Co-producing healthcare quality improvement : the prerequisites for, the value of and the lessons from co-production in a Swedish cardiac care setting

Sammanfattning: Background: The promotion of the best possible health and care is challenging to healthcare organizations worldwide. Healthcare organizations’ capability to improve the quality of care is therefore crucial to the sustainability of the welfare state. Research implies that co-production of healthcare, involving persons with disease, their families and healthcare professionals, has the potential to promote healthcare quality improvement and the best possible health and care. However, the evidence base for co-production in social and healthcare contexts is rather weak. Thus, the overall aim of this thesis was to explore the prerequisites for and the value of co-production and to provide lessons for future co-produced healthcare quality improvement initiatives in cardiac care.Methods: All studies were conducted in a cardiac care setting in the southern part of Sweden between the years 2016 and 2023. The research had a qualitative design with a practice-oriented interactive research approach, underpinned by healthcare improvement science and pragmatism. Persons with atrial fibrillation or heart failure, their family members, and healthcare professionals participated in the research. Two models for co-production were explored – the Learning Café (LC) and Experience-Based Co-Design (EBCD). Data collection included patients’ ratings regarding their sense of security in everyday life, focus group interviews, project documentation, individual interviews, field notes from observations, and meeting minutes from stakeholders’ individual and joint EBCD feedback events. Data analysis entailed inductive or deductive qualitative content analysis and reflexive thematic analysis. Self-determination theory, the COM-B model and the MUSIQ framework were applied during the research process to promote an in-depth understanding of the concept of co-production.Findings: This research exemplifies a learning journey toward co-production in a Swedish cardiac care setting. Barriers to and facilitators of co-production were identified on different levels – the individual, the relational and the systemic levels. Individual barriers to co-production included poor health and limited health literacy among persons with heart disease. Relational barriers included professionals not inviting patients and their family members to be involved in healthcare co-4 production. Barriers on the systemic level included time and resource constraints and varying understanding of how co-production might be applied in practice. Both self-centered motivations, such as wanting to learn more about a specific disease, and community-centered motivations, such a wanting to improve healthcare services, were identified to be facilitators to co-production. The LC and the EBCD process created value for its participants and the organization, including improved disease knowledge; relatedness; strengthened coping strategies and improved self-efficacy; awareness about the patient and family member perspective; and knowledge about what needs to change in heart failure care.Conclusions: This thesis proposes how healthcare co-production might be practiced, particularly in cardiac care contexts which have seen only limited implementation of such initiatives. Self-centered motivations to co-produce were common among persons with heart disease and their family members, whereas community-centered motivations dominated among professionals. Future co-production initiatives should draw on these motivations. Furthermore, future co-production initiative should seek to overcome barriers to co-production by letting stakeholders participate on their own terms, by promoting a cultural change toward shared power between patients, family members and professionals and by encouraging healthcare leaders and mangers to support healthcare quality improvement. Furthermore, this thesis proposes that co-production brings value to its stakeholders in terms of improved coping strategies persons with heart disease and family members and enhanced work satisfaction among professionals. Future research is warranted to understand how co-production might be implemented and play out in various healthcare contexts and with other groups of persons living with chronic disease.