Search

Objective Primary care physicians (PCPs) recently started using standardised care pathways (PCPs) to refer patients to specialists for diagnostics in Sweden. The aim of the current study is therefore to examine PCPs views of implementing standardised care pathways (SCPs) in cancer care. Method In total, 27 semi-structured interviews (17 individual and 10 group interviews) were conducted within 24 primary care units, including 61 physicians representing the public and private sectors. Interviews were conducted during 2017 and 2018. Data were analysed using a thematic analysis approach. Results Eight themes, including both perceived opportunities and challenges with the SCPs, were identified in the analysis. Most PCPs valued the SCPs, citing that they expedited the referral system and decreased patient waiting time. However, the guidelines were not completely clear leaving PCPs to wonder what constituted an SCP referral, who should initiate the referral, and how PCPs should communicate and collaborate with specialists. Conclusion SCPs were a welcomed organisational change by PCPs, where PCPs thought that the SCPs could help in providing better patient care to potential cancer patients. However, updated guidelines and clarifications within the SCPs are warranted to have increased services for both the patients and medical personnel.

Background Safety culture can be described and understood through its manifestations in the organization as artefacts, espoused values and basic underlying assumptions and is strongly related to leadership-yet it remains elusive as a concept. Even if the literature points to leadership as an important factor for creating and sustaining a mature safety culture, little is known about how the safety work of first line managers’ is done and how they balance the different and often conflicting organizational goals in everyday practice. The purpose of this study was to explore how health care first line managers perceive their role and how they promote patient safety and patient safety culture in their units. Methods Interview study with first line managers in intensive care units in eight different hospitals located in the middle of Sweden. An inductive qualitative content analysis approach was used, this was then followed by a deductive analysis of the strategies informed by constructs from High reliability organizations. Results We present how first line managers view their role in patient safety and exemplify concrete strategies by which managers promote patient safety in everyday work. Conclusions Our study shows the central role of front-line managers in organizing for safe care and creating a culture for patient safety. Although promoted widely in Swedish healthcare at the time for the interviews, the HSOPSC was not mentioned by the managers as a central source of information on the unit’s safety culture.

Background The use of low-value care (LVC) is widespread and has an impact on both the use of resources and the quality of care. However, few studies have thus far studied the factors influencing the use of LVC from the perspective of the practitioners themselves. The aim of this study is to understand why physicians within primary care use LVC. Methods Six primary health care centers in the Stockholm Region were purposively selected. Focus group discussions were conducted with physicians (n = 31) working in the centers. The discussions were coded inductively using a grounded theory approach. Results Three main reasons for performing LVC were identified. Uncertainty and disagreement about what not to do was related to being unaware of the LVC status of a practice, guidelines perceived as conflicting, guidelines perceived to be irrelevant for the target patient population, or a lack of trust in the guidelines. Perceived pressure from others concerned patient pressure, pressure from other physicians, or pressure from the health care system. A desire to do something for the patients was associated with the fact that the visit in itself prompts action, symptoms to relieve, or that patients' emotions need to be reassured. The three reasons are interdependent. Uncertainty and disagreement about what not to do have made it more difficult to handle the pressure from others and to refrain from doing something for the patients. The pressure from others and the desire to do something for the patients enhanced the uncertainty and disagreement about what not to do. Furthermore, the pressure from others influenced the desire to do something for the patients. Conclusions Three reasons work together to explain primary care physicians’ use of LVC: uncertainty and disagreement about what not to do, perceived pressure from others, and the desire to do something for the patients. The reasons may, in turn, be influenced by the health care system, but the decision nevertheless seemed to be up to the individual physician. The findings suggest that the de-implementation of LVC needs to address the three reasons from a systems perspective.

Background There is increasing interest in and demands for partnerships between academia and healthcare practices. Few empirical studies have described the influence of such partnerships from a practice perspective. The purpose of this study was to evaluate the impact of a reform launched to increase integration between primary care and academia and to identify potential reasons for why the observed impact occurred in three areas targeted by the reform: research, student education, and continued professional development. Methods The study was conducted in Stockholm County, the largest healthcare region in Sweden, at the introduction of a partnership between primary care and academia, including eight coordinating centres and approximately 500 surrounding primary care units. A programme theory-based qualitative approach to evaluation was used, building on document analysis, and in-depth interviews with the centre managers (n = 6) and coordinators (n = 8) conducted 42–66 months after the initiation of the reform. Results The analysis showed that the reform had some impact on all three areas targeted by the reform: research, student education, and continued professional development. The input that contributed most extensively to the impact was the establishment of facilitating roles. Most changes occurred at the coordinating centres and primarily in the area of student education. The effect on student education was primarily due to having prior experience in this area and perceptions of timely benefits of students to care practice. Conclusions Partnerships between primary care and academia hold the potential of practice impact. To increase integration between primary care and academia, the components of the integration must be understandable and relevant for primary care practitioners, and importantly, compliant with delivery of primary care.

Purpose The purpose of this paper is to explore factors influencing early implementation and intermediate outcomes of a healthcare-academia partnership in a primary healthcare setting. Design/methodology/approach The Academic Primary Healthcare Network (APHN) initiative was launched in 2011 in Stockholm County, Sweden and included 201 primary healthcare centres. Semi-structured interviews were conducted in 2013-2014 with all coordinating managers (n=8) and coordinators (n=4). A strategic change model framework was used to collect and analyse data. Findings Several factors were identified to aid early implementation: assignment and guidelines that allowed flexibility; supportive management; dedicated staff; facilities that enabled APHN actions to be integrated into healthcare practice; and positive experiences from research and educational activities. Implementation was hindered by: discrepancies between objectives and resources; underspecified guidelines that trigger passivity; limited research and educational activities; a conflicting non-supportive reimbursement system; limited planning; and organisational fragmentation. Intermediate outcomes revealed that various actions, informed by the APHN assignment, were launched in all APHNs. Practical implications The findings can be rendered applicable by preparing stakeholders in healthcare services to optimise early implementation of healthcare-academia partnerships. Originality/value This study increases understanding of interactions between factors that influence early stage partnerships between healthcare services and academia in primary healthcare settings.

Background Many countries have implemented standardized cancer patient pathways (CPPs) to reduce waiting times in cancer care and to ensure timely and quick diagnosis as well as treatment. Yet, no studies have explored the implementation process as perceived by the health care professionals working in the CPPs. The aim of this study is to explore the experiences of health care professionals (HPCs) involved in the CPPs. Methods A descriptive qualitative design was adopted. Thematic analysis was applied to individual interviews conducted in 2016–2017 with 58 participants working in six different CPPs in Sweden’s largest region, covering care for around 2.3 million inhabitants. Results In general, the health care professionals had a positive attitude towards the implementation of the CPPs. Our findings showed that the CPPs require close collaboration, both between and within different health care professional groups and units, something that was not always probable due to differences in resource capacity. Better dissemination to all relevant professionals, better conceptualization, and equivalent opportunities in terms of resources were identified by the respondents as being important yet lacking in practice. The analysis showed possible negative effects of the CPP, such as crowding-out on other patient groups. Conclusion The CPPs were introduced to address challenges with long waiting times and unequal cancer care. By exploring the experiences of health care professionals involved in the implementation of CPPs, our findings show challenges with multi-level coordination and collaboration, policy dissemination, and resource constraints. The analysis also showed that the implementation of CPPs risk being accompanied by unintended effects such as longer waiting times for other patients and patient groups in need of the same health care resources. The results shed light on and contribute to an understanding of the challenges, opportunities and ways forward.

Purpose – The purpose of this paper is to explore how healthcare managers construct the manager role in relation to the medical profession in their organisations. Design/methodology/approach – In total, 18 of Sweden’s 20 healthcare chief executive officers (CEOs) and 20 clinical department managers (CDMs) were interviewed about their views on management of physicians. Interviews were performed in the context of one aspect of healthcare management; i.e., management of physicians’ sickness certification practice. A discourse analysis approach was used for data analysis. Findings – Few managers used a management-based discourse to construct the manager role. Instead, a profession-based discourse dominated and managers frequently used the attributes “physician” or “non-physician” to categorise themselves or other managers in their managerial roles. Some managers, both CEOs and CDMs, shifted between the management- and profession-based discourses, resulting in a kind of “yes, but […]” approach to management in the organisations. The dominating profession-based discourse served to reproduce the power and status of physicians within the organisation, thereby rendering the manager role weaker than the medical profession for both physician and non-physician managers. Research limitations/implications – Further studies are needed to explore the impact of gender, managerial level, and basic profession on how managers construct the manager role in relation to physicians. Practical implications – The results suggest that there is a need to address the organisational conditions for managers’ role taking in healthcare organisations. Originality/value – Despite the general strengthening of the manager position in healthcare through political reforms during the last decades, this study shows that a profession-based discourse clearly dominated in how the managers constructed the manager role in relation to the medical profession on the workplace level in their organisations.

Objectives: Health care is undergoing changes and this requires the participation and leadership of all health-care professions. While numerous studies have explored leadership competence among physicians and nurses, the physiotherapy profession has received but limited attention. The aim of this study was to explore how leadership manifests in the patient-therapist interaction among physiotherapists in primary health care and how the physiotherapists themselves relate their perception of leadership to their clinical practice. Methods: A qualitative study with semi-structured interviews was conducted with a purposive sample of 10 physiotherapists working in primary health care. The interviews were analyzed using inductive qualitative content analysis. Results: Five themes were identified related to how leadership manifests in the patient-therapist interaction: (1) establishing resonant relationships; (2) engaging patients to build ownership; (3) drawing on authority; (4) building on professionalism; and (5) relating physiotherapists clinical practice to leadership. Conclusion: This study describes how leadership manifests in the patient-physiotherapist interaction. The findings can be used to empower physiotherapists in their clinical leadership and to give them confidence in taking on formal leadership roles, thus becoming active participants in improving health care. Future studies are needed to explore other aspects of leadership used in physiotherapy clinical practice.

Background Leadership has been identified as an influential factor in implementation processes in healthcare organizations. However, the processes through which leaders affect implementation outcomes are largely unknown. The purpose of this study is to analyse how managers interpret and make sense of a large scale top-down implementation initiative and what implications this has for the implementation process. This was studied at the implementation of an academic primary healthcare initiative covering 210 primary healthcare centres in central Sweden. The aim of the initiative was to integrate research and education into regular primary healthcare services. Methods The study builds on 16 in-depth individual semi-structured interviews with all managers (n = 8) who had operative responsibility for the implementation. Each manager was interviewed twice during the initial phase of the implementation. Data were analysed using a thematic approach guided by theory on managerial role taking based on the Transforming Experience Framework. Results How the managers interpreted and made sense of the implementation task built on three factors: how they perceived the different parts of the initiative, how they perceived themselves in relation to these parts, and the resources available for the initiative. Based on how they combined these three factors the managers chose to integrate or separate the different parts of the initiative in their management of the implementation process. Conclusions This research emphasizes that managers in healthcare seem to have a substantial impact on how and to what extent different tasks are addressed and prioritized in top-down implementation processes. This has policy implications. To achieve intended implementation outcomes, the authors recognize the necessity of an early and on-going dialogue about how the implementation is perceived by the managers responsible for the implementation. Electronic supplementary material The online version of this article (10.1186/s12913-018-3360-y) contains supplementary material, which is available to authorized users.

BACKGROUND: Women's participation in medicine and the need for gender equality in healthcare are increasingly recognised, yet little attention is paid to leadership and management positions in large publicly funded academic health centres. This study illustrates such a need, taking the case of four large European centres: Charité - Universitätsmedizin Berlin (Germany), Karolinska Institutet (Sweden), Medizinische Universität Wien (Austria), and Oxford Academic Health Science Centre (United Kingdom). CASE: The percentage of female medical students and doctors in all four countries is now well within the 40-60% gender balance zone. Women are less well represented among specialists and remain significantly under-represented among senior doctors and full professors. All four centres have made progress in closing the gender leadership gap on boards and other top-level decision-making bodies, but a gender leadership gap remains relevant. The level of achieved gender balance varies significantly between the centres and largely mirrors country-specific welfare state models, with more equal gender relations in Sweden than in the other countries. Notably, there are also similar trends across countries and centres: gender inequality is stronger within academic enterprises than within hospital enterprises and stronger in middle management than at the top level. These novel findings reveal fissures in the 'glass ceiling' effects at top-level management, while the barriers for women shift to middle-level management and remain strong in academic positions. The uneven shifts in the leadership gap are highly relevant and have policy implications. CONCLUSION: Setting gender balance objectives exclusively for top-level decision-making bodies may not effectively promote a wider goal of gender equality. Academic health centres should pay greater attention to gender equality as an issue of organisational performance and good leadership at all levels of management, with particular attention to academic enterprises and newly created management structures. Developing comprehensive gender-sensitive health workforce monitoring systems and comparing progress across academic health centres in Europe could help to identify the gender leadership gap and utilise health human resources more effectively.

Background Health policy has strengthened the demand for coordination between clinicians and managers and introduced new medical manager roles in hospitals to better connect medicine and management. These developments have created a scholarly debate of concepts and an increasing ‘hybridization’ of tasks and roles, yet the organizational effects are not well researched. This research introduces a multi-level governance approach and aims to explore the organizational needs of doctors using Sweden as a case study. Methods We apply an assessment framework focusing on macro-meso levels and managerial-professional modes of hospital governance (using document analysis, secondary sources, and expert information) and expand the analysis towards the micro-level. Qualitative explorative empirical material gathered in two different studies in Swedish hospitals serves to pilot research into actor-centred perceptions of clinical management from the viewpoint of the ‘managed’ and the ‘managing’ doctors in an organization. Results Sweden has developed a model of integrated hospital governance with complex structural coordination between medicine and management on the level of the organization. In terms of formal requirements, the professional background is less relevant for many management positions but in everyday work, medical managers are perceived primarily as colleagues and not as experts advising on managerial problems. The managers themselves seem to rely more on personal strength and medical knowledge than on management tools. Bringing doctors into management may hybridize formal roles and concepts, but it does not necessarily change the perceptions of doctors and improve managerial–professional coordination at the micro-level of the organization. Conclusion This study brings gaps in hospital governance into view that may create organizational weaknesses and unmet management needs, thereby constraining more coordinated and integrated medical management.

Background Health care has experimented with many different quality improvement (QI) approaches with greater variation in name than content. This has been dubbed pseudoinnovation. However, it could also be that the subtleties and differences are not clearly understood. To explore this further, the purpose of this study was to explore how hospital managers perceive lean in the context of QI. Methods We used a qualitative study design with semi-structured interviews to explore twelve top managers’ perceptions of the relationship between lean and quality improvement (QI) at a university-affiliated hospital. Results Managers described that QI and lean shared the same overall purpose: focus on patient needs and improve efficiency and effectiveness. Employee involvement was emphasized in both strategies, as well as the support offered by managers of staff initiatives. QI was perceived as a strategy that could support structural changes at the organizational level whereas lean was seen as applicable at the operational level. Moreover, lean carried a negative connotation, lacked the credibility of QI, and was perceived as a management fad. Conclusions Aspects of QI and lean were misunderstood. In a context where lean remains an abstract term, and staff associate lean with automotive applications and cost reduction, it may be fruitful for managers to invest time and resources to develop a strategy for continual improvement and utilize vocabulary that resonates with health care staff. This could reduce the risk that improvement efforts are rejected out of hand. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1838-z) contains supplementary material, which is available to authorized users.