemic attack (TIA), bleeding gastic ulcer, chronic obstructive pulmonary disease (COPD), childbirth, heart failure and hip fracture) in 2012–2013 designated ‘before accreditation‘or 2017–2018‘ after accreditation’. The main outcome measures were LOS, all-cause AR and all-cause 30-day mortality. We computed adjusted cause-specific hazard rate (HR) ratios using Cox Proportional Hazard regression with before accreditation as reference. The analyses were controlled for age, sex, cohabitant status, in-hospital rehabilitation, type of admission, diagnosis and cluster effect at patient and hospital levels. Results The mean LOS was 13.4 days [95% confidence interval (95% CI): 10.8, 15.9] before accreditation and 7.5 days (95% CI: 6.10, 8.89) after accreditation. LOS of patients hospitalized after accreditation was significantly shorter [overall, adjusted HR = 1.23 (95% CI: 1.04, 1.46)]. By medical condition, only women in childbirth had a significantly shorter LOS [adjusted HR = 1.30 (95% CI: 1.04, 1.62)]. In total, 12.3% of inpatients before and 9.5% after accreditation were readmitted acutely within 30 days of discharge, and 30-day mortality was 3.3% among inpatients before and 2.8% after accreditation, respectively. No associations were found overall or by medical condition for AR [overall, adjusted HR = 1.34 (95% CI: 0.82, 2.18)] or 30-day mortality [overall, adjusted HR = 1.33 (95% CI: 0.55, 3.21)]) after adjustment for potential confounding factors. Conclusion First-time hospital accreditation in the Faroe Islands was associated with a significant reduction in LOS, especially of women in childbirth. Notably, shorter LOS was not followed by increased AR. There was no evidence that first-time accreditation lowered the risk of AR or 30-day mortality.

Background The impact of hospital accreditation on the experiences of patients remains a weak point in quality improvement research. This is surprising given the time and cost of accreditation and the fact that patient experiences influence outcomes. We investigated the impact of first-time hospital accreditation on patients’ experience of support from health-care professionals, information and involvement in decisions. Objective We aimed to examine the association between first-time hospital accreditation and patient experiences. Methods We conducted a longitudinal study in the three Faroese hospitals that, unlike hospitals on the Danish mainland and elsewhere internationally, had no prior exposure to systematic quality improvement. The hospitals were accredited in 2017 according to a modified second version of the Danish Healthcare Quality program. Study participants were 18 years or older and hospitalized for at least 24 h in 2016 before or 2018 after accreditation. We administered the National Danish Survey of Patient Experiences for acute and scheduled hospitalization. Patients rated their experiences of support, information and involvement in decision-making on a 5-point Likert scale. We calculated individual and grouped mean item scores, the percentages of scores ≥4, the mean score difference, the relative risk (RR) for high/very high scores (≥4) using Poisson regression and the risk difference. Patient experience ratings were compared using mixed effects linear regression. Results In total, 400 patients before and 400 after accreditation completed the survey. After accreditation patients reported increased support from health professionals; adjusted mean score difference (adj. mean diff.) = 1.99 (95% confidence interval (CI): 1.89, 2.10), feeling better informed before and during the hospitalization; adj. mean diff. = 1.14 (95% CI: 1.07; 1.20) and more involved in decision-making; adj. mean diff. = 1.79 (95% CI: 1.76; 1.82). Additionally, the RR for a high/very high score (≥4) was significantly greater on 15 of the 16 questionnaire items. The greatest RR for a high/very high score (≥4) after accreditation, was found for the item ‘Have you had a dialogue with the staff about the advantages and disadvantages of the examination/treatment options available?’; RR= 5.73 (95% CI: 4.51, 7.27). Conclusion Hospitalized patients experienced significantly more support from health professionals, information and involvement in decision-making after accreditation. Future research on accreditation should include the patients’ perspective.

Background Significant resources are spent on hospital accreditation worldwide. However, documentation of the effects of accreditation on processes, quality of care and outcomes in healthcare remain scarce. This study aimed to examine changes in the delivery of patient care in accordance with clinical guidelines (recommended care) after first-time accreditation in a care setting not previously exposed to systematic quality improvement initiatives. Methods We conducted a before and after study based on medical record reviews in connection with introducing first-time accreditation. We included patients with stroke/transient ischemic attack, bleeding gastric ulcer, diabetes, chronic obstructive pulmonary disease (COPD), childbirth, heart failure and hip fracture treated at public, non-psychiatric Faroese hospitals during 2012–2013 (before accreditation) or 2017–2018 (after accreditation). The intervention was the implementation of a modified second version of The Danish Healthcare Quality Program (DDKM) from 2014 to 2016 including an on-site accreditation survey in the Faroese hospitals. Recommended care was assessed using 63 disease specific patient level process performance measures in seven clinical conditions. We calculated the fulfillment and changes in the opportunity-based composite score and the all-or-none score. Results We included 867 patient pathways (536 before and 331 after). After accreditation, the total opportunity-based composite score was marginally higher though the change did not reach statistical significance (adjusted percentage point difference (%): 4.4%; 95% CI: − 0.7 to 9.6). At disease level, patients with stroke/transient ischemic attack, bleeding gastric ulcer, COPD and childbirth received a higher proportion of recommended care after accreditation. No difference was found for heart failure and diabetes. Hip fracture received less recommended care after accreditation. The total all-or-none score, which is the probability of a patient receiving all recommended care, was significantly higher after accreditation (adjusted relative risk (RR): 2.32; 95% CI: 2.03 to 2.67). The improvement was particularly strong for patients with COPD (RR: 16.22; 95% CI: 14.54 to 18.10). Conclusion Hospitals were in general more likely to provide recommended care after first-time accreditation.