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Research and practice are increasingly showing that leadership and organisational factors significantly influence the success of an improvement initiative. But which actions and which factors are important, for which types of improvement? How does leadership take account of or influence organisational factors? Leaders want more than general principles, but mature leaders are also rightly suspicious of precise directions about which actions to take, knowing that they will need to shape their actions to their situation. Research does provide some answers to these questions, and these are presented in the paper. Where there is no strong evidence from research, the paper draws on experiential and consultant reports and theories to provide 'best available evidence' guidance to different leaders, noting also the limitations of an evidence-based approach for guiding a leader's improvement actions and the opportunities for research. [ABSTRACT FROM AUTHOR]

A 10-year quality journey of a Swedish university hospital is described in this case study based on a variety of data sources. A series of quality initiatives were implemented according to total quality management (TQM) 'best practice.' Many projects were successful, but still a majority of those did not meet the staff's requirement of practical relevance, and they provoked scepticism toward instruments introduced and resistance to service-related quality definitions. The hospital's incentive structures did not reward an engagement in improvement activities. The findings are interpreted as demonstrating that the programs were viewed upon as part of a 'management' rather than 'professional' agenda, despite the underlying philosophy of TQM. It is suggested that applying professional practice development approaches to improvement initiatives might help to overcome the barrier thus created. [ABSTRACT FROM AUTHOR]

Health care decisions could be better informed by research evidence, but there are many areas in which there is little or inconclusive research. Pooling expert knowledge is one way to generate theories and make predictions in areas where there is little clear research evidence. This article addresses these two perspectives in parallel: (1) how to systematically build expert models that have a high predictive and explanatory value by the use of the Integrative Group Process and (2) a model to predict which quality improvement initiatives will be successful, the Swedish Organizational Change Model. The model reveals 11 factors important for successful improvement. Tests of the model conclude that it predicts a high number of successful and unsuccessful initiatives. It can thus be used to diagnose weaknesses in improvement efforts, to measure an organization's overall potential for successful improvement, and to prioritize potential initiatives under consideration. [ABSTRACT FROM AUTHOR]

Abstract Background Service accreditation is a structured process of recognising and promoting performance and adherence to standards. Typically, accreditation agencies either receive standards from an authorized body or develop new and upgrade existing standards through research and expert views. They then apply standards, criteria and performance indicators, testing their effects, and monitoring compliance with them. The accreditation process has been widely adopted. The international investments in accreditation are considerable. However, reliable evidence of its efficiency or effectiveness in achieving organizational improvements is sparse and the value of accreditation in cost-benefit terms has yet to be demonstrated. Although some evidence suggests that accreditation promotes the improvement and standardization of care, there have been calls to strengthen its research base. In response, the ACCREDIT (Accreditation Collaborative for the Conduct of Research, Evaluation and Designated Investigations through Teamwork) project has been established to evaluate the effectiveness of Australian accreditation in achieving its goals. ACCREDIT is a partnership of key researchers, policymakers and agencies. Findings We present the framework for our studies in accreditation. Four specific aims of the ACCREDIT project, which will direct our findings, are to: (i) evaluate current accreditation processes; (ii) analyse the costs and benefits of accreditation; (iii) improve future accreditation via evidence; and (iv) develop and apply new standards of consumer involvement in accreditation. These will be addressed through 12 interrelated studies designed to examine specific issues identified as a high priority. Novel techniques, a mix of qualitative and quantitative methods, and randomized designs relevant for health-care research have been developed. These methods allow us to circumvent the fragmented and incommensurate findings that can be generated in small-scale, project-based studies. The overall approach for our research is a multi-level, multi-study design. Discussion The ACCREDIT project will examine the utility, reliability, relevance and cost effectiveness of differing forms of accreditation, focused on general practice, aged care and acute care settings in Australia. Empirically, there are potential research gains to be made by understanding accreditation and extending existing knowledge; theoretically, this design will facilitate a systems view of accreditation of benefit to the partnership, international research communities, and future accreditation designers. "Accreditation of health-care organisations is a multimillion dollar industry which shapes care in many countries. Recent reviews of research show little evidence that accreditation increases safety or improves quality. It's time we knew about the cost and value of accreditation and about its future direction." [Professor John Øvretveit, Karolinska Institute, Sweden, 7 October 2009]

Background: Effective management of crises is a major challenge for healthcare organisations and their managers. Research suggests that to respond to evolving and unpredictable crises, such as the Covid-19 pandemic, an organisation needs the capability to continually adapt to the changing situation using relevant knowledge. However, there are few empirical studies using an organisational resilience perspective to understand how a health system responds to this type of crisis. This study aimed to describe managers' perspectives on what influenced the response to the Covid-19 pandemic in the Region Stockholm healthcare system for older people., Methods: Data collection was conducted through in-depth semi-structured interviews with assistant managers (n = 3) and managers of inpatient geriatric services outside of acute care hospitals (n = 8), managers of three acute care hospitals (n = 3); and the crisis management team for geriatric services (n = 3). Data was analysed using qualitative content analysis., Results: Crisis management of geriatric care in the Stockholm healthcare system during the Covid-19 pandemic's first 15 months was influenced by a combination of service specific aspects, 'Internal flexible responses', collaborative aspects, 'Coordination within the system', and governance aspects 'Adaptive steering'., Conclusions: This study contributes to empirical knowledge about organisational resilience. Managers' responses are facilitated when the governance allow them more flexibility in their internal responses and enable their cross-organisational collaboration. A coordinating function across healthcare services is an important enabler in a crisis when the function has well-established, trustful prior collaborations with the services., (The International Journal of Health Planning and Management© 2024 The Author(s). The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.)

Introduction: Many patient safety practices are only partly established in routine clinical care, despite extensive quality improvement efforts. Implementation science can offer insights into how patient safety practices can be successfully adopted., Objective: The objective was to examine the literature on implementation of three internationally used safety practices: medication reconciliation, antibiotic stewardship programmes and rapid response systems. We sought to identify the implementation activities, factors and outcomes reported; the combinations of factors and activities supporting successful implementation; and the implications of the current evidence base for future implementation and research., Methods: We searched Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Education Resources Information Center from January 2011 to March 2023. We included original peer-reviewed research studies or quality improvement reports. We used an iterative, inductive approach to thematically categorise data. Descriptive statistics and hierarchical cluster analyses were performed., Results: From the 159 included studies, eight categories of implementation activities were identified: education; planning and preparation; method-based approach; audit and feedback; motivate and remind; resource allocation; simulation and training; and patient involvement . Most studies reported activities from multiple categories. Implementation factors included: c linical competence and collaboration; resources; readiness and engagement; external influence; organisational involvement; QI competence; and feasibility of innovation . Factors were often suggested post hoc and seldom used to guide the selection of implementation strategies. Implementation outcomes were reported as: fidelity or compliance; proxy indicator for fidelity; sustainability; acceptability; and spread . Most studies reported implementation improvement, hindering discrimination between more or less important factors and activities., Conclusions: The multiple activities employed to implement patient safety practices reflect mainly method-based improvement science, and to a lesser degree determinant frameworks from implementation science. There seems to be an unexploited potential for continuous adaptation of implementation activities to address changing contexts. Research-informed guidance on how to make such adaptations could advance implementation in practice., Competing Interests: Competing interests: All authors have completed the ICMJE form for disclosure of competing interests. JTO, ES, SH, HVW have been supported in their work on this paper by grants from the Research Council of Norway, the Western Norway Regional Health Authority, and the Bergen Hospital Trust. MH has been supported in her work on this paper by grants from the Research Council of Norway, and by employment as a researcher by the Fonna Hospital Trust. SH has headed the reference group for the Norwegian Patient Safety Campaign (2011–2014, honorary without payment), and is a paid member of the Regional Committee for Medical Ethics since 2021. PEA has coauthored this paper as part of his work at the Norwegian Centre for Antiobiotic Use in Hospitals, Haukeland University Hospital. He is also an editor of the national guidelines for antibiotic use in hospitals, member of the editorial board of the national guidelines for antibiotic use in primary care, and member of the national breakpoint committee, all without extra funding, as part of his ordinary work. NS has recieved consulting fees as director of London Safety and Training Solutions. RKL has coauthored this paper salaried as an academic librarian at the University of Bergen., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Objective: To contribute actionable knowledge how to increase appropriate use of digital technologies in primary care by understanding clinical managers experiences with a digital connection system, Always Open, during the COVID-19 pandemic., Design and Subjects: The overall design was a qualitative study with directed content analysis method. Data were collected from documents and focus group (n = 12) interviews with clinical managers (n = 99) of primary care. The seven domains of the Non-adoption, Abandonment, and challenges to the Scale-up, Spread and Sustainability (NASSS) framework was used to understand the implementation process, as described by the clinical managers., Results: Focus group participants reported that their units made their own local decisions to make more use of the technology provided by the health system. Most participants considered that the technology was ready to use, despite some limitations, that included individual clinician's and patient preferences, and how ready their unit was for making changes to practice and organization. Some raised concerns about how standardizing some aspects possibly conflicted with the decentralized management model of the organization. The overall experience was reported to be positive, with an intention to sustain the achievements., Conclusion: Focus group interviews found that clinical unit managers reported that they and their staff were positive about the digital technology system for remote care. For the future, they wanted changes to be made at different levels of the health system to better combine digital and physical care. Possibilities to use digital technology to integrate primary and hospital health care were identified.

This perspectives article considers the challenges posed by anti-science and how we can use research to respond more effectively. In public health, the challenges were more visible and the impact more serious during the COVID-19 pandemic. In part, this was due to a more organized anti-science and effective use of narrative methods. Regarding climate change, the role of anti-science represents a critical issue, but perhaps more recognized in environmental research and practice. The article draws on a narrative review to show some of the research into the nature of anti-science and the challenges it poses. It proposes that, as researchers, practitioners, and educationalists, we can be more effective if we make more use of recent research in the sciences of communications, behavior, and implementation, and shows some of the resources we can use to help our work be more relevant in the new era in which we are living.

The article that this commentary considers describes the use of systems modelling in an action research (AR) project that helped improvement teams to understand the dynamics of their service as a system. This commentary seeks to make the complex article easier to understand for those unfamiliar with the subjects. It describes the advantages, disadvantages and benefits, and suggests developments of this approach for research and practice using digital technologies. The conclusion of the commentary is that dynamic system modelling combined with AR is useful for certain purposes and can produce benefits in terms of a more sophisticated understanding of systems and feedback loops for practitioners. However, there are challenges for researchers unfamiliar with AR and dynamic system modelling as well workshop facilitation expertise., (© 2023 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Can we speed the testing, implementation and spread of management innovations in a systematic way to also contribute to scientific knowledge? Researchers and implementers have developed an approach to test and revise a local version of an innovation during its implementation. The chapter starts with a case example of an application of this combination of implementation and quality improvement sciences and practices (improve-mentation). It then summarizes four examples of this approach so as to help understand what improve-mentation is and how it is different from traditional quality improvement and traditional implementation of evidence-based practices. It considers gaps in knowledge that are hindering both more use of improve-mentation to generate scientific knowledge about spread and implementation, as well as more use of improve-mentation by health care service organizations and researchers. It closes by proposing fruitful research and development that can address these knowledge gaps to speed the implementation, sustainment and spread of care and management innovations., (Copyright © 2023 Stephen M Shortell, Lawton Robert Burns and Jennifer L. Hefner. Published under exclusive licence by Emerald Publishing Limited.)

Background: Investigations of implementation factors (e.g., collegial support and sense of coherence) are recommended to better understand and address inadequate implementation outcomes. Little is known about the relationship between implementation factors and outcomes, especially in later phases of an implementation effort. The aims of this study were to assess the association between implementation success (measured by programme fidelity) and care providers' perceptions of implementation factors during an implementation process and to investigate whether these perceptions are affected by systematic implementation support., Methods: Using a cluster-randomized design, mental health clinics were drawn to receive implementation support for one (intervention) and not for another (control) of four evidence-based practices. Programme fidelity and care providers' perceptions (Implementation Process Assessment Tool questionnaire) were scored for both intervention and control groups at baseline, 6-, 12- and 18-months. Associations and group differences were tested by means of descriptive statistics (mean, standard deviation and confidence interval) and linear mixed effect analysis., Results: Including 33 mental health centres or wards, we found care providers' perceptions of a set of implementation factors to be associated with fidelity but not at baseline. After 18 months of implementation effort, fidelity and care providers' perceptions were strongly correlated (B (95% CI) = .7 (.2, 1.1), p = .004). Care providers perceived implementation factors more positively when implementation support was provided than when it was not (t (140) = 2.22, p = .028)., Conclusions: Implementation support can facilitate positive perceptions among care providers, which is associated with higher programme fidelity. To improve implementation success, we should pay more attention to how care providers constantly perceive implementation factors during all phases of the implementation effort. Further research is needed to investigate the validity of our findings in other settings and to improve our understanding of ongoing decision-making among care providers, i.e., the mechanisms of sustaining the high fidelity of recommended practices., Trial Registration: ClinicalTrials.gov Identifier: NCT03271242 (registration date: 05.09.2017)., (© 2022. The Author(s).)

Objective: To describe the design and impact of a systematic, enterprise-wide process for engaging US Department of Veterans Affairs (VA) leadership in prioritizing scarce implementation and evaluation resources., Data Sources: From 2017 to 2021, the VA Quality Enhancement Research Initiative (QUERI) identified priorities from local, regional, and national leaders through qualitative discussions and a national survey and tracked impacts via reports generated from competitively funded initiatives addressing these priorities., Study Design: Guided by the Learning Health System framework and QUERI Implementation Roadmap, QUERI engaged stakeholders to nominate and rank-order priorities, peer-reviewed and funded initiatives to scale up and spread evidence-based practices (EBPs) using theory-based implementation strategies, and evaluated the impact of these initiatives using the QUERI Impact Framework., Data Collection/extraction Methods: QUERI collected priority nominations through qualitative discussions and a web-based survey, and live voting was used to rank-order priorities. QUERI-funded teams regularly submitted progress reports describing the key activities, findings, and impacts of the quality improvement (QI) initiatives using a standardized form created in the VA Research Electronic Data Capture (REDCap)., Principal Findings: QUERI launched five QI initiatives to address priorities selected by VA leadership. In partnership with 28 health system leaders, these initiatives are implementing 10 EBPs across 53 sites, supporting 1055 VA employees in delivering evidence-based care. The success of these initiatives led to an expansion of QUERI's process to address 2021 VA leadership priorities: virtual care, health disparities, delayed or suppressed care due to COVID-19, employee burnout, long-term and home care options, and quality and cost of community care., Conclusions: QUERI, a unique program embedded in a national integrated health system, deployed a novel approach to inform policy making and enhance the real-world impact of research through prioritization of limited resources, rigorous peer-review, and assessment of impacts on the health system, employees, and Veterans., (© 2022 Health Research and Educational Trust. This article has been contributed to by US Government employees and their work is in the public domain in the USA.)

Background: Awareness of patients' innovative capabilities is increasing, but there is limited knowledge regarding the extent and nature of patient-driven innovations in the peer-reviewed literature., Objectives: The objective of the review was to answer the question: what is the nature and extent of patient-driven innovations published in peer-reviewed scientific journals?, Eligibility Criteria: We used a broad definition of innovation to allow for a comprehensive review of different types of innovations and a narrow definition of 'patient driven' to focus on the role of patients and/or family caregivers. The search was limited to years 2008-2020., Sources of Evidence: Four electronic databases (Medline (Ovid), Web of Science Core Collection, PsycINFO (Ovid) and Cinahl (Ebsco)) were searched in December 2020 for publications describing patient-driven innovations and complemented with snowball strategies., Charting Methods: Data from the included articles were extracted and categorised inductively., Results: A total of 96 articles on 20 patient-driven innovations were included. The number of publications increased over time, with 69% of the articles published between 2016 and 2020. Author affiliations were exclusively in high income countries with 56% of first authors in North America and 36% in European countries. Among the 20 innovations reported, 'Do-It-Yourself Artificial Pancreas System' and the online health network 'PatientsLikeMe', were the subject of half of the articles., Conclusions: Peer-reviewed publications on patient-driven innovations are increasing and we see an important opportunity for researchers and clinicians to support patient innovators' research while being mindful of taking over the work of the innovators themselves., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Diabetes care is often sub-optimal. Quality improvement (QI) initiatives are intended to improve care processes and thereby improve patient outcomes. There is a need to assess the degree of implementation of QI strategies, as a prerequisite to managing implementation., Aims: Our study aims to describe the level of implementation of six QI strategies for improving primary care of diabetes (self-management support, team changes, case management, patient education, electronic patient registers and patient reminders)., Methods: A survey and focus groups were conducted between October 2018 and January 2019. We invited eleven general practices in South Auckland, New Zealand. We constructed a questionnaire assessing six QI initiatives, adapting questionnaire items from published instruments. A summary score was calculated by QI strategy and by practice., Results: Five practices participated. All were simultaneously implementing clinical team changes, patient education, electronic patient registers and patient reminders, but type and level of implementations varied between the practices. The scoring system discriminated between practices with respect to both individual strategies and the practice summary score. Practices engaged well with the assessment. Results were reported back to practices who confirmed that the scoring was plausible. The study describes key features and challenges during the implementation process., Conclusions: It is important to measure implementation of QI strategies. In this study of five practices, the instrument developed, and the associated measurement processes, were acceptable to practices and the results appear discriminatory and plausible., Competing Interests: Dr Aguirre-Duarte reports grants from Counties Manukau District Health Board during the conduct of the study.

Purpose: Decentralisation of decision-making from central to lower level organisation has been proposed as a way to increase innovation and make services more responsive to local needs. The purpose of this study was to discover research that can contribute to understanding decentralisation as one strategy for resolving challenges in healthcare service delivery organisations. This scoping review provides examples and research-informed guidance for decentralisation research, planning and implementation., Findings: There is limited empirical research into management decentralisation within primary and community care, but some useful frameworks for assessing and planning decentralisation. Rapid changes are being made to workforce redesign, substitution and patient co-production. Research into such 'micro-decentralisation' is not considered in the decentralisation literature. Neither is how the context of culture, systems and regulations affects implementation of this type of decentralisation. Our recent experience suggests that management decentralisation can enable fast and effective local changes to respond to the evolving Severe acute respiratory syndrome coronavirus 2 (SARS COV-2) pandemic., Conclusions: Decentralisation can create conditions that support innovation and improvement locally to develop primary and community care. Managers and policy makers can use an appropriate decentralisation strategy to address challenges in workforce retention and recruitment, rising care demands and expectations of patients. There are opportunities for researchers to provide actionable knowledge about changes in organisations and management which could address current challenges in healthcare., (© 2020 John Wiley & Sons Ltd.)

The purpose of the article is to illustrate how implementation science concepts and methods can be applied by researchers and implementers to understand and assist emergency management in a large primary and community healthcare organization. The article refers to a single-case implementation action evaluation of an emergency management system in a healthcare organization. It describes the methods used in this study and findings to explain how a joint healthcare and university research team were able to use the science and methods both to help implementation and contribute to science. We report two sets of findings. First, findings about implementation of emergency management to illustrate how the investigation adapted implementation science and concepts to achieve the objectives evaluation. We discovered that implementation science provides useful concepts to understand contextual factors and adds to knowledge about organizational change and emergency management in the uncertain and evolving situation we encountered. The second set of findings are the strengths and limitations of both implementation science and the action evaluation methods we used to achieve the dual objectives of practical help with implementation and to contribute to science. The article uses the first implementation action evaluation study of the response of large public primary and community healthcare organization to a pandemic to illustrate how implementation science can be applied. This type of study was able to improve implementation of the response as well as contribute to scientific knowledge about emergency healthcare management and organization., Competing Interests: Conflict of interestThe authors do not have income apart from their employment. They do not have are not other conflicts or competing interests. There is a potential bias in that the authors are both employees of Region Stockholm healthcare and are reporting on the implementation of the emergency management system in their employing organization. The second author did not carry out interviews or analyze the survey., (© The Author(s) 2021.)

This article describes a rapid implementation research project with the Stockholm health care system to assist the system to respond to the COVID-19 pandemic. It uses this example to illustrate some ways in which implementation research and knowledge can contribute to improving service responses to the pandemic and its consequences as these evolve over the coming months. A sub-specialty of rapid implementation science is proposed to provide practical assistance and as one way to develop implementation research., Plain Language Abstract: This article describes a rapid implementation research project with the Stockholm health care system to assist the system to respond to the COVID-19 pandemic. It uses this example to illustrate some ways in which implementation research and knowledge can contribute to improving service responses to the pandemic and its consequences as these evolve over the coming months. A sub-specialty of rapid implementation science is proposed to provide practical assistance and as one way to develop implementation research., Competing Interests: Declaration of conflicting interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The author and some research team members were employed by the Stockholm Region Government and by the Karolinska Institutet medical university and conducted the research in addition to their other funded projects and work assignments. One research member was retired and not employed by either organization. Because the author and some of the researchers were dually employed by the university and the Stockholm Region Government, there is a potential conflict of interest and potential for bias in their investigation of how their employers implemented emergency management. This commentary offers the author’s perspectives on the project and process but does not present findings, and procedures to manage potential bias will be described in a forthcoming research report., (© The Author(s) 2020.)

INTRODUCTION Sweden is unique in adopting a 'no-lockdown' public health approach to the SARS-CoV-2 (COVID-19) outbreak. There were fears that health services would not be able to care for high numbers of COVID-19 patients. AIM To describe and review the emergency response of a public primary and community health-care organisation in Stockholm, Sweden, to the demand for care for COVID-19 and non-COVID-19 patients during March-July 2020, and summarise preparations for the months to follow. METHODS This was a rapid implementation action research case study, which also draws on one author's experience as Chief Executive Officer and other members' experience in an emergency management group. RESULTS Sweden experienced similar mortality per million population to the UK, despite the different public health strategy used to address the COVID-19 outbreak. The Stockholm-integrated public primary and community health-care service, serving a population of 2.3 million, made many changes quickly. One change included coordinating non-acute private health-care services, following the local government emergency directive to do so. DISCUSSION It is possible that the fast and effective response by management and services in primary and community health care reduced infection and hospital demand, which contributed to a lower mortality than otherwise expected. The actions and preparations described for Stockholm's response may provide ideas for other health-care systems. The partnership research approach between the Karolinska Medical University and the Region Stockholm health-care system used in this project shows that rapid research methods have advantages for both partners in an emergency situation.

Personal health records (PHRs) are thought to offer benefits and are promoted by health policy makers and some healthcare systems. Evidence for usage by patients in hospital is limited.  This article reports a one-day workshop hosted by the Royal College of Physicians that considered the evidence of the value to patients and others, the challenges to adoption and use of PHRs and sought to identify the practical and research questions that need to be answered.  The purpose of this article is to provide readers with an overview of the issues and possible future for hospital application of PHRs in the UK's NHS, especially for supporting self-care, family carers and advancing person-centred care. It aims to share the experience and ideas of those taking part in the workshop and reference resources that we have found useful while highlighting areas for future research.

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.

Faster and more widespread implementation could help more patients to benefit more quickly from known effective treatments. So could more effective implementation of better assessment methods, service delivery models, treatments and services. Implementation at scale and 'descaling' are ways for hospitals and health systems to respond to rising demands and costs. The paper proposes ways to provide leaders with the information that would help them to decide whether and how to scale up a proven improvement. We draw on our knowledge of the improvement and implementation literature on the subject and on our experience of scale up programs in Kaiser Permanente, in Swedish county health systems, and in international health. We describe a '3S' scale up infrastructure and other ingredients that appear necessary for successful widespread improvement, and list the resources that we have found useful for developing scale up programs. The paper aims to encourage more actionable research into scale up, and shows the opportunities for researchers to both advance implementation and improvement science and contribute to reducing suffering and costs in a more timely and effective way., (© The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Patients at the center of care is often the stated focus of clinicians and healthcare services. The quality and safety movement has shown that effective organization of care is needed, in addition to professional skills. This movement has provided professionals and others with methods to improve both organization and practice for patients. These methods include measurement to give those carrying out improvement feedback about the effects of their changes. New types of measures that enable patients to report treatment outcomes can now be use in quality improvement and quality reporting to bring a renewed focus on making care more patient-centered. Although used for some time in research, these measures are relatively new tools for quality improvement and not all research measures are suitable for everyday feedback or improvement projects. The purpose of the paper is to provide an introduction to the use and value of patient-reported outcome measures in quality improvement and to give practical guidance and resources for using PROMs for quality improvement. It draws on the authors' experiences using patient reported outcomes measures for quality research and improvement and their workshop at the 2016 Tokyo ISQUA conference, as well as on reviews and guidance documents about the use of PROMs. It does not provide a comprehensive and systematic review of research, but an overview and introduction to PROMs for quality improvement., (© The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Shared electronic health and social care records in some service systems are already showing some of the benefits of digital technology and digital data for integrating health and social care. These records are one example of the beginning "digitalisation" of services that gives a glimpse of the potential of digital technology and systems for building coordinated and individualized integrated care. Yet the promise has been greater than the benefits, and progress has been slow compared to other industries. This paper describes for non-technical readers how information technology was used to support integrated care schemes in six EU services, and suggests practical ways forward to use the new opportunities to build person-centered integrated care.

For older people with multiple chronic co-morbidities, strategies to coordinate care depend heavily on information exchange. We analyse the information-sharing difficulties arising from differences between patients' oral narratives and medical sense-making; and whether a modified form of 'narrative medicine' might mitigate them. We systematically compared 66 general practice patients' own narratives of their health problems and care with the contents of their clinical records. Data were collected in England during 2012-13. Patients' narratives differed from the accounts in their medical record, especially the summary, regarding mobility, falls, mental health, physical frailty and its consequences for accessing care. Parts of patients' viewpoints were never formally encoded, parts were lost when clinicians de-coded it, parts supplemented, and sometimes the whole narrative was re-framed. These discrepancies appeared to restrict the patient record's utility even for GPs for the purposes of risk stratification, case management, knowing what other care-givers were doing, and coordinating care. The findings suggest combining the encoding/decoding theory of communication with inter-subjectivity and intentionality theories as sequential, complementary elements of an explanation of how patients communicate with clinicians. A revised form of narrative medicine might mitigate the discursive gap and its consequences for care coordination., (© 2017 The Authors. Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL.)

'Does it work?' is not the only question that practical improvers have of those investigating of quality improvements. They also want to know, 'Will it work here? What conditions do we need to implement and sustain it? Can we adapt it? How much will it cost and save? Is there enough evidence to spread it?'This perspectives article describes methods that investigators can use to answer these questions about improvement changes and improvement methods. It suggests that one reason why research is underused by improvers is because there is little research that answers these questions that would enable improvers to decide whether or how to implement an improvement in their local setting. It shows improvers that answers are possible and where improvers might find research and reports which answer these questions. It is based on reviews of research and reports about methods for producing valid and actionable knowledge to answer these questions. It describes a new 'quality improvement investigation movement' which is uniting applied researchers and improvers to use innovative methods to answer these questions. These investigators recognize the strengths of the randomized controlled trail method, and how easy it is to draw the wrong conclusions from data generated using lower cost and more timely methods. It emphasizes how investigators can choose a method suited to each question, describe the limitations of the method and communicate to improvers the degree of certainty of their answers to the questions., (© The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose - The purpose of this paper is to identify opportunities for improving primary care services for people with chronic illnesses by comparing how Sweden and US services use evidence-based practices (EBPs), including digital health technologies (DHTs). Design/methodology/approach - A national primary healthcare center (PHCC) heads surveys in 2012-2013 carried out in both countries in 2006. Findings - There are large variations between the two countries. The largest, regarding effective DHT use in primary care centers, were that few Swedish primary healthcare compared to US heads reported having reminders or prompts at the point of care (38 percent Sweden vs 84 percent USA), despite Sweden's established electronic medical records (EMR). Swedish heads also reported 30 percent fewer centers receiving laboratory results (67 percent Sweden vs 97 percent USA). Regarding following other EBPs, 70 percent of Swedish center heads reported their physicians had easy access to diabetic patient lists compared to 14 percent in the USA. Most Swedish PHCC heads (96 percent) said they offered same day appointment compared to 36 percent in equivalent US practices. Practical implications - There are opportunities for improvement based on significant differences in effective practices between the countries, which demonstrates to primary care leaders that their peers elsewhere potentially provide better care for people with chronic illnesses. Some improvements are under primary care center control and can be made quickly. There is evidence that people with chronic illnesses in these two countries are suffering unnecessarily owing to primary care staff failing to provide proven EBP, which would better meet patient needs. Public finance has been invested in DHT, which are not being used to their full potential. Originality/value - The study shows the gaps between current and potential proven effective EBPs for services to patients with chronic conditions. Findings suggest possible explanations for differences and practical improvements by comparing the two countries. Many enhancements are low cost and the proportionate reduction in suffering and costs they bring is high.

Background: A Swedish version of the USA Agency for Healthcare Research and Quality "Hospital Survey on Patient Safety Culture" (S-HSOPSC) was developed to be used in both hospitals and primary care. Two new dimensions with two and four questions each were added as well as one outcome measure. This paper describes this Swedish version and an assessment of its psychometric properties which were tested on a large sample of responses from personnel in both hospital and primary care., Methods: The questionnaire was mainly administered in web form and 84215 forms were returned (response rate 60%) between 2009 and 2011. Eleven per cent of the responses came from primary care workers and 46% from hospital care workers. The psychometric properties were analyzed using both the total sample and the hospital and primary care subsamples by assessment of construct validity and internal consistency. Construct validity was assessed by confirmatory (CFA) and exploratory factor (EFA) analyses and internal consistency was established by Cronbachs's α., Results: CFA of the total, hospital and primary care samples generally showed a good fit while the EFA pointed towards a 9-factor model in all samples instead of the 14-dimension S-HSOPSC instrument. Internal consistency was acceptable with Cronbach's α values above 0.7 in a major part of the dimensions., Conclusions: The S-HSOPSC, consisting of 14 dimensions, 48 items and 3 single-item outcome measures, is used both in hospitals and in primary care settings in Sweden for different purposes. This version of the original American instrument has acceptable construct validity and internal consistency when tested on large datasets of first-time responders from both hospitals and primary care centres. One common instrument for measurements of patient safety culture in both hospitals and primary care settings is an advantage since it enables comparisons between sectors and assessments of national patient safety improvement programs. Future research into this version of the instrument includes comparing results from patient safety culture measurements with other outcomes in relation to safety improvement strategies.

Purpose: This study aims to describe implementation of simulator-based medical team training and the effect of this programme on inter-professional working in an intensive care unit (ICU)., Design/methodology/approach: Over a period of two years, 90 percent (n = 152) of the staff of the general ICU at Karolinska University Hospital, Huddinge, Sweden, received inter-professional team training in a fully equipped patient room in their own workplace. A case study method was used to describe and explain the planning, formation, and results of the training programme., Findings: In interviews, the participants reported that the training had increased their awareness of the importance of effective communication for patient safety. The intervention had even had an indirect impact by creating a need to talk, not only about how to communicate efficaciously, but also concerning difficult care situations in general. This, in turn, had led to regular reflection meetings for nurses held three times a week. Examples of better communication in acute situations were also reported. However, the findings indicate that the observed improvements will not last, unless organisational features such as staffing rotas and scheduling of rounds and meetings can be changed to enable use of the learned behaviours in everyday work. Other threats to sustainability include shortage of staff, overtime for staff, demands for hospital beds, budget cuts, and poor staff communication due to separate meetings for nurses and physicians., Originality/value: The present results broaden our understanding of how to create and sustain an organizational system that supports medical team training.

This paper summarises the findings from an empirical longitudinal study of a health and social care consortium for people with mental health problems in one area in Stockholm. The aim was to describe the formation and structure of coordination within the consortium, and to assess the intermediate impact on care processes and client outcomes. A multiple-method case study design, theoretically informed by the Pettigrew and Whipp model of strategic change (1993) was applied. Data was gathered from interviews with informants from different organisations at different times in the development of the consortium, and from administrative documents, plans and service statistics showing some of the intermediate changes and client outcomes. The findings revealed activities and factors both helping and hindering the formation of coordination arrangements. One of the most significant hindering factors was the central county purchasing organisation focusing more on volume and costs, with payments for specific units and services, and with less emphasis on quality of the services. Few studies have described implementation of changes to improve coordination with reference to context over a long period of time, as well as assessing different results. This study contributes to knowledge about improved methods for this type of research, as well as knowledge about developing coordination between public health and welfare services. One lesson for the current policy is that, where full structural integration is not possible, then client-level coordination roles in each sector are useful to connect sector services for shared clients., (Copyright © 2011 John Wiley & Sons, Ltd.)

Background: Both research and practice show that waiting lists are hard to reduce. Implementing complex interventions for reduced waits is an intricate and challenging process that requires special attention for surrounding factors helping and hindering the implementation. This article reports a case study of a hospital implementation of operational plans for reduced waits, with an emphasis on the process of change., Methods: A case study research design, theoretically informed by the Pettigrew and Whipp model of strategic change, was applied. Data were gathered from individual and focus group interviews with informants from different organizational levels at different times and from documents and plans., Findings: The findings revealed arrangements both helping and hindering the implementation work. Helping factors were the hospital's contemporary savings requirements and experiences from similar change initiatives. Those hindering the actions to plan and agree the changes were unclear support functions and unclear task prioritization., Conclusions and Practice Implications: One contribution of this study is to demonstrate the advantages, disadvantages, and challenges of a contextualized case study for increased understanding of factors influencing organizational change implementation. One lesson for current policy is to regard context factors that are critical for successful implementation.

Purpose: The purpose of this paper is to compare the implementation of 12 different organisation and management innovations (OMIs) in Swedish healthcare, to discover the generic and specific factors important for successful healthcare improvement change in a public health system., Design/methodology/approach: Longitudinal cross-case comparison of 12 case studies was employed, where each case study used a common framework for collecting data about the process of change, the content of the change, the context, and the intermediate and final outcomes., Findings: Clinical leaders played a more important part in the development of these successful service innovations than managers. Strategies for and patterns of change implementation were found to differ according to the type of innovation. Internal organisational context factors played a significant role in the development of nearly all, but external factors did not. "Developmental evolution" better described the change process than "implementation"., Research Limitations/implications: The 12 cases were all of relatively successful change processes: some unsuccessful examples would have provided additional testing of the hypotheses about what would predict successful innovation which were used in the case comparison. The cross-case comparative hypothesis testing method allows systematic comparison if the case data are collected using similar frameworks, but this approach to management research requires considerable resources and coordination., Practical Implications: Management innovations that improve patient care can be carried out successfully by senior clinicians, under certain circumstances. A systematic approach is important both for developing and adapting an innovation to a changing situation. A significant amount of time was required for all involved, which could be reduced by "fast-tracking" approval for some types of change., Originality/value: This is the first empirical report comparing longitudinal and contextualised findings from a number of case studies of different organisational and management healthcare innovations. The findings made possible explanations for success factors and useful practical recommendations for conditions needed to nurture such innovation in public healthcare.

Purpose: The purpose of this paper is to describe and explain a clinician-led improvement of a hip fracture care process in a university hospital, and to assess the results and factors helping and hindering change implementation., Design/methodology/approach: The paper has a mixed methods case study design. Data collection was guided by a framework directing attention to the content and process of the change, its context and outcomes., Findings: Using a multiprofessional project team, beneficial changes in the early parts of the care process were achieved, but inability to change surgical staff work practices meant that the original goal of operating patients within 24 hours was not reached. After three years, top management introduced a hospital-wide process improvement programme, which "took over" the responsibility for improving hip fracture care., Research Implications/limitations: A clear vision why change is needed and what needs to be done, which is well communicated by a respected clinical leader, can motivate personnel, but other influences are also needed to bring about change. Without a plan agreed and supported by top management, changes are likely to be limited to parts of the process and improvements to patient care may be minimal. These and other findings may be applicable to similar situations in other services., Originality/value: This case study is an illustration of both the strengths and the weaknesses of a "bottom-up, clinician-champion-led improvement initiative" in a complex university hospital.

Context can be defined as all factors that are not part of a quality improvement intervention itself. More research indicates which aspects are 'conditions for improvement', which influence improvement success. However, little is known about which conditions are most important, whether these are different for different quality interventions or whether some become less or more important at different times in carrying out an improvement. Knowing more about these conditions could help speed up and spread improvements and develop the science. This paper proposes ways to build knowledge about the conditions needed for different changes, and to create conditional-attribution explanations to provide qualified generalisations. It describes theory-based, non-experimental research designs. It also suggests that 'practical improvers' can make their changes more effective by reflecting on and revising their own 'assumption-theories' about the conditions which will help and hinder the improvements they aim to implement.

If a quality improvement is found effective in one setting, would the same effects be found elsewhere? Could the same change be implemented in another setting? These are just two of the 'generalisation questions' which decision-makers face in considering whether to act on reported improvement. In this paper, some of the issues are considered and a programme of research for testing improvements in different settings is proposed to build theory and practical guidance about implementation and results in different settings.