Factors for successful improvement of Swedish healthcare

Detta är en avhandling från Stockholm : Karolinska Institutet, Department of Learning, Informatics, Management and Ethics (Lime)

Sammanfattning: The Swedish OCM, developed by an Integrative Group Process, was found to be a valid model able to distinguish successful from unsuccessful organizations in terms of improvement. A majority of healthcare organizations applied the Internal Collaborative strategy which lacks the patient centered task alignment characterizing those organizations predicted to be successful by their relatively superior Swedish OCM score. Managers tend to overestimate the prospects of organizational achievement and need support in creating more succesful change contexts. The Swedish healthcare system is struggling with financial limitations, an increasing demand for healthcare and the growing possibility to care for and cure more people than ever before. At the same time studies suggests that between 20-50% of healthcare expenditure is due to costs from poor quality and that about 30-40% of patients do not receive care based on current scientific evidence and best practice. Healthcare organizations undertake various improvement initiatives to cope with these problematic situations but only 20-40% of the improvement efforts aimed at changing practice are successful. From this follows that economical investments as well as time, and human resources are wasted and organizational willingness to embrace further necessary change initiatives diminishes. The Swedish Organizational Change Manager (Swedish OCM) is Bayesian model intended for use in promoting improvement initiatives and increasing their probability of success. The model was developed using the Integrative Group Process, and frames factors which influence the probability of successfully managing improvement initiatives in Swedish healthcare. The model has also been tested empirically based on a survey of Skellefteå Medical Services. Which validated that the model predicts 80% of the successful, and 75% of the failed improvement initiatives. It can thus be used to diagnose weaknesses in improvement initiatives and to guide corrective actions. Through the Swedish OCM, more became known about what seems important for improvement strategies in the context of Swedish healthcare. However, in order to aid policymakers a broader picture of improvement work in Sweden was needed. Thus, all clinical department and primary care center managers in Sweden was surveyed with respect to their views on improvement. In the data analysis the following predominating patterns emerged: improvement methods used were mainly different types of meetings and guidelines, and the main areas of improvement involved administrative routines. Drivers for improvement were mainly intra-organizational, i.e., focused on staff needs. Extra-organizational influences such as patients and comparative data were viewed as less important. Managers in most organizations (80%) perceived this strategy as successful. However, there were little data to support the levels of success perceived. This commonly utilized improvement strategy is denoted the Internal Collaborative Strategy (ICS). This analysis did not reveal other competing improvement strategies. The Swedish OCM was therefore used to stratify the survey material into two different populations. Units with an exceptionally high Swedish OCM score were postulated to possess the prerequisites for successful improvement (n=24) and comprised one population. The other population contained the remaining units with relatively lower Swedish OCM scores and represent the improvement strategies characteristic of the ICS (n=1038). Comparing these two populations revealed an alternative improvement strategy departing from the ICS. The population with high Swedish OCM score put practical emphasis on patient focus, measuring outcomes, feedback of data, inter-organizational collaboration, communication, information, culture, and development of administration and management. Thus these organizations center their attention on behavioral changes of practice, supported by data. This strategy is denoted patient centered task alignment PCTA strategy. Finally, using the same dataset, managers perceptions of organizational change and improvement were investigated. This was done based on theories of diffusion of innovation. A population of respondents who perceived their outcomes from improvement initiatives as superior was selected (n=845). The analysis indicated that there are three main underlying factors that characterizing managers perceptions of improvement. These are: 1) difficulties in the use of improvement practices and techniques 2) conflict between improvement work and the organization and 3) approaches in use are perceived as effective. In conclusion, there is a need to support change initiatives with practical knowledge about how to use improvement concepts, e.g., local adaptation. There is also a need to find strategies to deal with the conflict between daily work and improvement work. Finally, the data indicates that there might be policy resistance in reorientating current improvement strategies, predominantly the Internal Collaborative Strategy, since managers perceived this as an effective approach to current problems.

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