The role of organizational factors in how efficiency-thoroughness trade-offs potentially affect clinical quality dimensions – a review of the literature

Knowledge boundaries for implementation of quality improvement interventions; a qualitative study

Introduction

Implementation and adoption of quality improvement interventions have proved difficult, even in situations where all participants recognise the relevance and benefits of the intervention. One way to describe difficulties in implementing new quality improvement interventions is to explore different types of knowledge boundaries, more specifically the syntactic, semantic and pragmatic boundaries, influencing the implementation process. As such, this study aims to identify and understand knowledge boundaries for implementation processes in nursing homes and homecare services.

Methods

An exploratory qualitative methodology was used for this study. The empirical data, including individual interviews (n = 10) and focus group interviews (n = 10) with leaders and development nurses, stem from an externally driven leadership intervention and a supplementary tracer project entailing an internally driven intervention. Both implementations took place in Norwegian nursing homes and homecare services. The empirical data was inductively analysed in accordance with grounded theory.

Results

The findings showed that the syntactic boundary included boundaries like the lack of meeting arenas, and lack of knowledge transfer and continuity in learning. Furthermore, the syntactic boundary was mostly related to the dissemination and training of staff across the organisation. The semantic boundary consisted of boundaries such as ambiguity, lack of perceived impact for practice and lack of appropriate knowledge. This boundary mostly related to uncertainty of the facilitator role. The pragmatic boundary included boundaries related to a lack of ownership, resistance, feeling unsecure, workload, different perspectives and a lack of support and focus, reflecting a change of practices.

Discussion

This study provides potential solutions for traversing different knowledge boundaries and a framework for understanding knowledge boundaries related to the implementation of quality interventions.

Exploring the influence of health system factors on adaptive capacity in diverse hospital teams in Norway: a multiple case study approach

OBJECTIVES

Understanding flexibility and adaptive capacities in complex healthcare systems is a cornerstone of resilient healthcare. Health systems provide structures in the form of standards, rules and regulation to healthcare providers in defined settings such as hospitals. There is little knowledge of how hospital teams are affected by the rules and regulations imposed by multiple governmental bodies, and how health system factors influence adaptive capacity in hospital teams. The aim of this study is to explore the extent to which health system factors enable or constrain adaptive capacity in hospital teams.

DESIGN

A qualitative multiple case study using observation and semistructured interviews was conducted between November 2020 and June 2021. Data were analysed through qualitative content analysis with a combined inductive and deductive approach.

SETTING

Two hospitals situated in the same health region in Norway.

PARTICIPANTS

Members from 8 different hospital teams were observed during their workday (115 hours) and were subsequently interviewed about their work (n=30). The teams were categorised as structural, hybrid, coordinating and responsive teams.

RESULTS

Two main health system factors were found to enable adaptive capacity in the teams: (1) organisation according to regulatory requirements to ensure adaptive capacity, and (2) negotiation of various resources provided by the governing authorities to ensure adaptive capacity. Our results show that aligning to local context of these health system factors affected the team's adaptive capacity.

CONCLUSIONS

Health system factors should create conditions for careful and safe care to emerge and provide conditions that allow for teams to develop both their professional expertise and systems and guidelines that are robust yet sufficiently flexible to fit their everyday work context.

Leading Quality and Safety on the Frontline - A Case Study of Department Leaders in Nursing Homes

Purpose

The role of healthcare leaders is becoming increasingly complex, and carries great responsibility for patients, employees, and the quality of service delivery. This study explored the barriers and enablers that department leaders in nursing homes encounter when managing the dual responsibilities in Health, Safety and Environment (HSE) and Quality and Patient Safety (QPS).

Methodology

Case study design with data collected through semi structured interviews with 16 department leaders in five Norwegian municipalities. We analyzed the data using qualitative content analysis.

Results

Data analysis resulted in four themes explaining what department leaders in nursing homes experience as barriers and enablers when handling the dual responsibility of HSE and QPS: Temporal capacity: The importance of having enough time to create a health-promoting work environment that ensures patient safety. Relational capacity: Relationships have an impact on work process and outcomes. Professional competence: Competence affects patient safety and leadership strategies. Organizational structure: Organizational frameworks influence how the dual responsibilities are handled.

Conclusion

Evidence from this study showed that external contextual factors (eg, legislations and finances) and internal factors (eg, relationships and expectations) are experienced as barriers and enablers when department leaders are enacting the dual responsibility of HSE and QPS. Of these, relationships were found to be the most significant contributor.

Managing patient safety and staff safety in nursing homes: exploring how leaders of nursing homes negotiate their dual responsibilities-a case study

Objective

Within healthcare, the role of leader is becoming more complex, and healthcare leaders carry an increasing responsibility for the performance of employees, the experience and safety of patients and the quality of care provision. This study aimed to explore how leaders of nursing homes manage the dual responsibility of both Health, Safety and Environment (HSE) and Quality and Patient Safety (QPS), focusing particularly on the approaches leaders take and the dilemmas they face. In addition, we wanted to examine how leaders experience and manage the challenges of HSE and QPS in a holistic way.

Design/setting

The study was designed as a case study. Data were collected through semi structured individual interviews with leaders of nursing homes in five Norwegian municipalities.

Participants

13 leaders of nursing homes in urban and rural municipalities participated in this study.

Results

Data analysis resulted in four themes explaining how leaders of nursing homes manage the dual responsibility of HSE and QPS, and the approaches they take and the dilemmas they face: 1.Establishing good systems and building a culture for a work environment that promotes health and patient safety.2.Establish channels for internal and external collaboration and communication.3.Establish room for maneuver to exercise leadership.4.Recognizing and having the mandate to handle possible tensions in the dual responsibility of HSE and QPS.

Conclusions

The study showed that leaders of nursing homes who are responsible for ensuring quality and safety for both patients and staff, experience tensions in handling this dual responsibility. They acknowledged the importance of having time to be present as a leader, to have robust systems to maintain HSE and QPS, and that conflicting aspects of legislation are an everyday challenge.

Medication Safety Gaps in English Pediatric Inpatient Units: An Exploration Using Work Domain Analysis

OBJECTIVES

Medication is a common cause of preventable medical harm in pediatric inpatients. This study aimed to examine the sociotechnical system surrounding pediatric medicines management, to identify potential gaps in this system and how these might contribute to adverse drug events (ADEs).

METHODS

An exploratory prospective qualitative study in pediatric wards in three hospitals in the north of England was conducted between October 2020 and May 2022. Analysis included a documentary analysis of 72 policies and procedures and analysis of field notes from 60 hours of participant observation. The cognitive work analysis prompt framework was used to generate a work domain analysis (WDA) and identify potential contributory factors to ADEs.

RESULTS

The WDA identified 2 functional purposes, 7 value/priority measures, 6 purpose-related functions, 11 object-related processes and 14 objects. Structured means-ends connections supported identification of 3 potential contributory factors-resource limitations, cognitive demands, and adaptation of processes. The lack of resources (equipment, materials, knowledge, and experience) created an environment where distractions and interruptions were unavoidable. Families helped provide practical support in medicines administration but were largely unacknowledged at an organizational level. There was a lack of teamwork with regards to medication with different professionals responsible for different parts of the system. Mandated safety checks on medicines were frequently omitted because of limited resources and perceived redundancy. Interventions to support adherence to safety policies were also often bypassed because they created more work.

CONCLUSIONS

The WDA has provided insights into the complex system of medication safety for children in hospital and has facilitated the identification of potential contributory factors to ADEs. We therefore advocate (in priority order) for processes to involve parents in the care of their children in hospital, development of skill-mix interventions to ensure appropriate expertise is available where it is needed, and modified checking procedures to permit staff to use their skills and judgment effectively and efficiently.

Key topics in pandemic health risk communication: A qualitative study of expert opinions and knowledge

Background

Science communication can provide people with more accurate information on pandemic health risks by translating complex scientific topics into language that helps people make more informed choices on how to protect themselves and others. During pandemics, experts in medicine, science, public health, and communication are important sources of knowledge for science communication. This study uses the COVID-19 pandemic to explore these experts’ opinions and knowledge of what to communicate to the public during a pandemic. The research question is: What are the key topics to communicate to the public about health risks during a pandemic?

Method

We purposively sampled 13 experts in medicine, science, public health, and communication for individual interviews, with a range of different types of knowledge of COVID-19 risk and communication at the national, regional and hospital levels in Norway. The interview transcripts were coded and analysed inductively in a qualitative thematic analysis.

Results

The study’s findings emphasise three central topics pertaining to communication about pandemic health risk during the first year of the COVID-19 pandemic in Norway: 1) how the virus enters the human body and generates disease; 2) how to protect oneself and others from being infected; and 3) pandemic health risk for the individual and the society.

Conclusion

The key topics emerging from the expert interviews relate to concepts originating from multiple disciplinary fields, and can inform frameworks for interprofessional communication about health risks during a pandemic. The study highlights the complexity of communicating pandemic messages, due to scientific uncertainty, fear of risk amplification, and heterogeneity in public health and scientific literacy. The study contributes with insight into the complex communication processes of pandemic health risk communication.

Exploring the role of leaders in enabling adaptive capacity in hospital teams - a multiple case study

Background

Resilient healthcare research studies how healthcare systems and stakeholders adapt and cope with challenges and changes to enable high quality care. Team leaders are seen as central in coordinating clinical care, but research detailing their contributions in supporting adaptive capacity has been limited. This study aims to explore and describe how leaders enable adaptive capacity in hospital teams.

Methods

This article reports from a multiple embedded case study in two Norwegian hospitals. A case was defined as one hospital containing four different types of teams in a hospital setting. Data collection used triangulation of observation and interviews with leaders, followed by a qualitative content analysis.

Results

Leaders contribute in several ways to enhance their teams’ adaptive capacity. This study identified four key enablers; (1) building sufficient competence in the teams; (2) balancing workload, risk, and staff needs; (3) relational leadership; and (4) emphasising situational understanding and awareness through timely and relevant information.

Conclusion

Team leaders are key actors in everyday healthcare systems and facilitate organisational resilience by supporting adaptive capacity in hospital teams. We have developed a new framework of key leadership enablers that need to be integrated into leadership activities and approaches along with a strong relational and contextual understanding.

Exploring factors influencing service trade-offs in the higher education sector: evidence from Malaysia

Purpose

Trade-offs are unavoidable in a competitive and difficult economic environment, causing a challenge for those wanting to provide consistently high-quality service across all touchpoints in the service delivery ecosystem, included in which is the higher education (HE) sector. This study aims to explore the key factors influencing service trade-offs related to the efforts of academics in Malaysia’s HE sector.

Design/methodology/approach

A self-administered questionnaire was distributed to 400 full-time academics from several higher learning institutions in Malaysia. Data were analysed using the partial least squares-structural equation modelling (PLS-SEM) approach.

Findings

The results reveal that service trade-offs in the HE sector were heavily influenced by service priorities. Customisation of services, meeting individual student needs, working under immense pressure within tight timeframes and focusing on teaching and research jointly contribute to academics’ service trade-offs in the HE sector. Indeed, the nature of the job necessitates such trade-offs by default, as academics are unable to cancel or postpone classes due to scheduling constraints and the requirement to be physically present during class sessions.

Practical implications

HE administrators and managers should provide academics with adequate resources, effective work allocation and optimal timeframes for task completion, as service priorities are the key factors influencing service trade-offs in Malaysia’s HE sector. The satisfaction of these needs would enable academics’ service priorities and trade-offs to be better balanced, thereby contributing to better operational efficiency, boosting organisational performance and maintaining business sustainability.

Originality/value

The empirical results serve to clarify the key factors influencing service trade-offs in the HE sector, thus expanding the extant literature, which has mostly concentrated on describing the same phenomena in the manufacturing sector. The proposed service trade-offs model would serve as a guideline for operational efficiencies in the HE sector to prevent future recurrence and reduce the potential risk of service disruption, thus mitigating the risk of dissatisfaction.

Balancing adaptation and innovation for resilience in healthcare - a metasynthesis of narratives

BACKGROUND

Adaptation and innovation are both described as instrumental for resilience in healthcare. However, the relatedness between these dimensions of resilience in healthcare has not yet been studied. This study seeks to develop a conceptual understanding of adaptation and innovation as a basis for resilience in healthcare. The overall aim of this study is therefore to explore how adaptation and innovation can be described and understood across different healthcare settings. To this end, the overall aim will be investigated by identifying what constitutes adaptation and innovation in healthcare, the mechanisms involved, and what type of responses adaptation and innovation are associated with.

METHODS

The method used to develop understanding across a variety of healthcare contexts, was to first conduct a narrative inquiry of a comprehensive dataset from various empirical settings (e.g., maternity, transitional care, telecare), that were later analysed in accordance with grounded theory. Narrative inquiry provided a contextually informed synthesis of the phenomenon, while the use of grounded theory methodology allowed for cross-contextual comparison of adaptation and innovation in terms of resilience in healthcare.

RESULTS

The results identified an imbalance between adaptation and innovation. If short-term adaptations are used too extensively, they may mask system deficiencies and furthermore leave the organization vulnerable, by relying too much on the efforts of a few individuals. Hence, short-term adaptations may end up a barrier for resilience in healthcare. Long-term adaptations and innovation of products, processes and practices proved to be of a lower priority, but had the potential of addressing the flaws of the system by proactively re-organizing and re-designing routines and practices.

CONCLUSIONS

This study develops a new conceptual account of adaptation and innovation as a basis for resilience in healthcare. Findings emerging from this study indicate that a balance between adaptation and innovation should be sought when seeking resilience in healthcare. Adaptations can furthermore be divided into short-term and long-term adaptations, creating the need to balance between these different types of adaptations. Short-term adaptations that adopt the pattern of firefighting can risk generating complex and unintended outcomes, but where no significant changes are made to organization of the system. Long-term adaptations, on the other hand, introduce re-organization of the system based on feedback, and therefore can provide a proactive response to system deficiencies. We propose a pattern of adaptation in resilience in healthcare: from short-term adjustments, to long-term reorganizations, to innovations.