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Research and citizens have noted failures in coordinating health and social services and professionals, and the need to address this issue to realize benefits from increasing specialisation. Different methods have been proposed and one has been structural integration of separate services within one organisation. This paper reports an empirical longitudinal study of the development of an integrated health and social care organisation in Sweden combining service provision, purchasing and political governance for a defined population. The study found a combination of influences contributed to the development of this new organisation. The initial structural macro-integration facilitated, but did not of itself result in better clinical care coordination. Other actions were needed to modify the specialised systems and cultures which the organisation inherited. The study design was not able to establish with any degree of certainty whether better patient and cost outcomes resulted, but it did find structural and process changes which make improved outcomes likely. The study concludes that coordinated actions at different levels and of different types were needed to achieve care coordination for patients and that a phased approach was necessary where management capacity and outside expertise are limited., (Copyright (c) 2010 Elsevier Ireland Ltd. All rights reserved.)

Purpose: The purpose of this paper is to examine the outcomes and evolution over a five-year period of a Swedish university hospital quality improvement program in light of enduring uncertainty regarding the effectiveness of such programs in healthcare and how best to evaluate it., Design/methodology/approach: The paper takes the form of a case study, using data collected as part of the program, including quality indicators from clinical improvement projects and participants' program evaluations., Findings: Overall, 58 percent of the program's projects (39/67) demonstrated success. A greater proportion of projects led by female doctors demonstrated success (91 percent, n=11) than projects led by male doctors (51 percent, n=55). Facilitators at the hospital continuously adapted the improvement methods to the local context. A lack of dedicated time for improvement efforts was the participants' biggest difficulty. The dominant benefits included an increased ability to see the "bigger picture" and the improvements achieved for patients and employees., Research Limitations/implications: Quality measurement, which is important for conducting and evaluating improvement efforts, was weak with limited reliability. Nevertheless, the present study adds evidence about the effectiveness of healthcare improvement programs. Gender differences in improvement team leadership merit further study. Improvement program evaluation should assess the extent to which improvement methods are locally adapted and applied., Originality/value: This case study reports the outcomes of all improvement projects undertaken in one healthcare organization over a five-year period and provides in-depth insight into an improvement program's changeable nature.

Objective: To explore outsourcing of primary health care (PHC) services in four municipalities in Finland with varying amounts and types of outsourcing: a Southern municipality (SM) which contracted all PHC services to a not-for-profit voluntary organization, and Eastern (EM), South-Western (SWM) and Western (WM) municipalities which had contracted out only a few services to profit or public organizations., Methods: A mail survey to all municipality politicians (response rate 52%, N=101) in 2004. Data were analyzed using cross-tabulations, Spearman correlation and linear regression analyses., Results: Politicians were willing to outsource PHC services only partially, and many problems relating to outsourcing were reported. Politicians in all municipalities were least likely to outsource preventive services. A multiple linear regression model showed that reported preference to outsource in EM and in SWM was lower than in SM, and also lower among politicians from "leftist" political parties than "rightist" political parties. Perceived difficulties in local health policy issues were related to reduced preference to outsource. The model explained 27% of the variance of the inclination to outsource PHC services., Conclusions: The findings highlight how important it is to take into account local health policy issues when assessing service-provision models.

Purpose: The aim of this paper is to stimulate debate about criteria for assessing the scientific contribution of a piece of management research and to guide and encourage researchers in writing papers for publication. The paper also seeks to reduce the number of papers submitted to journals and reviewers which are really unfinished early drafts or which do provide knowledge which could contribute to reducing suffering., Design/methodology/approach: The paper draws on and discusses the difference between practical research for a manager and scientific research, as well as the author's experience as researcher, writer, reviewer, editor, research methods course leader and director of research., Findings: The discussion highlights that the author should draft the paper under the suggested headings and fulfil criteria of validity, reliability, supported conclusions, generalisability, ensuring that each section follows on from the other, and that the findings are related to previous research., Research Limitations/implications: This is the author's personal view about how to carry out and write research to get published, without discussions of other views., Practical Implications: The findings in this paper may provoke more debate about management science and the role of this journal. The guidance may help many researchers publish their management research., Originality/value: The paper links practical guidance with discussion of criteria for scientific contribution in a readable way.

Purpose: The purpose of this paper is to describe patient complaints and claims data from Swedish databases and assess their value for scientific research and practical health care improvement., Design/methodology/approach: The article first describes previous research into patient claims and similar schemes. It then presents three types of data on patient claims and complaints in Sweden: data generated by the Patient Insurance Fund, the Medical Responsibility Board and the Patients' Advisory Committees and considers methodological issues in using the data., Findings: The databases' value is problems related to spontaneous reporting, which makes it difficult to know how much the data correspond to general injury rates and health care patterns. Another issue is the balance between the size of study materials and the timeliness, e.g. when diagnosis-specific analysis requires data pooling over several years in order to reach adequate case numbers. Adjustment for confounders not present in the databases, e.g. data on hospital case-mix, may add to difficulties using the data in comparative analyses of safety performance., Research Limitations/implications: The databases' safety analysis and quality improvement value depends on understanding their function, data collection method and their limitations as a source of data about the true incidence and prevalence of injuries and safety problems., Originality/value: This is the first thorough review of the possibilities and limitations associated with the use of claims and complaints data in health care research and improvement.

Objective: To describe an implementation of one information technology system (electronic medical record, EMR) in one hospital, the perceived impact, the factors thought to help and hinder implementation and the success of the system and compare this with theories of effective IT implementation. To draw on previous research, empirical data from this study is used to develop IT implementation theory., Design: Qualitative case study, replicating the methods and questions of a previously published USA EMR implementation study using semi-structured interviews and documentation., Setting: Large Swedish teaching hospital shortly after a merger of two hospital sites., Participants: Thirty senior clinicians, managers, project team members, doctors and nurses., Results: The Swedish implementation was achieved within a year and for under half the budget, with a generally popular EMR which was thought to save time and improve the quality of patient care. Evidence from this study and findings from the more problematic USA implementation case suggests that key factors for cost effective implementation and operation were features of the system itself, the implementation process and the conditions under which the implementation was carried out., Conclusion: There is empirical support for the IT implementation theory developed in this study, which provides a sound basis for future research and successful implementation. Successful implementation of an EMR is likely with an intuitive system, requiring little training, already well developed for clinical work but allowing flexibility for development, where clinicians are involved in selection and in modification for their department needs and where a realistic timetable is made using an assessment of the change-capability of the organization. Once a system decision is made, the implementation should be driven by top and departmental leaders assisted by competent project teams involving information technology specialists and users. Corrections for unforeseen eventualities will be needed, especially with less developed systems, requiring regular reviews of progress and modifications to systems and timetables to respond to user needs.

Background: Ventilator-associated pneumonia (VAP) is a serious nosocomial infection, leading to high mortality and high costs of treatment in developed and limited-resource countries. A collaborative quality improvement (QI) project was conducted in 18 secondary and tertiary care hospitals in Thailand to address the problem., Methods: The project, conducted between February 2004 and May 2005, entailed three face-to-face meetings--two national workshops and two regional workshops (each conducted twice). Education on VAP prevention, including guidelines and the ventilator bundle, was conducted for intensive care unit staff and all relevant personnel. The collaborative's effectiveness was assessed by VAP rate, a self-administered questionnaire, and face-to-face interviews., Results: Within 12 months, the pooled VAP rate decreased from 13.3 to 8.3 per 1,000 ventilator-days. The costs of antibiotic treatment for VAP decreased by more than one half. More than 80% of interviewed participants reported that the QI method could be applied effectively in their organization., Discussion: VAP surveillance during this project revealed a gradual reduction of the VAP rate. The project's relative overall success appears to reflect, as reported elsewhere, a well-organized program, support from hospital administrators, and workshop leaders' presentation of proven QI methods and clinical interventions.

Quality methods of many types have been widely used in hospitals. Although a number of specific projects have shown evidence of improvement, there is no strong evidence of the effectiveness of organization-wide or system programs over a period of time. There is no evidence of which approaches might be more suitable for different settings, or of value for money compared, for example, to employing more doctors and nurses. Jönköping is widely known in Sweden and internationally as one long-running example of a successful systemwide improvement program. As with other programs, critics and researchers have asked for evidence of improved outcomes for patients and of the costs of the program. There are methodological challenges to providing strong evidence of these outcomes, even in small projects where it is easier to attribute outcomes to interventions, at least over the short term. However, there are ways to gather data that are more objective than participants' and consultants' reports and that are useful for assessing the value of the program and to enable others to learn from the experience of Jönköping. This article presents such data from a case study of the program carried out in 2006. It presents evidence of how the program was implemented, of some results, and of the unusual conditions that appear to have shaped or allowed the program to be carried out in the way described. There is some evidence of process improvements in a number of departments and of outcomes improvement in one department. The program is widely perceived to be of benefit and some of the explanations for this are presented.

The World Health Organization makes a case for the importance of voluntary organizations in promoting health at local levels. The purpose of this paper is to contribute to understanding which factors explain local voluntary associations (LVAs) participation in health promotion in local contexts. It does so through (i) identifying indicators that represent determinants of health promotion action which were reported by LVAs and by (ii) comparing their actions with these determinants. The data reported are from a questionnaire survey of all registered LVAs in four municipalities in Finland. Principal component analysis revealed four determinants of health promotion action. Four factors in the final multivariate model explained over half of the variance of LVAs engagement in health promotion action: competence, values 'healthy' and also opportunities and municipality. There is some evidence to support a model of health promotion action which has not been tested empirically in relation to these types of organization. More detailed studies of determinants of health promotion action are needed to shape strategies in local communities.

Much has been written about quality in patient care and clinical support services, but very little about the quality of purchasing. This paper gives an overview of quality issues in purchasing, and offers guidelines and practical steps for purchasers to improve service quality--both their own and their providers'. It defines quality in purchasing and considers how purchasers can influence markets and work with providers to improve health services quality. The paper gives practical guidance for improving quality, which recognises the limited resources and skills which purchasers have for the task. It addresses some issues raised by purchaser/managers: How does a purchasing organisation measure and improve quality? Is there a better way of specifying and monitoring quality than the "shopping-list of standards" approach--what should be asked of providers? How can information about clinical quality, outcome and costs, be obtained in a form in which reliable comparisons can be made? Is quality accreditation or registration a good predictor of future quality?

Many quality improvement interventions such as educational programmes, hospital quality strategies, and quality evaluation systems have not been evaluated. The aim of this paper is to encourage research into these "quality improvement processes" by presenting suitable designs and methods, and by describing research approaches which are less familiar in healthcare. The paper proposes that the choice of research design depends on the level and complexity of the intervention. Theory-building approaches are more suitable than experimental theory testing approaches for evaluating higher-level complex interventions and for understanding critical context factors. Collaborative action evaluation studies can provide useful information for decision makers--an examples is given. "User focused" research can provide knowledge for developing more effective quality intervention processes and for making better decisions about their use and implementation.

By 2005 all healthcare organizations in Europe will be required to take part in a quality evaluation scheme and to collect data about the quality of their service. Hospitals and doctors will need to prove they are safe--quality is no longer assumed. These were the predictions of a recent workshop of Nordic quality experts. The pressures to assess quality are increasing, and there are many assessment, certification, accreditation and measurement schemes in use. Which is best? What evidence is there that any have been effective? How should a hospital or region introduce such a scheme? There are many proponents for different schemes, and an increasing amount of experience to help answer these questions, but little research. This paper provides an overview for non-specialists of the different quality evaluation and indicator schemes for inspection and improvement. It draws on the experiences of quality specialists and leaders in each Nordic country who have applied the schemes in public hospitals and healthcare services. How a scheme is introduced and used may be more important than which particular scheme is chosen. This is one conclusion of the Nordic workshop. Other conclusions are that there is a need for clinicians to be involved, a need to balance simplicity and low cost with scientific validity and credibility with clinicians, and a need for research into different schemes to discover their costs and benefits in healthcare.

How much time and money should we devote to quality activities? Will the results be worth the resources which we invest? How can we calculate the return on our quality investments? These questions are raised by managers, clinicians and policy-makers, but they are rarely answered, which may explain the loss of credibility of some quality activities. This paper gives examples of the cost of poor quality, describes and illustrates a simple method for quality costing, and discusses the economics of quality. It considers why there is little research and teaching about the subject, and proposes how managers and clinicians can take a more economically-informed approach to quality in public healthcare.