Patient involvement in quality improvement: a survey comparing naturalistic and reflective approaches

BACKGROUND

This study investigates reflective and naturalistic approaches to patient involvement in quality improvement. The reflective approach, using, for example, interviews, provides insights into patient needs and demands to support an established improvement agenda. The naturalistic approach, for example, observations, is used to discover practical problems and opportunities that professionals are currently unaware of.

METHODS

We assessed the use of naturalistic and reflective approaches in quality improvement to see whether they differed in their impact on patient needs, financial improvements and improved patient flows. Four possible combinations were used as a starting point: restrictive (low reflective-low naturalistic), in situ (low reflective-high naturalistic), retrospective (high reflective-low naturalistic) and blended (high reflective-high naturalistic). Data were collected through an online cross-sectional survey using a web-based survey tool. The original sample was based on a list of 472 participants enrolled in courses on improvement science in three Swedish regions. The response rate was 34%. Descriptives and ANOVA (Analysis of Variance) in SPSS V.23 were used for the statistical analysis.

RESULTS

The sample consisted of 16 projects characterised as restrictive, 61 as retrospective and 63 as blended. No projects were characterised as in situ. There was a significant effect of patient involvement approaches on patient flows and patient needs at the p<0.05 level (patient flows, (F(2, 128)=5.198, p=0.007) and patient needs (F(2, 127)=13.228, p=0.000)). No significant effect was found for financial results.

CONCLUSIONS

Moving beyond restrictive patient involvement is important to meet new patient needs and improve patient flows. This can be done either by increasing the use of a reflective approach or by increasing the use of both reflective and naturalistic approaches. A blended approach with high levels of both is likely to produce better results in addressing new patient needs and improving patient flows.

Quality functions' use of customer feedback as activation triggers for absorptive capacity and value co-creation

Purpose

The purpose is to understand how the role of quality functions might evolve amidst digitalisation and an increased focus on services. This study focuses on customer feedback and how it can function as activation triggers for developing absorptive capacity, as well as how it relates to the value creation processes.

Design/methodology/approach

Following a qualitative research design, the authors gathered primary data from interviews with quality managers at 17 UK and Swedish firms and triangulated it with secondary information from the firms' web pages.

Findings

The findings show that customer feedback-based activation triggers can support development of absorptive capacity in the quality function if there are established processes for acting on customer feedback. This is often the case for codified feedback, which normally concerns products. However, digitalisation offers new opportunities of engaging in value co-creation, and firms need to develop digital capabilities to manage new technologies and data analytic tools. For personalised feedback (the main category of service-related feedback), established processes are missing.

Originality/value

This study work contributes to knowledge about how quality functions respond to customer feedback on both products and services. It clarifies why the quality function sometimes struggles to contribute to service quality as much as to product quality. From a theory development perspective, the authors contribute to understanding customer feedback-based activation triggers, how they lead to development of absorptive capacity and their relation to value co-creation on a functional level.

What contributes to auditee satisfaction in external ISO 9001 audits?

Purpose

This study aims to explore factors that contribute to auditee satisfaction in external audit fieldwork of ISO 9001, and relationships between these factors.

Design/methodology/approach

The purpose is addressed through a single case study and based upon data collected by a questionnaire. Data were analysed using probabilistic graphical models.

Findings

An auditor's knowledge of operations is shown to be the single most important factor contributing to auditee satisfaction in the study. Furthermore, establishing a co-operative audit atmosphere and focussing on business improvements support the co-creation of value in the interaction between auditor and auditee, while a focus on ISO compliance appears to be more of a hygiene factor.

Research limitations/implications

This paper is based on a study of one company and its interactions with one of the certification bodies for external auditing. Hence, the generalisability of the findings is limited by the case study method.

Practical implications

This paper identifies that an auditor's knowledge of operations and a focus on improvements and co-creation of value can improve auditee satisfaction and appreciation of the audit process.

Originality/value

Previous research has concluded that audit fieldwork is a key attribute associated with auditee satisfaction. This paper adds to this body of knowledge by empirically examining the specific factors within audit fieldwork that contribute to auditee satisfaction and focuses on value-creation in the audit process. By understanding these factors and moving towards a service perspective on audits with value co-creation as focus, it is possible to enhance the value of external audits.

Value configurations for balancing standardization and customization in chronic care: a qualitative study

BACKGROUND

Demands for both customization and standardization are increasing in healthcare. At the same time, resources are scarce, and healthcare managers are urged to improve efficiency. A framework of three value configurations - shop, chain, and network - has been proposed for how healthcare operations can be designed and organized for efficient value creation. In this paper, use of value configurations for balancing of standardization and customization is explored in the context of care for chronic mental conditions.

METHODS

A typical case is presented to illustrate the manifestations of conflicting demands between customization and standardization, and the potential usefulness of the value configurations framework. Qualitative data were collected from managers and care developers in two focus groups and six semi-structured interviews, completed by a national document describing a care pathway. Data were coded and analysed using an insider-outsider approach.

RESULTS

Operationalization of the balance between standardization and customization were found to be highly delegated and ad hoc. Also, the conflict between the two demands was often seen as aggravated by scarce resources. Value configurations can be fruitful as a means of discussing and redesigning care operations if applied at a suitable level of abstraction. Applied adequately, all three value configurations were recognized in the care operations for the patient group, with shop as the overarching configuration. Some opportunities for improved efficiency were identified, yet all configurations were seen as vital in the chronic care process.

CONCLUSIONS

The study challenges the earlier proposed organizational separation of care corresponding to different value configurations. Instead, as dual demand for customization and standardization permeates healthcare, parallel but explicated value configurations may be a path to improved quality and efficiency. Combined and intermediate configurations should also be further investigated.

Increasing the value of quality management systems

Purpose

Over one million organisations have a quality management system (QMS) certified to the ISO 9001 standard; however, the system requires a lot of resources and its value has been questioned. This critique also leads to a questioning of the strategic relevance of quality management. The purpose of this paper is to explore how different types of uses of QMS correlate with management perceptions of quality management in terms of respect, cost and strategic importance.

Design/methodology/approach

The paper is based on a mixed method data collection strategy, quantitative data being collected from a survey in 8 organisations (n = 108) and qualitative data being collected from 12 interviews with quality managers in 12 different organisations.

Findings

The paper shows that a compliance-oriented QMS usage will more likely lead to a view of quality management as costly and of little respect, than a business or improvement-oriented QMS usage. Moreover, it nuances the view on compliance-oriented usage, showing that it is mainly documentation that negatively influences how management views quality management, whereas standardisation that is part of the compliance-oriented use is perceived as more value-adding.

Originality/value

This paper suggests three types of QMS use, namely, business management, improvement, and compliance-oriented use, and that a wise selection of how to use the QMS will affect the respect, strategic importance and cost that management associates with quality management.

Exploring power shifts as an enabler for a strengthened patient role in quality improvements: a Swedish survey study

Objectives

This study examined the relationship between professionals’ perceptions of a strengthened role for the patient and of patient involvement in quality improvement (QI) and whether professionals’ experiences in improvement science were a moderator on such a relationship.

Design

From a predominantly close-ended, 44-item questionnaire, 4 questions specifically concerning professionals′ perception on patient involvement in QI were analysed.

Setting

Three Swedish regions.

Participants

155 healthcare professionals who had previously participated in courses in improvement science.

Results

The covariate patient involvement was significantly related to a perceived strengthened patient role. There was also a significant interaction effect between degree of patient involvement and professionals’ experience in the area of improvement science on a strengthened patient role. The result shows that there is a relationship between the perceived level of patient involvement in improvements and professionals’ perceptions of a strengthened patient role. In this study, the covariate, perceived patient involvement, was significantly related to experiences of more equal relationships between patients and healthcare professionals. There was also a significant interaction effect between the degree of patient involvement and professionals’ experience in the area of improvement science, for a more equal relationship between patients and healthcare professionals.

Conclusion

Increased patient involvement in QI is a means of strengthening the patient role and supporting a more equal relation between patients and healthcare professionals. Furthermore, empirical evidence shows that the healthcare professionals’ experiences in the area of improvement science support a strengthened patient role and a more equal power relationship, but for this to happen, the mindset of professionals is key. Future research is needed to capture and investigate the experiences from patients and relatives about being involved in QI in healthcare, and to study the effects on quality in care processes.

“Brave men” and “emotional women”: A literature review on gendered norms towards patients with pain

Background

More women than men report chronic pain but despite the large body of research on sex differences there is a lack of knowledge on the influence of social and cultural gender. As gender norms can lead to gender bias in health care it is important to raise awareness about them. The purpose of this study was to illustrate gendered norms about men and women with chronic pain in scientific journals, and to analyze how societal norms are reproduced in health care.

Methods

A literature search of the databases PsycINFO, CINAHL and PubMed was conducted, January 2000 to April 2015, with the search term chronic pain combined with femininity, masculinity, gender bias, gender stereotypes and gender roles. A total of 77 articles met the inclusion criteria and were analyzed qualitatively. The integrative approach enabled a review of articles from both social and medical sciences, and to include qualitative and quantitative research. The material was sorted into theoretical categories and further coded into substantive categories.

Results

The included articles showed a variety of gendered norms about men’s and women’s experience and expression of pain, their identity, lifestyle and coping style. Women were described as emotional and hysterical, constantly dealing with mistrust from health care. Men were pictured as brave, stoic and struggling with their sense of masculinity. Prevailing societal norms are consolidated in health care, positioning the masculine man as the ideal patient.

Conclusions

Gender stereotypes are reproduced in healthcare, which can lead to gender bias in the treatment of patients with pain. The findings were used to develop a tool, “the pain cube”, aimed to improve health care providers’ consciousness about gendered norms.

Key messages

Men and women with chronic pain are depicted in a stereotypical way in scientific articles. Increased awareness about gendered norms can support health care professionals in providing equitable care.

Fit for purpose? Exploring competence in quality management

Purpose

The purpose of this paper is to use competence theory to explore the fit between actual competencies of quality management (QM) practitioner and the perception of QM competence needs in organisations.

Design/methodology/approach

This paper is based on a cross-case quantitative study design featuring a survey of QM practitioners (n = 249) within eight large Swedish organisations. The research instrument was a questionnaire covering seven themes within QM. The analysis is based on descriptive statistics.

Findings

The results show that while the perception of formal QM competence may seem sufficient, the evolving nature of QM requires knowledge, skills and attitudes that are also apt for more external and explorative perspectives. There is a bias towards competence for exploitative QM rather than explorative QM. Organisational logics preserving and possibly reinforcing a perceived “competence lag” in organisations are identified and described.

Originality/value

Few empirical studies within QM explore the competencies required for QM practices. This paper contributes to QM research in providing arguments for adopting the competence theory as a foundation for organising current and future QM work.

Exploring the phase for highest impact on radicality: a cross-sectional study of patient involvement in quality improvement in Swedish healthcare

OBJECTIVES

Involving patients in quality improvement is often suggested as a critical step for improving healthcare processes. However, this comes with challenges related to resources, tokenism, validity and competence. Therefore, to optimise the use of available resources, there is a need to understand at what stage in the improvement cycle patient involvement is most beneficial. Thus, the purpose of this study was to identify the phase of an improvement cycle in which patient involvement had the highest impact on radicality of improvement.

DESIGN

An exploratory cross-sectional survey was used.

SETTING AND METHODS

A questionnaire was completed by 155 Swedish healthcare professionals (response rate 34%) who had trained and had experience in patient involvement in quality improvement. Based on their replies, the impact of patient involvement on radicality in various phases of the improvement cycle was modelled using the partial least squares method.

RESULTS

Patient involvement in quality improvement might help to identify and realise innovative solutions; however, there is variation in the impact of patient involvement on perceived radicality depending on the phase in which patients become involved. The highest impact on radicality was observed in the phases of capture experiences and taking action, while a moderate impact was observed in the evaluate phase. The lowest impact was observed in the identify and prioritise phase.

CONCLUSIONS

Involving patients in improvement projects can enhance the quality of care and help to identify radically new ways of delivering care. This study shows that it is possible to suggest at what point in an improvement cycle patient involvement has the highest impact, which will enable more efficient use of the resources available for patient involvement.

Clinician experiences of healthy lifestyle promotion and perceptions of digital interventions as complementary tools for lifestyle behavior change in primary care

BACKGROUND

Evidence-based practice for healthy lifestyle promotion in primary health care is supported internationally by national policies and guidelines but implementation in routine primary health care has been slow. Referral to digital interventions could lead to a larger proportion of patients accessing structured interventions for healthy lifestyle promotion, but such referral might have unknown implications for clinicians with patients accessing such interventions. This qualitative study aimed to explore the perceptions of clinicians in primary care on healthy lifestyle promotion with or without digital screening and intervention.

METHODS

Focus group interviews were conducted at 10 primary care clinics in Sweden with clinicians from different health professions. Transcribed interviews were analyzed using content analysis, with inspiration from a phenomenological-hermeneutic method involving naïve understanding, structural analysis and comprehensive understanding.

RESULTS

Two major themes captured clinicians' perceptions on healthy lifestyle promotion: 1) the need for structured professional practice and 2) deficient professional practice as a hinder for implementation. Sub-themes in theme 1 were striving towards professionalism, which for participants meant working in a standardized fashion, with replicable routines regardless of clinic, as well as being able to monitor statistics on individual patient and group levels; and embracing the future with critical optimism, meaning expecting to develop professionally but also being concerned about the consequences of integrating digital tools into primary care, particularly regarding the importance of personal interaction between patient and provider. For theme 2, sub-themes were being in an unmanageable situation, meaning not being able to do what is perceived as best for the patient due to lack of time and resources; and following one's perception, meaning working from a gut feeling, which for our participants also meant deviating from clinical routines.

CONCLUSIONS

In efforts to increase evidence-based practice and lighten the burden of clinicians in primary care, decision- and policy-makers planning the introduction of digital tools for healthy lifestyle promotion will need to explicitly define their role as complements to face-to-face encounters. Our overriding hope is that this study will contribute to maintaining meaningfulness in the patient-clinician encounter, when digital tools are added to facilitate patient behavior change of unhealthy lifestyle behaviors.

A value-based taxonomy of improvement approaches in healthcare

Purpose The concept of value is becoming increasingly fashionable in healthcare and various improvement approaches (IAs) have been introduced with the aim of increasing value. The purpose of this paper is to construct a taxonomy that supports the management of parallel IAs in healthcare. Design/methodology/approach Based on previous research, this paper proposes a taxonomy that includes the dimensions of view on value and organizational focus; three contemporary IAs - lean, value-based healthcare, and patient-centered care - are related to the taxonomy. An illustrative qualitative case study in the context of psychiatric (psychosis) care is then presented that contains data from 23 interviews and focuses on the value concept, IAs, and the proposed taxonomy. Findings Respondents recognized the dimensions of the proposed taxonomy and indicated its usefulness as support for choosing and combining different IAs into a coherent management model, and for facilitating dialog about IAs. The findings also suggested that the view of value as "health outcomes" is widespread, but healthcare professionals are less likely than managers to also view value as a process. Originality/value The conceptual contribution of this paper is to delineate some important characteristics of IAs in relation to the emerging "value era". It also highlights the coexistence of different IAs in healthcare management practice. A taxonomy is proposed that can help managers choose, adapt, and combine IAs in local management models.

Initiating quality management in a small company

Purpose

– The purpose of this paper is to identify critical aspects of quality management (QM) adoption in a small company. QM is more widely applied in large companies than in small ones. Previous research has pointed to QM ideas as sound and valid for small companies, but that many such initiatives fail because of poor implementation. With scarcity of resources and expertise, it is critical to study how QM can be initiated in small companies with often sceptical owner-managers.

Design/methodology/approach

– This paper is based on a single case study of a small company; data has been collected through two sets of interviews: one in late 2009 and one in mid-2012, as well as project reports and public financial data. This allows for a study of the adoption process over time.

Findings

– This study points to four critical areas when initiating QM work in a small company: the importance of initiation, the importance of contextualisation, QM adoption as an iterative process, and the need for external support.

Originality/value

– This paper highlights the importance of overcoming small business owners’ reluctance towards QM. Most research on QM initiatives in small companies has focused on the stages that follow an actual decision to begin a QM initiative. This paper shows that it is critical to carefully consider the stages leading to the decision. Further, it contributes with a case study on a small company, otherwise uncommon in QM research.

Using an adapted approach to the Kano model to identify patient needs from various patient roles

Purpose

– The purpose of this paper is to study how an account of multiple patient roles when using the Kano model in healthcare improvements can support identification of a wide range of patients’ needs.

Design/methodology/approach

– The study presented in this paper was part of a longitudinal action research study. The empirical material was collected by various methods (interviews, a focus group, participative observations, and a survey) over a two-month period within the Children’s and Women’s Healthcare department in a Swedish hospital. The respondents included the management team, healthcare professionals, patients, and the patients’ partners.

Findings

– The study shows that incorporating a view of multiple patient roles into application of the Kano model, and using input on customer needs obtained from patients, relatives, and healthcare professionals, helps to identify a wide range of patients’ needs.

Originality/value

– The view on patients within healthcare is being transformed from one based on servility to that of patients as customers. This paper elaborates on a hands-on way of applying the Kano model based on a view of multiple patient roles as a means to support this new patient view. The application builds on input from various groups (such as patients and healthcare professionals), and, by using input from various stakeholders. This approach appears to overcome a gap, identified in earlier research, of either relying solely on patients, or solely on healthcare professionals, when identifying patients’ need. Rather input from several groups – patients, relatives, and professionals – are suggested to be used in combination.

Designing quality of care--contributions from parents: Parents' experiences of care processes in paediatric care and their contribution to improvements of the care process in collaboration with healthcare professionals

AIMS AND OBJECTIVES

The aim of this article was to explore whether current quality dimensions for health care services are sufficient to capture how parents perceive and contribute to quality of health care.

BACKGROUND

New quality improvement initiatives that actively involve patients must be examined with a critical view on established quality dimensions to ensure that these measures support patient involvement.

DESIGN

This paper used a qualitative and descriptive design.

METHODS

This paper is based on interviews with parents participating in two experience-based co-design projects in a Swedish hospital that included qualitative content analysis of data from 12 parent interviews in paediatric care.

RESULTS

Health care professionals often overemphasize their own significance for value creation in care processes and underappreciate parents' ability to influence and contribute to better quality. However, quality is not based solely on how professionals accomplish their task, but is co-created by health care professionals and parents. Consequently, assessment of quality outcomes also must include parents' ability and context.

CONCLUSIONS

This paper questions current models of quality dimensions in health care, and suggests additional sub-dimensions, such as family quality and involvement quality.

RELEVANCE TO CLINICAL PRACTICE

This paper underscores the importance of involving parents in health care improvements with health care professionals to capture as many dimensions of quality as possible.

A developmental view on implementation of quality management concepts

Purpose

– The purpose of this paper is to examine the value of a developmental learning view on implementation of quality management (QM) concepts. QM concepts are common in various organizations; some implement them smoothly, others struggle and sometimes even abandon the initiatives. What is then a successful implementation – is it the use a specific QM method as a standard problem solving approach, or is it that learning has occurred during implementation?

Design/methodology/approach

– The paper is based on an illustrative case study carried out at a hospital in western Sweden. The data have been collected through about 130 hours of participation in project work by the first author and through seven face-to-face interviews of about one hour each.

Findings

– It is shown that a Design for Six Sigma pilot project with a narrow view on implementation could be regarded as a failure, but it gave rise to much learning and new improved ways of working. Hence, it is argued that a developmental view on implementation can support learning by an emergent and experimental approach to implementation processes.

Originality/value

– Much research has been done on how to increase the success rate of implementations of QM initiatives, e.g. procedures to follow to reach an outcome where the new way of working is standard procedure. Less research has problematized the implementation process, questioning what a successful outcome of an implementation is.