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Falandry C, Bacchetta J, Doret-Dion M, Ferraro-Peyret C, Confavreux CB, Douplat M, Feugier P, Friggeri A, Bolze PA, Dargaud Y, Messager A, Wallon M, Geffroy L, Matillon Y, Bradwejn J. Tailoring a specific medical leadership development program for faculty members: the Lyon-Ottawa experience. MEDICAL EDUCATION ONLINE 2024; 29:2308955. [PMID: 38290044 PMCID: PMC10829808 DOI: 10.1080/10872981.2024.2308955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/18/2024] [Indexed: 02/01/2024]
Abstract
The development of leadership skills has been the topic of several position statements over recent decades, and the need of medical leaders for a specific training was emphasized during the COVID-19 crisis, to enable them to adequately collaborate with governments, populations, civic society, organizations, and universities. However, differences persist as to the way such skills are taught, at which step of training, and to whom. From these observations and building on previous experience at the University of Ottawa, a team of medical professors from Lyon (France), Ottawa, and Montreal (Canada) universities decided to develop a specific medical leadership training program dedicated to faculty members taking on leadership responsibilities. This pilot training program was based on a holistic vision of a transformation model for leadership development, the underlying principle of which is that leaders are trained by leaders. All contributors were eminent French and Canadian stakeholders. The model was adapted to French faculty members, following an inner and outer analysis of their specific needs, both contextual and related to their time constraints. This pilot program, which included 10 faculty members from Lyon, was selected to favor interactivity and confidence in older to favor long-term collaborations between them and contribute to institutional changes from the inner; it combined several educational methods mixing interactive plenary sessions and simulation exercises during onescholar year. All the participants completed the program and expressed global satisfaction with it, validating its acceptability by the target. Future work will aim to develop the program, integrate evaluation criteria, and transform it into a graduating training.
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Affiliation(s)
- Claire Falandry
- Service de Gériatrie, Centre Hospitalier de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- Université de Lyon, Laboratoire CarMeN de l’Université de Lyon, INSERM U.1060/Université Lyon1/INRA U. 1397/INSA Lyon/Hospices Civils Lyon, Pierre-Bénite, France
| | - Justine Bacchetta
- Néphrologie Rhumatologie Dermatologie Pédiatrique, Hopital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
- Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, France
- UMR 1033, INSERM, Lyon, France
| | - Muriel Doret-Dion
- Service de Chirurgie Gynécologique et Oncologique, Obstétrique, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
- Faculté De Médecine Et De Maïeutique Lyon Sud - Charles Mérieux, Université Lyon 1, Oullins, France
| | - Carole Ferraro-Peyret
- Centre de biopathologie des tumeurs, Hôpitaux Est, Hospices Civils de Lyon, Bron, France
- ISPB Faculté de pharmacie, INSERM 1052, CNRS5286, Centre de Recherche sur le Cancer de Lyon, Université de Lyon, Lyon, France
| | - Cyrille B. Confavreux
- Service de Rhumatologie Sud, Hôpital Lyon Sud, Hospices Civils de LyonPierre-Bénite, France
- Université Lyon 1, UFR médecine Lyon Est, INSERM UMR 1033, Lyon, France
| | - Marion Douplat
- Service des Urgences, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
- Université de Lyon, Laboratoire RESHAPE - Research on Healthcare Performance, Université Lyon 1, Lyon, France
| | - Patrick Feugier
- Service de Chirurgie Vasculaire et Endovasculaire, Centre Hospitalier Lyon Sud, Hospices Civils de LyonPierre-Bénite, France
- Université de Lyon, UFR médecine Lyon Est, Université Lyon1, Pierre-Bénite, France
| | - Arnaud Friggeri
- Service d’Anesthésie-Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
- Université de Lyon, Faculté De Médecine Et De Maïeutique Lyon Sud - Charles Mérieux, Université Lyon 1, Oullins, France
| | - Pierre-Adrien Bolze
- Service de Chirurgie Gynécologique et Oncologique, Obstétrique, Hôpital Lyon Sud, Hospices Civils de LyonPierre-Bénite, France
- Centre pour l’Innovation en Cancérologie de Lyon (CICLY EA3738), Université Lyon 1, Oullins, France
| | - Yesim Dargaud
- Centre d’Hémophilie de Lyon, Unité d’Hémostase clinique, Hôpital Louis Pradel, Bron, France
- Université de Lyon, Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, France
| | - Alexandre Messager
- Human Resources and Faculty/Clinical Leadership Development, Ottawa University, Ottawa, Canada
| | - Martine Wallon
- Service de Parasitologie et de Mycologie Médicale, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- Université de Lyon, Waking Team, Centre de Recherche en Neurosciences de Lyon, Bron, France
| | - Loïc Geffroy
- Stratégie et management des organisations, Université Lyon 1, Lyon, France
| | - Yves Matillon
- Laboratoire Parcours Santé Systémique, Université Lyon 1, Lyon, France
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Carroll E, Tan C, Hayes S, Mordang S, Rizzo G, Zaia V, Montagna E, Könings KD, Wiese A, O'Tuathaigh C. Implementing high-value, cost-conscious care: experiences of Irish doctors and the role of education in facilitating this approach. BMC MEDICAL EDUCATION 2024; 24:684. [PMID: 38907222 PMCID: PMC11191173 DOI: 10.1186/s12909-024-05666-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 06/14/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Adopting high-value, cost-conscious care (HVCCC) principles into medical education is growing in importance due to soaring global healthcare costs and the recognition that efficient care can enhance patient outcomes and control costs. Understanding the current opportunities and challenges doctors face concerning HVCCC in healthcare systems is crucial to tailor education to doctors' needs. Hence, this study aimed to explore medical students, junior doctors, and senior doctors' experiences with HVCCC, and to seek senior doctors' viewpoints on how education can foster HVCCC in clinical environments. METHODS Using a mixed-methods design, our study involved a cross-sectional survey using the Maastricht HVCCC-Attitude Questionnaire (MHAQ), with a subset of consultants engaging in semi-structured interviews. Descriptive analysis provided insights into both categorical and non-categorical variables, with differences examined across roles (students, interns, junior doctors, senior doctors) via Kruskal-Wallis tests, supplemented by two-group analyses using Mann-Whitney U testing. We correlated experience with MHAQ scores using Spearman's rho, tested MHAQ's internal consistency with Cronbach's alpha, and employed thematic analysis for the qualitative data. RESULTS We received 416 responses to the survey, and 12 senior doctors participated in the semi-structured interviews. Overall, all groups demonstrated moderately positive attitudes towards HVCCC, with more experienced doctors exhibiting more favourable views, especially about integrating costs into daily practice. In the interviews, participants agreed on the importance of instilling HVCCC values during undergraduate teaching and supplementing it with a formal curriculum in postgraduate training. This, coupled with practical knowledge gained on-the-job, was seen as a beneficial strategy for training doctors. CONCLUSIONS This sample of medical students and hospital-based doctors display generally positive attitudes towards HVCCC, high-value care provision, and the integration of healthcare costs, suggesting receptiveness to future HVCCC training among students and doctors. Experience is a key factor in HVCCC, so early exposure to these concepts can potentially enhance practice within existing healthcare budgets.
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Affiliation(s)
- Evan Carroll
- School of Medicine, University College Cork, Cork, Ireland
| | - Crisann Tan
- School of Medicine, University College Cork, Cork, Ireland
| | - Samantha Hayes
- School of Medicine, University College Cork, Cork, Ireland
| | - Serge Mordang
- Educational Development and Research, School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Maastricht University Office, Maastricht University , Maastricht, Netherlands
| | - Gabriella Rizzo
- Department of Medicine, Cork University Hospital, Cork, Ireland
| | - Victor Zaia
- Faculdade de Medicina do ABC, Centro Universitário FMABC, Santo André, SP, Brazil
| | - Erik Montagna
- Faculdade de Medicina do ABC, Centro Universitário FMABC, Santo André, SP, Brazil
| | - Karen D Könings
- Educational Development and Research, School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Anél Wiese
- Medical Education Unit, School of Medicine, University College Cork, Cork, Ireland
| | - Colm O'Tuathaigh
- Medical Education Unit, School of Medicine, University College Cork, Cork, Ireland.
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Wolf A, Erichsen Andersson A, Wikström E, Bååthe F. Untangling the perception of value in value-based healthcare - an interview study. Leadersh Health Serv (Bradf Engl) 2024; 37:130-141. [PMID: 38635293 DOI: 10.1108/lhs-07-2023-0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
PURPOSE Value-based health care (VBHC) argues that health-care needs to re-focus to maximise value creation, defining value as the quota when dividing the outcomes important for the patient, by the cost for health care to deliver such outcomes. This study aims to explore the perception of value among different stakeholders involved in the process of implementing VBHC at a Swedish hospital to support leaders to be more efficient and effective when developing health care. DESIGN/METHODOLOGY/APPROACH Participants comprised 19 clinicians and non-clinicians involved in the implementation of VBHC. Semi-structured interviews were conducted and content analysis was performed. FINDINGS The clinicians described value as a dynamic concept, dependent on the patient and the clinical setting, stating that improving outcomes was more important than containing costs. The value for non-clinicians appeared more driven by the interplay between the outcome and the cost. Non-clinicians related VBHC to a strategic framework for governance or for monitoring different continuous improvement processes, while clinicians appreciated VBHC, as they perceived its introduction as an opportunity to focus more on outcomes for patients and less on cost containment. ORIGINALITY/VALUE There is variation in how clinicians and non-clinicians perceive the key concept of value when implementing VBHC. Clinicians focus on increasing treatment efficacy and improving medical outcomes but have a limited focus on cost and what patients consider most valuable. If the concept of value is defined primarily by clinicians' own assumptions, there is a clear risk that the foundational premise of VBHC, to understand what outcomes patients value in their specific situation in relation to the cost to produce such outcome, will fail. Health-care leaders need to ensure that patients and the non-clinicians' perception of value, is integrated with the clinical perception, if VBHC is to deliver on its promise.
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Affiliation(s)
- Axel Wolf
- Institute of Health Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden and Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
| | - Annette Erichsen Andersson
- Institute of Health Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden and Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ewa Wikström
- Department of Business Administration, School of Business, Economics and Law, University of Gothenburg, Gothenburg, Sweden, and
| | - Fredrik Bååthe
- Institute for Studies of the Medical Profession, LEFO, Oslo, Norway; Institute of Stress Medicine at Region Västra Götaland, Gothenburg, Sweden and Institute of Health Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Thusini S, Soukup T, Chua KC, Henderson C. How is return on investment from quality improvement programmes conceptualised by mental healthcare leaders and why: a qualitative study. BMC Health Serv Res 2023; 23:1009. [PMID: 37726753 PMCID: PMC10510269 DOI: 10.1186/s12913-023-09911-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 08/13/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Return on Investment (ROI), whereby the ratio of costs to benefits is assessed, is encouraged in-order to justify the value of Quality Improvement (QI) programmes. We previously performed a literature review to develop a ROI conceptual framework for QI programmes. We concluded that, QI-ROI is conceptualised as any monetary and non-monetary benefit. In the current study, we explored if this finding is shared by mental healthcare leaders. We also investigated the stability of this conceptualisation against influencing factors and potential for disinvestment. METHODS We performed qualitative interviews with leaders in an NHS mental health organisation. There were 16 participants: nine board members and seven senior leaders. The interviews were held online via Microsoft Teams and lasted an hour on average. We performed deductive-inductive analysis to seek data from our initial ROI framework and any new data. RESULTS We found that in mental healthcare, QI-ROI is also conceptualised as any valued monetary and non-monetary benefits. There was a strong emphasis on benefits to external partners and a de-emphasis of benefit monetisation. This conceptualisation was influenced by the 1) perceived mandates to improve quality and manage scarce resources, 2) expectations from QI, 3) health and social care values, 4) ambiguity over expectations, and 5) uncertainty over outcomes. Uncertainty, ambiguity, and potential for disinvestment posed a threat to the stability of this conceptualisation but did not ultimately change it. Health and social care values supported maintaining the QI-ROI as any benefit, with a focus on patients and staff outcomes. Socio-political desires to improve quality were strong drivers for QI investment. CONCLUSION Mental healthcare leaders primarily conceptualise QI-ROI as any valued benefit. The inclusion of externalised outcomes which are hard to attribute may be challenging. However, mental healthcare services do collaborate with external partners. The de-emphases of benefit monetisation may also be controversial due to the need for financial accountability. Mental healthcare leaders recognise the importance of efficiency savings. However, they raised concerns over the legitimacy and utility of traditional ROI as a tool for assessing QI value. Further research is needed to bring more clarity on these aspects of the QI-ROI concept.
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Bååthe F, von Knorring M, Isaksson-Rø K. How hospital top managers reason about the central leadership task of balancing quality of patient care, economy and professionals' engagement: an interview study. Leadersh Health Serv (Bradf Engl) 2022; ahead-of-print:261-274. [PMID: 36573612 PMCID: PMC10427974 DOI: 10.1108/lhs-02-2022-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/27/2022] [Accepted: 10/04/2022] [Indexed: 12/28/2022]
Abstract
PURPOSE This study aims to deepen the understanding of how top managers reason about handling the relationships between quality of patient care, economy and professionals' engagement. DESIGN/METHODOLOGY/APPROACH Qualitative design. Individual in-depth interviews with all members of the executive management team at an emergency hospital in Norway were analysed using reflexive thematic method. FINDINGS The top managers had the intention to balance between quality of patient care, economy and professionals' engagement. This became increasingly difficult in times of high internal or external pressures. Then top management acted as if economy was the most important focus. PRACTICAL IMPLICATIONS For health-care top managers to lead the pursuit towards increased sustainability in health care, there is a need to balance between quality of patient care, economy and professionals' engagement. This study shows that this balancing act is not an anomaly top-managers can eradicate. Instead, they need to recognize, accept and deliberately act with that in mind, which can create virtuous development spirals where managers and health-professional communicate and collaborate, benefitting quality of patient care, economy and professionals' engagement. However, this study builds on a limited number of participants. More research is needed. ORIGINALITY/VALUE Sustainable health care needs to balance quality of patient care and economy while at the same time ensure professionals' engagement. Even though this is a central leadership task for managers at all levels, there is limited knowledge about how top managers reason about this.
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Affiliation(s)
- Fredrik Bååthe
- Institute for Studies of the Medical Profession, LEFO, Oslo, Norway; Institute of Stress Medicine at Region Västra Götaland, Gothenburg, Sweden and Institute of Health and Care Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Mia von Knorring
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Karin Isaksson-Rø
- Institute for Studies of the Medical Profession, LEFO, Oslo, Norway and Department of Behavioural Sciences in Medicine, Institute of Basic Medical Sciences, Medical Faculty, University of Oslo, Oslo, Norway
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Thusini S, Milenova M, Nahabedian N, Grey B, Soukup T, Chua KC, Henderson C. The development of the concept of return-on-investment from large-scale quality improvement programmes in healthcare: an integrative systematic literature review. BMC Health Serv Res 2022; 22:1492. [PMID: 36476622 PMCID: PMC9728007 DOI: 10.1186/s12913-022-08832-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Return on Investment (ROI) is increasingly being used to evaluate financial benefits from healthcare Quality Improvement (QI). ROI is traditionally used to evaluate investment performance in the commercial field. Little is known about ROI in healthcare. The aim of this systematic review was to analyse and develop ROI as a concept and develop a ROI conceptual framework for large-scale healthcare QI programmes. METHODS We searched Medline, Embase, Global health, PsycInfo, EconLit, NHS EED, Web of Science, Google Scholar using ROI or returns-on-investment concepts (e.g., cost-benefit, cost-effectiveness, value). We combined this terms with healthcare and QI. Included articles discussed at least three organisational QI benefits, including financial or patient benefits. We synthesised the different ways in which ROI or return-on-investment concepts were used and discussed by the QI literature; first the economically focused, then the non-economically focused QI literature. We then integrated these literatures to summarise their combined views. RESULTS We retrieved 10 428 articles. One hundred and two (102) articles were selected for full text screening. Of these 34 were excluded and 68 included. The included articles were QI economic, effectiveness, process, and impact evaluations as well as reports and conceptual literature. Fifteen of 68 articles were directly focused on QI programme economic outcomes. Of these, only four focused on ROI. ROI related concepts in this group included cost-effectiveness, cost-benefit, ROI, cost-saving, cost-reduction, and cost-avoidance. The remaining articles mainly mentioned efficiency, productivity, value, or benefits. Financial outcomes were not the main goal of QI programmes. We found that the ROI concept in healthcare QI aligned with the concepts of value and benefit, both monetary and non-monetary. CONCLUSION Our analysis of the reviewed literature indicates that ROI in QI is conceptualised as value or benefit as demonstrated through a combination of significant outcomes for one or more stakeholders in healthcare organisations. As such, organisations at different developmental stages can deduce benefits that are relevant and legitimate as per their contextual needs. TRIAL REGISTRATION Review registration: PROSPERO; CRD42021236948.
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Affiliation(s)
| | | | | | - Barbara Grey
- South London and Maudsley NHS Foundation Trust, London, UK
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Tragl L, Savage C, Andreen-Sachs M, Brommels M. Who counts when health counts? A case-study of multi-stakeholder initiative to promote value-creation in Swedish healthcare. Health Serv Manage Res 2022; 36:109-118. [PMID: 35570729 PMCID: PMC10080372 DOI: 10.1177/09514848221100751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A European initiative to design a "medical information framework" conceptualised how multiple stakeholders join in collaborative networks to create innovations. It conveyed the ways in which value is created and captured by stakeholders. We applied those insights to analyse a multi-stakeholder initiative to promote improvement of Swedish healthcare. Our longitudinal case study covered totally fifty stakeholders involved in a national project, aiming at designing a system to support value-based evaluation and reimbursement. During the project the focus changed from reimbursement to benchmarking. Sophisticated case-mix adjusting algorithms were designed to make outcome comparisons valid and incorporated in a software platform enabling detailed analysis of eight patient groups across seven regional health authorities. Those were deliverables demonstrating value created. However, the project was unable to transfer the system into routine use in the regions, a failed value-capture. The initial success was promoted by collaborative processes in diagnosis-specific working groups of well-informed and engaged professionals. The change of focus away from reimbursement decreased the involvement among health authorities, leaving no centrally placed persons to push for implementation. It highlights the importance of health professionals as the key stakeholder, who has both the know-how instrumental to creating an innovation, and the local involvement guaranteeing its implementation.
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Affiliation(s)
- Leonard Tragl
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics (LIME), 27106Karolinska Institute, Sweden
| | - Carl Savage
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics (LIME), 27106Karolinska Institute, Sweden
| | - Magna Andreen-Sachs
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics (LIME), 27106Karolinska Institute, Sweden
| | - Mats Brommels
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics (LIME), 27106Karolinska Institute, Sweden
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Doctors as Resource Stewards? Translating High-Value, Cost-Conscious Care to the Consulting Room. HEALTH CARE ANALYSIS 2022; 30:215-239. [PMID: 35562635 PMCID: PMC9741564 DOI: 10.1007/s10728-022-00446-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2022] [Indexed: 12/14/2022]
Abstract
After many policy attempts to tackle the persistent rise in the costs of health care, physicians are increasingly seen as potentially effective resource stewards. Frameworks including the quadruple aim, value-based health care and choosing wisely underline the importance of positive engagement of the health care workforce in reinventing the system-paving the way to real affordability by defining the right care. Current programmes focus on educating future doctors to provide 'high-value, cost-conscious care' (HVCCC), which proponents believe is the future of sustainable medical practice. Such programmes, which aim to extend population-level allocation concerns to interactions between an individual doctor and patient, have generated lively debates about the ethics of expanding doctors' professional accountability. To empirically ground this discussion, we conducted a qualitative interview study to examine what happens when resource stewardship responsibilities are extended to the consulting room. Attempts to deliver HVCCC were found to involve inevitable trade-offs between benefits to the individual patient and (social) costs, medical uncertainty and efficiency, and between resource stewardship and trust. Physicians reconcile this by justifying good-value care in terms of what is in the best interest of individual patients-redefining the currency of value from monetary costs to a patient's quality of life, and cost-conscious care as reflective medical practice. Micro-level resource stewardship thus becomes a matter of working reflexively and reducing wasteful forms of care, rather than of making difficult choices about resource allocation.
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Communication Skills and Transformational Leadership Style of First-Line Nurse Managers in Relation to Job Satisfaction of Nurses and Moderators of This Relationship. Healthcare (Basel) 2021; 9:healthcare9030346. [PMID: 33803822 PMCID: PMC8003159 DOI: 10.3390/healthcare9030346] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/24/2021] [Accepted: 03/15/2021] [Indexed: 11/17/2022] Open
Abstract
The job satisfaction of nurses is reflected in almost all organizational outputs of medical facilities. First-line nurse managers (FLNMs), who are directly related to subordinate nurses, have a great influence on this satisfaction. The aim of our paper is to examine the connection between communication skills and the transformation style of FLNMs management with the job satisfaction of nurses and to verify the influence of three moderators on the strength of this relationship. The chosen moderators-the practice of managing FLNMs, the degree of control (span of control) and psychosocial work-follow from theoretical studies. The moderating effect of the variable management practice is also significant from the point of view of Slovak legislation. The sample consisted of 132 FLNMs from five university hospitals in Slovakia. Data collection took place in the form of a questionnaire. All data were processed using the SPSS 24 software package. A series of regression analyzes were used to identify the proposed hypotheses. ANOVA analysis was used to analyze multiple dependencies. We worked at a 5% level of significance. The findings point to the strong direct effects of communication skills and the transformational leadership style of FLNMs on nurses' job satisfaction. Moderation effects are mild, but significant in the case of management and span of control practices. The lower values of both variables reinforce the positive relationships among the two predictors and the job satisfaction of nurses. The third moderator, psychosocial work factors, also have a significant moderating effect, which is negative, and the higher value of this moderator mitigates both positive direct effects.
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Tolf S, Mesterton J, Söderberg D, Amer-Wåhlin I, Mazzocato P. How can technology support quality improvement? Lessons learned from the adoption of an analytics tool for advanced performance measurement in a hospital unit. BMC Health Serv Res 2020; 20:816. [PMID: 32873286 PMCID: PMC7460799 DOI: 10.1186/s12913-020-05622-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/03/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Technology for timely feedback of data has the potential to support quality improvement (QI) in health care. However, such technology may pose difficulties stemming from the complex interaction with the setting in which it is implemented. To enable professionals to use data in QI there is a need to better understand of how to handle this complexity. This study aims to explore factors that influence the adoption of a technology-supported QI programme in an obstetric unit through a complexity informed framework. METHODS This qualitative study, based on focus group interviews, was conducted at a Swedish university hospital's obstetric unit, which used an analytics tool for advanced performance measurement that gave timely and case mix adjusted feedback of performance data to support QI. Data was collected through three focus group interviews conducted with 16 managers and staff. The Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework guided the data collection and analysis. RESULTS Staff and managers deemed the technology to effectively support ongoing QI efforts by providing timely access to reliable data. The value of the technology was associated with a clear need to make better use of existing data in QI. The data and the methodology in the analytics tool reflected the complexity of the clinical conditions treated but was presented through an interface that was easy to access and user friendly. However, prior understanding of statistics was helpful to be able to fully grasp the presented data. The tool was adapted to the needs and the organizational conditions of the local setting through a collaborative approach between the technology supplier and the adopters. CONCLUSIONS Technology has the potential to enable systematic QI through motivating professionals by providing timely and adequate feedback of performance. The adoption of such technology is complex and requires openness for gradual learning and improvement.
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Affiliation(s)
- Sara Tolf
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Johan Mesterton
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Ivbar Institute, Stockholm, Sweden
| | - Daniel Söderberg
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Isis Amer-Wåhlin
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Department of Women and Child Health, Karolinska Institutet, Stockholm, Sweden
| | - Pamela Mazzocato
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Department for Research, Development, Education and Innovation, Södertälje Hospital, Södertälje, Sweden
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von Thiele Schwarz U, Nielsen K, Edwards K, Hasson H, Ipsen C, Savage C, Simonsen Abildgaard J, Richter A, Lornudd C, Mazzocato P, Reed JE. How to design, implement and evaluate organizational interventions for maximum impact: the Sigtuna Principles. EUROPEAN JOURNAL OF WORK AND ORGANIZATIONAL PSYCHOLOGY 2020; 30:415-427. [PMID: 34518756 PMCID: PMC8432268 DOI: 10.1080/1359432x.2020.1803960] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 07/27/2020] [Indexed: 11/17/2022]
Abstract
Research on organizational interventions needs to meet the objectives of both researchers and participating organizations. This duality means that real-world impact has to be considered throughout the research process, simultaneously addressing both scientific rigour and practical relevance. This discussion paper aims to offer a set of principles, grounded in knowledge from various disciplines that can guide researchers in designing, implementing, and evaluating organizational interventions. Inspired by Mode 2 knowledge production, the principles were developed through a transdisciplinary, participatory and iterative process where practitioners and academics were invited to develop, refine and validate the principles. The process resulted in 10 principles: 1) Ensure active engagement and participation among key stakeholders; 2) Understand the situation (starting points and objectives); 3) Align the intervention with existing organizational objectives; 4) Explicate the program logic; 5) Prioritize intervention activities based on effort-gain balance; 6) Work with existing practices, processes, and mindsets; 7) Iteratively observe, reflect, and adapt; 8) Develop organizational learning capabilities; 9) Evaluate the interaction between intervention, process, and context; and 10) Transfer knowledge beyond the specific organization. The principles suggest how the design, implementation, and evaluation of organizational interventions can be researched in a way that maximizes both practical and scientific impact.
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Affiliation(s)
- Ulrica von Thiele Schwarz
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
- Medical Management Centre, LIME, Karolinska Institutet, Stockholm, Sweden
| | - Karina Nielsen
- Institute of Work Psychology (IWP), University of Sheffield, Sheffield, UK
| | - Kasper Edwards
- Department of Management Engineering, Technical University of Denmark, Lyngby, Denmark
| | - Henna Hasson
- Medical Management Centre, LIME, Karolinska Institutet, Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine, Stockholm, Sweden
| | - Christine Ipsen
- Department of Management Engineering, Technical University of Denmark, Lyngby, Denmark
| | - Carl Savage
- Medical Management Centre, LIME, Karolinska Institutet, Stockholm, Sweden
| | | | - Anne Richter
- Medical Management Centre, LIME, Karolinska Institutet, Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine, Stockholm, Sweden
| | - Caroline Lornudd
- Institute of Environmental Medicine (IMM), Karolinska Institutet, Stockholm, Sweden
| | - Pamela Mazzocato
- Medical Management Centre, LIME, Karolinska Institutet, Stockholm, Sweden
| | - Julie E. Reed
- NIHR CLAHRC for Northwest London, Chelsea and Westminster Hospital, London, UK
- School of Health and Welfare, Halmstad University, Halmstad, Sweden
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Savage M, Savage C, Brommels M, Mazzocato P. Medical leadership: boon or barrier to organisational performance? A thematic synthesis of the literature. BMJ Open 2020; 10:e035542. [PMID: 32699130 PMCID: PMC7375428 DOI: 10.1136/bmjopen-2019-035542] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE The influx of management ideas into healthcare has triggered considerable debate about if and how managerial and medical logics can coexist. Recent reviews suggest that clinician involvement in hospital management can lead to superior performance. We, therefore, sought to systematically explore conditions that can either facilitate or impede the influence of medical leadership on organisational performance. DESIGN Systematic review using thematic synthesis guided by the Enhancing Transparency in Reporting the synthesis of Qualitative research statement. DATA SOURCES We searched PubMed, Web of Science and PsycINFO from 1 January 2006 to 21 January 2020. ELIGIBILITY CRITERIA We included peer-reviewed, empirical, English language articles and literature reviews that focused on physicians in the leadership and management of healthcare. DATA EXTRACTION AND SYNTHESIS Data extraction and thematic synthesis followed an inductive approach. The results sections of the included studies were subjected to line-by-line coding to identify relevant meaning units. These were organised into descriptive themes and further synthesised into analytic themes presented as a model. RESULTS The search yielded 2176 publications, of which 73 were included. The descriptive themes illustrated a movement from 1. medical protectionism to management through medicine; 2. command and control to participatory leadership practices; and 3. organisational practices that form either incidental or willing leaders. Based on the synthesis, the authors propose a model that describes a virtuous cycle of management through medicine or a vicious cycle of medical protectionism. CONCLUSIONS This review helps individuals, organisations, educators and trainers better understand how medical leadership can be both a boon and a barrier to organisational performance. In contrast to the conventional view of conflicting logics, medical leadership would benefit from a more integrative model of management and medicine. Nurturing medical engagement requires participatory leadership enabled through long-term investments at the individual, organisational and system levels.
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Affiliation(s)
- Mairi Savage
- Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Carl Savage
- Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Mats Brommels
- Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Pamela Mazzocato
- Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
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Storkholm MH, Mazzocato P, Savage C. Make it complicated: a qualitative study utilizing a complexity framework to explain improvement in health care. BMC Health Serv Res 2019; 19:842. [PMID: 31727069 PMCID: PMC6857274 DOI: 10.1186/s12913-019-4705-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 10/31/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Successful application of Quality Improvement (QI) methods is challenging, and awareness of the role context plays has increased. Complexity science has been advocated as a way to inform change efforts. However, empirical support is scarce, and it is still difficult to grasp the practical implications for QI interventions. The aim of this study was to use a complexity-based leadership framework to explain how managers in a clinical department addressed external requirements to cut costs without compromising patient outcomes and experience. METHODS Explanatory case study design of a Danish OB/GYN department tasked to improve efficiency. Data came from documents, 30 interviews, and 250 h of observations over 3 years. A Complexity Analysis Framework that combined two complexity-based leadership frameworks was developed to analyze all changes implemented to reduce cost, while maintaining clinical quality. RESULTS Managers reframed the efficiency requirement as an opportunity for quality improvement. Multiple simple, complicated, and complex situations were addressed with an adaptive approach to quality improvement. Changes were made to clinical pathways for individual conditions (n = 37), multiple conditions (n = 7), and at the organizational level (n = 9). At the organizational level, changes addressed referral practice, physical space in the department, flow and capacity, discharge speed, and managerial support. Managers shared responsibility with staff; together they took a "professional path" and systematically analyzed each clinical pathway through process mapping, attentive to patterns that emerged, before deciding on the next steps, such as a engaging in a complex process of probing - the iterative development and testing of new responses. CONCLUSIONS Quality improvement efforts could benefit from an understanding of the importance of learning and sharing responsibility to deal with the co-existing degrees of contextual complexity in modern health care. By "making things complicated" through a systematic analysis that engages staff in an open and reflective dialog, clinical praxis and established organizational structures can be questioned and improved. The Complexity Analysis Framework could then help managers to identify improvement opportunities, know when to implement technical solutions, and when to keep abreast of emerging patterns and allow appropriate responses to complex challenges to evolve.
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Affiliation(s)
- Marie Höjriis Storkholm
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Pamela Mazzocato
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
| | - Carl Savage
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
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Korlén S, Amer‐Wåhlin I, Lindgren P, Thiele Schwarz U. Exploring staff experience of economic efficiency requirements in health care: A mixed method study. Int J Health Plann Manage 2019; 34:1439-1455. [DOI: 10.1002/hpm.2813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 04/29/2019] [Indexed: 11/10/2022] Open
Affiliation(s)
- Sara Korlén
- Medical Management Centre, Department of LIME Karolinska Institutet Stockholm Sweden
| | - Isis Amer‐Wåhlin
- Medical Management Centre, Department of LIME Karolinska Institutet Stockholm Sweden
| | - Peter Lindgren
- Medical Management Centre, Department of LIME Karolinska Institutet Stockholm Sweden
- The Swedish Insitute for Health Economics Sweden
| | - Ulrica Thiele Schwarz
- Medical Management Centre, Department of LIME Karolinska Institutet Stockholm Sweden
- School of Health, Care and Social Welfare Mälardalen University Västerås Sweden
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Storkholm MH, Savage C, Tessma MK, Salvig JD, Mazzocato P. Ready for the Triple Aim? Perspectives on organizational readiness for implementing change from a Danish obstetrics and gynecology department. BMC Health Serv Res 2019; 19:517. [PMID: 31340843 PMCID: PMC6657111 DOI: 10.1186/s12913-019-4319-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 07/02/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND As health care strives towards the Triple Aim of improved population health, patient experience, and reduced costs, an organization's readiness for change may be a key factor. The concept refers to the collective commitment of organizational members to a change and belief in their shared ability to make that change happen (efficacy). This study aims to assess the organizational readiness for implementing large-scale change at a clinical department in pursuit of the Triple Aim and to determine key associated factors. METHODS A cross-sectional study at a Danish Obstetrics and Gynecology department faced with external pressure to become more efficient without compromising patient outcomes and experience. The Organisational Readiness for Implementing Change (ORIC) questionnaire was distributed to all employees (n = 403). Descriptive statistics was used to assess overall organizational readiness and single items. The between-group differences in subject characteristics were assessed with independent t-test and non-parametric test. Multiple linear regression was employed to control for potential confounders. RESULTS Response rate was 72%. The level of agreement with the commitment statements was high, and low with the efficacy statements. We did not observe statistically significant differences in the overall score between organizational sections or in relation to gender, age, or profession. Managerial status (B = 3.2, 95% CI = .52, 5.9, P = .02) or interim employment(B = 2.7, 95% CI = .47, 4.9, P = .02) were significant predictors of a high change efficacy score after controlling for potential confounders. CONCLUSIONS Changes related to pursuit of the Triple Aim were seen as something that "has to" be done, but left managers, and even more so staff, wondering what "to do" and "how to" do it. Change strategies should therefore address these uncertainties by translating political "have to's" proposals that resonate with staff, spark engagement, and clarify "how to" deal with the complexity of large-scale change.
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Affiliation(s)
- Marie Höjriis Storkholm
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Carl Savage
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
| | - Mesfin Kassaye Tessma
- Medical Statistics Unit, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Jannie Dalby Salvig
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Pamela Mazzocato
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
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Savage M, Storkholm MH, Mazzocato P, Savage C. Effective physician leaders: an appreciative inquiry into their qualities, capabilities and learning approaches. BMJ LEADER 2018. [DOI: 10.1136/leader-2017-000050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
PurposeThe aim of this study was to explore the qualities and capabilities effective physician leaders attribute to their success in leading change and how they developed these.MethodThe authors interviewed 20 emerging and senior leaders using a semistructured interview guide informed by appreciative inquiry. Data were subjected to an inductive qualitative content analysis to identify themes related to qualities, capabilities and learning approaches.ResultsThe qualities identified were clarity of purpose to improve care, endurance, a positive outlook and authenticity. They were considered innate or developed during participants’ upbringing. Capabilities were to ground management in medicine, engage others, catalyse systems by acting on interdependencies and employ a scientific approach to understand problems and measure progress. Capabilities were developed through cross-pollination from a diversity of work experiences, reflection, when education was integrated with practice and when their organisational environment nurtured ambition and learning.ConclusionsThis study reframes current leadership thinking by empirically identifying qualities, capabilities, and learning approaches that can contribute to effective physician leadership. Instead of merely adapting leadership development programmes from other domains, this study suggests there are capabilities unique to effective physician leadership: ground management in medicine and employ a scientific approach to problem identification and solution development. The authors outline practical implications for individuals and organisations to support leader development as a cohesive organisational strategy for learning and change.
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Salvig CD, Storkholm MH, Salvig JD, Uldbjerg N. Reducing the number of obstetrical beds by challenging traditions. Acta Obstet Gynecol Scand 2018; 97:1157-1161. [PMID: 29777635 DOI: 10.1111/aogs.13382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 05/09/2018] [Indexed: 11/30/2022]
Abstract
The aim of this commentary is to describe changes in women's care at an obstetric department that made it possible to reduce the number of beds from 40 to 29. Patient pathways were reviewed and revised using lean methodology. The mean length of stay was reduced from 70 to 59 h and the mean numbers of hospitalizations per woman from 1.26 to 1.20. At the organizational level, we introduced a Family Department, home management of newborns, home monitoring of the women with cardiotocography and blood samples, and intrapartum Group B Streptococcus-PCR. Additionally, an After Birth Clinic and network meetings for vulnerable women were established. In patient pathway, we reduced the hospitalization indicated by preterm premature rupture of membranes, preeclampsia and observation after birth laceration. According to National Patient Satisfaction surveys, there was no decrease in women's satisfaction after reducing the number of beds.
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Affiliation(s)
- Camilla D Salvig
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Marie H Storkholm
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Jannie D Salvig
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Uldbjerg
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
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Storkholm MH, Mazzocato P, Tessma MK, Savage C. Assessing the reliability and validity of the Danish version of Organizational Readiness for Implementing Change (ORIC). Implement Sci 2018; 13:78. [PMID: 29871691 PMCID: PMC5989337 DOI: 10.1186/s13012-018-0769-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/22/2018] [Indexed: 11/25/2022] Open
Abstract
Background Organizational change initiatives in health care frequently achieve only partial implementation success. Understanding an organizational readiness for change (ORC) may be a way to develop more effective and efficient change strategies. Denmark, like many countries, has begun a major system-wide structural reform which involves considerable changes in service delivery. Due to the lack of a validated Danish instrument, we aimed to translate and validate a Danish version of the Organizational Readiness for Implementing Change (ORIC) questionnaire. It measures if organizational members are confident in their collective commitment towards and ability (efficacy) to implement organizational change. ORIC is concise, grounded in theory, and designed, but not yet validated among employees in a real hospital setting. Methods The 12-item ORIC instrument was translated into Danish and back-translated to English. Employees (N = 284) at a hospital department facing a major organizational change in the Central Denmark Region completed the questionnaire. Face and content validity was ascertained. Exploratory factor analysis (EFA) and a confirmatory factor analysis (CFA) were used to assess construct validity. Reliability was assessed with Cronbach’s alpha. Item response theory (Rasch analysis) was used to determine item and person reliability. Results Response rate was 72%. A two factor (commitment and efficacy), 11-item scale, of the Danish language ORIC was shown to be valid (CFI = .95, RMSEA = .067, and CMNI/DF = 2.32) and reliable (Cronbach’s alpha 0.88) in a health care setting. Item response analysis confirmed acceptable person and item separation reliability. Conclusions Our version of ORIC showed acceptable validity and reliability as an instrument for measuring readiness for implementing organizational change in a Danish-speaking health care population. For health care managers interested in evaluating their organizations and tailor change strategies, ORIC’s brevity and theoretical underpinnings could make it an appealing and feasible tool to develop more successful change efforts. Electronic supplementary material The online version of this article (10.1186/s13012-018-0769-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marie Höjriis Storkholm
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18A, 171 77, Stockholm, Sweden. .,Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark.
| | - Pamela Mazzocato
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18A, 171 77, Stockholm, Sweden
| | - Mesfin Kassaye Tessma
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Carl Savage
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18A, 171 77, Stockholm, Sweden
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