Researching

Patient Safety
and Quality in
Healthcare
A NORDIC PERSPECTIVE
Researching
Patient Safety
and Quality in
Healthcare
A NORDIC PERSPECTIVE

KARINA AASE
EDITED BY
LENE SCHIBEVAAG

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Library of Congress Cataloging‑in‑Publication Data

Names: Aase, Karina, editor. | Schibevaag, Lene, editor.

Title: Researching patient safety and quality in healthcare : a Nordic
perspective / Karina Aase and Lene Schibevaag.
Description: Boca Raton : Taylor & Francis, 2017.
Identifiers: LCCN 2016011478 | ISBN 9781472477132 (hard cover)
Subjects: LCSH: Medical care--Norway--Quality control. | Medical
care--Sweden--Quality control. | Medical care--Denmark--Quality control. |
Patients--Norway--Safety measures. | Patients--Sweden--Safety measures. |
Patients--Denmark--Safety measures.
Classification: LCC RA399.N8 R43 2017 | DDC 362.109481--dc23
LC record available at http://lccn.loc.gov/2016011478

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Contents
Editors�����������������������������������������������������������������������������������������������������������������������ix
Contributors��������������������������������������������������������������������������������������������������������������xi
Introduction�������������������������������������������������������������������������������������������������������������xix

Chapter 1 Status of Nordic Research on Patient Safety and Quality of Care........1

Sissel Eikeland Husebø, Siri Wiig, Veslemøy Guise,
Marianne Storm and Britt Sætre Hansen

Section I  Perspectives on Patient Safety

and Quality in Healthcare

Chapter 2 Patient-Centred Care in the Nordic Countries.................................... 27

Marianne Storm and Angela Coulter

Chapter 3 Studying Patient Safety and Quality from Different

Methodological Angles and Perspectives............................................ 43
Siri Wiig and Tanja Manser

Chapter 4 What Is the Role of Theory in Research on Patient Safety

and Quality Improvement?: Is There a Nordic Perspective
to Theorising?...................................................................................... 57
Karina Aase and Jeffrey Braithwaite

Chapter 5 Working in an Institutionally Layered System on

Patient Safety and Quality................................................................... 75
Hester van de Bovenkamp, Annemiek Stoopendaal and Roland Bal

Section II  Contemporary Nordic

Research – Macro-Level Issues

Chapter 6 Centralisation Efforts to Improve the Quality of Care and

Reduce the Costs in Healthcare Systems............................................ 89
Pia Kjær Kristensen and Søren Paaske Johnsen

v
vi Contents

Chapter 7 National Clinical Registries: Ten Years of Experience with

Improving Quality of Care in Denmark........................................... 103
Søren Paaske Johnsen, Jan Mainz and Paul D. Bartels

Chapter 8 Side Effects of Overdoing It: Lessons from a Comprehensive

Hospital Accreditation Programme.................................................. 115
Carsten Engel and Henning Boje Andersen

Section III  Contemporary Nordic

Research – Meso-Level Issues

Chapter 9 A Multidisciplinary and Multifactor Approach to

Falls Prevention: The RFPNetwork.................................................. 131
Tarja Tervo-Heikkinen, Marja Äijö and Arja Holopainen

Chapter 10 Coordination of Discharge Practices for Elderly Patients

in Light of a Norwegian Healthcare Reform..................................... 145
Heidi Helen Nedreskår and Marianne Storm

Chapter 11 Leading Quality and Patient Safety Improvement in

Norwegian Hospitals......................................................................... 161
Inger Johanne Bergerød and Siri Wiig

Section IV  Contemporary Nordic

Research – Micro-Level Issues
Chapter 12 Telecare in Home Healthcare Services: Implications for
Quality and Safety............................................................................. 179
Veslemøy Guise, Anne Marie Lunde Husebø, Marianne Storm,
Kirsti Lorentsen Moltu and Siri Wiig

Chapter 13 Coping with Complexity: Sensemaking in Specialised

Home Care..................................................................................... 195
Mirjam Ekstedt
Contents vii

Chapter 14 Administration of Intravenous Medication: Process Variation

across Hospital Wards....................................................................... 211
Eija Kivekäs, Kaisa Haatainen, Hannu Kokki
and Kaija Saranto

Appendix��������������������������������������������������������������������������������������������������������������� 225

Index���������������������������������������������������������������������������������������������������������������������� 235
Editors
Professor Karina Aase, University of Stavanger, is an internationally recognised
quality and safety expert with a multi-sector background. She is the founder of the
Quality and Safety in Healthcare Systems research group at the Department of
Health. Under Aase’s leadership, this group has become Norway’s largest and most
influential multidisciplinary research group within the field of healthcare quality
and patient safety, boasting more than 20 affiliated researchers, as well as numer-
ous national and international collaborators. Professor Aase has a proven record of
gaining and leading large funding grants. Aase has a publication record in merited
journals, has edited several books on patient safety and quality in healthcare and
is an associate editor of BMC Health Services Research. She is a member of the
National Council for the Patient Safety Programme and has currently been appointed
by the King in Council as a member of a government committee proposed to suggest
a new organisation of state ownership of the specialist healthcare services.
Lene Schibevaag has a bachelor degree in physiotherapy from the University of
Northumbria and has worked for several years as a physiotherapist in both a hos-
pital and a municipality setting in England and Norway. She has a master’s degree
in societal safety from the University of Stavanger with a dissertation on transi-
tional care entitled ‘Multidisciplinary Collaboration: A study of the physiothera-
pist role in transitional care of the elderly’. Schibevaag is currently working as a
research coordinator for the ‘Quality and Safety in Healthcare’ research group at
the University of Stavanger, Norway.

ix
Contributors
Marja Äijö, PhD, is a principal lecturer at Savonia University of Applied Sciences,
School of Health Care, Finland. Äijös’ teaching field is gerontology and her main
research interests are physical activity, cardiovascular diseases and all-cause mor-
tality among older people and simulation teaching and learning among healthcare
students.
Henning Boje Andersen is a professor of healthcare management at the Technical
University of Denmark (DTU) in the Department of Management Engineering.
His background is in philosophy and human factors, and his R&D activities,
beginning at Risø National Laboratory in 1984 and continued at DTU since 2008,
have been focused on human and organisational factors that influence performance
in safety critical domains including aviation, maritime operations and healthcare.
His recent research and teaching projects include the design and implementation of
healthcare technology for quality improvement, tele-health and independent living
for the elderly.
Roland Bal is a professor of healthcare governance at Erasmus University in
Rotterdam, the Netherlands. He obtained his MSc in health science and his PhD in
science and technology studies. His research interests include the relation between
science, policy and practice and governance infrastructures in healthcare. He led
the evaluation of several large-scale evaluations of quality and safety of care pro-
grams in the Netherlands and participated in the EU-funded QUASER project on
quality management in European hospitals. Related to his work on quality, he
participates in research on information technologies in healthcare and the ways
in which healthcare organisations ‘organise for transparency’. He is a co-founder
of the academic collaborative on supervision in healthcare, which is run by the
Healthcare Inspectorate of the Netherlands.
Paul D. Bartels is an MD and a specialist in chemical pathology. He is the director
of the Danish Clinical Registries – a national quality improvement programme. Also,
he is the head of the European Society for Quality in Healthcare (ESQH) Office for
Quality Indicators, Aarhus, and an ESQH fellow (past president of ESQH). Bartels
is a former medical director of Randers Central Hospital and a former senior lecturer
in chemical pathology, University of Aarhus, and a former chairman of the Danish
Committee for Quality Assurance in Chemical Pathology. He is a clinical lecturer at
Aalborg University. Bartels is the author and co-author of numerous publications on
quality and patient safety in healthcare.
Inger Johanne Bergerød is a PhD candidate in health and medicine at the
University of Stavanger. She has worked as an oncology nurse and middle man-
agement in the Department of Hematology and Oncology at Stavanger University
since 1999. Bergerød holds a master’s degree in health science from 2012 (thesis title:
‘Leadership, quality and patient safety – A comparative case study of two Norwegian

xi
xii Contributors

hospitals’). The research for the master thesis was done in collaboration with the
University of Stavanger in the EU FP7 project ‘Quality and Safety in European
Hospitals’. The title of Bergerød’s commenced PhD study is ‘Improving the quality
and safety of cancer care: A study of next-of-kin involvement’. Key research interests
are oncology, nursing, leadership, patient safety, quality improvement, next-of-kin,
organisational safety and cultural factors.
Hester van de Bovenkamp, PhD, is an associate professor of public administration
in healthcare at Erasmus University Rotterdam, the Netherlands. Her main field of
interest is citizen participation and representation in healthcare decision-making.
Her research is focused on the various forms of citizen participation and represen-
tation that can be found at different levels of the healthcare system (micro, meso,
macro). She participated in numerous studies on this subject. She also studies the
governance of healthcare quality using an institutional perspective. On this subject
she participated in several studies including the EU-funded QUASER project which
focused on quality work in hospitals across Europe.
Jeffrey Braithwaite, PhD, is the foundation director of the Australian Institute
of Health Innovation, a director of the Centre for Healthcare Resilience and
Implementation Science and a professor of Health Systems Research, Faculty of
Medicine and Health Sciences, Macquarie University, Australia. His research
examines the changing nature of health systems, particularly patient safety, stan-
dards and accreditation, leadership and management, the structure and culture of
organisations and their network characteristics, which has attracted funding of some
AUD$90 million. He holds visiting professorial appointments at the University of
Birmingham, UK; Newcastle University, UK; the University of Southern Denmark;
the University of New South Wales, Australia and the Canon Institute of Global
Studies, Tokyo, Japan.
Angela Coulter is a health policy analyst and a researcher who specialises in patient
and public involvement in healthcare. She is the director of Global Initiatives at
the Informed Medical Decisions Foundation, Boston, and a senior research scientist
in the Nuffield Department of Population Health, University of Oxford. A social
scientist by training, Angela, has a doctorate in health services research from the
University of London. From 2000 to 2008, she was the chief executive of Picker
Institute Europe. Previous roles included director of Policy and Development at the
King’s Fund and director of the Health Services Research Unit at the University of
Oxford. She is an adjunct professor at the University of Southern Denmark and a
senior visiting fellow at the King’s Fund in London, holds honorary fellowships at
the UK Faculty of Public Health and the Royal College of General Practitioners and
is a trustee of National Voices.
Angela has published more than 300 research papers and reports and several
books including The Autonomous Patient, The European Patient of the Future (win-
ner of the 2004 Baxter Award), The Global Challenge of Healthcare Rationing,
Hospital Referrals, Engaging Patients in Healthcare (highly commended by the
BMA) and Understanding and Using Health Experiences. She was the founding
editor of Health Expectations, an international peer-reviewed journal on patient and
Contributors xiii

public involvement in healthcare and health policy. She has won awards for her work
from the Donabedian Foundation of Barcelona in 2012 and the International Shared
Decision Making Conference in 2013.
Mirjam Ekstedt, RN, is an associate professor at the Royal Institute of Technology
and at the Medical Management Centre, LIME, at Karolinska Institutet in Stockholm.
She is leading a research program on systems safety in healthcare, with focus
on management and decision-making at the sharp end of complex organisations,
patients’ and family caregivers’ involvement and implementation of patient-centred
innovations and communication systems. She gained her PhD in psychosocial medi-
cine at Karolinska Institutet with focus on burnout and sleep and effects of fatigue
and stress on health and performance.
Carsten Engel, MD, is the deputy chief executive at IKAS, the Danish Institute
for Quality and Accreditation in Healthcare. His background is clinical practice as
anaesthesiologist and management experience at the departmental and hospital level.
Since 2004, he has devoted full time to quality management and improvement in
healthcare, taking a leading part in the development and management of the Danish
healthcare accreditation programme (DDKM). Through the Accreditation Council
of the International Society of Quality in Health Care (ISQua), he is engaged in
accreditation internationally and he serves as an ISQua Expert. While not primar-
ily a researcher, he takes a keen interest in supporting research in accreditation and
quality improvement strategies in general and in spreading results of such research.
Veslemøy Guise, MA, is a PhD candidate at the Department of Health Studies,
University of Stavanger, Norway. Guise is a medical sociologist by background and
has worked as a healthcare researcher in New Zealand and the United Kingdom in
addition to Norway. Her current research is centred on the Safer@Home – Simulation
and training and is concerned with the development, implementation and evalua-
tion of telecare training programs for healthcare professionals working in municipal
home healthcare services.
Kaisa Haatainen, PhD, is an adjunct professor (mental health promotion) of nursing
sciences at the University of Eastern Finland. For the last three years, she has been
working as a patient safety manager at Kuopio University Hospital. Coordinating
patient safety at the hospital level and developing the reporting and measuring of it
are in the focus of her daily job. Dr. Haatainen has a membership as an expert at the
Finnish Centre for Evidence-Based Health Care, an affiliated centre of the Joanna
Briggs Institute. Her research interests are in mental well-being and patient safety.
Currently, she is leading a research project focusing on patient safety.
Britt Sætre Hansen is a professor in nursing and an intensive care nurse with a
­master’s degree from the University of Bergen and PhD from the University of
Stavanger in 2009. Her PhD thesis is about differences in intensive care nurses’ and
physicians’ inter- and intraprofessional understanding of protocol-directed wean-
ing from mechanical ventilation. She is employed at the University of Stavanger
and Buskerud and Vestfold University College where she is supervising and teach-
ing master students in research methods. Her research relates to interprofessional
xiv Contributors

collaboration and implementation of evidence-based knowledge. She is also employed

as a senior advisor at Stavanger University Hospital and works with research, profes-
sional development and dissemination of research in clinical practice.
Arja Holopainen, PhD, is a research director at the Nursing Research Foundation.
Holopainen is also the director of two international collaborating centres in Finland:
(1) the Finnish Centre of Evidence-Based Health Care (Joanna Briggs Institute) and
(2) the WHO Collaborating Centre for Nursing. Her main research interest concerns
evidence-based health care and how to synthesis evidence (systematic reviews), as
well as how to improve and to evaluate evidence-based practices.
Sissel Eikeland Husebø is a postdoctor candidate and has experience within a wide
variety of acute care clinical settings. She is an intensive care nurse and has worked
at SAFER simulation centre (www.safer.net) for seven years designing, implement-
ing and facilitating simulation-based learning in the nursing and healthcare. Her
PhD thesis is about condition for learning in simulation with focus on team-based
resuscitation in nursing education. She is currently employed at the University of
Stavanger and Stavanger University Hospital where she supervises nursing, master
and PhD students. Her ongoing research is on interprofessional clinical leadership
in teams in the emergency department and interprofessional decision-making in the
hospital setting.
Anne Marie Lunde Husebø, RN, GN, MSc, is an associate professor at the
Department of Health Studies, University of Stavanger, Norway. Husebø conducts
research within the field of health promotion in chronic disease and on telecare in
primary care services. She defended her thesis in December 2015 titled ‘Exercise
during breast cancer treatment. A study of physical and psychosocial outcomes, and
motivational challenges’. Husebø has vast experience as a nurse specialist (geriatric
nursing) working in long-term care facilities for the elderly.
Søren Paaske Johnsen is a research consultant and an associate professor in clini-
cal epidemiology at Aarhus University Hospital and Aarhus University, Denmark.
Dr. Johnsen’s primary field of interest is quality of clinical care, including the use
of evidence-based care, effectiveness and safety of recommended clinical interven-
tions and evaluation of quality improvement strategies. The activities are primarily
focused on the scientific use of clinical quality databases and administrative reg-
isters. Dr. Johnsen received his medical degree and PhD degree in epidemiology
from Aarhus University. He has worked with clinical quality databases since the
late 1990s and for 10  years was the head of Centre for Clinical Databases at the
Department of Clinical Epidemiology, Aarhus University Hospital. This centre is
one of three national Danish centres supporting clinical databases with expertise in
clinical epidemiology and biostatistics. He currently leads a research group working
with quality of care at Aarhus University Hospital and Aarhus University.
Eija Kivekäs, MSc (health management), RN, is a project researcher and a doctoral
student in Health and Human Services Informatics at the University of Eastern
Finland, Department of Health and Social Management. Kivekäs has coordi-
nated several clinical development projects and worked as a project manager for
Contributors xv

several years. Her research interest is the role of patient safety in electronic health
records as well as competencies and management issues in information system
implementation.
Hannu Kokki, MD, PhD, is a professor of anaesthesiology at the University
of Eastern Finland, School of Medicine, at Kuopio Campus. He is the chair of
the committee on pharmacotherapy at the Hospital District of Northern Savo in
Kuopio University Hospital and a clinical expert for the Finnish Office for Health
Technology Assessment and Patients Insurance Centre. Hannu Kokki has a large
research network in clinical medicine, pharmacology, social pharmacy and nurs-
ing sciences.
Pia Kjær Kristensen, MHSc, is a PhD student at the University of Aarhus,
Department of Clinical Epidemiology, Aarhus University Hospital, and Department
of Orthopaedic Surgery Horsens Regional Hospital, Denmark. Pia’s primary field
of interest is clinical epidemiology, including quality of clinical care, the organisa-
tion of in-hospital care and evaluation of quality improvement strategies among
patients with hip fracture. Pia has conducted research within the healthcare sector
since 2013 with projects covering overall associations between selected aspects of
structure of care (orthogeriatric specialisation and patient volume) and process per-
formance measures, 30-day mortality and hospital bed-day use. Currently, she is a
part of the research group working with quality of care at Aarhus University Hospital
and Aarhus University.
Jan Mainz is a professor of quality improvement and health services research at
Aalborg University Hospital and an adjunct professor at the University of Southern
Denmark. He is the deputy director of psychiatry in North Denmark Region. Jan Mainz
is the Danish representative in the OECD Health Care Quality Indicator Project since
2002 and member of the OECD Bureau. He is also the member of WHO’s Advisory
Committee of the WHO Report on Safety and Quality of Health Care Services. He
is the former project manager and he has been responsible for the development of
indicators and measurements in the Danish National Indicator Project. He was the
chairman of the Nordic Ministers Council Project on indicators monitoring in the six
Nordic countries (Sweden, Norway, Finland, Iceland, Greenland and Denmark) in
2002–2012. From 1999 to 2005, he was the president of the Danish Society for Quality
in Health Care, and from 2003 to 2005, president of the European Society for Quality in
Health. His main research activities relate to quality improvement and quality manage-
ment, performance and outcome measurement, quality monitoring and health services
research and patient empowerment.
Tanja Manser is a full professor for patient safety and director of the Institute for
Patient Safety at the University Hospital Bonn, Germany. Her research focuses on
adaptive coordination in acute care settings, quality and safety of patient handoffs,
clinical risk management, safety climate in healthcare and implementation of patient
safety practices. She received a PhD in psychology from the University of Zurich in
2002 and completed her habilitation in work and organisational psychology at ETH
Zurich in 2008.
xvi Contributors

Kirsti Lorentsen Moltu is an occupational therapist who works with the adult
and elderly population in the home healthcare services in Stavanger municipality,
Norway. Moltu has worked as a project coordinator in several municipality telec-
are projects. Her primary responsibility has been concerned with patient follow-up
and training during the implementation of new technologies. She has also had an
active role as the municipality’s representative in the Safer@Home – Simulation and
­training research project.
Heidi Helen Nedreskår has a bachelor’s degree in nursing, with specialisation
in intensive and geriatric nursing, and a master’s degree in health science. In con-
nection with health studies at the University of Stavanger, she has been affiliated
to the project ‘Quality and safety in transitional care of the elderly’. Nedreskår
has many years of clinical experience in both hospital and municipality services
and has held different positions in management and administration in healthcare
service. Nedreskår is now holding an administrative position in Stavanger munici-
pality working towards palliative care, dementia care and patients in need of care
in institutions.
Kaija Saranto, PhD, FACMI, FAAN, works as a full professor in health and human
services informatics at the University of Eastern Finland, Department of Health and
Social Management. In 2012, the HHSI master’s degree programme received the
status ‘IMIA accredited’ as the very first internationally. Dr. Saranto has a number of
memberships in both academic and expert groups focusing on ICT use in the society.
Dr. Saranto acts also as the deputy director at the Finnish Centre for Evidence-Based
Healthcare, an affiliated centre of the Joanna Briggs Institute. Her research interest
is the role of classifications in EHRs as well as educational and organisational issues
in information system implementation. Currently, she is also leading a research
group focusing on patient safety.
Annemiek Stoopendaal, PhD, is an assistant professor of organisational anthro-
pology in healthcare at the Erasmus University Rotterdam, Department of Health
Policy and Management. Her research interests are on healthcare management
and governance, with specific emphasis on the work and behaviour of health-
care managers, complex interventions and the governance and supervision of
quality and safety in healthcare. She is interested in the boundaries and bind-
ings between different levels in the organisation of healthcare. She participates
in the academic collaborative on supervision in healthcare, which is run by the
Healthcare Inspectorate of the Netherlands and is involved in research on regula-
tion and supervision. The research methods she uses are qualitative, ethnographic
and formative research.
Marianne Storm is an associate professor at the Institute of Health Sciences at
the University of Stavanger. She holds a PhD in management from the University of
Stavanger and a master’s degree in health science from the University of Bergen. She
has a nursing background. In her postdoctoral studies, she was principal investiga-
tor for phase 2 of the research project ‘Quality and safety in transitional care of the
elderly’ funded by the Norwegian Research Council (NRC). She has been an affili-
ated researcher in Safer@Home, a research project funded by the NRC involving the
Contributors xvii

use of welfare technology in healthcare for the elderly. Her research areas include
healthcare quality, patient experience and user involvement, transitional care, wel-
fare technology, learning, organisational culture, intervention research and statistical
analysis.
Tarja Tervo-Heikkinen, PdD, RN, is a clinical nurse consultant at the Kuopio
University Hospital (KUH), Clinical Development, Education and Research Unit
of Nursing (CDERUN). Dr. Tervo-Heikkinen’s responsibility areas are fall pre-
vention, pressure ulcer prevention, patient education and evidence-based nurs-
ing. She is the chairman of the RFP Network and also a member of KUH’s Care
Ethics Committee. Before her current post, Tervo-Heikkinen worked as a univer-
sity researcher at the University of Eastern Finland and project manager at the
Attractive and Health Promoting Health Care. Dr. Tervo-Heikkinen is also mem-
ber of core staff of the Finnish Centre of Evidence-Based Health Care (Joanna
Briggs Institute). Her doctoral thesis (2008) title was ‘The Effectiveness of Nursing
in Specialized Health Care’.
Siri Wiig, PhD, is a professor of quality and safety in healthcare systems at the
University of Stavanger (UiS), Norway. She is part of the research centre SEROS –
Centre for Risk Management and Societal Safety, UiS. Wiig has a part-time affilia-
tion as chief engineer within organisational safety at the Petroleum Safety Authority,
Norway. Wiig holds a PhD in risk management and societal safety from 2008 (title
of PhD: ‘Contributions to Risk Management in the Public Sector’) and a master of
science in societal safety and planning from 2002. Wiig has conducted research
on quality and safety and risk management in three sectors: the healthcare sector
(primary and specialised services), municipal sector (emergency preparedness and
primary healthcare) and petroleum sector. Wiig has been full-time researcher in the
EU-FP 7 project: ‘Quality and Safety on European Union Hospitals’ (2010–2013).
Key research interests are organisational safety, human factors, risk management,
societal safety, risk regulation, risk perception, patient safety, quality improvement,
learning, sociotechnical systems and welfare technology.
Introduction
This book is about research on patient safety and quality in healthcare seen
from a Nordic perspective. There is today an abundant literature on the topic
in an international context, dominated by authors from the United States, the
United Kingdom, Canada and Australia. This edited collection will try to distil
the flavours of contemporary Nordic research on patient safety and quality in
healthcare. In doing so, we will present the Nordic characteristics by pursuing
different topics such as patient-centred care, methodology and theory, as well
as showcasing a set of exemplary Nordic research contributions grouped around
macro-political issues, meso-level organisational issues and micro-level clinical
practice issues.

RATIONALE BEHIND THE BOOK

Due to a growing amount of research activities and research groups across the Nordic
countries since the millennium, the Nordic Research Network for Safety and Quality
in Healthcare (NSQH) was established in 2008. The purpose of the NSQH network
(NSQH, 2016) is to promote and advance patient safety and quality research in the
healthcare sector and to facilitate increased collaboration on research and utilisa-
tion of research results amongst the Nordic countries across research institutions
and clinical settings. It has also been a long-term goal for the network to establish
a Nordic research agenda. Following the NSQH network initiative, the first Nordic
Patient Safety Conference was established in 2010 (Stockholm) succeeded by the
Nordic Conference on Research in Patient Safety and Quality in Healthcare 2012
(Copenhagen) and 2014 (Stavanger).
Despite these valuable efforts to establish a more sustainable research stream in
the Nordic countries, no overview of research on patient safety and quality in Nordic
healthcare has so far been presented. The book will therefore meet this demand by
systematically presenting research from the Nordic countries within the field. Invited
scholars have reflected upon specific topics such as patient-centred care, methodol-
ogy, theory and institutional layering related to the Nordic research context. Also,
a set of research contributions have been selected for presentation to reflect the
multi-layered nature of healthcare involving a complex set of stakeholders, service
providers and activities. As such, we believe that this edited volume will create a
basis for reflecting the nature of contemporary Nordic research on patient safety and
quality in healthcare constituting a useful framework for crafting a research agenda
and for making visible areas for knowledge sharing and cross-country research
collaborations.
In an international context, the book will give an overview of the Nordic per-
spective on patient safety and quality research that so far has been lacking in the

xix
xx Introduction

c­ urrent literature. Identifying and describing characteristics of the Nordic perspective

might thus benefit researchers and practitioners in other contexts.

WHAT IS PATIENT SAFETY AND QUALITY IN HEALTHCARE?

The conceptual pair of patient safety and quality is employed in many contexts of
today’s healthcare systems and also research wise. The relationship between patient
safety and quality can be expressed in several ways, the most common being to view
quality in healthcare as the overarching umbrella under which patient safety resides.
For example, the Institute of Medicine (IOM) considers patient safety as indistin-
guishable from the delivery of quality healthcare. An early definition of quality in
healthcare is expressed by the IOM as follows:
The degree to which health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent with current professional
knowledge
Kohn et al. (2000); Berg and Cassels (1992)

After the millennium, descriptions of quality have been centred around conceptual
dimensions such as the six dimensions suggested by IOM (2000):

1.
Safe – avoiding injuries to patients from the care that is supposed to help them
2.
Effective – providing services based on scientific knowledge to all who
could benefit and refraining from providing services to those not likely to
benefit (avoiding underuse and overuse)
3.
Patient centred – providing care that is respectful of and responsive to
­individual patient preferences, needs and values and ensuring that patient
values guide all clinical decisions
4. Timely – reducing waits and sometimes harmful delays for both those who
receive and those who give care
5. Efficient – avoiding waste, in particular waste of equipment, supplies, ideas
and energy
6. Equitable – providing care that does not vary in quality because of personal
characteristics, such as gender, ethnicity, geographic location and socio-
economic status

Several countries now base their definition and description of quality on all or sev-
eral of the six dimensions (Wiig et  al., 2014), including the Nordic countries.
The patient safety dimension is most often related to the avoidance or prevention
of patient harm. A well-established definition of patient safety is made by Charles
Vincent:
The avoidance, prevention and amelioration of adverse outcomes or injuries stemming
from the process of healthcare
Vincent (2010)
Introduction xxi

As such, patient safety is an attribute of healthcare systems; it minimises the

­incidence and impact of, and maximises recovery from, adverse events (Emmanuel
et  al., 2005). Adverse events could be seen as the outcome of poor patient safety
but also as something inevitable in healthcare processes. The World Healthcare
Organisation (WHO) defines adverse events as follows:

An injury related to medical management, in contrast to complications of disease.

Medical management includes all aspects of care, including diagnosis and treat-
ment, failure to diagnose or treat, and the systems and equipment used to deliver care.
Adverse events may be preventable or non-preventable

WHO (2005)

To assess whether an injury is caused by clinical treatment or care and not by the
course of the disease is in many cases not a straightforward task. Adverse events
often involve complex chains of action where competence, accessible treatment
methods, time and patient conditions are involved.
In addition to the landmark report ‘To err is human’ (US; IOM, 2000), a few large-
scale system failures such as the Bristol Royal Infirmary Case (UK; Kennedy, 2001)
and the Mid Staffordshire Case (UK; Francis, 2013) have been important d­ rivers
for prioritisation, focus and research on patient safety internationally. Nationally,
there are also cases in which high-profile inquiries have been raised, for example, the
Radboud Case in the Netherlands (Dutch Patient Safety Board, 2008). Paramount to
the understanding of these complex safety cases is the system p­ erspective applied
to document the inter-relational or multi-layered context (e.g. managerial factors,
professional factors, organisational factors, cultural factors) behind the development
of the crises.
Unlike the patient safety field, quality and quality improvement have a longer
research tradition within healthcare. While the patient safety field so far has been
occupied mainly with establishing the degree of adverse events and the causal drivers
behind them, the quality field has been driven by a more applied focus of improve-
ment processes (see also Chapter 4). The quality research focuses more on finding
and documenting effective processes gaining desirable outcomes, for example, as
shown in the Michigan Intensive Care Unit project, which attracted international
attention by successfully reducing rates of central venous catheter bloodstream
infections (Dixon-Woods, 2011).
The amount of international research studies within patient safety and quality has
increased rapidly over the last two decades. Still, much of the evidence is from developed
nations (Jha et al., 2010), and while data from transitional and developing countries are
increasing, more studies are needed to cover the global nature of patient safety and qual-
ity in healthcare. Major stakeholders behind the international patient safety and quality
agenda are amongst others the WHO, Institute for Healthcare Improvement and Agency
for Healthcare Research and Quality. Some would claim that the focus so far has been
dominated by an instrumental approach focusing on formal and structural d­ imensions
to develop evidence-based tools, measurements and resources (Pronovost et al., 2015).
xxii Introduction

Research principles to guide future contributions are therefore suggested as follows

(Iedema, 2009):

1. Research must engage with both the predictability and the complexity of
the sites and processes it seeks to describe, explain and/or impact on.
2. Engaging with complexity implicates researchers in experiencing it in a
process of sensemaking of the practical and affective consequences for
practitioners inhabiting and enacting that complexity.
3. Besides numerically based descriptions, abstracted explanations and pro-
cedural prescriptions, research evidence must encompass experiential data,
collaboratively produced accounts and/or experience-based designs.

THE NORDIC CONTEXT

The Nordic countries consist of Denmark, Finland, Iceland, Norway and Sweden.
The Nordic model is one of the welfare states characterised by a large public sec-
tor, welfare services and a social safety net. High standards of living, high levels of
employment, relatively small differences in income, a high level of gender equality
and the population’s trust in public systems have been indicated as success factors
(Nordic Council of Ministers, 2014). The Nordic model is also used in characteris-
ing the regulation of occupational safety and work environment in Nordic countries
based on a three-pillar system involving employers, employees and regulatory bod-
ies (Karlsen and Lindøe, 2006). By means of specific rules and procedures which
demand the employer and employees to co-operate, mandatory performance stan-
dards and participative relations between workers and management, the Nordic
countries have, since the 1970s, gradually improved the working environment giving
enhanced safety for the workers.
The Nordic model is visible in the healthcare systems of the Nordic countries by
publicly funded health services, social rights and equal access to health services.
Globalisation, increasing life expectancy and economic trends, put pressure on the
Nordic welfare states. A smaller number of people will have to support the ageing
population, increasing the demand on public finances. Within the healthcare sector,
more diseases will be treatable, and increasingly costly medical technology will be
developed (Nordic Council of Ministers, 2014). Alongside these pressures, the social
and health services need to remain stable, safe and of high quality. Co-operation
between the Nordic governments on health falls under the auspices of the Nordic
Council of Ministers on Health and Social Affairs. The Nordic co-operation has
developed a strategy for the social affairs and health sector from 2013 and onwards,
focusing on four specific objectives designed to strengthen sustainable welfare and
health in the Nordic region:

1. Ensuring social security in the Nordic region in a constantly changing

labour market
2. Active preventive measures
3. Improving quality and safety in the social and health services
4. Promoting innovation and research
Introduction xxiii

In light of this book, the third objective on quality and safety is of specific relevance.
Here, the Nordic countries will focus on exchanges of experience and knowledge in
order to ‘ensure that the services are effective, safe, co-ordinated, involve the users
and exploit resources effectively’ (Nordic Council of Ministers, 2013, p. 71). It is
worth noting that the quotation covers five of the six quality dimensions suggested
by the IOM in their common definition of quality in healthcare (IOM, 2000). For
more information on the Nordic countries, see Chapter 1.
The patient rights focus in the Nordic countries is distinct and unambiguous with
health legislation reinforcing policies ensuring equal access to health services. At the
turn of the century, the Nordic region had undergone a rapid development in legally
safeguarding patient rights compared to many other countries. Of eight European coun-
tries introducing such laws at the time, four were Nordic (Denmark, Iceland, Finland,
Sweden) (Fallberg, 2000). Norway had their Patient Rights Act enforced from 2001. The
Nordic policymakers have since then attempted to move the healthcare systems towards
greater patient centredness by promoting patient rights; involving patient organisations;
and encouraging patient choice, patient information and patient feedback. For more
information on patient-centred care in the Nordic countries, see Chapter 2.
It is worth noting that the Nordic countries have not experienced any high-profile
system failures such as the Bristol case or the Mid Staffordshire case that have
driven the governmental regulation or research focus in a certain direction. With a
­population of approximately 26 millions (OECD, 2013), one might also claim that the
Nordic countries are ‘midgets’ when it comes to research budgets and power to influ-
ence research agendas. Chapter 1 states that there are 163 research publications from
the Nordic countries in peer-reviewed journals between 2000 and 2014. It should be
of common interest to see how these research contributions give another angle at
patient safety and quality in healthcare compared to other countries.

A NORDIC RESEARCH PERSPECTIVE?

An opportune question is whether or not it is possible to distil the characteristics of
a Nordic perspective to research on patient safety and quality in healthcare. On the
one hand, the Nordic countries are heavily influenced by international strategies and
approaches, seen in, for example, the adoption of the IOM quality dimensions, WHO
guidelines (e.g. safe surgical checklists) and national campaigns and accreditation pro-
grammes adopted based on the experiences of other countries. Based on the contri-
butions of this book, we would claim that this adoption of international influence is
more salient at a national macro-political and strategic level, while at an organisational
meso-level and work practice–based micro-level, the Nordic traits are more apparent.
At the macro-level, we can trace international topics such as centralisation (volume–
outcome relationship), accreditation and national campaigns in the Nordic research lit-
erature (see also Chapters 6 and 8). In Chapter 7, the authors document that the Nordic
countries and in particular Sweden and Denmark have a long tradition for working
with national clinical registries and therefore have extensive experience with both the
strengths and limitations of such registries. This should be of particular interest for the
increasing number of other countries planning to establish national clinical registers.
We assume that country size is an explanatory factor for why some of the Nordic
xxiv Introduction

countries have succeeded in their work with national registries. On the contrary, the
authors of Chapter 8 (Engel and Boje Andersen) speculate why the national strategy
on hospital accreditation in Denmark has not been as successful as in other Nordic
and non-Nordic countries. The emphasis on ‘bottom-up’ approaches refraining from
‘forcing’ individuals or departments into improvement efforts that is characteristic of
the Nordic model might be an explanatory factor here.
At the meso-level, issues pertaining to a system perspective seem to characterise
parts of the Nordic literature on patient safety and quality. Chapter 1 documents a
number of studies trying to identify factors influencing patient safety and quality
outcomes as well as understanding work processes and contexts. This might not be
a very particular feature of the Nordic research perspective solely. Given the com-
plex features of modern healthcare and its context sensitivity, such studies should
nevertheless be valued in light of the specificities of the Nordic context which taken
together with other contexts needs to be addressed and described if we are to effec-
tively inform patient safety and quality improvement efforts.
At the micro-level, the perspective of patients and next of kin is highly evident in
the Nordic healthcare policies (see Chapter 2) and in the patient safety and quality
research literature (see Chapter 1). Policy wise, the patient perspective involves patient
rights, transparency and access to information on system performance. Research wise,
the patient perspective includes numerous accounts of patient experiences, their prefer-
ences and evaluations of the healthcare services they have received. We claim this is
a cornerstone of the Nordic model and approach to healthcare provision. This entails
principles of equality, the legal rights of patients and minimal power distance between
providers and recipients of care characteristic of the Nordic welfarism and thinking.
A generic issue salient in both the international and Nordic research literature on
patient safety and quality is the lack of explicit theory application and development
(Chapters 1 and 4). The authors of Chapter 4 (Aase and Braithwaite) nevertheless
claim that selected Nordic scholars and settings have had a profound influence on
current research. These scholars are Jens Rasmussen (socio-technical approach to
safety), Erik Hollnagel (self-organisation, organisational resilience), John Øvretveit
(evaluation of quality improvement) and a setting Jönköping in Sweden (system-wide
improvement). We can trace the contributions of these scholars and setting and see
their ideas and influence having a discernible Nordic flavour, and as being reflected
in current Nordic and international safety and quality research.

A READER’S MANUAL
Each of the book chapters can be read separately and without knowledge of the
contents of the preceding chapters. The contributions in the book have been grouped
into five different sections (introduction, perspectives, macro-political issues, meso-
level organisational issues and micro-level work system issues) each of them forming
a natural collocation useful for coherent reading.
In Chapter 1 (Husebø, Wiig, Guise, Storm, Sætre Hansen), an integrative systematic
review has been conducted of the Nordic research literature on patient safety and qual-
ity (2000–2014) in order to conclude with suggestions for a future research agenda.
Research needs to involve amongst others evaluations of strategies and initiatives
Introduction xxv

for patient involvement, studies across primary care and specialist care (as opposed
to ­single-level studies), cross-country comparisons and the study of the association
between organisational and cultural characteristics and healthcare outcome.
In Section I, we present a set of generic issues relating to research on patient
safety and quality. Storm and Coulter (Chapter 2) describe patient-centred care in
the Nordic countries concluding that the topic is high on the macro-political agenda
but there is still more to do to ensure that the healthcare systems are truly patient
centred. Wiig and Manser (Chapter 3) reflect on the methodological challenges of
researching patient safety and quality in healthcare, based on three characteristics
of the healthcare context: conceptualisation of patient safety and quality, continu-
ous contextual changes and patient involvement. Aase and Braithwaite (Chapter 4)
indicate that theory seems to be under-represented in the international as well as
the Nordic literature on patient safety and quality in healthcare but still claim that
selected Nordic scholars have influenced the theoretical thinking within patient
safety and quality improvement, respectively. Bovenkamp, Stoopendal and Bal
(Chapter 5) delve into the topic of institutionally layered healthcare systems, using
the case of the Netherlands as an example. Such institutional complexity can be seen
also in the Nordic countries, demonstrating the need for addressing the institutional
context of healthcare organisations and their power relations vis-à-vis external par-
ties, hospital boards and professionals’ organisations.
In Section II, we continue with raising macro-political issues of importance for
patient safety and quality, presenting three Danish research contributions. Kjær
Kristensen and Paaske Johnsen (Chapter 6) present an important overview of research
studying the impacts of centralisation efforts on quality of care and costs, addressing
the heavily debated volume–outcome relationship. Bartels, Mainz and Paaske Johnsen
(Chapter 7) describe experiences with the use of national clinical registries as an essen-
tial component of a well-functioning healthcare system. Engel and Boje Andersen
(Chapter 8) address the Danish strategy of using hospital accreditation as a means to
improve patient safety and quality, reflecting on the spread of control requirements
and a gap between perceived meaningful clinical quality and the control requirements.
In Section III, we concentrate on regional and organisational meso-level issues,
presenting three contributions covering regional networks, co-ordination issues and
management issues. Tervo-Heikkinen, Äijö and Holopainen (Chapter 9) describe the
importance of establishing a multidisciplinary and multi-actor network for falls pre-
vention in a Finnish region. Nedreskår and Storm (Chapter 10) study the hands-on
effects of a national reform on cross-level co-ordination of discharge practices for
elderly, documenting changes in management continuity, informational continuity and
relational continuity. Bergerød and Wiig (Chapter 11) address how leadership along
with organisational and cultural factors strongly influences patient safety and quality
improvement work in two Norwegian hospital settings, stating how managers and their
organisations have different responses dependent on their contextual setting.
In Section IV, we address a selection of micro-level issues pertaining to work sys-
tems and clinical practice. Guise, Husebø, Storm, Moltu and Wiig (Chapter 12) explore
healthcare professionals’ perspectives on patient safety and quality implications of
implementing virtual home healthcare visits, indicating that positive implications are
related to current Norwegian healthcare policy. Ekstedt (Chapter 13) describes how
xxvi Introduction

cognitive strategies are used by professionals in specialised home care settings to

manage problem-solving and decision-making in everyday clinical work, using sen-
semaking theory to contribute to this understanding. Kivekäs, Haatainen, Koiki and
Saranto (Chapter 14) address the issue of local variability using the case of intravenous
medication errors with infusion pumps in different hospital settings.

Karina Aase
Lene Schibevaag

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Disability. Washington, DC: National Academy Press.
Dutch Safety Board (2008). Een onvolledig bestuurlijk proces: Hartchirurgie in UMC
St Radbound. Rapport Onderzoeksraad voor Veiligheid. Den Haag, April 2008.
Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry:
Executive Summary. London, U.K.: The Stationery Office: Mid Staffordshire NHS
Foundation Trust Public Inquiry.
Hallberg, L.H. (2000). Patients rights in the Nordic countries. European Journal of Health
Law, 7: 123–143.
Iedema, R. (2009). New approaches to researching patient safety. Social Science & Medicine,
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IOM. (2000). To Err Is Human: Building a Safer Health System. Washington, DC: National
Academy Press.
Jha, A.K., Prasopa-Plaizier, N., Larizgoitia, I., Bates, D.W., on behalf of the Research Priority
Setting Working Group of the WHO World Alliance for Patient Safety. (2010). Patient safety
research: An overview of global evidence. Quality and Safety in Health Care, 19: 42–47.
Karlsen, J.E. and Lindøe, P. (2006). The Nordic OSH model at a turning point? Policy and
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Wiig, S., Aase, K., Plessen, C., Burnett, S. et al. (2014). Talking about quality: Exploring how
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Organization, Geneva, Switzerland.
 1 Status of Nordic Research
on Patient Safety and
Quality of Care
Sissel Eikeland Husebø, Siri Wiig, Veslemøy Guise,
Marianne Storm and Britt Sætre Hansen

CONTENTS
Introduction................................................................................................................. 2
Background.................................................................................................................2
Aim and Research Questions......................................................................................2
The Nordic Region: What Is It?.................................................................................. 2
Nordic Co-operation to Promote Patient Safety and Quality...................................... 3
Methods.......................................................................................................................4
Design....................................................................................................................4
Search Methods......................................................................................................4
Review Process......................................................................................................5
Analytical Framework............................................................................................ 6
Results.........................................................................................................................7
Phase 1: Distribution between Countries, Theoretical, Empirical
and Methodological Contributions......................................................................... 7
Phase 2: Current Domains of Patient Safety and Quality Research
in the Nordic Setting..............................................................................................8
Domain 1 – Evaluating Progress in Patient Safety (48 Studies)............................ 9
Domain 2 – Translating Evidence into Practice (58 Studies).............................. 11
Domain 3 – Assessing and Improving Culture (18 Studies)................................ 12
Domain 4 – Identifying and Mitigating Hazards (31 Studies)............................. 13
Domain 5 – Evaluating the Association between Organisational
Characteristics and Outcomes (8 Studies)........................................................... 14
Discussion................................................................................................................. 14
Conclusion................................................................................................................ 15
Acknowledgements................................................................................................... 16
References................................................................................................................. 16

1
2 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

INTRODUCTION
This chapter provides an overview of the Nordic research on patient safety and qual-
ity based on a review of the literature. Evidence is summarised and synthesised to
provide suggestions for a possible future Nordic research agenda.

BACKGROUND
In an international context, large-scale system failures such as the Bristol Royal
Infirmary Inquiry (Kennedy, 2001, Kohn et al., 2000), the Mid Staffordshire Public
Inquiry (Francis, 2013) and investigation of critical incidents in Dutch hospitals
(Behr et al., 2015) have put patient safety on the agenda (Martin and Dixon-Woods,
2014). In all cases, large numbers of patients died or suffered due to insufficient
care or malpractice over time and this practice was able to continue despite regula-
tory systems and inspectorates being in place to detect such failures (Weick and
Sutcliffe, 2003). Compared to the Nordic countries, there have not been any system
failures of a similar scale. Denmark, Finland and Sweden have specific patient safety
laws, while Norway has incorporated patient safety and quality dimensions into sev-
eral laws and regulations. Quality improvement strategies have been in place in the
majority of the Nordic countries over several decades (since 1995 in Norway, 1990 in
Sweden, 1975 in Denmark and 1994 in Finland). Iceland has a national quality devel-
opment plan for the health services aiming at enhancing patient safety and quality
and in 2007 the authorities published the first policy on quality in healthcare services
(Sigurgeirsdóttir et al., 2014). The progress of patient safety and quality research in
the Nordic countries has been more sporadic and fragmented, and to date, a limited
overview exists.
To our knowledge, the Nordic research literature on patient safety and quality has
not been reviewed earlier, and it is therefore worth undertaking further investigation
to suggest a future Nordic research agenda in the Nordic countries.

AIM AND RESEARCH QUESTIONS

The aim of the current literature review is to provide an overview of the Nordic
research literature on patient safety and quality in healthcare and to suggest direc-
tions for a future research agenda.
The review questions addressed are as follows:

1. What is the current research on patient safety and quality in healthcare?

2. Which empirical fields and research methods have been addressed?
3. Which domains of patient safety and quality can be identified?

THE NORDIC REGION: WHAT IS IT?

The Nordic region consists of the countries Denmark, Finland, Sweden, Iceland,
Norway and the self-governed areas of the Faroe Islands, Greenland and Åland.
The total population in the Nordic region is around 26 million inhabitants (Table 1.1).
Status of Nordic Research on Patient Safety and Quality of Care 3

TABLE 1.1
Population Based on Numbers from OECD (2013) and www.norden.org
and Health Expenditure in the Nordic Countries
Population in 2011 (OECD, Health Expenditure per Health Expenditure as
Country 2013) (in thousands) Capita 2011 (USD) Share of GDP (%)
Norway 4.952 5669 9.3
Denmark 5.571 4448 10.9
Finland 5.388 3374 9.0
Iceland 319 3305 9.0
Sweden 9.447 3925 9.0

Source: OECD, Health at a Glance 2013: OECD Indicators, OECD Publishing, 2013. http://dx.doi.
org/10.1787/health_glance-2013-en.

The region as a whole is sparsely populated, with the exception of Denmark

(www.norden.org). The health expenditure figures for all five countries in the region
are shown in Table 1.1 (OECD, 2013).

NORDIC CO-OPERATION TO PROMOTE

PATIENT SAFETY AND QUALITY
The Nordic region has established a cross-country co-operation within health and
social affairs. The co-operation falls under the responsibility of the Nordic Council
of Ministers on Health and Social Affairs. The Nordic collaboration is anchored
politically, financially and culturally and is an important player in a European and
international context. The co-operation is based on the shared set of Nordic values,
which constitutes the basis for the Nordic welfare model (Norden, 2013). The tradi-
tional image of the Nordic model is of a welfare state characterised by a large public
sector that provides its citizens with generous benefits, welfare services and a social
safety net (Norden, 2014). The welfare state is supported by the principles of equal
opportunities and social solidarity and security for all inhabitants, regardless of gen-
der, ethnicity, faith, belief, disability, age and sexual orientation. The welfare model
promotes social rights and equal access to social and healthcare services, education
and culture. This also applies to care of those who are part of socially disadvantaged
and vulnerable groups in society (Norden, 2013, p. 65).
A common Nordic strategy on health and social affairs has been developed
(Norden, 2013). The strategy includes the specific goal of improving patient safety
and quality of health and social services. The strategy emphasises the common chal-
lenge of an ageing population with an increased need for care and advocates for
experience and knowledge exchange to ensure quality.
During the past years, most hospital services in the Nordic countries have under-
gone centralisation processes based on a rationale of the relationship between
organising, volume and quality of treatment. The strategy also focuses on Nordic
co-operation to promote patient safety. Due to their size, the Nordic countries should
4 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

work closer in clinical multi-centre studies to evaluate the effectiveness and safety
of new diagnostic methods and treatment. The development and use of new technol-
ogy and e-health is also a prioritised area (Norden, 2013). User involvement and
patient perspectives are furthermore a critical part of the Nordic strategy to achieve
high-quality care, and patient experiences are regularly followed up by collecting
standardised national patient surveys in specialist healthcare settings (Anell et al.,
2012; Holmboe et al., 2014). The extent to which these data are used to guide quality
improvement and research in the clinical setting is however not clear.

METHODS
Design
An integrative systematic review methodology was used (Burns et  al., 2011,
pp. 418–463). This involves a multi-stage strategy that includes problem identification,
literature search, data evaluation, data analysis and presentation (Whittemore and
Knafl, 2005). The chosen approach was considered appropriate to allow for inclusion
of studies with diverse methodologies and provide a fuller understanding of current
research in the Nordic countries (Whittemore and Knafl, 2005). To minimise bias in
the review process, a review protocol was developed, and a systematic search in line
with Lefebvre et al. (2011) was undertaken.

Search Methods
Two of the authors (VG and SEH) searched the following five online databases
in the period 1 June to 31 July 2014: Cinahl, ASP, Medline, Scopus and PubMed.
The databases were chosen for their comprehensive collection of peer-reviewed
academic journals in the area of patient safety and quality of care. The search
was conducted using a combination of the following terms: patient safety, quality,
quality improvement, Nordic, Norway, Sweden, Denmark, Finland and health-
care. Table 1.2 displays the databases, search terms, combinations and number
of hits.
The search was limited to information available in the title, abstract and key-
words. Items had to feature empirical data material from at least one of the Nordic
countries to be included. Quality assessment was not undertaken, and therefore,
no  items were excluded based on the assessment of the methods, study design or
outcomes. Further inclusion and exclusion criteria were as follows:

• Language: abstracts in English, Norwegian, Danish, Swedish or Finnish

were included.
• Date: only studies published between 2000 and 2014 were included.
• Clinical setting: studies from both primary and specialised healthcare ser-
vices were included.
• Abstracts from study protocols, PhD theses and research conferences were
excluded.
Status of Nordic Research on Patient Safety and Quality of Care 5

TABLE 1.2
Search in Databases, Terms and Hits
Databases Terms and Combinations Hits
Cinahl Patient safety 10,409
ASP Patient safety 52,249
Medline Patient safety 47,529
Scopus Patient safety 62,391
Pubmed Patient safety 14,166
Cinahl Quality/quality improvement 81,243
ASP Quality/quality improvement 403,075
Medline Quality/quality improvement 412,666
Scopus Quality/quality improvement 1,714,996
Pubmed Quality/quality improvement 57,114
Cinahl Healthcare 29,433
ASP Healthcare 48,446
Medline Healthcare 74,746
Scopus Healthcare 172,404
Pubmed Healthcare 85,062
Cinahl Nordic/Norway/Sweden/Denmark/Finland 8,945
ASP Nordic/Norway/Sweden/Denmark/Finland 57,168
Medline Nordic/Norway/Sweden/Denmark/Finland 4,705
Scopus Nordic/Norway/Sweden/Denmark/Finland 186,530
Pubmed Nordic/Norway/Sweden/Denmark/Finland 52,886
Cinahl Combined search 92
ASP Combined search 176
Medline Combined search 288
Scopus Combined search 984
Pubmed Combined search 303
Total number of hits 1,843
Duplicates removed 801
Excluded 8
The total number of hits screened 1,034

Review Process
A two-phased literature review process was conducted. In phase 1, we applied a
broad approach to answer review questions one and two. In phase 2, a framework for
patient safety research and improvement (Pronovost et al., 2009) was used to obtain
a deeper analysis of the included abstracts to answer review question three.
In phase 1, 1034 abstracts were divided among the five chapter authors and a team
of researchers from the ‘Quality and Safety in Healthcare Systems’ research group
at the University of Stavanger (see ‘Acknowledgement’ section). Each reviewer then
worked individually to include or exclude items according to information in the title,
abstract and keywords and the inclusion/exclusion criteria. During this process, the
6 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

reviewers excluded 844 of 1034 abstracts from the sample because they did not meet
the inclusion criteria. All reviewers used a data extraction tool to get a clear over-
view of the remaining 190 studies, while ensuring further consistency in the review
process. The data extraction tool covered the dimensions of (1) author, year of pub-
lication and country; (2) title; (3) theory used; (4) methods used; (5) empirical field;
(6) topics (limited to five keywords) and (7) any specific issues worth noting.
In phase 2, authors BSH and SEH closely assessed the remaining 190 abstracts.
Based on the inclusion criteria and the research questions, 27 additional abstracts
were removed during this process, which resulted in a sample of 163 abstracts
included for data extraction and further analysis according to a framework for patient
safety research and improvement (Pronovost et al., 2009).

Analytical Framework
Pronovost et al.’s (2009) ‘Framework for Patient Safety Research’ was used to clas-
sify the included abstracts. The framework includes five domains with associated
subdomains (see Table 1.3). The framework was developed to address many of the
issues emerging from a growing international desire for higher quality and safer

TABLE 1.3
Framework for Patient Safety Research
Domain and Subdomains Description
1.  Evaluating progress in patient safety Develop valid and feasible measures to
evaluate progress to improve patient safety
2.  Translating evidence into practice Develop and evaluate interventions that
A. Summarise the science increase the extent to which patients
B. Measure performance receive evidence-based medicine
C. Understand the current process and context of work
D. Ensure all patients reliably receive the
intervention and patient/next of kin experiences
3.  Assessing and improving culture Strategies and interventions to improve
A. What is safety culture? safety culture and communication
B. How do you measure safety culture?
C. How do you use safety culture results?
4.  Identifying and mitigating hazards Use of retrospective and prospective
A. Retrospective identification of hazards analyses to identify and mitigate safety
B. Prospective identification of hazards hazards at the microscopic level (unit or
C. Mitigating hazards department, in-depth evaluation) and
macroscopic (institutional, country) levels
5. Evaluating the association between organisational Evaluate organisational characteristics that
characteristics and outcomes help or hinder research efforts or patient
safety practices, for example the association
between staffing and patient outcomes.

Source: Pronovost, P. et al., Circulation, 119, 330, 2009.

Status of Nordic Research on Patient Safety and Quality of Care 7

healthcare and is based on the Institute of Medicine’s strategies for improvement

and literature regarding knowledge transfer and diffusion of innovation (IOM, 2001;
Pronovost et al., 2009; Stepnick and Findlay, 2003). Quality studies are included in
the framework, since the authors acknowledged that the boundaries between safety
and the broader concept of quality remain poorly defined (Pronovost et al., 2009).
We considered various analytical frameworks as Donabedian (2005) as others have
done (e.g. Jha et al., 2010). However, Pronovost et al.’s (2009) framework was chosen
because it provides more detailed information about the illuminated topics beyond.
Each abstract was read several times and coded, and then coding judgements
were discussed openly. Coding accuracy within each domain and subdomains was
done in line with Pronovost et al. (2009). In domains where subdomains were insuf-
ficiently described in Pronovost et  al. (2009), abstracts were coded based on the
two authors’ (BSH and SEH) own interpretation.

RESULTS
A main finding in this Nordic literature review is the large amount of abstracts
involving qualitative studies focusing on patient perspective, patient involvement,
and patients’ and next of kin’s experiences with healthcare services. Most of the
Nordic literature on patient safety and quality in healthcare published in peer-
reviewed journals comes from Sweden. The methodological approaches vary and
include a mix of quantitative and qualitative methods. There is an overweight of
literature from the specialised healthcare services, with much less attention on pri-
mary care services. The included abstracts cover all domains in the Framework for
Patient Safety Research (Pronovost et al., 2009), with most abstracts (58) belonging
in domain 2 – Translating evidence into practice, while fewest abstracts (8) were
allotted to domain 5 – Evaluating the association between organisational character-
istics and outcomes. In the remainder of the results section, we present the detailed
findings of the two-phased review process.

Phase 1: Distribution between Countries, Theoretical,

Empirical and Methodological Contributions
The distribution of abstracts between countries is as follows: Norway, 35; Denmark, 33;
Sweden, 77 and Finland, 18. Only 8 of the 163 included items mention the use of theory
in the abstract, including implementation theory and models for understanding success
in quality improvement, organisational learning, indicators, guidelines and standardisa-
tion. Empirical fields are summarised in Table 1.4 according to specialised healthcare,
primary healthcare, a mix of primary and specialised healthcare and others.
The amount of abstracts in the ‘other’ category is high. Several abstracts were dif-
ficult to review with regard to empirical field. The ‘other’ category includes studies
focusing on data from national registries, evaluation of guidelines, reviews, indica-
tors, waiting lists, presentation of national projects, reimbursement and several stud-
ies stating ‘healthcare’ as empirical setting.
Abstracts from the specialised healthcare services involve in-hospital, pre-­
hospital, maternity, intensive and emergency care and education and training of
8 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

TABLE 1.4
Empirical Fields Covered in the Nordic Patient Safety
and Quality Literature
Empirical Field Distribution of Abstracts
Primary healthcare 30
Specialised healthcare 72
Primary and specialised healthcare 7
Other 54

TABLE 1.5
Methodological Approaches Used in Nordic Patient
Safety and Quality Literature
Methodological Approach Distribution of Abstracts
Qualitative 53
Quantitative 88
Mixed 7
Review 8
Not stated 7

health professionals. Abstracts from primary care setting cover nursing homes, home
healthcare services, general practitioner services and dental care in nursing homes.
The assessment of methodological approaches indicates a big variety of qualita-
tive, quantitative and mixed methods being used (see Table 1.5). The qualitative
methods include case studies, semi-structured interviews, focus group interviews,
observation studies, action research, studies of root cause analyses, retrospective
patient record reviews and document analysis.
The quantitative methods include surveys and questionnaires, randomised con-
trolled trials, national registries studies, evaluation of guidelines, pre-test and post-
test measurement, cohort studies and prospective cohort studies.
Among the included abstracts are eight literature reviews. Topics here cover
impact of work culture on quality in nursing homes, oral hygiene in elderly people
in hospitals and nursing homes, an automated dose dispensing service for primary
healthcare patients, a road map for patient safety research approaches, costs of
patient safety and quality in healthcare, research on quality improvement and qual-
ity evaluation and indicators and quality data based on national clinical databases.

Phase 2: Current Domains of Patient Safety and Quality

Research in the Nordic Setting
We found that the largest proportion of abstracts (58) cover domain 2 – Translating
evidence into practice, including 38 abstracts on patient/next of kin experiences,
Status of Nordic Research on Patient Safety and Quality of Care 9

followed by domain 1 – Evaluating progress in patient safety (48), domain 4 –

Identifying and mitigating hazards (31), domain 3 – Assessing and improving culture
(18) and domain 5 – Evaluating the association between organisational characteris-
tics and outcomes (8) (Pronovost et al., 2009) (see Table 1.6). A list of the 163 journal
articles coded and analysed in the review appears as Appendix A.

Domain 1 – Evaluating Progress in Patient Safety (48 Studies)

Most of the abstracts evaluating progress in patient safety focus on the development
and testing of patient safety and quality measurements and indicators and factors
that influence patient safety and patient outcomes. A few abstracts are concerned
with the monitoring of healthcare-associated infections, and a few deal with the
development of theory, models and methods.
Development and testing of measurements and indicators (21 studies). Several
studies report development and testing of a variety of measurements, such as health
information and communication technology (ICT) (Adler-Milstein et al., 2014), pro-
cess and outcome improvements in healthcare (Andersson et al., 2013), a reporting
system for patient safety incidents (Bjørn et  al., 2009), risk assessment concern-
ing pressure ulcers (Fossum et  al., 2012), patient participation in the Emergency
Department (Frank et  al., 2011), Global Trigger Tool (Mattsson et  al., 2013;
Schildmeijer et al., 2012), the Nordic Patient Experiences Questionnaires (Oltedal
et al., 2007; Skudal et al., 2012), a cross-cultural measure to assess parents’ satisfac-
tion with care of children with chronic conditions (Schmidt et al., 2008) and a retro-
spective record review of no-harm incidents to improve patient safety (Schildmeijer
et al., 2013). Development and testing of indicators and checklists comprise patient
safety indicators, checklist for outpatient surgery (Helmiö et al., 2012), best practice
in the delivery of healthcare to immigrants (Jensen et al., 2010), clinical indicators
and standards in an outpatients’ department for sub-acute low back pain patients
(Johansen et al., 2004), patient-centred healthcare quality indicators for rheumatoid
arthritis (Petersson et  al., 2014), evidence-based national indicators (Wettermark
et al., 2006b), patient-specific quality indicators and quality evaluation and indica-
tors for tonsillectomy (Sjøhart Lund et al., 2010).
Factors that influence patient safety and patient outcomes (20 studies). Studies on
influencing factors include, for example, physician’s self-evaluation of the consultation
(Ahlén and Gunnarsson, 2013), home healthcare nurses awareness of fall prevention in
clinical practice (Berland et al., 2012) and that the selection of older patients eligible for
a surgical treatment is likely to be based on the health status and the safety of surgical
procedures rather than chronological age (Oksuzyan et al., 2013).
Studies on quality improvement methods are common and positive changes
are reported concerning clinical guidelines and communication methods such as
Situation – Background – Assessment – Recommendation (Wallin and Thor, 2008).
A few studies emphasise using ICT as a tool to improve patient safety in health-
care. The studies demonstrate a demand for a common exchange format, a need
for ICT tools for documenting clinical contents, significant gaps in design, imple-
mentation and use of ICT in healthcare to ensure patient safety and that a change
from paper forms to electronic laboratory requests by general practitioners show
10 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

TABLE 1.6
Domains and Subdomains Covered in the Nordic Patient Safety and
Quality Literature
No. of
Domains and Subdomains Studies Study ID
1. Evaluating progress in patient 48 3,6,11,13,14,16,17,20,27,32,35,37,44,48,49,50,
safety 53,62,64,65,72,75,80,81,86,88,91,94,98,111,112,
113,119,121,124,127,131,134,135,140,145,150,
151,153,159,160,161,162
A. Summarise the science 1 13
B. Development and testing of 21 3,11,20,32,35,37,48,62,64,75,88,94,98,111,112,114,
measurements and indicators 119, 121,140,150,161
C. Factors that influence patient 20 6,14,16,17,27,49,65,72,80,81,86,91,113,131,135,145,
safety and patient outcome 151,153,159,160
D. Monitoring healthcare- 3 44,127,134
associated infections
E. Development of theory, 3 50,53,162
models and methods
2. Translating evidence into 58 2,5,10,19,22,23,26,30,31,36,37,39,40,41,42,43,
practice 55,57,59,60,63, 66,69,71,73,74,77,84,87,89,93,
99,102,103,104,105,107,108,110,117,118,120,
122,128,130,132,133,137,141,142,143,146,147,
149,154,156,157,163
A. Summarise the science 1 117
B. Measure performance 2 99,110
C. Understand the current 17 22,23,30,31,57,60,63,71,73,102,103,107,143,146,147,
process and context of work 149,163
D. Ensure all patients reliably 38 2,5,10,19,26,36,38,39,40,41,42,43,55,59,66,69,74,77,
receive the intervention and 84,87,89,93,104,105,108,118,120,122,128,130,132,
patient/next of kin experiences 133,137,141,142,154,156,157
3. Assessing and improving culture 18 1,28,34,47,54,61,68,82,92,90,96,97,
115,123,124,129,136,144
A. Theory and measurement 2 47,54
development
B. Mapping patient safety culture 4 1,61,92,97
C. Factors that influence 12 28,34,68,82,90,96,115,123,124,129,136,144
communication
4. Identifying and mitigating 31 8,9,15,18,21,24,25,45,46,52,56,58,67,70,76,78,79,
hazards 83,85,95,100,101,106,109,116,125,126,138,139,
152,158
A. Medical hazards 21 8,9,18,21,24,25,52,70,78,83,85,95,100,101,106,109,
116,125,138,139,158
B. Medication hazards 10 15,45,46,56,58,67,76,79,126,152
5. Evaluating the association 8 4,7,12,29,33,51,148,155
between organisational
characteristics and outcomes
Status of Nordic Research on Patient Safety and Quality of Care 11

positive effects on reducing errors and costs (Bernstein et al., 2006; Johansen and
Rasmussen, 2009; Kuusela et al., 2011).
Only one study used risk analysis to develop and manage routines for reducing
the risks of an ICT tool and found a reduction in risk due to technology and equip-
ment and in the area of training and competence (Öhrn and Eriksson, 2007). Studies
in medication procedures report a need for improved communication and informa-
tion in primary care (Bakken et  al., 2007), whereas variation between the differ-
ent primary care centres with regard to the prescribing doctors’ compliance with
guidelines from the regional drug and therapeutics committee was found to be great
(Wettermark et  al., 2006a). The utilisation of drugs was difficult to forecast due
to uncertainties about the rate of adoption of new medicines and various ongoing
healthcare reforms and activities to improve the quality and efficiency of prescribing
(Wettermark et al., 2010).
Monitoring healthcare-associated infections (3 studies). Only a handful of studies
examine, for example, healthcare-associated infections (Hajdu et al., 2011; Struwe
et al., 2006; Thorstad et al., 2011).
Development of theory, models and methods (3 studies). This subdomain com-
prises only three studies focusing on the development of theory and methods (Hofoss
and Deilkås, 2008; Hovlid and Bukve, 2014; Øvretveit, 2002).

Domain 2 – Translating Evidence into Practice (58 Studies)

The studies included in the domain of translating evidence into practice are var-
ied in setting and perspective. Most studies highlight experiences and perceptions
of healthcare services from patients and next of kin. Many other studies focus on
healthcare workers’ perspectives on safety and quality issues.
Ensure all patients reliably receive the intervention (38 studies). This subdo-
main has the largest amount of studies included. The studies focus, for example,
on the effects of an educational programme for heart failure patients (Agvall et al.,
2013), the need for improvement in adherence to guidelines for medication in long
term and asthma treatments for children (Ingemansson et al., 2012), how imple-
mentation of ICT can influence documentation practice regarding pressure ulcers
and malnutrition in nursing homes and hospitals (Fossum et al., 2013; Gunningberg
et  al., 2009) and examination of nurses’ knowledge and knowledge gaps on the
prevention and treatment of pressure ulcers (Källman and Suserud, 2009). Several
intervention programmes are examined, such as one on patient rehabilitation
(Frølich et al., 2010), another on follow-up of older patients after discharge (Rytter
et  al., 2010), a multi-professional teamwork programme in primary care (Sipilä
et  al., 2008) and a quality improvement programme which demonstrates better
patient outcomes (Thor et al., 2010).
The studies dealing with evaluation, experience and perception of health-
care services from the patients and next of kin perspective contribute to extensive
knowledge in this subdomain. The studies reveal ambiguous findings concerning
experiences and preferences of care and treatment. On the one hand, some stud-
ies feature h­ ospitalised patients expressing satisfaction with involvement and par-
ticipation in decision-making and the quality of care and treatment (Browall et al.,
12 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

2013; Skarstein et al., 2002). On the other hand, shortcomings in meeting patients’
needs and expectations, in undertaking patient-centred care, and in patient involve-
ment in patient safety are reported in other studies (Bjorkman and Malterud, 2009;
Kaakinen et al., 2013; Wolf et al., 2012). One study also noted ambiguous results
regarding whether or not communication training programmes for healthcare profes-
sionals influence patient outcomes (Nørgaard et al., 2012).
Several studies reporting quality evaluations from parents and relatives reveal
shortcomings in paediatric care and patient transfer within hospitals and mental
health care, but there are also reports of satisfaction with the quality of maternity
care as evaluated by immigrant parents (Ammentorp et al., 2001; Häggström et al.,
2014; Johansson et al., 2014; Ranji et al., 2012).
Understand the current process and context of work (17 studies). This subdo-
main incorporates results regarding the perceptions, experiences and responses of
nurses and physicians regarding ‘good’ patient care, patient education and medi-
cal treatment, prerequisites for implementing evidence-based practice and factors
promoting quality improvement. Prerequisites for the implementation of guidelines
in fast-track surgery and standardised care plans are involvement of nurses in the
process and use of a workshop-practice method (Jakobsen et  al., 2014; Jakobsson
and Wann-Hansson, 2013). Implementation and effects of ICT reveal differences in
nurses’ and doctors’ reporting versus improvement of outpatient referral and cost
efficacy (Rahimi et al., 2008, 2009).
Summarise the science (1 study) which is a literature review showing that patients
using an automated dose dispensing service had more inappropriate drugs in their
regimens (Sinnemäki et al., 2013).
Measure performance (2 studies). In this subdomain, we included only two stud-
ies, one regarding which method has the best effect on cardiopulmonary resuscita-
tion outcomes (Putzer et al., 2013) and one if a specialised cancer centre can achieve
good local control on patients with inadequate surgery (Sampo et al., 2012).

Domain 3 – Assessing and Improving Culture (18 Studies)

In the domain of assessing and improving culture, we include studies assessing
safety culture or examinations of factors that influence communication.
Theory and measurement development for assessing safety culture (2 studies).
This subdomain comprises only two studies focusing on theory development (Hovlid
et al., 2012) and psychometric properties of the ‘Hospital Survey on Patient Safety
Culture’ measurement tool (Hedsköld et al., 2013).
Mapping patient safety culture (4 studies). Two studies mapping patient safety cul-
ture (Aase et al., 2008; Olsen and Aase, 2010) were included. The other two included
studies give insights into patients’ views on adverse events and older patients’ per-
spectives on medical approaches (Itoh et al., 2006; Pedersen et al., 2008).
Factors that influence communication (12 studies). In this subdomain, the
included studies deal with a variety of factors that influence communication between
healthcare providers and patients. Listening to the patient views through a structured
computer-facilitated patient–clinician dialogue focuses treatment sessions and has a
positive effect on patients’ quality of life, need for care, and treatment satisfaction
Status of Nordic Research on Patient Safety and Quality of Care 13

(Bylund, 2008), using patients’ knowledge may improve education materials pro-
vided to patients undergoing colorectal cancer surgery (Smith et al., 2014) and using
cognitive artefact analysis improve patient handovers between hospital and com-
munity care (Johnson et al., 2013). In primary care settings, factors that influence
communication include hospital information to patients with a need for follow-up by
general practitioners (Vægter et al., 2012).

Domain 4 – Identifying and Mitigating Hazards (31 Studies)

In this domain, most of the included studies identify adverse events, medication
errors and mortality rates in the hospital setting.
Medical hazards (21 studies). Several of the studies identify adverse events
(complications and infections) and mortality in the hospital setting. These include
post-operative complications after, for example, incontinence and urinary stress
incontinence surgery (Ammendrup et al., 2009a,b), in conjunction with temporary
pacemaker treatment (Bjørnstad et  al., 2012), vascular surgery (Brattheim et  al.,
2011), orthopaedic care (Unbeck et al., 2010), cancer treatment and care (Lipczak
et al., 2011) and intracranial tumour operations (Solheim et al., 2012). Communication
failure between staff members is another important contributing factor of severe
patient safety incidents (Rabøl et  al., 2011). For orthopaedic patients, many more
adverse events are detected using the Wimmera model with manual screening than
in other traditional local and nationwide reporting systems (Unbeck et  al., 2008).
Patients dying of heart disease compared to those dying from cancer were found to
have received lower quality of care (Brännström et al., 2012). In emergency depart-
ments, adverse events were mainly found to be related to overcrowdings, lack of beds
on wards and intensive care units, technical problems, diagnostic procedures and
treatments (Khorram-Manesh et al., 2009). In Danish mental healthcare, psychiatric
patients were found to receive a lower quality of somatic care (Steinø et al., 2013).
In telenursing, threats to patient safety were related to the surrounding society,
organisation of telenursing, the telenursing practice and the caller (Röing et  al.,
2013). In primary care, the presence of subjective memory complaints for older peo-
ple was not significantly associated with an increase in all-cause mortality (Siersma
et al., 2013).
Medication hazards (10 studies). Several included studies report medication
errors and factors that influence such errors. Studies from the hospital setting reveal
that interruption during the preparation of medication increases the risk for errors
(Berg et al., 2013; Härkänen et al., 2013), the same applies to the high number of
generic drugs and frequent generic substitutions in use (Håkonsen et  al., 2010).
In one study, 20% of drug users reported adverse drug events during the previous
month (Hakkarainen et al., 2013). Interventions such as repeated adverse drug reac-
tions information letters to physicians and nurses did not increase the reporting
rate of adverse drug events (Johansson et al., 2011). Similarly, the use of electronic
patient record systems and tools did not change work processes related to medication
procedure and information management to a safer procedure (Kivekäs et al., 2014).
In primary care, gross variations in general practitioners’ practice exist regarding
medication treatment (Kristoffersen et al., 2006).
14 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

Domain 5 – Evaluating the Association between Organisational

Characteristics and Outcomes (8 Studies)
Only a handful of studies examine the association between organisational character-
istics and outcomes, and the themes and findings of this domain diverge in several
directions. For example, included studies in specialised healthcare settings report
that specially educated healthcare staff may contribute to good quality diabetes care
(Adolfsson et al., 2010), identify important factors related to the assessment of patient
safety (Alenius et al., 2014), report associations between work culture and quality of
care (André et al., 2013), note a discrepancy between the actual complaint rate of
patients’ complaints of adverse events and the number of respondents stating that
they have had reasons to complain (Wessel et al., 2012), discuss how waiting lists or
queues could be reduced (Eriksson et al., 2011) and demonstrate that healthcare poli-
cymakers and hospital leaders have to design and implement strategies to help their
staff members recognise and value the contribution that patient involvement and
patient experiences can make to the improvement of healthcare (Wiig et al., 2013).
In primary care, studies highlight delegation to unlicensed personnel as prereq-
uisites for a functioning organisation involving a number of contradictions such as
nurses lack of control, powerlessness, vagueness regarding responsibility and resig-
nation (Bystedt et al., 2011) and note that district nurses are an underused resource
regarding their work situation after the free-choice system in primary care (Hollman
et al., 2014).

DISCUSSION
The aim of this review was to provide a status of the Nordic patient safety and quality
research literature and to suggest directions for a future research agenda. We found
that the main strength of the Nordic literature on patient safety and quality is the
amount of studies of patients’ and next of kin’s perspectives (including experience,
preferences and evaluations) on healthcare services. These findings do however reflect
some ambiguous results regarding perceptions and experiences of meeting patients’
needs and expectations, patient-centred care and patient involvement. This implies a
need for rigorous multisite evaluations of the implementations of patient-centred care
and patient involvement in the Nordic countries. One explanation for this feature of
the Nordic research may be found in the Nordic healthcare model, characterised by
short distances within healthcare systems hierarchies, and based on an ethos of strong
patient rights and equality of healthcare services (Norden, 2013, 2014).
Among the Nordic countries, Sweden stands out with the largest proportion of
studies, especially concerning large studies of patient registry data on, for exam-
ple mortality rates in psychiatric healthcare and hospital-related adverse events
(Björkenstam et al., 2012; Khorram-Manesh et al., 2009). The results from these two
studies (Björkenstam et al., 2012; Khorram-Manesh et al., 2009) may give directions
for future targeted interventions to decrease mortality rates in psychiatric healthcare
and adverse events in hospitals in Sweden and across the Nordic countries.
Finnish researchers have done considerable work in identifying and mitigating
medication risk in the hospital setting, indicating a need for the implementation of
Status of Nordic Research on Patient Safety and Quality of Care 15

interventions to prevent and mitigate such errors. Several of the included studies
have developed and tested measurements and indicators in a Nordic context. Such
specific measures are needed to provide a sufficiently broad view on patient safety
and quality and are a prerequisite to move the science forward (Pronovost et  al.,
2009). Consequently, research in this domain should continue.
Based on the reviewed abstracts, the three largest shortcomings in Nordic stud-
ies relate (1) performance measurement (process or outcome) in the healthcare set-
ting, (2) assessing and improving safety culture and (3) evaluating the association
between organisational characteristics and outcomes. To close these gaps, the Nordic
countries have to continue to keep creating capacity in terms of organisational and
cultural factors and methods to assess and measure performance in patient safety
and quality research. Moreover, there is a need to create a research infrastructure
between the Nordic countries and to evaluate the cost–benefit ratio of improvement
efforts and interventions in line with suggestions from Pronovost et al. (2009) focus-
ing on a much closer collaboration between researchers and hospital leaders.
There are no studies involving cross-country comparisons of patient safety and
quality in the Nordic countries (Appendix A). This stands out as an important area
for future research and corresponds well to the Nordic strategy on the health and
social sector, emphasising the need for cross-country research within the Nordic
countries in the years to come (Norden, 2013).
Another gap identified is the small amount of research abstract from the primary
care setting or a combination of the specialised and primary care settings. The lack
of patient safety research from a primary care perspective mirrors findings from the
international literature (Pearson and Aromataris, 2009), adding emphasis to impor-
tance of knowledge in this area. Furthermore, only one identified study focuses on
intervention sustainability, implying more attention to longitudinal studies in patient
safety and quality both within and across the Nordic countries.
The review has several limitations that need to be addressed. The possibility of
excluding relevant studies due to too broad or too narrow a search strategy (e.g. terms
and databases used) is a potential threat to the study’s validity. Data extraction was
based only on the reading of abstracts, and neither quality appraisal nor hand searches
in reference lists were not performed, which might also represent a threat to the
­validity of the review. In addition, the classifying of the included studies in phase 2
was done by only two of the authors, representing a risk of potential bias. A possible
strength with the review is that the analyses identified several new subdomains in
the patient safety framework of Pronovost et al. (2009). The review has also provided
a broad overview of the patient safety and quality research in the Nordic countries.

CONCLUSION
The majority of the Nordic research on patient safety and quality relates to evaluat-
ing progress in patient safety, translating evidence into practice and identification of
hazards. The ‘patient’ voice in the Nordic research literature contributes with valu-
able knowledge to the international patient safety and quality research community
on how to further develop patient-centred healthcare services. Development and test-
ing of measurements and indicators for patient safety is important in the continuing
16 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

development of robust measures. The findings that identify and mitigate medical
hazards can be used to learn how to prevent risks and adverse events.
There is a lack of studies addressing assessing and improving culture and
evaluating the association between organisational characteristics and outcomes
indicating a need for future research to assess the influence of organisational and
cultural factors in patient safety and quality in the Nordic healthcare context. Our
suggestions for the direction of future patient safety and quality research in the
Nordic countries imply

• Rigorous multisite evaluations studies of implementations of patient-­

centred care initiatives and patient involvement strategies
• Large studies of patient registry data
• Identification and mitigation of medication-related risks studies
• Studies in primary care or a combination of specialised and primary care
settings
• Studies with cross-country comparisons of patient safety and quality
• Studies of measuring performance
• Studies measuring performance, assessment and improvement of patient
safety culture
• Evaluations of the association between organisational characteristics and
healthcare outcomes

ACKNOWLEDGEMENTS
At The Third Nordic Conference on Research in Patient Safety and Quality in
Healthcare – NSQH 2014, a pre-conference workshop was organised in Stavanger
with the topic ‘Nordic research on patient safety and quality in health care – status
and suggestions for future direction’. We want to acknowledge and thank the scientific
committee of the NSQH 2014 and the international group of experts for their contribu-
tion and valuable comments in the pre-conference workshop. Especially, we want to
thank Tanja Manser, Jeffrey Braithwaite and Angela Coulter. We also want to thank
members of the research group, Lene Schibevaag, Cecilie Haraldseid, Randi Nisja
Heskestad and Dagrunn Nåden Dyrstad, for their contribution in review phase 1.

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Section I
Perspectives on Patient Safety
and Quality in Healthcare
 2 Patient-Centred Care
in the Nordic Countries
Marianne Storm and Angela Coulter

CONTENTS
Quality through Patients’ Eyes................................................................................. 27
The Nordic Healthcare Setting.................................................................................. 29
Policies...................................................................................................................... 29
Patient Organisations................................................................................................ 30
Patient Rights............................................................................................................ 31
Patient Choice........................................................................................................... 32
Patient Information................................................................................................... 33
Patient Experience Surveys....................................................................................... 35
Complaints and Redress............................................................................................ 36
Current State of Play and Remaining Challenges..................................................... 36
Conclusion................................................................................................................ 39
References................................................................................................................. 39

This chapter looks at the quality of healthcare through patients’ eyes, focusing on
policies and practices in the Nordic countries (Norway, Denmark, Sweden and
Finland) aimed at ensuring that health services are responsive to the needs of the
people who use them. We describe some key concepts and outline the challenges
faced by those wanting to move health systems in a more patient-centred direction.

QUALITY THROUGH PATIENTS’ EYES

Paternalistic care models, based on assumptions that healthcare professionals know
what is in the best interest of their patients and can make decisions on their behalf with-
out involving them, are now being challenged (Coulter, 2011). Over the last 20 years,
there has been a shift from viewing patients as passive recipients of healthcare to con-
sidering them as active participants. This demands new types of relationships between
patients and health professionals that emphasise collaboration, information sharing
and involvement in treatment decisions (Ocloo and Fulop, 2012). The patient’s perspec-
tive is seen as a valuable source of knowledge about health and disease and measur-
ing their experiences and acting to tackle any problems identified as a central aim of
quality improvement programmes. The goal is to ensure that services are responsive to
patients’ experiences, needs and values (Institute of Medicine, 2001).
Patient-centredness is an overarching aim for improving the quality of healthcare
in many countries (Docteur and Coulter, 2012). The U.S. Institute of Medicine (IOM)

27
28 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

defines patient-centredness as care that is respectful and responsive to individuals’

­preferences, needs and values and ensures that patients’ own values guide clinical deci-
sions (IOM, 2001). The IOM report emphasises the importance of shared knowledge
between professionals and patients, patients’ rights to see their own medical information
and clinical records, transparency and access to information on system performance
for patients and their families. Co-ordination, continuity and effective team work are
key attributes of a patient-centred system. Opportunities for collective engagement and
involvement in health service development are also considered important for improving
service quality (Andreassen, 2005; Coulter, 2011; Crawford et al., 2003).
In reviewing the literature on patient-centred care, Mead and Bower (2000)
pointed to several distinctive elements: the incorporation of social and psychological
factors for understanding diseases and treatment effects; healthcare professionals
who see the person in the patient and are aware of the patient’s experiences and
feelings and shared responsibility between health professionals and patients, includ-
ing shared decision-making. These factors form the basis of a therapeutic alliance
where patients and professionals are expected to reach agreement on treatment goals
and management plans. There is encouraging evidence that education and training
of health professionals in patient-centred treatment and care can lead to improved
communications, greater satisfaction and more appropriate decision-making (Lewin
et al., 2009). Evidence shows that shared decision-making helps to increase patients’
knowledge, leading to greater confidence in their choices and more active participa-
tion in treatment (Duncan et al., 2010; Storm and Edwards, 2013). Reported barriers
to implementation of shared decision-making include perceptions of lack of time and
lack of fit with traditional clinical routines. Motivating health professionals is seen as
one key to success (Légaré et al., 2010).
High-quality care means acknowledging the perspectives of service users, their
experiences of and expectations of service provision (Andreassen, 2005). User
involvement goes beyond the individual patient’s influence on his or her own treat-
ment and care to encompass influencing the development and delivery of healthcare
services (Andreassen, 2005; Crawford et  al., 2003). For example, Crawford et  al.
(2003) list numerous methods adopted by mental health trusts in London to enhance
service users’ influence on service development: users are involved in staff appoint-
ments; they contribute to staff training programmes; they help to assess the quality
of services and they are involved in the governance of the organisations, attending
trust board meetings. They are also actively involved in designing, delivering and
disseminating health research, particularly in studies that aim to improve safety and
quality (Beresford, 2005; Smith et al., 2009).
Tritter (2009) proposed a framework for user involvement in health services
encompassing multiple objectives. His framework differentiates between five cat-
egories of involvement:

1. Decisions about treatment and care

2. Service development
3. Service evaluation
4. Education and training of health professionals
5. Research
Patient-Centred Care in the Nordic Countries 29

He draws a distinction between individual and collective involvement, contrasting

­situations when patients and users act on their own behalf to acting on behalf of groups
or populations. He also distinguishes between direct involvement where service users
have the power and authority to participate in decisions and indirect involvement where
users contribute information, but the decisions are made by health professionals. The
framework encompasses both reactive user involvement, where patients respond to a
predefined agenda, and proactive involvement, where service users shape the agenda
and set their own objectives. Direct proactive involvement is a key feature of experi-
enced based co-design where patient and professionals participate in a face-to-face
collaborative venture to co-design services (Bate and Robert, 2006).

THE NORDIC HEALTHCARE SETTING

Norway, Denmark, Sweden and Finland are parliamentary democracies operating at
three administrative levels: the state, the regions and the municipalities. The com-
mon view in these Nordic countries is that citizens in a democracy should not only
be governed but also have a right and a responsibility to take part in governing. Civil
rights are protected, ensuring that the law applies equally to all members of the
community, including the right to vote and to access health and welfare (Eriksen and
Weigård, 1993). The welfare states in the Nordic countries are underpinned by the
principles of equal opportunities, social solidarity and security for all people regard-
less of characteristics such as gender, age, ethnicity, sexual orientation or religion
(Eriksen and Weigård, 1993; Nordisk Ministerråd, 2013).
We will now describe the ways in which Nordic policymakers are attempting to
move healthcare systems towards greater patient-centredness by involving patient
organisations; promoting patient rights and encouraging patient choice, patient infor-
mation and patient feedback.

POLICIES
Improving quality and safety in the health, welfare and social services is a politi-
cal priority for the Nordic co-operation on social affairs and health (Nordisk
Ministerråd, 2013). The main emphasis is on ensuring that health, care and welfare
services are effective, safe, co-ordinated, involving service users and being respon-
sive to their needs.
Strengthening the patients’ role in healthcare services has been a government pri-
ority in Norway for two decades (Norwegian Directorate of Health, 2005; Norwegian
Ministry of Health and Care Services, 1996). In 2005, the Norwegian Directorate
of Health launched a strategy for quality improvement for the period 2005–2015. In
common with the IOM in the United States (IOM, 2001), the strategy defines health-
care quality as that which is effective, safe, patient-centred, co-ordinated, resource
effective and accessible (Deilkås et  al., 2015; Norwegian Directorate of Health,
2005). Norway launched its first national patient safety campaign in 2011, and the
first report to Parliament on quality and safety in healthcare was issued in 2012.
In Denmark, the Health and Medicine Authority published the first National
Strategy for Quality in 1993. The strategy addressed the responsibilities of leaders
30 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

and health professionals, and it was followed by a specific strategy on national

­quality registries. National surveys on patients’ experiences have been carried out
annually since 2000. Patient-centred care has only recently become an explicit goal
of Danish healthcare (Knudsen et al., 2015). In April 2015, the Danish Ministry of
Health launched the National Quality Programme for Health 2015–2018 with a par-
ticular emphasis on patient-centred care and involvement of patients and their next
of kin and training of professionals to facilitate a patient-centred approach (Danish
Ministry of Health, 2015).
In Sweden, reducing waiting time, increasing efficiency and patient choice have
been key priorities in national healthcare reforms (Øvretveit et al., 2015). In 2010, a
law was passed giving patients a choice of primary healthcare centre, and in 2011, an
Act setting out healthcare providers responsibilities for patient safety was introduced
(Øvretveit et al., 2015).
In January 2008, the Finnish government adopted a National Development Pro­
gramme for Social Welfare and Health Care. The central themes of the programme were
to reduce inequalities in health and welfare and increase the quality, effectiveness and
accessibility of health and social services. Strengthening the position of users (patient
empowerment) was an important goal (Vuorenkoski et al., 2008).

PATIENT ORGANISATIONS
Engaging citizens in health is considered important to increase public understanding
of health issues, to reduce health inequalities, to encourage democratic accountabil-
ity and to ensure that the health system is responsive to people’s needs and prefer-
ences (Coulter, 2011). Voluntary patient organisations are important channels for
public engagement. In each of the Nordic countries, there are a large number of
patient organisations, commonly formed around particular diseases or health prob-
lems. The organisations vary in size and in the extent to which they are profession-
ally run (Olejaz et al., 2012; Ringard et al., 2013; Winblad and Ringard, 2009). They
provide information, help and support to patients; they maintain dialogues with the
relevant health authorities, engage in service delivery and support research (Anell
et al., 2012; Olejaz et al., 2012; Toiviainen et al., 2010; Vuorenkoski et al., 2008). The
larger patient organisations in the Nordic countries aim to influence health policy
in various ways. They participate in parliamentary hearings and act as members of
publicly appointed boards and councils (Olejaz et al., 2012; Winblad and Ringard,
2009).
In Norway, patient groups have played an important role in setting the health
policy agenda ensuring that patients have the right to information about their health
status and the ability to participate in decisions about their care and treatment
(Andreassen, 2005). The Norwegian Federation of Organisations of Disabled People
(FFO) is an umbrella organisation with 80 member organisations for people with
­disabilities and chronic diseases representing about 335,000 members. Their main
goal is to improve living conditions and the fulfilment of human rights for all those
with disabilities and chronic diseases (FFO, 2016).
There are between 200 and 300 patient groups in Denmark. Many of these
groups have explicitly taken on policy advocacy, giving input into health debates and
Patient-Centred Care in the Nordic Countries 31

ensuring that patients’ views are not neglected (Olejaz et al., 2012). Danish Patients is
an umbrella organisation for 79 patient associations representing 870,000 members.
They aim to contribute to the development of a patient-focused healthcare ­system
through targeted efforts to ensure that patient involvement remains high on the polit-
ical agenda (Danish Patients, 2015).
According to Anell et al. (2012) there are more than 100 patient and consumer
organisations representing different patient groups in Sweden. The largest such
organisation is the Swedish Rheumatism Association with about 50,000 members.
Their primary goal is to support their members in their everyday efforts to cope with
their condition, educating policymakers, for example, on the importance of access
to rehabilitation and shorter waiting times for treatment (Swedish Rheumatism
Association, 2016).
In Finland, there are about 130 patient organisations, some of which are members
of national health and social welfare umbrella organisations (Toiviainen et al., 2010).
The Cancer Society of Finland is one of the largest umbrella groups with 12 pro-
vincial cancer associations and 6 national patient organisations among its members
(Cancer Society of Finland, 2016).

PATIENT RIGHTS
Health legislation complements and reinforces policies ensuring people equal
access to health and social services. Norway, Finland and Denmark have estab-
lished separate bills on patients’ rights. Common themes addressed include the
right to make informed decisions, the right to comprehensible information and
decisions made in partnership between clinician and patient (Danish Health Act,
2014; Norwegian Patient Rights Act, 1999; The Finnish Act on the Status and
Rights of Patients No. 785/1992). Information is necessary to access and bene-
fit from treatment, and its importance is recognised as a prerequisite for mak-
ing informed choices about treatment and to consent to treatment and healthcare
(Kjellevold, 2005).
In Norway, the Patient Rights Act, which came into force in 2001, ensures the
right to access healthcare, to receive information and to access personal health
records and a right to confidentiality, to consent to or decline treatment, to par-
ticipate in treatment decisions and to choose a hospital for treatment. Patients are
entitled to information about their rights, duties and practices and to professional
advice relevant to their individual needs. The right to participate in the implementa-
tion of healthcare is stated in the Patient Rights Act § 3-1. Participation is expected
to be adapted to the individual’s capacity. The Patients’ Rights Act also entitles those
with chronic or long-term conditions to an individual care plan. In Norway, patients
also have the right to have medical decisions reviewed and, if necessary, reversed
(Ringard et al., 2013).
In Denmark, an Act on Patient Rights was passed in 1998 focusing on rights
to information, to self-determination, to informed consent and to ensuring that
healthcare personnel respect patients’ dignity, integrity and autonomy. This
includes the right to access information about their health condition, test results,
treatment options and risks of complications, adapted to the individuals’ capacities
32 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

and needs. Rights to share information with family members, to access their per-
sonal health records and to confidentiality are also enshrined in a revised version
of the Act. This commits to easy and equal access to healthcare for all citizens
in Denmark, to choice of health provider and hospital, together with a waiting-
time guarantee to ensure prompt access to health services. Stated objectives also
include general requirements regarding high quality of care, continuity of care
(coherent and linked services) and transparency of the health system (ensuring
quality indicators on clinical performance becoming available on the Internet)
(Olejaz et al., 2012).
In Sweden, there is no specific law regulating patients’ rights. Instead, Sweden
uses multiple pieces of legislation to protect patients’ rights, such as choice of pro-
vider and treatment, the right to information about health, the right to privacy and to
access medical records and the right to a second opinion when suffering from a life-
threatening disease (Anell et al., 2012). These are incorporated in other legislation
and are formulated in policy agreements between the state and the county councils.
In 2011, Sweden enacted a new patient safety law, which aims to protect everyone
affected by healthcare, both patients and family members, giving new opportunities
for influencing healthcare contents and report cases of wrong treatment (Øvretveit
et al., 2015).
An act on patients’ status and rights in Finland came into force in 1993 (the Act
on the Status and Rights of Patients) (Vuorenkoski et al., 2008). It applies to every
part of the healthcare system and to services provided in social welfare institutions.
This act concerns the following issues: the right to appropriate healthcare and social
services; the right to receive healthcare within the waiting-time limits; the right to
information about health status, treatment and possible risks; the right to autonomy
and informed consent to treatment; the right to confidentiality and to access relevant
medical documents and the right to complain (The Finish National Supervisory
Authority for Welfare and Health, 2012; Vuorenkoski et al., 2008).

PATIENT CHOICE
New public management (NPM) is an ideology that emerged following critiques of
bureaucracy and inefficiency in the public sector (Stamsø, 2005). A core goal of NPM
has been to increase the public sector’s ability to deliver economically efficient ser-
vices by adapting market models, principles and ideas from the private sector (Busch
et al., 2003; Christensen and Lægreid, 2001; Glenngård et al., 2011). NPM empha-
sises that citizens should be viewed as consumers of public services, free to choose
among different services and to participate in service planning (Busch et al., 2003).
In healthcare, this approach represented a significant shift in focus from viewing
patients as passive and dependent to seeing them as active and competent consumers.
Patients are empowered to choose the services that fit their needs, preferences and
are of high quality (Storm et al., 2009). An important component of this approach
was the notion that people should be able to access information on the quality of
care in different organisations to enable them to select the best (Coulter, 2011). It was
hoped that this would provide both financial incentives and other types of ‘market
signals’ to encourage providers to ensure that their services were of sufficiently high
Patient-Centred Care in the Nordic Countries 33

quality to attract customers (patients). There are several possible types of choices
in healthcare in the Nordic countries, including choice of general practitioner (GP),
hospital or type of provider (public, voluntary or private sector).
People in Norway can choose their GP. Patients also have the right to choose any
public hospital across the country for elective care (Norwegian Patient Rights Act,
1999). The information service ‘Helsenorge’ supports patients’ right to choose where
to receive treatment and provides information on hospital waiting times for specific
patient groups (Helsenorge, 2016). Norway has a system of individual waiting-time
guarantees for patients (Ringard et al., 2013). According to the Norwegian Patient
Rights Act (1999), all patients referred to a hospital have the right to have their health
status evaluated within 30 working days. The hospital will decide whether there is
need for medical care and provide information on when treatment is expected to take
place. Patients with the same diagnosis may have different waiting times, depending
on the severity of the disease and other factors specific to the individual (Norwegian
Directorate of Health, 2006). Patients have an additional right to travel abroad if
treatment cannot be provided in Norway or it cannot be provided within a given time
frame (Ringard et al., 2013).
People in Denmark can register with a GP of their own choice, practising close to
their home. Since 1993, patients have been free to choose any hospital in the country as
long as the treatment takes place at the same level of specialisation (Olejaz et al., 2012).
Denmark also has a waiting-time guarantee. If a patient is not offered treatment within
1 month of referral, he or she can choose treatment at any private hospital or clinic in
the country by agreement with the health region or abroad (Olejaz et al., 2012).
Choice of primary care provider became mandatory in Sweden in January 2010
(The primary choice reform). Patients can register with any public or private pro-
vider/primary healthcare centre accredited by the local county council (Anell et al.,
2012). Sweden has a waiting-time guarantee for elective treatment introduced in
2005, referred to as a ‘0-7-90-90’ rule. This means instant contact with the primary
health service system for a medical consultation, seeing a GP within 7 days, consult-
ing specialist within 90 days referral and no more than 90 days to receive treatment
following diagnosis (Anell et al., 2012; Øvretveit et al., 2015). If these criteria are not
met, the county council must offer care at an alternative provider. There is a publicly
available website that provides information about current waiting times (Anell et al.,
2012; Väntetider i vården, 2016).
Since 2014, patients in Finland have had the right to choose any health ­centre or
unit within their municipality, and any hospital providing specialist care, in consulta-
tion with the referring doctor. Finland has a maximum waiting-time limit for elective
treatment. The need for specialist healthcare must be assessed within three weeks of
referral, and further clinical assessments must commence within 3 months. Hospital
treatment must begin within six months of the initial assessment (Finnish National
Supervisory Authority for Welfare and Health, 2012; Vuorenkoski et al., 2008).

PATIENT INFORMATION
Improving access to and use of health information is essential for people to make
informed choices about their health. People need relevant, reliable and comprehensible
34 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

information provided in a timely manner. Printed or electronic information can

improve patient’s knowledge and their understanding of their condition, increase
their sense of empowerment, improve coping ability and reduce anxiety (Coulter,
2011). In the Nordic countries, there are health information portals accessible via
the Internet covering information on health and illness, patient rights and the qual-
ity of care to inform people’s choice of provider. Each country has patient offices or
patient ombudsmen providing information and advice on patient rights, choice and
complaint procedures.
In Norway, the Internet portal ‘helseNorge’ disseminate information on patient
rights and public health services (Helsenorge, 2016). Users can access information
on fees, electronic prescriptions, vaccinations and how to change their GP. There is
also information on health and disease to support self-care and involvement in the
health system and on quality indicators to support hospital choice, with links to the
Health and Social Services ombudsman. Every county in Norway has an ombuds-
man to safeguard patients’ rights. The ombudsman provides advice and guidance
on patients’ rights, what to do if you experience an adverse event and assistance
with formulating complaints (Ringard et al., 2013).
Every region in Denmark has a patient office and advice service, similar to a
regional ombudsman (Winblad and Ringard, 2009). Their primary task is to provide
patients with advice on their rights to choice of provider and treatment, how to make
a complaint and claim compensation and waiting list guarantees. The patient advisor
acts as a counsellor and a problem-solver in close dialogue between patients, rela-
tives and hospital staff (Olejaz et al., 2012). In addition, Denmark has several web-
sites established by the National Board on Health, Danish Regions and the Ministry
of Health ensuring patients have access to information, including information about
waiting times for operations and procedures and information about hospital perfor-
mance and quality (Olejaz et al., 2012).
In Sweden, each county council and municipality has a patients’ advisory com-
mittee to support individuals with information, promoting contact between patients,
professionals and health services (Anell et al., 2012). There is also a health infor-
mation portal which is a collaborative initiative by all county councils and regions
in Sweden. The website provides written medical information and information
about care pathways, a chat service and a 24-hour phone line where medical staff
are available to give medical advice and advice on where to seek care if neces-
sary (1177 Vårdguiden, 2016). Citizens may also create their own account in order
to make healthcare appointments, renew drug prescriptions and obtain information
about test results (Anell et al., 2012).
Finland has a website providing information about moving to and living in
Finland, the Finish health service system and patient rights (Infopankki.fi, 2016).
Individual patient organisations are also a valuable source of information. For
example, the Cancer Society of Finland has a website providing information
about types of cancer, patients’ rights and a professional advice service available
by e-mail, phone and chat (Cancer Society of Finland, 2016). All healthcare units
in Finland must appoint a patient ombudsman obliged to inform patients about
their rights and to assist with complaints about treatment (Winblad and Ringard,
2009).
Patient-Centred Care in the Nordic Countries 35

PATIENT EXPERIENCE SURVEYS

Patient experience data are a key resource for assessing, monitoring and improv-
ing quality of care (Berwick, 2009; Coulter, 2011). Topics commonly covered in
questionnaire surveys include access and waiting times, provision of information,
communications with health or social care professionals, quality of the physical
environment, involvement in decisions, support for self-care, co-ordination of care,
quality of life and health status (Coulter et al., 2014). Patients’ experience is posi-
tively associated with indicators of clinical effectiveness and patient safety, uptake of
preventive care and appropriate resource use (Doyle et al., 2013). Isaac et al. (2010)
reported an association between level of patient experience and several patient safety
indicators. Better patient experiences were associated with reduced rates of pressure
ulcers, fewer infections due to medical care and fewer post-operative complications
such as bleeding, respiratory failure, pulmonary embolism and sepsis.
In Norway, Sweden and Denmark, national surveys of patients’ experiences are
conducted regularly, but this is not the case in Finland which has no national patient
survey programme (Skudal et al., 2012). The Norwegian Knowledge Centre for the
Health Services conducts national surveys of patients’ experiences at Norwegian
hospitals. These reveal both strengths and weaknesses; for example, hospital dis-
charge was the area most complained about in 2011, 2012 and 2013 while patient
safety achieved the highest scores, followed by experiences of patients’ relatives and
communications with nursing staff (Bjerkan et al., 2014). A study ‘Patient safety and
quality of health care in 2013’ conducted with a random sample of the Norwegian
population found that 42% of respondents had experienced an adverse event follow-
ing contact with health services affecting themselves or a family member. Only 39%
of those who had had this experience reported the event to staff inside or outside the
hospital. Of those that did, most drew it to the attention of a doctor, nurse or phar-
macist (41%), hospital manager (28%) or the Norwegian System for Compensation to
Patients (26%) (Haugum et al., 2013).
The National Danish Survey of Patient Experiences is an annual nationwide
questionnaire survey for assessing patients’ experiences (Olejaz et al., 2012). Among
all respondents in 2014, the most positive feature was perceptions of friendly staff,
while reports on patient involvement, patient-perceived errors and provision of
discharge information were more negative. Patients and their families complained
about insufficient involvement in decisions about treatment and care, and many
complained that they were not properly informed about the effects and side effects
of new medications. Patients admitted via emergency settings reported the most
negative experiences (Patientoplevelser, 2014).
A national population survey was initiated in Sweden in the 1990s to assess the
general population’s attitudes, knowledge and expectations towards healthcare perfor-
mance and to compare responses in different county councils (Anell et al., 2012). In the
2014 survey, about 64% of respondents felt that waiting times at health centres were rea-
sonable, and 77% knew that they could call 1177 for advice and assistance on healthcare
(Befolkningsundersökning, 2014). Every 2 years, a National Swedish Patient Survey is
conducted in all county councils and regions. The survey asks about communications
with staff, information provision, participation, confidentiality, accessibility, perceived
36 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

usefulness and overall satisfaction. In Spring 2014, the National Patient Survey was
conducted among those experiencing inpatient specialised medical care. The most
positive areas were perceived usefulness of treatment while the lowest scores related to
involvement and accessibility (Swedish Patient Survey, 2014). A stated purpose of this
survey is to guide people in their choice of health provider (Anell et al., 2012).

COMPLAINTS AND REDRESS

Patients in Norway, Sweden, Finland and Denmark have a right to complain about
their medical treatment and health services received. Patient complaints can concern
breaches to patient rights (e.g. waiting time, information and consent to treatment) or
malpractice or harm to the patient (Winblad and Ringard, 2009). Complaint proce-
dures can serve as one means of influencing the quality of healthcare through feed-
back to professional staff and organisations (Anell et al., 2012). These administrative
bodies also gather information about and respond to the feelings and reactions of the
patient and their next of kin (Winblad and Ringard, 2009).
According to the Patient Rights Act, patients in Norway can file a complaint to
the county medical officer if they believe that they have not received the services
they were entitled to. Complaints must be addressed to the person or organisation
that made the decision, with a right of appeal to the county or the National Board of
Health Supervision (Ringard et al., 2013).
The Danish National Agency for Patients’ Rights and Complaints is responsible
for dealing with complaints about professional treatment, the disregard of patient
rights and decisions on compensation made by the Patient Insurance Association
(Olejaz et al., 2012).
In Sweden, every county council has an advisory committee where people can
address questions or complaints relating to medical treatment. The advisory com-
mittee is responsible for providing advice and for sorting out problems, reporting to
professionals and services on any irregularities of significance to the patient (Anell
et al., 2012). In cases of gross neglect or if an individual is anxious about reporting
their complaints, an alternative is to apply to the government agency responsible for
disciplinary measures (Anell et al., 2012).
In Finland, the Patient’s charter states that patients who are dissatisfied with their
care can submit a complaint to the director of the relevant provider organisation
or alternatively to the regional or national authority (Finish National Supervisory
Authority for Welfare and Health, 2012). In the case of patient injury during treat-
ment, the Patient Insurance Centre can be consulted for compensation.

CURRENT STATE OF PLAY AND REMAINING CHALLENGES

As we have seen, quality and safety in health, welfare and social services is a politi-
cal priority in the Nordic countries. There are unambiguous health policies empha-
sising patients’ and their families’ rights to be engaged and involved in their own
treatment and care and in the development of health services. There are also a large
number of patient organisations exercising influence on health policymaking and
providing advice and support to patients and the public.
Patient-Centred Care in the Nordic Countries 37

Health legislation complements and reinforces policies ensuring equal access to

health and social services. Norway, Denmark and Finland have established separate
bills, while Sweden uses multiple pieces of legislation to protect patients’ rights.
Choice of primary care provider (GP and healthcare centre/unit/hospital) has
become mandatory in the four Nordic countries and there are waiting-time guaran-
tees. Patients and citizens can easily access information about their rights and about
health, disease and self-care and the quality of care on national websites. There
are patient offices or patient ombudsmen in every region providing information and
advice, and they play an important role in situations of complaints and redress.
There are few formal or legislative barriers preventing patients exercising choice
in the Nordic countries (Vrangbæk et al., 2007). Nevertheless, a comparative study of
Denmark, Norway and Sweden showed that patients exercised their right to choose
hospitals to only a limited degree. Limitations in patients’ knowledge about their right
to choose, coupled with lack of information and support from their GP, were suggested
as possible explanations (Vrangbæk et al., 2007). Ringard (2010) analysed Norwegian
GPs’ referral decisions for elective treatment. He found that GPs were most likely to
send patients to a hospital other than their local one if they were in need of elective
knee operations. Longer waiting times and distance from the local hospital increased
the likelihood of an out-of-area referral. According to Glenngård et al. (2011), about
60% of the population in three Swedish counties felt that they had made a choice of
provider following the introduction of the choice and privatisation legislation in 2010.
The likelihood of choosing a provider increased with the introduction of new providers
in the county and the perception of having enough information to make an informed
choice. Those who preferred direct access to a specialist were less likely to choose to
travel further for their care. However, people tended to choose providers they had previ-
ously been in contact with and many did not make active efforts to look for information.
Providing patients with easy access to information about their rights and the qual-
ity of care has been a key priority in the Nordic countries. In Sweden, the population
survey (Befolkningsundersökning, 2014) reported a 10% increase in the proportion
of respondents who said that they knew that they could call 1177 for advice and
assistance. However, the extent to which people make use of this type of informa-
tion is currently unknown (Anell et al., 2012). Glenngård et al. (2011) report that the
two most common sources of information for people in the three Swedish coun-
ties responding to the survey were health providers followed by the Internet. People
living in urban areas, those with higher education and younger people, were more
likely to look for information on the Internet than other groups. The authors of this
study noted the limitations of this type of search, making informed decisions about
healthcare providers quite difficult. Information about symptoms and the benefits
and harms of treatments is an essential prerequisite for shared decision-making, but
there is a lack of web-based decision support to assist patients in choosing among
treatment options (Docteur and Coulter, 2012).
National surveys of patient experiences with their hospital stay are conducted
regularly in Norway, Sweden and Denmark. These indicate high levels of satisfac-
tion with certain aspects of care, such as communications with health professionals,
while also pointing to several priorities for improvement, for example involvement in
decision-making, information and preparation for hospital discharge, co-­ordination
38 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

of care and accessibility of services (Bjerkan et al., 2014; Patientoplevelser Denmark,

2014; Swedish Patient Survey, 2014).
However, despite the progressive policies, it seems that in certain respects the
Nordic countries may be lagging behind other western developed countries when
it comes to measures of patients’ experience. The Commonwealth Fund’s 2011
International Health Policy survey, which include data from Norway and Sweden
but not Denmark or Finland, pointed to information gaps during hospital discharge
(Schoen et al., 2011), with the Nordic countries performing worse in this respect than
most other countries in this eleven-country survey. In Sweden 67% of respondents
and in Norway 71% reported the following problems:

1. Not given sufficient information about how to deal with their symptoms and
when to seek further care
2. Not given information about who to contact for questions about their condi-
tion or treatment
3. Not given a written plan for care after discharge
4. No arrangements made for follow-up visits
5. Did not receive clear instructions about prescribed medication

In the United Kingdom, the comparative percentage was 26%. This evidence of poor
performance is of concern because lack of preparedness and support for self-care
can increase the risk of adverse events and avoidable readmissions to hospital.
Similarly, the 2014 International Health Policy Survey, which focused on older
adults, suggested that the Nordic countries performed worse than many other coun-
tries in respect of access, co-ordination and patient-centred care (Osborn et  al.,
2014). There were less positive responses from people living in Norway and Sweden
in response to questions about doctor–patient relationships, self-care of chronic con-
ditions and end-of-life care:

• About 40% reported that their doctor always or often encouraged them
to ask questions, while more than 80% reported this in the United States,
Australia, France and Germany.
• Only 23% in Sweden and 27% in Norway reported that a healthcare pro-
fessional discussed their main goals and gave instructions on symptoms to
watch for in the past year, while almost 60% in the United Kingdom and the
United States said they had had such discussions.
• Only 30% of respondents in Sweden and 20% in Norway said they had
discussed their care preferences if they became unable to make decisions
for themselves, while more than 70% of those in the United States and
Germany had had such discussions.

Access to information about their condition, involvement in decisions about their care,
support for self-management and encouragement of more conversations about end-of-
life care are considered very important for enabling people to cope with chronic ill-
ness and to navigate the healthcare system effectively (Docteur and Coulter, 2012).
Patient-Centred Care in the Nordic Countries 39

It is therefore of some concern that patients in these Nordic countries do not appear to
be receiving sufficient support to empower them to make appropriate health choices.

CONCLUSION
Patient-centredness is an overarching aim for improving the quality of healthcare in the
Nordic countries. Key attributes of a patient-centred health system are shared knowl-
edge between professionals and patients, information to and involvement of patients
in decision-making about treatment and care, transparency and access to information
on system performance. Co-ordination and continuity of care are important, as are
opportunities for collective engagement and co-design of service developments. The
Nordic countries have introduced many progressive health policies, but there is still
more to do to ensure that the systems are truly patient-centred. An important future
direction is to strengthen the role of patients as active participants in their own care.
Particular priorities include encouraging shared decision-making about treatments
underpinned by appropriate information, together with personalised care planning
and self-care support. Building health literacy among the population and encourag-
ing health ­professionals to recognise the key role of patients and their families as co-
producers of health will also be important in the next stage of health system reform.

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 3 Studying Patient Safety
and Quality from
Different Methodological
Angles and Perspectives
Siri Wiig and Tanja Manser

CONTENTS
Introduction............................................................................................................... 43
Aim and Limitations.................................................................................................44
Landscape of Methods and Perspectives.................................................................. 45
Three Contextual Issues Challenging Research on Patient Safety and Quality........46
Conceptualising Patient Safety and Quality.........................................................46
A Continuously Changing Context...................................................................... 47
Patient Involvement.............................................................................................. 48
Discussion................................................................................................................. 49
Research Addressing Conceptualisation of Patient Safety and Quality............... 49
Research Addressing Changing Contexts............................................................ 50
Research Addressing Patient Involvement........................................................... 51
What Is Next in the Nordic Context?........................................................................ 52
References................................................................................................................. 53

INTRODUCTION
Patient safety and quality in healthcare has become an international prior-
ity involving research programmes and policy reforms to build safer and better
healthcare systems (e.g. WHO, 2008; Iedema, 2009; Jha et  al., 2010; Shekelle
et  al., 2011; Mitchell et  al., 2015). This also applies to the Nordic context, with
the Nordic countries having both separate country-specific strategies and cross-
national strategic collaborations to improve patient safety and quality in healthcare
(Norden, 2013). Several initiatives aiming at structural (e.g. regulation, accredita-
tion, national error reporting system) and cultural improvement (e.g. patient safety
culture measurement, leadership walk rounds) have been undertaken already and
will further be implemented in the years to come (e.g. Vuorenkoski, 2008; Anell
et al., 2012; Meld.St nr. 10, 2012–2013; Olejaz et al., 2012; Saunes and Ringaard,
2013; Sigurgeirsdóttir et al., 2014).

43
44 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

Understanding patient safety and quality improvement interventions and mech-

anisms within complex healthcare systems has become an increasingly important
research field (Øvretveit, 2014; Mason et al., 2015; Portela et al., 2015). Research is
a key component of improving patient safety and quality (Pronovost et al., 2015) as
it creates an in-depth understanding of the problems and thus a basis for effective
and sustainable improvement. The World Health Organization (WHO) has suggested
that the top five research priorities among developed countries, such as the Nordic
countries, are related to

1. Lack of communication and co-ordination (including discontinuity and

co-ordination across organisations)
2. Latent errors and organisational failures
3. Poor safety culture and blame-oriented processes
4. Cost-effectiveness of risk reduction strategies
5. Developing better safety indicators (WHO, 2008; Bates et al., 2009)

Despite prolonged effort, the field is improving slowly, which is partly due to limited
evidence for the development and dissemination of successful practices (Pronovost
et al., 2009; Shekelle et al., 2011). In 2011, an Agency of Healthcare Research and
Quality expert group argued that research approaches require more extensive use
of theory; a more detailed description of interventions and their implementation;
enhanced explanation of desired and undesired outcomes and improved description
and measurement of context and how context influences improvement interventions
(Shekelle et al., 2011).
While research is crucial to improving patient safety and quality, there is increas-
ing concern that research strategies and methods are not sufficiently adapted to
the complexities of healthcare. Some claim that too much attention has been paid
to the formal and structural dimensions at the expense of the social and affective
dimensions relevant to patient safety and quality (Bate et  al., 2008; Idema, 2009;
Wiig et al., 2014a). Since the role of social processes is under-researched, there is a
need for approaches that enable to grasp the interactive processes of establishing and
sustaining patient safety and quality.

AIM AND LIMITATIONS

This chapter reflects on the challenges of researching patient safety and quality
in healthcare (Brown et al., 2008; Pronovost et al., 2009; Portela et al., 2015) and
on methodological choices such as the selection of appropriate theoretical frame-
works, research design, data collection methods, context mapping, analytical tools,
understanding interventions and explaining results. The aim is to discuss the char-
acteristics of the healthcare research context and the implications of different meth-
odological perspectives.
In doing so, we assume that readers have a good understanding of most research
methods and designs (e.g. Denzin and Lincoln, 1994; Reason and Bradbury, 2001;
Yin, 2004; Creswell, 2014). Hence, we will only briefly cover the landscape of meth-
ods and perspectives.
Patient Safety and Quality from Different Methodological Angles and Perspectives 45

LANDSCAPE OF METHODS AND PERSPECTIVES

The landscape of research methods and perspectives that have been applied to
patient safety and quality in healthcare is large and sprawling. It varies depend-
ing on multiple factors such as philosophy of science positioning, professional and
academic background, theoretical perspectives and level of interest (Fulop et  al.,
2001). For example, understanding of patient safety risk may vary from a positivist
view conceptualising risk as a physically given attribute where objective facts can
be explained, predicted and controlled to a constructivist view arguing that risk is a
socially constructed phenomenon (e.g. Renn, 1992, 2007).
Methodological approaches may vary from quantitative designs relying on the
‘gold standard’ of randomised controlled trial designs focusing on direct inferences
on causality on the one hand to qualitative designs and ethnographic approaches on
the other hand focusing on in-depth inquiry aiming to understand work practices,
culture, processes, social interaction, meanings of the social world and why and how
changes appear (Fulop et al., 2001; Portela et al., 2015). Moreover, a wide range of
theoretical perspectives and models (Davidoff et al., 2015) can be applied to guide
research from, for example, simple linear to complex safety models developed within
the safety sciences (Hollnagel, 2004; Hollnagel et al., 2013). Within the tradition of
quality improvement, different models and tools (e.g. Total Quality Management,
Lean thinking, Six Sigma) have been widely used to guide quality improvement
in healthcare organisations (Øvretveit and Staines, 2007; Bate et al., 2008; Powell
et al., 2009; Robert et al., 2011; Wiig et al., 2014a). These theories and models are not
always well defined and healthcare organisations often draw on a range of tools and
principles from different approaches (Powell et al., 2009). Although a wide range
of theories exist within patient safety and quality (see also Chapter 4), the role and
value of theory is still under-recognised and mystified in healthcare. Davidoff et al.
(2015) propose that more informed use of theory could strengthen improvement pro-
grammes and facilitate the evaluation of their effectiveness.
Patient safety and quality in healthcare is not the province of any one discipline,
research design or method of measurement, therefore understanding and improve-
ment require a collaborative synthesis of different perspectives and contributions
(Walshe and Boden, 2006; Pronovost et al., 2015). Research aiming at understand-
ing the causes of adverse events and patient harm is complex, because the events
often relate to multiple factors (e.g. communication, teamwork, care process design,
instrumentation and facilities, human resources, service organisation, management
and leadership). According to Walshe and Boden (2006), a range of disciplines,
including psychology, sociology, clinical epidemiology, quality management, tech-
nology and informatics and the law, all have important parts to play in approaching
and analysing errors and adverse events. The advantage of different disciplines and
backgrounds is that they foster diversity and complementary perspectives and con-
ceptual understandings of patient safety and quality.
The choice of level of inquiry constitutes an important aspect within the meth-
odological landscape. Different schools of thought focus their study on the same
research topic but at different organisational or system level. The choice of level
is partly informed by theory and partly by pragmatism (Fulop et al., 2001). Level
46 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

of interest may vary from studies of a single level involving either the clinical
micro-level (clinical team), the meso-level (organisational level) or the macro-level
(national level) to multi-level approaches including several or all levels and the role
of interaction and interfaces between them. Also, depending on the chosen level of
inquiry, the assignment of these levels is fluid ranging from the individual clinician
to cross-country comparisons. As a general rule of thumb, multi-level approaches
should always include one level above and below the focal level of inquiry.
However,  the current research usually includes a single care sector (e.g. primary
or specialised healthcare services) and seldom embraces a multi-level perspective
(Wiig, 2008; Robert et al., 2011).

THREE CONTEXTUAL ISSUES CHALLENGING RESEARCH

ON PATIENT SAFETY AND QUALITY
In the following, we highlight three specific characteristics of the healthcare con-
text and how they challenge research. First, we focus on how patient safety and
quality are conceptualised; second, we point out the changing nature of the health-
care system and third, we highlight the role of patients and patient involvement in
healthcare.

Conceptualising Patient Safety and Quality

Research methods need to capture how patient safety and quality are understood,
created, enacted and sustained. Conceptualising patient safety and quality thus con-
stitutes a challenge that research needs to approach.
Looking at patient safety, Vincent (2006: 14) argues that it is concerned pri-
marily with the avoidance, prevention and amelioration of adverse outcomes or
injuries stemming from healthcare itself. Safety does not reside in a person, device
or department, but emerges from the processes and the interfaces in the socio-­
technical system of healthcare. This implies that safety depends on interaction
between multiple actors, technologies and processes (e.g. Robert et al., 2011; Wiig
et al., 2014a; Waterson et al., 2015). Having this in mind, Pronovost et al. (2015)
argue that healthcare researchers so far have been unable to capture the complexity
of patient safety conceptualisation, because of lacking transdisciplinary approaches
(i.e. multidisciplinary combined applied and basic research principles). They argue
that many healthcare researchers tend to consciously and narrowly focus on con-
ceptualisations in isolation rather than considering them as a result of several
interdependent conceptualisations (systems at work). Too often, research focuses
on mono-disciplinary approaches adopting a linear approach from basic to clini-
cal research. What is missing is a systematic, sector-wide approach, underpinned
by conceptualisations of safety science adopted in other industries but not yet in
healthcare (Pronovost et al., 2015).
Looking at quality, conceptualisation is also complex. Diverse definitions of
quality have been developed and often include the six dimensions of effectiveness,
timeliness, safety, equity, efficiency and patient centredness. Here, patient safety is
Patient Safety and Quality from Different Methodological Angles and Perspectives 47

conceptualised as a sub-dimension of quality. Some of these dimensions may be

inherently conflicting in practical settings (e.g. improved safety might reduce patient
centredness or efficiency) (Wiig et al., 2013), and the different quality dimensions
may require different methodological approaches to collect and analyse data. Hence,
including all dimensions in research activities is a challenging methodological task.
It implies that researchers sometimes limit the number of included quality dimen-
sions, in order to be able to go into details. A study of quality conceptualisations
across European hospitals demonstrated how a delimitation of the quality conceptu-
alisation in the research constituted a challenge for the data collection and analysis
(Wiig et al., 2014b). The ‘narrow’ conceptualisation of quality used (clinical effec-
tiveness, patient safety and patient experience) evolved into a limitation in the analy-
sis demonstrating how other quality dimensions emerged from the data (efficiency,
time, economic issues). A broader conceptualisation of quality would have enabled
a more thorough and consistent exploration of the data. However, this study dem-
onstrated that the quality conceptualisations differed across system levels (macro–
meso–micro), among professional groups (nurses, doctors, managers) and between
the micro systems (Wiig et al., 2014b).
Further, patient safety and quality can be conceptualised as moving targets
(Vincent and Amalberti, 2015) since meanings and concepts are dynamic and
dependent upon innovation and improvement within the healthcare context itself.
What was accepted as sound professional practice 10 years ago might not be con-
sidered acceptable by professional or regulatory bodies today. As standards improve
and concerns for patient safety and quality increase, an increasing number of adverse
events are, for example, regarded as preventable. Vincent and Amalberti (2015) argue
that innovations and improving standards alter our conceptualisation of both harm
and preventability in healthcare. From a practical, conceptual and methodological
perspective, this is challenging as the definition of what constitutes patient harm or
safe care is becoming difficult to pin down since a growing amount of events with
changing characteristics are labelled a safety issue. The same argument is also rel-
evant for quality standards and acceptable level of care quality (Braut, 2011).

A Continuously Changing Context

Healthcare is characterised by the need to continuously address changes either
imposed on the system, team or individual healthcare professionals by governmental
bodies (e.g. national reforms and standards), technological or professional develop-
ment (e.g. new knowledge, procedures, competence or diagnostic tools) or driven
from an internal need for organisational change (e.g. restructuring or downsizing) or
driven by patients (e.g. demands for involvement) to mention some. Understanding
how patient safety and quality processes are affected by these change processes is a
challenging research task, and the same applies for evaluating interventions imple-
mented within these systems. Interventions occur in contexts that are difficult to
describe in detail in terms of how and what factors influence the results. This makes
it difficult for others to understand and repeat the intervention (Øvretveit, 2014).
A prominent example is the introduction of the safe surgery checklist that may fail
to achieve the intended improvements if not accompanied by other elements such
48 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

as staff training and leadership support. Often, we learn from a failed replication
attempt and the differences between contexts.
Another feature of a continuously changing context is the care process itself. The
increasing degree of specialisation in healthcare combined with the demands for
treatment at the lowest possible care level causes a growing number of handovers.
These changes imply that patients are transferred between and within service levels
(primary and acute services), services types (intensive care, cancer care) and teams.
Previous research states that – across different healthcare settings – current handover
processes are highly variable and potentially unreliable (Manser and Foster, 2011).
More knowledge is required to understand these contextual changes and how they
affect patient safety and quality. This requires methodological approaches and per-
spectives that manage to map change and care processes along different patient path-
ways and trajectories.

Patient Involvement
Even though patient and public involvement (PPI) has become part of everyday
rhetoric in many countries, it often proofs difficult in practice (Coulter, 2011). A
Norwegian study of patient experiences in quality improvement in hospitals dem-
onstrated that macro-level policymakers had wide-ranging expectations for the inte-
gration of patient experiences. Results nevertheless demonstrated a lack of expertise
in Norwegian hospitals of adapting and implementing tools and methods for using
patient experiences as a resource in quality improvement (Wiig et al., 2013). Patients
and family can play a distinct role in improving patient safety and quality by, for
example, choosing safe healthcare providers, observe and check care processes,
identify and report complications and adverse events, give feedback and advocate
attention to patient safety and quality issues (Coulter, 2011). Sutton et  al. (2015)
found three main types on patient involvement in patient safety in their literature
review relating to (1) monitoring treatment and speaking up, (2) patient perception of
safety and experiences of raising concerns and (3) patient feedback and error report-
ing. Another systematic review of patient involvement in patient safety revealed
three different themes relating to (1) satisfaction with and need for knowledge about
healthcare and the health system, (2) sharing responsibility and accountability for
safety and (3) the need to overcome language barrier to prevent harm and error
(Severinson and Holm, 2015). These two reviews demonstrate different themes and
activities related to patient involvement in patient safety at both individual and col-
lective level that research needs to explore in more detail.
In terms of patient involvement in quality improvement, efforts often focus on
technicalities of involvement such as training of patients and healthcare profes-
sionals to strengthen their skills and technical knowledge (e.g. be more articulate,
able to ‘represent’) (Renedo et al., 2015). Other PPI methods to involve patients,
beyond educational programmes, are, for example, family meetings, discharge
plans in transitional care, checklists or home visits (Dyrstad et al., 2014). However,
the role of organisational context in supporting PPI is rarely analysed, although
elements of organisational culture could be important to mediate success. In an
ethnographic study investigating PPI activities in England, Renedo et al. (2015)
Patient Safety and Quality from Different Methodological Angles and Perspectives 49

found four key elements in the organisational culture that contributed to success-
ful PPI in quality improvement:

1. Emphasis on non-hierarchical, multidisciplinary collaboration between

patients and professionals
2. Staff ability to model desired improvement and PPI behaviours of mutual
recognition and respect
3. Commitment to rapid improvement to ensure translation of research to
practice
4. Constant and iterative process of collecting data and reflection facilitated
by the use of quality improvement methods and the commitment to act on
that learning (Renedo et al., 2015)

The growing influential role of patients and their families in healthcare adds com-
plexity to patient safety and quality research. It implies a need for methodologi-
cal angles and perspectives that acknowledge the role of the patient and the family
(Coulter, 2011) by also engaging them actively in the research process. The previous
research highlights ‘soft’ dimensions related to patient involvement, such as respect,
commitment, accountability and responsibility that researchers and practitioners
need to address more thoroughly than today.

DISCUSSION
As outlined earlier, the healthcare context represents several research challenges.
In this section, we will discuss the role of different methodological perspectives in
overcoming these challenges.

Research Addressing Conceptualisation of Patient Safety and Quality

Since patient safety and quality concepts and dimensions differ and are interrelated
(Doyle et al., 2013), they require different angles and methods to collect data. For
example, studying the two dimensions, cost-effectiveness of patient safety improve-
ment, researchers need to collect data from economic figures, ­calculate i­ ntervention
costs and map decrease or increase in the defined variables. According to Recende
et  al.’s (2012) review of methods used in economic evaluation in patient safety,
costs are rarely evaluated as part of implementing patient safety improvement mea-
sures. The review demonstrates a narrow perspective on the costs related to a few
adverse event types (healthcare-associated infections/infection control activities
and m­edication-related adverse events). Recente et al. (2012) recommend stronger
emphasis on transparency, data collection and methodological choices. Research
programmes in the EU and the Nordic counties often require economic evaluations
of interventions, but as demonstrated in the review this is complicated. We believe
that a broader perspective in economic evaluations should be applied. The evalua-
tions could be supplemented by using methods such as focus groups, semi-­structured
interviews to explore, for example, senior managers’ perspective on resources
invested in improvement efforts over time such as accreditation programmes, change
50 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

in staffing level or establishment of learning arenas. Also, ­questionnaires could

support the understanding of economic consequences of improvements measures.
Analysed together with commonly used ­economic evaluations in a mixed methods
approach they can contribute to a broader c­ onceptualisation of resources invested
in patient safety and quality, beyond the single perspective of adverse events. This
discussion also relates to what is conceptualised as evidence in research on patient
safety and quality. Is it merely outcome measures (e.g. infection rate, mortality)
or could process measures provide valuable information on the relation between
patient safety, quality and costs? Since research on patient safety and quality is still
in its early stages, it needs both.
Despite the complexity of the patient safety and quality conceptualisations in
healthcare improvement, healthcare generally operates in silos. Improvement efforts
are often superficial, fragmented and not well co-ordinated. To overcome this issue,
there has been a call for more multidisciplinary research approaches (Pronovost
et al., 2015). Different disciplines contribute with different conceptualisations fos-
tering a broader perspective in research. Within organisational sciences, the concept
of requisite variety is used when discussing the need for a divergence in analytical
perspectives among members required to understand the complexity of a system
(e.g. Weick, 1987). Applied to research, this means research teams need enough
analytical variety to conceptualise important information, diagnose the problem
and suggest relevant improvement measures. But there are also potential obstacles
to multidisciplinary research, which are often not discussed. Disciplines and tradi-
tions within disciplines stem from different paradigms and theories of knowledge.
Clearly, these differences are important and are likely to influence a broad range
of aspects relevant to the research, such as types of research undertaken, focus on
process or outcome, the role of context and generalisability and the types of meth-
ods. It is suggested that multidisciplinary research is easiest when researchers from
different disciplines share paradigms or represent a less extreme end of perspectives
working together (Fulop et al., 2001). However, while a common language and gen-
eral openness towards other perspectives is critical, analytical conceptualisation still
needs to be variable enough to actually benefit from diversity.

Research Addressing Changing Contexts

Continuous change challenges some research methods and favours others. The
choice of methods depends on the aim and research problem (explorative, descrip-
tive, explanatory or experimental). For those methods exploring a phenomenon in its
context, such as case studies or action research, the change processes constitute part
of the context that the research tries to understand. Instead of controlling influencing
factors or confounders, researchers then focus on providing an in-depth description
of the research context, helping others to assess if findings are relevant in another
context. Such studies provide valuable insights into context characteristics that can
be included in explanatory studies.
Patient safety and quality research also needs to explore the consequences
of changes implemented at different levels, such as reforms or organisational
restructuring. Improvement efforts in healthcare systems undergoing fundamental
Patient Safety and Quality from Different Methodological Angles and Perspectives 51

restructuring require greater understanding of how organisational context affects

outcomes (e.g. Aiken et  al., 1997) and processes. At the national level, several
Nordic countries implement system-wide reforms (e.g. the co-ordination reform
described in Chapter 10 or national clinical registries in Chapter 7) that require
scientific evaluation of implications (structure, process, outcome), the implementa-
tion process and strengths and weaknesses (Øvretveit, 2014). Such research evi-
dence should inform stakeholders’ future decision-making.
The changes into more highly specialised and centralised hospital services in the
Nordic countries will require more cross-country collaboration (Norden, 2013), with
the potential of adding handover and fragmentation to service provision. Manser
(2013) discusses this in a critical reflection of current research approaches to patient
handover and criticises the current predominant research strategy to study isolated
handover episodes in studying this changing context. This strategy replicates the
problem of fragmentation of care that we aim to overcome by improving handover.
Thus, there is a need for a patient-centred approach to handover research investigat-
ing the interdependencies of handovers occurring along the care path. The patient
and the family are the only ones with a complete experience and picture of the patient
journey and research methods need to integrate these experiences in the research to
understand the implications of the changing context on patient safety and quality.
Possible approaches may be both qualitatively and quantitatively oriented by using,
for example, observations of patients through the healthcare system over time, inter-
views with patients and family along the pathway, surveys with several measure-
ments to map involvement at different stages of the care process or a combination
of methods. Such approaches may contribute to novel insights and help increase the
effectiveness and sustainability of interventions to improve handover (Manser, 2013:
194) in both a Nordic and an international perspective.

Research Addressing Patient Involvement

Most healthcare research would be impossible without active involvement of
patients. Patient involvement in research ranges from involvement in only one part
of the study to conducting and controlling the entire study. There is limited evi-
dence that patient involvement improves the quality and impact of research (Coulter,
2011; Staley, 2015). However, the patient perspective and patient involvement should
be considered integral to research on patient safety and quality to further develop
our understanding of the systems and challenges in service provision. This means,
for example, including patients as informants, stakeholders, members in advisory
groups and co-researchers adding to the multidisciplinary perspectives held by
the researchers and clinicians. Within patient safety research, it is also important
to include the voice of the harmed patients (Ocloo, 2010). The latter is challeng-
ing, as patients might no longer be alive, and next of kin in grief might have to be
approached by researchers. The demand for future studies on patient safety and qual-
ity in healthcare will require methods that enable grasping both patient involvement
and the patient perspective to avoid a fragmented (e.g. only one stakeholder in the
care pathway) or a one-sided picture (e.g. only the hospital/health professional per-
spective) of patient safety and quality. Angel and Frederiksens’ (2015) recent review
52 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

on patient involvement concludes that empirical studies do not consider whether it is

at all possible to overcome the embedded societal structures in which patients must
participate. Involvement in its ideal form cannot be achieved, they argue, due to the
unequal relationship between patients and professionals. A suggested way forward is
to consider patient involvement on a case-by-case basis, based on patients’ situation
and professionals’ attitudes (Angel and Frederiksen, 2015: 1536).
To overcome the narrow focus on technicalities of PPI and explore the soft dimen-
sions (e.g. respect, commitment, accountability and responsibility), the study by
Renedo et al. (2015) offers an interesting angle. Their study approached the role of
organisational context and culture for PPI by using a large ethnographic study of PPI
activities. They conducted in-depth interviews with patients and carers involved in
improvement projects and spent numerous hours observing PPI activities to investi-
gate how PPI was organised and enacted in practice. Moreover, observation included
meetings where teams of healthcare professionals, researchers and patient partici-
pants came together to work in improvement projects and events to facilitate learning
about quality improvement methods and PPI. This illustrates research focusing on
a high degree of qualitative methods including a collaborative component between
researchers, patients and healthcare professionals to understand processes and prac-
tical aspects of patient involvement: what happens when people participate, what
kind of actions do patients engage with as part of their involvement and what is the
nature of professional–patient interactions. These topics cannot be explored by tra-
ditional RCT design and strict emphasis on causality. This is a developing research
area and future research needs to focus on elements of, for example, trust, responsi-
bility and power issues (Severinson and Holm, 2015), but as it becomes more mature
there is need for methods to provide evidence of the effect of patient participation on
patient safety and quality processes, structures and outcome.

WHAT IS NEXT IN THE NORDIC CONTEXT?

We need research perspectives and methods that are able to conceptualise the com-
plex characteristics of patient safety and quality as continuously moving targets. The
complexity of the context and the concepts call for research approaches integrating
a variety of methods (qualitative, quantitative, mixed methods) that build on each
other to explore and explain the different conceptual dimension and the emergence
of patient safety and quality. This requires multidisciplinary research approaches,
cultures in healthcare valuing diversity and research programmes at national and
Nordic level requesting collaboration between different disciplines and stakeholders.
The Nordic model and values (described in Chapter 1) are challenged, because
of three megatrends: the digital revolution, globalisation and increasing life expec-
tancy (Norden, 2014). Hence, the Nordic healthcare context faces similar challenges
of change involving a growing population of elderly, while the predicted number
of healthcare professionals is too low. Significant changes are expected in the way
healthcare is delivered and e-health and telecare are expected to have an increasingly
important role (Norden, 2013; Guise et  al., 2014; Wiig et  al., 2014c). The Nordic
research community should be closely coupled to the implementation of changes in
at least two ways: first, by research approaches focusing on foresight and scenario
Patient Safety and Quality from Different Methodological Angles and Perspectives 53

building and consequence analysis to predict future patient safety and quality
­implications, avoid pitfalls and take action in light of possible and desirable future
outcome (Durance and Godet, 2010; Ringland, 2010) and, second, by evaluating
patient safety and quality implications of the change processes over time by using
a variety of methods (qualitative, quantitative, mixed methods) and data sources
(registry data, indicators, patient-reported outcome, patient and health professionals,
healthcare managers and policymakers).
Last but not least, future research should include patients and family members
not only as a valuable information and data source, but as partners in research.
Researchers need to identify innovative approaches to integrate patients and families
as partners to inform research questions and methods and develop the research team’s
capability of targeting the different conceptualisations of patient safety and quality.
The Nordic countries and the Nordic model (Karlsen and Lindøe, 2006) appear as a
possible context that could integrate patient involvement in research. Being charac-
terised by a low level of hierarchy, tripartite collaboration, equal opportunities and a
large public sector that provides its citizens with generous benefits, welfare services
and social safety net (Karlsen and Lindøe, 2006; Norden, 2014), the Nordic context
should foster patient involvement in patient safety and quality research.

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 4 What Is the Role of
Theory in Research
on Patient Safety and
Quality Improvement?
Is There a Nordic
Perspective to Theorising?
Karina Aase and Jeffrey Braithwaite

CONTENTS
Introduction............................................................................................................... 58
What Do We Mean by Theory?................................................................................ 58
The ‘Under-Use’ of Theories and the Development of a Framework......................60
Safety Science Theories and Their Application in Healthcare................................. 61
Root Cause Analysis, Swiss Cheese Model (Energy and Barrier Perspective).... 62
Learning and Reporting (HRO Perspective)........................................................ 63
Resilient Healthcare (Resilience Engineering Perspective)................................. 63
Quality Improvement Theories and Their Application in Healthcare.......................64
Structure–Process–Outcome Framework.............................................................64
Plan–Do–Study–Act Cycle.................................................................................. 65
Six Sigma............................................................................................................. 65
Statistical Process Control...................................................................................66
System-Wide Multi-Model Approaches...............................................................66
Quality Improvement Healthcare Approaches Summarised................................66
A Nordic Perspective?.............................................................................................. 67
Implications – ‘Good’ Theorising within Patient Safety and Quality
Improvement Research?............................................................................................ 69
Conclusion................................................................................................................ 70
References................................................................................................................. 70

57
58 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

In this chapter, we will discuss ways in which theory plays a role in research on patient
safety and quality improvement. In general, theory provides us with the capacity to
understand and account for empirical phenomena, to explain relationships between
constructs and to predict conditions under which relationships are more likely to
hold. More specifically, in improvement and implementation work and other applied
domains, theory gives us a framework by which to conduct evaluations to understand
what works and why. Within research on patient safety and quality improvement in
healthcare, the role of theory has so far been under-reported or under-recognised,
or both. We will investigate the reasons for this and look at different ‘applications’
of theory within patient safety and quality improvement, respectively. We will also
reflect on the question of whether there is a possible – or potential – Nordic perspec-
tive to theorising within patient safety and quality.

INTRODUCTION
In order to embark on tackling these issues, it is useful to consider whether the
Nordic countries as a collective might in fact be different from other parts of the
world. Responding to this question feeds into our overall quest to appreciate Nordic
patient safety and quality improvement and Nordic theorising. Our immediate
answer is yes and no.
Supporting the no side, we note some obvious facts about Western society – that
countries which comprise ‘the West’ are increasingly homogeneous, with converg-
ing cultures, economies and world views. We may characterise this phenomenon
by its technical term – globalisation, also called the McDonaldization (Ritzer, 1993)
of the world. And yet there are obvious deep cultural, literary and societal differ-
ences which set countries and regions apart. The Nordic countries have a rich history
which stamps their contemporary distinctiveness (Hermannsson, 1910; Hollander,
1997; Christiansen, 2006). Threads of history and literature feed into the modern
manifestation of Nordic distinctiveness including social solidarity, welfareism, indi-
vidual hardiness and a humane outlook on life. For a further discussion of aspects
of Nordic (and international) distinctiveness and cultural characteristics, see House
et al. (2004). From House et al.’s GLOBE study of comparative international differ-
ences, we know that Nordic European societal culture has features such as an orien-
tation towards performance and a humane orientation. It also has features, according
to this research, of relatively low levels of assertiveness, both in values and in prac-
tice. These features are relative and characterise Nordic society compared to, for
example, U.S. individualism.

WHAT DO WE MEAN BY THEORY?

Let us now assess theory and its use in patient safety and quality improvement.
Theory can mean anything from a simple guess or mere speculation to articulation
of a set of interrelated and logical propositional constructs that provide explanatory
and predictive power (Mark et al., 2004). The diverse meanings that can be attrib-
uted to the word ‘theory’ led Merton (1967) to suggest that it has the potential to
What Is the Role of Theory in Research on Patient Safety and Quality Improvement? 59

obscure rather than create understanding. Despite this, the development of theory
that leads to an understanding of patient safety and quality improvement should be
of paramount importance for several reasons (West, 2001; Walshe, 2007). Theory
can be used, for example,

1. As a framing device to call attention to some features of the phenomenon

being studied and to direct attention away from other aspects
2. To aggregate knowledge such that it can then be generalised from one
­setting to another
3. To recommend ways of organising to improve safe and high-quality
patient care
4. To avoid simplistic or standardised solutions or interventions to complex
patient safety and quality improvement initiatives for which high levels of
variance in context, content and application are often inherent and desired
characteristics

A common description of the elements in a theory in healthcare is provided by

Meleis (1997):

an organized, heuristic, coherent and systematic articulation of a set of statements

related to significant questions that are communicated in a meaningful whole for the
purpose of providing a generalizable form of understanding.

Notwithstanding that we can arrive at a comprehensive definition of this type, dif-

ferent disciplines sometimes have diverging views of what constitutes theory, and
there are many kinds of theory. There is a diverse range of theories potentially rel-
evant to patient safety and quality improvement, which encompass a wide variety
of disciplines from anthropology, psychology, sociology, behavioural economics
and management and organisational sciences. Meleis’ definition of theory can be
characterised as constituting a description of a formal, publicly developed theory
(Davidoff et al., 2015). Alongside formal theories are the more informal experience-
based theories most often at work in improvement efforts. The challenge according
to Davidoff and colleagues is to combine the two theory domains.
Because formulating ‘good theory’ is inherently difficult, Sutton and Staw (1995)
identified examples of what theory is not. According to them, theory is not repre-
sented by an extensive list of references in which logical relationships are explained
elsewhere. Models and variables must be accompanied by logical statements that
explain not only how variables are related but also why they are related. Similarly,
theory is not represented by a mere description of observed relationships, beta
weights or factor loadings. Data can describe relationships between variables but
cannot explain why the relationships hold.
Nor is theory a laundry list of variables or a diagram used to depict a structural
equation model. And nor is theory rendered – at least not explicitly – in evidence-
based clinical practice guidelines or in so-called best practices. Theory results from
a process of systematic and logical reasoning, either deductive or inductive, through
60 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

which the occurrence or nonoccurrence of some phenomenon can be understood

and predicted (Sutton and Staw, 1995, p. 11 in Mark et al., 2004).
Davidoff et al. (2015) following Merton (1968) make a useful distinction between
grand theory, mid-range theory and programme theory. Grand theory is formu-
lated at a high level of abstraction, making generalisations that apply across many
different domains (e.g. a theory of social inequality). Mid-range (or m
­ iddle-range)
theories are delimited in their area of application and are intermediate between
‘working hypotheses’ and a ‘conceptual scheme’ (e.g. the theory of diffusion of
innovations). Programme theories provide a ‘small theory’ for each intervention
being purposefully practical and accessible (e.g. working models, logic model,
driver diagram).

THE ‘UNDER-USE’ OF THEORIES AND

THE DEVELOPMENT OF A FRAMEWORK
Many healthcare professionals, including practitioners responsible for quality
improvement, are mystified and often alienated by the word ‘theory’ and by theories
themselves, which because they can be complex, or abstract, or both, discourages
them from using them in their work and research (Davidoff et al., 2015). The poten-
tial ‘users’ of theory furthermore form a diverse group, ranging from improvers
(who might be practitioners, managers or policymakers) to academic researchers.
The ‘improvers’ are interested in theory to the extent that it can help them do their
work better, if they want to have or apply theory at all. For the ‘researchers’, theory
itself is frequently the object of study with the aim to confirm, disconfirm or refine
an extant theory – or build a new one. It is in part the differences in the interests
and practices of improvers and researchers that explain the underlying distinctions
between improvement projects and research studies (Davidoff, 2014). Thus, both
groups differ in their underlying epistemologies and secure and apply knowledge in
different ways.
Theory has not commonly been used in the fields of patient safety and quality
improvement research (Grol et al., 2007; Walshe, 2007; Foy et al., 2011; Lipworth
et al., 2013) – at least, explicitly. A review of 235 implementation studies found that
only 53 mentioned or used theory in any demonstrable way and that only 14 were
explicitly theory based (Davies et al., 2010). Similarly, most reports of patient safety
practice evaluations do not report any theoretical model underpinning the interven-
tion. Even for the most commonly studied patient safety practices such as checklists,
medication reconciliation and falls prevention, a review of published evaluations
found only two studies that even partially reported a theory for why the practices
should work (Foy et al., 2011). Whether or not researchers report their use of theory
or their hypotheses, it is nevertheless obvious we use theories and hypotheses all the
time. Everyone formulates and is driven by theories and hypotheses but they remain
relatively invisible. Policymakers issue a policy, theorising that this will shape oth-
ers’ behaviours; clinicians treat patients, theorising that they will get well as a con-
sequence; patients trust their clinicians, theorising that this is a better bet than the
alternative.
What Is the Role of Theory in Research on Patient Safety and Quality Improvement? 61

Why might it be the case, then, that researchers and improvement practitioners
within healthcare quality and safety are so poor at explicitly mobilising theory to
support their findings or interventions? Lipworth et al. (2013) point to several reasons:

1. Unawareness of relevant theories or neglect to draw upon any conceptual

perspective.
2. Difficulty in choosing from the abundance of theories available.
3. If applying a particular theory, the one selected may prove insufficiently
broad to account for all relevant factors in the field of study.

In an attempt to solve some of these issues, the theoretical domains framework

(TDF) has been designed to apply in a variety of settings (Michie et al., 2005). The
TDF consists of a set of conceptual determinants and associated constructs from
psychological and organisational theory that is assumed to influence behaviour and
behavioural change. The framework was established to more accurately identify bar-
riers and levers and to design interventions with sufficient theoretical richness to
address them (Michie et  al., 2008). The TDF consists of 14 domains: knowledge,
skills, social and professional role and identity, beliefs about capabilities, optimism,
beliefs about consequences, reinforcement, intention, goals, memory, attention and
decision processes, environmental context and resources, social influences, emotion
and action planning (for more details, see Cane et al., 2012).
In a thematic synthesis of 50 studies of various clinical quality interventions
mapped to the domains of the TDF, Lipworth et al. (2013) found that the framework
could be used to map most, if not all, of the attitudinal and behavioural barriers and
facilitators of uptake of clinical quality interventions. All 14 domains emerged as rel-
evant, and the authors suggested a possible additional domain, taking the total to 15,
related to perceived trustworthiness of those instituting clinical quality interventions.

SAFETY SCIENCE THEORIES AND THEIR APPLICATION

IN HEALTHCARE
The safety science research field in general, at least among some adherents, has
been occupied, and sometimes preoccupied, with theorising. Anthropologists, soci-
ologists and critical realists have, for example, discussed and created models for
understanding risk (Parker and Stanworth, 2005), while others have created theories
for understanding the organisational and cultural drivers for safety (e.g. Braithwaite
et al., 2010). In the following, we have listed six different theoretical perspectives
manifesting in the safety science field (Aase and Rosness, 2013):

1. The energy and barrier perspective, according to which accidents can be

understood and prevented by focusing on dangerous energies and means
by which such energies can reliably be separated from vulnerable targets
(Gibson, 1961; Haddon, 1970, 1980). Reason’s Swiss Cheese Model is
­probably the most well-known example of such defence-in-depth barrier
thinking, also applied frequently within healthcare (Reason, 2000).
62 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

2. Perrow’s theory of normal accidents, which explains some major accidents

in terms of a mismatch between the properties of the technology to be
­controlled and the structure of the organisation responsible for controlling
the technology (Perrow, 1984).
3. The theory of High Reliability Organisations (HRO), which proposes that
some organisations have achieved an outstanding capacity to handle com-
plex technologies without generating major accidents by building organ-
isational redundancy and a capacity to reconfigure in adaptation to peak
demands and crisis (Rochlin et al., 1987; LaPorte and Consolini, 1991).
4. The information processing perspective (Turner, 1978; Turner and Pidgeon,
1997), which conceptualises an accident as a breakdown in the flow and
interpretation of information that is linked to physical events.
5. The decision-making perspective, with a focus on the handling of conflict-
ing objectives, including accounts of how activities migrating towards the
boundary of acceptable performance.
6. The resilience engineering perspective, which combines and elaborates
concepts and ideas from previous perspectives in an effort to build a more
coherent understanding of resilience in socio-technical systems and to pro-
vide tools to help organisations monitor and build resilience (Hollnagel
et al., 2006).

These different theoretical perspectives have distinguishable foci and operate at

­different levels. Despite their increasing popularity in the broader safety science field,
they have had limited applications within the patient safety and quality improvement
domains in healthcare, with some exceptions we describe below.

Root Cause Analysis, Swiss Cheese Model (Energy and Barrier Perspective)
Root cause analysis (RCA) is now widely used in many healthcare systems interna-
tionally. It stems from James Reasons’ conceptualisation of human error based on a
psychological tradition whereby errors are explained by linear cause–effect chains
and prevented by a set of barriers in the so-called defence-in-depth (Reason, 1990).
Following from this, the well-known Swiss Cheese Model was developed, visualis-
ing the defence-in-depth principle. RCA is a method of identifying the root causes
of faults or adverse events based on a linear cause–effect model. The root cause
prevents the final undesirable event from recurring, whereas a causal factor is one
that affects an event’s outcome but is not a root cause (see Braithwaite et al., 2006).
RCA is one of the most widely used methods to improving patient safety, but few
data exist that uphold its effectiveness, and critics are abundant (e.g. Rasmussen,
1997; Braithwaite et al., 2015). The quality of RCA varies across facilities, and its
effectiveness in lowering risk, or improving patient safety, has not been systemati-
cally established (e.g. Iedema, 2006; Shaqdan et al., 2014).
Following from the focus on RCA, the patient safety research field has also
been occupied with the taxonomy or classification of patient safety concepts. The
World Health Organization’s World Alliance for Patient Safety has developed an
International Classification for Patient Safety. This categorisation system aims to
What Is the Role of Theory in Research on Patient Safety and Quality Improvement? 63

transform patient safety information collected from disparate systems into a com-
mon format, thereby facilitating aggregation, analysis and learning. The conceptual
framework consists of 10 high level classes: incident type, patient outcomes, patient
characteristics, incident characteristics, contributing factors/hazards, organisational
outcomes, detection, mitigating factors, ameliorating actions and actions taken to
reduce risk. The 10 classes are presented in a flow chart (Sherman et al., 2009). The
basic principle behind the theory involves clarifying predefined characteristics in
order to manage future incidents.

Learning and Reporting (HRO Perspective)

Partly in line with the taxonomic view of errors and adverse events reported earlier,
learning and feedback from past experience is seen as a major building block in
preventive safety work. The 2000 Institute of Medicine (IOM) report (Kohn et al.,
2000) identified under-reporting of adverse events as a patient safety issue and rec-
ommended that hospitals develop non-punitive environments to promote incident
reporting. Patient safety advocates called for intensifying the reporting and a­ nalysis
of adverse events and near-misses, and most hospitals have today implemented
a variety of reporting systems modelled, in part, on experiences in the aviation
industry (Tamuz and Harrison, 2006).
The hallmark report ‘An organisation with a memory’ (UK Department of
Health, 2000) supported the arguments raised earlier but more clearly related the
issues of learning from adverse events to the theoretical areas of organisational
culture and safety information systems. Currently, multiple countries operate
with mandatory national systems for reporting and learning from adverse events.
Denmark became the first country to introduce nationwide mandatory reporting,
as laid out in the Danish Act on Patient Safety in 2004. The Act obligates frontline
personnel to report adverse events to a national reporting system. Hospital owners
are obligated to act on the reports, and the National Board of Health is obligated to
communicate the learning nationally. The reporting system is intended for learning
and frontline personnel cannot be sanctioned for reporting (Danish National Board
of Health, 2007).

Resilient Healthcare (Resilience Engineering Perspective)

Applying resilience engineering concepts to healthcare has become an increasingly
important research area within patient safety circles over the last decade. In a review
of the resilience engineering literature assessing 237 studies, Ringhi et  al. (2015)
found that healthcare accounted for 19% of the studies. They also reported that theo-
retical discussions or contributions accounted for more than 50% of the resilience
engineering studies (including ‘why resilience?’ and ‘what is resilience?’).
The major thread of the argument of resilient healthcare theory is to appreciate
that healthcare is resilient to a large extent and that everyday performance, such as
clinical practice, succeeds more often than it fails. Healthcare personnel adjust their
practices to match the conditions. Facilitating work flexibility, and actively trying
to increase the capacity of healthcare personnel to deliver care more effectively, is
64 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

a key component in resilient healthcare. This involves focusing on how everyday

performance usually succeeds rather than on why it occasionally fails and actively
working towards improving the former rather than preventing the latter (Hollnagel
et al., 2013; Wears et al., 2015; Braithwaite et al., in press).

QUALITY IMPROVEMENT THEORIES AND

THEIR APPLICATION IN HEALTHCARE
The quality improvement literature is large and diverse. Theories and models are not
always well defined and healthcare improvers, researchers and organisations often
draw on a range of tools and principles from different approaches (Powell et  al.,
2009). Unlike parts of the safety science field preoccupied with theoretical debates,
research on quality in healthcare has been more empirically driven, focusing on
practical, technical tools for improvement. However, there is also growing aware-
ness that a solely technical–empirical approach to quality improvement will not be
sufficient to embed and sustain the organisational change necessary to improve qual-
ity. Organisational, cultural and other contextual factors are increasingly considered
crucial to the success of quality improvement initiatives (Powell et al., 2009; Wiig
et al., 2014).
Another point where quality improvement and patient safety research departs
from the broader safety science field is in the degree of applications of different
theoretical perspectives or models in healthcare settings. As indicated earlier, we
have seen limited application of safety theories and models in healthcare, with some
exceptions. Within the quality improvement field more broadly there are abundant
applications of a diverse set of theories and models in healthcare. Most of these
theoretically based quality improvement approaches (with the marked exception of
Donabedian’s (1988) structure–process–outcome framework) come originally from
manufacturing industries in the field of total quality management and continuous
quality improvement processes and techniques (Berwick, 1996). Later, we will
briefly mention some of the approaches applied in healthcare. The descriptions are
based on Sales (2013), Powell et al. (2009), Boaden (2009) and Boaden et al. (2008).

Structure–Process–Outcome Framework
Donabedian’s (1988) framework for understanding factors influencing the quality of
care, and in particular outcomes of health services, has been influential in practice
and widely adopted in the literature on healthcare quality improvement. Donabedian
proposed that the structure of health services (e.g. physical facilities, types of ser-
vices available, staffing levels) influences the process of care. Care processes include
specific interventions such as surgery, prescribing medications and monitoring pro-
cesses of care. These factors influence outcomes, which can be at several different
levels, although the original framework focuses on patient-level outcomes of care.
These outcomes include whether a patient survives a care episode delivered during
an acute event, the quality of life someone has after receiving health services and
other sequelae of the health condition and of health services received (e.g. adverse
events). In later work, Donabedian also focused on system-level outcomes, such as
What Is the Role of Theory in Research on Patient Safety and Quality Improvement? 65

cost and efficiency (e.g. 1990). Widely adopted, but also critiqued for being too sim-
ple and overtly linear, the structure–process–outcome framework was designed (in
Donabedian’s own words) as ‘a handy classification scheme’. It has been influential,
too, as an input in the development of other approaches, for example, the seven pillars
for quality (similar to the six quality principles outlined by the United States’s IOM)
and the 11 essential principles for quality assurance (Schiff and Rucker, 2001).

Plan–Do –Study–Act Cycle

The Institute for Healthcare Improvement (IHI) in the United States has been the
most prominent advocate for the application of continuous quality improvement in
healthcare. The tenets of quality improvement according to this approach include the
use of data and statistical analysis to identify and control processes; the use of bench-
marking; the use of teams to identify problems, processes and solutions and the use
of some form of improvement process, usually described as a cycle: plan, do, study
(or check) and act. The Plan–Do–Study–Act (PDSA) cycle was originally devel-
oped by Deming (1986) and presented as the basis of the ‘Model for Improvement’
(Langley et al., 1996). The approach is typically applied repeatedly in small cycles
and is sometimes suggested as one of the phases in Six Sigma and Lean thinking.
IHI has developed the principles into processes called collaboratives involving a
number of teams working together with a group of experts to plan, implement and
monitor improvements in care.
The impact of PDSA cycles accompanied with collaborative arrangements in
healthcare appears to depend on the focus of the collaborative, the participants and
their host organisation and the style and method of implementing the collaborative
(Øvretveit et al., 2002). Its application in healthcare has been studied (compared with
other approaches), although there is little evidence to suggest it is more cost-effective
than any other approach. There is mixed evidence of its efficacy and contributions to
improvement (Taylor et al., 2014).

Six Sigma
Six Sigma is an improvement or redesign approach developed initially in manufac-
turing. The approach has been heavily promoted in the U.S. healthcare system. It is
presented as a systematic method for strategic process improvement and develop-
ment relying on statistical methods to reduce deficiencies that customers can identify,
also known as ‘customer-defined defect rates’ (Linderman et al., 2003). A common
method within Six Sigma includes the process improvement methodology similar
to the PDSA cycle: Define, Measure, Analyse, Improve and Control. Many organ-
isations appear to have re-labelled total quality management as Six Sigma, and a
recent development is the use of ‘Lean Six Sigma’, meant to facilitate streamlining
of processes.
There are a variety of reports on the application of Six Sigma in healthcare but
few that take a systematic approach to assessing its effectiveness. The evidence is
descriptive, with little by way of fundamental critique, examination of effectiveness
or independent evaluation.
66 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

Statistical Process Control

Statistical Process Control (SPC) methods can be traced to Shewhart (1931) who
identified the difference between ‘natural’ variation in measures of a process (termed
the ‘common cause’) and variation that could be controlled (termed the ‘assignable’
cause). Processes that exhibited only common cause variation are said to be in a state
of statistical control. SPC is a key tool in the total quality management framework
and is also used in Six Sigma and sometimes with the PDSA cycle. Recognition of
the importance of variation in healthcare has led to an interest in SPC, and a variety
of applications have been reported (Thor et al., 2007). Its application may be limited
by the extent to which the objective of improvement is the reduction of variation, the
complexity and appropriateness of data sets representing aggregations of different
types of patients or units and the implications of the underlying statistics of having
very small or very large data sets.

System-Wide Multi-Model Approaches

In practice, quality improvement models and their tools are used in a variety of
ways. They are rarely applied singly or sequentially; what is more common in health-
care settings is to draw on combinations or hybrids of the main approaches. Powell
et  al. (2009) have reviewed healthcare settings that stand out in the literature as
particularly successful or integrated examples of system-wide approaches to qual-
ity improvement. The Jönköping quality improvement programme (Sweden; see
description later in the chapter), the Kaiser Permanente system (United States), the
Quality Enhancement Research Initiative of the Veterans Health Administration
(United States) and the Organising for Quality leading hospitals (United Kingdom,
the Netherlands, United States) are all examples of such system-wide approaches
to quality improvement based on a variety of theoretical approaches and models.
While each is a unique example, they have common elements in their programmes:
effective leadership, an emphasis on teamwork, receptive organisation cultures and
support for continuous improvement of care processes. And what stands out in the
description and evaluation of these blended approaches is that quality improvement
models need to be supported with networks, structures, cultures and systems to
undergird the ‘organisational and human processes’ of quality.

Quality Improvement Healthcare Approaches Summarised

Reviewing the models and system-wide approaches to quality improvement shows
that there are strong commonalities between them: although they may have different
emphases, many share similar theoretical constructions, underlying objectives and
the distinctions between the approaches are often blurred in practice (Powell et al.,
2009). Moreover, each of the approaches and the data used to underpin them can
be used either to enable quality improvement by ‘inspiring and developing’ or to
­mandate quality improvement through ‘policing, punishing and rewarding’.
Despite the many insights into implementation emerging from the literature, it
remains challenging to assess the impact of specific theories, models or approaches
What Is the Role of Theory in Research on Patient Safety and Quality Improvement? 67

or to make comparisons across applications. There does seem to be a consensus that

there is no one ‘right’ or preferred quality improvement theory, framework or model.
Instead, successful quality improvement is more about the interaction between any
given approach and its implementation in the local context (Ovretveit et al., 2011;
Mittman, 2015).

A NORDIC PERSPECTIVE?
So, explicit applications of theory seem to be under-represented or under-reported in the
international literature on patient safety and quality (Walshe, 2007; Davies et al., 2010;
Foy et al., 2011), but many theories, frameworks and models are used in practice. As
documented elsewhere in this book, there seems to be no exception to this general rule
in the case of Nordic peer-reviewed academic journal articles within quality and patient
safety between 2000 and 2014. A main finding in the literature review reported in
Chapter 1 was the lack of theory in use. Of 163 Nordic journal articles only 8 (Johansen
et al., 2004; Øvretveit, 2007; Rahimi et al., 2009; Hovlid et al., 2012; Ingemansson et al.,
2012; Jakobsson and Wann-Hansson, 2013; Hovlid and Bukve, 2014; Jakobsen et al.,
2014) mentioned a theoretical perspective in the paper’s abstract (e.g. ­implementation
theory, model for understanding quality implementation, organisational learning).
One might deduce from this that there is no Nordic flavour to theorising within
quality and patient safety. Again our answer to the question is yes and no. Despite the
fact that, mirroring the broader literature, explicit theorising seems to be missing in
Nordic peer-reviewed articles over the last 15 years, we can nevertheless discern that
selected Nordic scholars in the past have put a substantial stamp of distinctiveness on
their work. Nordic scholars have developed or used theories and influenced the theo-
retical thinking of others within patient safety and quality improvement activities. And
further, contemporary Nordic researchers seem to bear the hallmark of these earlier
influences.
We can trace some of this Nordic influence by drawing on the work of three
scholars. These are Jens Rasmussen, Erik Hollnagel and John Øvretveit, and a ­setting –
Jönköping, in Sweden. Within the safety science field, the well-known Danish scholar
Rasmussen provided key concepts for understanding safety and accidents, many of
which resonate through the decades and remain relevant today. His publications,
spanning from 1969 to 2000, are too early to be included in the more recent literature
review presented in Chapter 1. Yet, Nordic (and international) authors with different
disciplinary influences (e.g. psychology, management and sociology) and orienta-
tions in the field of safety have indeed incorporated, in different ways, Rasmussen’s
ideas into their studies, building upon different aspects of his research over several
decades. Principles such as degree of freedom, self-organisation and adaptation, the
defence-in-depth fallacy and also Rasmussen’s notions of error still offer powerful
insights into the challenge of predicting and preventing major accidents (LeCoze,
2014). Even though Rasmussen did not specifically direct the majority of his work
towards healthcare, many of his ideas are prevalent in the patient safety research field.
Especially, Rasmussen’s move from a micro view of accidents to a macro (socio-
technical ­perspective), one in which he was trying to apprehend the bigger picture
of error, and his views of where safety science is seen as a cross-disciplinary pursuit
68 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

(Rasmussen, 1997, 2000; Rasmussen and Svedung, 2000) have sparked some of the
current trends in healthcare safety (e.g. Nemeth et al., 2008; Hollnagel et al., 2013).
One of Rasmussen’s early collaborators and later a critic of among others his ‘skill-
rule-knowledge’ model, Erik Hollnagel is another highly influential Danish safety
science scholar. Hollnagel has in many ways elaborated on some of Rasmussen’s
ideas related to self-organisation and the principles of a functional versus struc-
tural approach. He is one of the main thinkers behind resilience engineering and
later resilient healthcare theories (e.g. Hollnagel et al., 2013; Hollnagel, 2014). As
such, Hollnagel has come to be seen as a leading scholar and invaluable knowledge
broker, bridging the divide between safety science and patient safety, for example.
Hollnagel’s work on theorising healthcare resilience has mainly been published in
books and is therefore not included in the literature review referred to in Chapter 1. It
is nevertheless among the most persuasive of recent work, and one which we predict
will become increasingly influential.
Within the Nordic quality improvement research field, the Jönköping Quality
Program is widely known in Sweden and is seen internationally as a long-running
example of a successful system-wide improvement programme (Bodenheimer et al.,
2007; Øvretveit and Staines, 2007; Staines et al., 2015). Jönköping County Council
has gone further than most health systems in building an impressive infrastructure
for quality improvement and of helping make learning and improvement part of
everyday clinical practice. The emphasis on a ‘bottom-up’ approach, and refrain-
ing from ‘forcing’ individuals or departments into quality improvement, has been
characteristic. The Swedish culture and conditions allow this in ways that may be
more difficult in other contexts (Øvretveit and Staines, 2007). In a later evaluation of
the Jönköping Quality Program, Staines and colleagues (2015) found five key issues
shaping the improvement programme over the last 10 years:

1. A rigorously managed succession of the chief executive officer

2. Adept management of a changing external context
3. Clear strategic direction relating to integration
4. A broadened conceptualisation of ‘quality’ (incorporating clinical effec-
tiveness, patient safety and patient experience)
5. Continuing investment in quality improvement education and research

As the Jönköping example indicates, we may claim that theorising in quality

improvement research takes a different and more applied approach than it does in
patient safety research. Implementation research has been closely linked to qual-
ity improvement. In this field, the Swedish scholar John Øvretveit has played a key
role in evaluating improvement and implementation efforts, influencing the Nordic
quality and safety research agenda. Øvretveit has for decades advocated for evi-
dence- and theory-based evaluation of both quality improvement and patient safety
(e.g. Øvretveit, 2014). Fifteen years ago, Øvretveit published work on the Norwegian
approach to integrated quality development (Øvretveit, 2001) and was also influ-
ential in the evaluation of the Swedish Jönköping Quality Program (Øvretveit and
Staines, 2007). Øvretveit has been a strong advocate for the development and use
What Is the Role of Theory in Research on Patient Safety and Quality Improvement? 69

of programme theory, that is intervention-specific working models or hypotheses

(e.g. Foy et al., 2011; Øvretveit, 2014).
As shown in Chapter 1, articulating a patient perspective in quality improvement
and patient safety seems prominent in the Nordic literature. There is solid extant
documentation on the evaluation, experiences and perceptions of healthcare services
from the perspective of patients and next of kin. Even though no specific theoreti-
cal foundation exists for the extensive Nordic incorporation of the patient perspec-
tive into Nordic improvement efforts, we nevertheless suggest this is a cornerstone
of a Nordic health model and approach to healthcare provision. This favours, and
entails, principles of equality, the legal rights of patients and minimal power dis-
tance (Norden, 2013, 2014) between providers and recipients of care. This, we fur-
ther ­suggest, is part of a humane, inclusive approach rooted in societal solidarity and
welfareism, which we identified earlier, and which characterised Nordic thinking
and theorising.

IMPLICATIONS – ‘GOOD’ THEORISING WITHIN

PATIENT SAFETY AND QUALITY IMPROVEMENT RESEARCH?
Efforts to build theory that is useful for both research and practice will depend on the
extent to which we are able to identify constructs that capture the complex interface
between the clinical, behavioural and organisational domains within which health-
care personnel and patients coexist and collaborate (Mark et al., 2004). Several such
frameworks have emerged such as the TDF (Michie et al., 2005, 2008; Cane et al.,
2012), theory-driven improvement evaluations (Grol et al., 2007; Walshe, 2007; Foy
et al., 2011; Davidoff et al., 2015) and frameworks for building theories of context
(Kaplan et al., 2012; McDonald, 2013). To a considerable degree, theories, models
and frameworks partly overlap and several of them underpin quality improvement
interventions. Within safety science and more specifically within patient safety,
there is a multiplicity of theoretical perspectives, and they appear in fragmented
and piecemeal ways. No universal frameworks exist, but nor would we expect this.
Pronovost et  al. (2009), for example, developed a framework for patient safety
research and improvement (see also Chapter 1) to clarify broad clinical and policy
domains that link to safety. The taxonomy is presented as a prioritisation tool rather
than a theoretical framework.
Synthesising what we have said in this chapter, then, we present a set of generic
issues that improvers and researchers might have regard to when theorising within
patient safety and quality, regardless of research topic or domain:

• Seek to make explicit the theoretical assumptions behind the choice of

research focus or improvement efforts (Grol et  al., 2007; Davidoff et  al.,
2015).
• Describe contextual factors (e.g. external, organisational, professional, man-
agerial, cultural, implementation–orientation) that might have an impact on
the theoretical assumptions of any research topic or improvement efforts
(Foy et al., 2011; Kaplan, 2012; Mc Donald, 2013).
70 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

• Base any initial theoretical assumptions on literature reviews, consensus-

driven approaches and/or conceptual frameworks (Foy et al., 2011; Davidoff
et al., 2015).
• Base any theorising on interdisciplinary collaborations (e.g. medical, nurs-
ing, psychology, sociology, management science) that can identify the core
of the theoretical perspectives (Foy et al., 2011).
• Be alert to the possibility of being led astray by apparently attractive
theories that may be partially inappropriate for the context or are flawed
(Davidoff et al., 2015).

CONCLUSION
Theory takes many forms, some informal, some highly structured. Formal theory
can complement informal, experience-based theory, helping to define areas of dys-
function in patient safety and quality, pinpointing their loci and identifying their pos-
sible mechanisms (Davidoff et al., 2015). Formal theoretical frameworks can allow
the accumulation of knowledge based on informal or small theories and empirical
observations.
All in all, in this chapter we have argued for the importance of theory for improv-
ers and researchers, and we would emphasise by way of concluding, four key points.

1. Explicit and formalised theorising is largely missing in research and prac-

tice within quality and safety in healthcare.
2. When theorising does occur, it takes on very different forms within the
fields of quality and safety.
3. There are many theoretical perspectives, theory-oriented models and
frameworks on which to draw.
4. We can trace the contribution of early theories, theorists and scholars such
as Rasmussen, Hollnagel and Øvretveit and a setting, Jönköping, and see
their ideas and influence having a discernible Nordic flavour, and as being
reflected in current Nordic and other international improvement work and
safety and quality research.

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 5 Working in an
Institutionally Layered
System on Patient
Safety and Quality*
Hester van de Bovenkamp,
Annemiek Stoopendaal and Roland Bal

CONTENTS
Introduction............................................................................................................... 75
Institutional Layering................................................................................................ 76
Institutional Layering in Dutch Healthcare............................................................... 77
Interactions between Layers..................................................................................... 78
Working with Layers................................................................................................. 81
Conclusions: Lessons from the Dutch Case..............................................................84
References................................................................................................................. 85

INTRODUCTION
In many Western healthcare systems, market elements, such as patient choice and
transparency, have been introduced. Dutch healthcare is a case in point. Here, a sys-
tem of regulated competition was officially introduced in 2006. The introduction of
the regulated market did not mean that other previously existing institutional arrange-
ments to govern healthcare quality, such as professional self-regulation and top-
down state regulation, have disappeared. Instead, these pre-existing arrangements
have become incorporated in and conditioned by regulated markets. This process of
adding institutional arrangements to the old can be described as one of institutional
layerings. Institutional layering in healthcare means that increasingly complicated
mixed arrangements to govern healthcare quality are introduced (Streeck and Thelen
2005). Since the institutional context of healthcare organisations impacts quality
and safety work and power relations in the healthcare sector, it is important to study
this context. More specifically, when this context becomes more complex because

* This chapter is based on van de Bovenkamp, H., Stoopendaal, A., Bal, R. Working with layers: The
governance and regulation of health care quality in an institutionally layered system, to be published
and van de Bovenkamp, H., de Mul, M., Quartz, J., Weggelaar, A., Bal, R., Institutional Layering in
governing health care quality, Public Administration, 92, 208–223, 2014.

75
76 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

of layering, of which the consequences can be unpredictable, it is important to learn

more about how institutional layering works out in healthcare practice.
This chapter reveals the process of institutional layering in Dutch healthcare and
shows the consequences this can have for actors working in such an institutionally
layered context and how they in turn try to change this context. We specifically focus
on the governance of quality of and in hospitals. The chapter is based on qualita-
tive research into institutional layering of the governance of healthcare quality in
the Netherlands and draws on interviews (n = 39) with key actors involved in the
governance of healthcare quality, such as hospital directors, quality staff in hospi-
tals, healthcare professionals, insurers, state regulators, policymakers and experts.
In addition, we analysed relevant documents and literature on the governance of
quality of care.

INSTITUTIONAL LAYERING
According to institutional theory, institutions shape the perception of problems and
possible solutions. Moreover, institutional arrangements are important for setting
incentives and constraints for action and shape power relations (March and Olson
1996; Mahoney and Thelen 2010). When analysing social processes, in this instance
quality improvement (QI) work, it is therefore important to take the institutional
context into account and try to understand this context in order to understand its
influence on these processes.
To further our understanding of institutional arrangements, typologies have been
developed (Helderman 2007; Pollitt and Bouckaert 2011). Table 5.1 is an example
of such a typology. It builds on a distinction between four institutional arrange-
ments (state, market, civil society and professional community) coupled with the
­governing mechanisms that are dominant within these arrangements (top-down
regulation, contracts, consultation and self-regulation, respectively). The ideal types

TABLE 5.1
Ideal Typical Institutional Arrangements with Dominant Governing
Mechanisms
Level of Self-Regulation of Collective Actors
Low High
Level of state High State and hierarchy: top-down Civil society/association: consultation
intervention regulation
Low Market: contract Professional community: self-regulation

Sources: Based on Helderman, J.K., Bringing the Market Back In? Institutional Complementarity
and Hierarchy in Dutch Housing and Health Care, Erasmus Universiteit Rotterdam,
Rotterdam, the Netherlands, 2007; Bal, R., De nieuwe zichtbaarheid: Sturing in tijden van
­marktwerking, Erasmus Universiteit Rotterdam, Rotterdam, the Netherlands, 2008.
Working in an Institutionally Layered System on Patient Safety and Quality 77

can be separated based on (1) the extent the state has a dominant position and is able
to influence decision-making and (2) the room private and societal actors have to
regulate themselves. Based on these axes, the typology separates four institutional
arrangements which differ in terms of who is able to play a key role, how decision-
making is organised and how decisions are implemented.
As said, the institutional arrangements in this table are ideal types. In practice,
institutional arrangements are often hybrids; they consist of elements from more
than one type. These ideal types therefore should be seen as a heuristic device that
helps us to analyse the institutional arrangement and its changes (i.e. moving closer
to or further away from a certain ideal type).
The concept of institutional layering has been introduced to better understand
(the dynamic development of) complex hybrid arrangements (Streeck and Thelen
2005; Mahoney and Thelen 2010). Institutional layering occurs when new institu-
tions are added to existing ones; new layers overlie others but do not necessarily
replace them (Dent 2003; Pollitt and Bouckaert 2011). In other words, existing insti-
tutions still play a role, albeit a different one. Institutional layering can occur when
challengers of the current system lack the capacity to change the original rules while
defenders of the current system are unable to prevent new rules being added to the
old (Streeck and Thelen 2005; Mahoney and Thelen 2010). Institutional ­layering
does not mean that new arrangements simply overlie others but that arrangements
interact with each other which can have important consequences for actors working
in such a layered arrangement. For example, people working in a hospital on qual-
ity and safety will have to deal with the effects of working in a system that is both
market driven and community based, asking them to compete and collaborate with
other hospitals.
However, these actors are not just passively undergoing the effects of their institu-
tional setting. They engage in institutional work which consists of the daily coping,
keeping up and strategic use of their institutional context which can both sustain and
change institutional structures (Feldman and Pentland 2003; Lawrence et al. 2011).
In order to understand the consequences of layering for actors working in a layered
healthcare system, it is therefore important to also look at the actions of these actors
in response to their institutional context. In this chapter, we look at both the process
of institutional layering in Dutch hospital care and how hospitals – more specifically,
boards of directors which are responsible for the quality of care in hospitals – engage
in institutional work.

INSTITUTIONAL LAYERING IN DUTCH HEALTHCARE

In this section, we describe the system of Dutch healthcare using the ideal types of
institutional arrangements described earlier (Table 5.1).
In the Netherlands, as in most countries, quality of care was originally strongly
based on self-regulation by the professional community (lower right quadrant
Table  5.1). This arrangement drew mainly on education and on quality instru-
ments such as peer review, clinical guidelines and visitation among peers (Klazinga
1996). The strong position of professionals to govern quality that is present in this
78 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

arrangement proved not to be easily replaced. However, as we show in the following,

throughout the years this position has been amended and increasingly other actors
drawing on other instruments became involved in the governance of quality of care.
From the end of the 1980s onwards, the civil society arrangement in which
­consultation with societal actors involved in healthcare – professionals, healthcare
providers, patient organisations, insurers and government – played an important role
in order to get a grip on healthcare costs (top right quadrant Table 5.1) (Bal 2008).
These consultations resulted in several acts to regulate quality, among which the
Individual Healthcare Professionals Act (1997) and the Quality of Care Act (1996).
After several years, it was concluded that the implementation of these acts by
healthcare organisations fell short (Casparie et al. 2001). For example, hospitals were
meant to build quality systems which they did only to a limited extent. As a result
of this, the question was raised if relying on self-regulation of the field was still ade-
quate. This resulted on the one hand in more state regulation of quality by giving the
Healthcare Inspectorate a more prominent role (top left quadrant Table 5.1). On the
other hand, it resulted in the introduction of the market-based system in 2006 (lower
left quadrant Table 5.1), which was from then on the official institutional arrangement
to govern quality.* Within this system, providers, insurers and patients are meant to
regulate healthcare through competition and closing contracts on three markets. In
the healthcare provision market, hospitals (mostly private not-for-profit) compete for
patients. In the healthcare insurance market (health insurance is obligatory), insur-
ers compete for the insured. Both healthcare providers and insurers are active in the
healthcare purchasing market. Here, insurers can buy care selectively on the basis of
quality and price. Transparency of healthcare quality through the use of indicators is
seen as a crucial instrument for the market to work, since quality information to make
informed decisions is needed by patients, insurers and providers alike.

INTERACTIONS BETWEEN LAYERS

In this section, we describe how the introduction of the regulated market interacts
with the other institutional layers the Dutch quality system is built on.
As stated earlier, self-regulation by the professional community has histori-
cally been strong. Respondents still recognise this as an important mechanism to
ensure quality. However, they feel that relying on self-regulation is not enough. Some
explicitly argue that outside pressure is needed for hospitals to work on QI, thereby
legitimising other actors to play a role in governing quality.

I have worked in hospitals for thirty years and it just does not happen [quality improve-
ment from within]. (…) one way or the other it proves to be incredibly difficult.
So therefore outside incentives are necessary to accomplish this or in any case to move
substantially ahead and they [hospitals] will never succeed on their own.
Healthcare insurer

* The introduction of the market arrangement was first and foremost an attempt to contain healthcare
costs. However, the idea was that market parties would compete not only on price but also on quality,
thereby giving healthcare providers an incentive to improve their quality.
Working in an Institutionally Layered System on Patient Safety and Quality 79

The introduction of a system of regulated competition has caused the focus to shift
from self-regulation (either by hospitals or by professionals) towards outside pres-
sure for change. An important instrument for this is transparency of quality through
the use of performance indicators. This transparency should allow patients to make
choices about which hospital to go to, insurers to selectively buy care from hospitals
and hospitals themselves to improve quality in order to stay ahead of the competi-
tion. The introduction of the market also means that other actors, such as insurers,
patient organisations and private consultants, have increasingly become involved
in QI. This outside interference does not mean that professional self-regulation is
gone. It still plays a role through the quality instruments of the profession which
are still in place (such as guidelines, peer review, medical education). The role
these instruments play do start to change however as a result of the introduction
of the market-based system since other actors also start to use them for regulatory
purposes. Guidelines of the professional community, for example, were originally
meant to guide choices of professionals who could decide, based on their profes-
sional autonomy, not to follow them. However, these guidelines are now also used
by other actors such as the Inspectorate as standards for good quality care, which
makes it harder for professionals to deviate from them when they think this is bet-
ter for the patient. This way, instruments such as guidelines which originally were
a way of safeguarding professional autonomy from outside regulation, can now, as
they are used more stringently by other actors, actually partly erode this autonomy
(e.g. Dent 2003).
The introduction of the regulated market also had its effect on the role of the
civil society arrangement in which a consensual mode of decision-making is the
dominant governance mechanism. Just as self-regulation, this institutional arrange-
ment is not gone. However, it did become somewhat less important. Insurers, for
example, argue that the consultation process takes too long to get results. Although
they think that consultation is still important, they feel it is not absolutely necessary
anymore and sometimes proceed with their QI efforts without consultation with the
field. One respondent who works for an insurance company which published a rank-
ing of hospitals with regard to breast cancer treatment explained that they chose to
publish this list without consulting the field first. She explains the rationale behind
this choice as follows:

Yes changes have been made after that [the introduction of the breast cancer lists], and
that mostly has to do with the involvement of professional and patient organizations. …
The breast cancer trajectory has been developed very fast. On purpose, since we really
wanted to make a statement: ‘we are going to do this’. And you know as soon as you
start to talk about it with someone, then everybody knows and then you do not get to
make your point as effectively. So it was an explicit choice. However, now we feel we
want to consult with professional and patient representative organizations beforehand;
however, that does not mean that we will follow them no matter what.
Healthcare insurer

The regulated market interacts with top-down state regulation in a different way.
These institutional arrangements can best be described as mutually reinforcing
80 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

since the introduction of regulated competition did not only put pressure on hospi-
tals to improve but it also put pressure on government to become involved in the
issue of healthcare quality. As a result of the increased transparency of healthcare
quality, ­situations of failing quality have come to the fore (Klink 2009). These can
often count on extensive attention from the media. In such a case, the Minister of
Health is often called to account in Parliament. One response of the Ministry has
been to stimulate markets parties to perform their designated role. An example of
this is urging insurers to selectively buy their care based on quality (Klink 2009;
Schippers 2011). A way to stimulate this process has been by increasing the number of
­diagnosis-related groups on which insurers can freely negotiate prices with hospitals
(Schippers 2011). Another response to instances of failing quality coming to light has
been to steer quality top down. One example of this is the Ministry’s response to the
publication of numbers on avoidable deaths:

Then the minister said that his ambition was … that the number of avoidable deaths,
whatever that is, would decrease by 50%. And there you see [the increased interfer-
ence] of government, that was quite unique, government had not said something like
that before … the minister had to explain to Parliament how something like that was
possible.
Healthcare inspector

A national safety programme forcing hospitals to have a safety system in place by

the end of 2012 was initiated by the Ministry as the result of this debate (www.
vmszorg.nl). Moreover, the Healthcare Inspectorate has increasingly taken on a
more stringent role in the supervision of healthcare quality, closing hospital wards
and surgeries which did not comply with the standards and putting an increas-
ing number of organisations under ‘stringent supervision’. Also, the Inspectorate
has been ordered to use methods like mystery guests (in which case inspectors
or members of the general public visit healthcare organisations pretending to be
family members of future clients in order to get a view of day-to-day care provi-
sion) and unannounced visits (in which case inspectors visit healthcare organisa-
tions unannounced) in order to get more grip on healthcare quality (Schippers
2012; Adams et al. 2015; Stoopendaal 2015). In addition, the Ministry has set up
a national quality institute, which is meant to stimulate guideline development, in
order to gain more control over quality (Klink 2010; https://www.zorginstituut­
nederland.nl/kwaliteit).
We can conclude that, as the term ‘regulated competition’ already seems
to imply, state and market arrangements are mutually reinforcing. Nevertheless, to
say that state and market are now the dominant arrangements is overstated, as self-
regulation and consultation are still very much at play as well, albeit with different
meanings attached. This means that the institutionally layered system that is in place
at the moment has caused many actors to be involved with the issue of quality of
care in hospitals, who all use their own instruments to govern quality or each other’s
instruments in different ways. A summary of the layered institutional arrangement
can be found in Table 5.2.
Working in an Institutionally Layered System on Patient Safety and Quality 81

TABLE 5.2
Layered Institutional Arrangement Dutch Healthcare
Institutional Important
Arrangement Actors Steering Instruments Period
Market Insurers, Competition, closing contracts, Officially introduced as the
healthcare transparency dominant arrangement in
providers, 2006, after an incremental
patients change process
State and Ministry of Top-down regulation through Always played a role,
hierarchy Health, legislation (e.g. Quality of Care importance increased
Healthcare Act, Individual Healthcare from the 2000s onwards
Inspectorate Professions Act) and supervision and especially after the
implementation of the
market-based system
Civil society/ Healthcare Consultation and deliberation, for Especially important in the
association professionals, example, in setting performance 1990s, still plays a role
providers, indicators. Was important in the but less dominant than
insurers, development of the Quality of Care before
patient Act in the 1990s. And again in
organisations, setting limits on economic growth
government of the healthcare sector in 2012
Professional Healthcare Medical training, peer review, Oldest, still highly
community professionals guidelines, visitation, quality important but less
systems dominant than before

WORKING WITH LAYERS

The layered arrangement means that hospitals have to deal with many actors with
diverging quality demands ranging from top-down government legislation, supervi-
sion and Q&S programmes; to negotiations with insurers; to visitation, guidelines
and education of professional organisations and to patient organisations that have
developed their own indicators, prizes and rankings. Moreover, due to the increased
transparency of quality of care, the media also plays an increasing role in the quality
debate, as do politicians who are responding to whatever is reported in the media.
Hospitals have to relate to all these actors and their quality and information demands
within differing governance regimes (market negotiations, state control, consultation
and self-governance). In the following, we discuss how hospital boards engage with
the layered institutional context and how they try to use and influence this context.
Our respondents emphasise the important role transparency, introduced as part
of the market-based system, and the resulting media attention for quality incidents
played in getting the subject of quality on the agenda of hospital boards.

The responsibility for the content of care was completely assigned to professionals; they
did not have to be accountable for this. This was changed legally with the introduction
of the Quality of Care Act in 1996. The Boards of Directors legally carry the final
82 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

responsibility for everything in the organization. That includes the quality and safety of
the care process. That has been duly noted for a long time. Nothing happened with that
however. Until, and that is the first time this was exposed, the Radboud case [case con-
cerning high mortality rates on a cardiology ward that lead to public upheaval in 2008]
Governance expert and former chief inspector

Incidents like these were analysed in terms of failing governance by both the
Inspectorate and the Ministry of Health. For example, the Ministry of Health empha-
sised the role and responsibility of the Supervisory Boards and the ‘indisputable
end responsibility’ of the Board of Directors in response to cases of failing quality
(Klink 2009; Schippers and Van Rijn 2013), reframing patient safety as a manage-
rial and governance issue (Behr et al. 2015). So even though the Board of Directors
was assigned the legal responsibility for ensuring quality of care already in the mid-
1990s, this was put into practice much later, when as a result of the introduction
of the regulated competition system accompanied by the increased transparency of
care, they were urged to take up their role. This role attributed to hospital boards in
ensuring quality of care has consequences for the internal power relations in hospi-
tals. The position of hospital boards vis-à-vis professionals has been strengthened as
a result, a relationship which is described as a continuous struggle.

If the relationship [between Board of Directors and medical professionals] is poor,

then the medical staff will say to the director: quality in the consultation room
is our thing. [I] agree when this concerns the one-on-one contact with the patient.
[I] disagree when this concerns what happens next. I don’t need to know what ­happens
in the consultation room, but I do need to know how the individual specialist and his
group of specialists work on quality and how they ensure the quality of care provided
in that consultation room
Former hospital director and former inspector

Boards of Directors draw on the institutionally layered context to get more grip
on quality and by consequence on healthcare professionals. In order to gain con-
trol, they, for example, built quality systems for which they draw on the myriad of
information that is available as a result of the layered arrangement with its informa-
tion demands of external actors. They also use instruments used by other actors to
strengthen their position internally. For example, Bal et al. (2015) have shown that
hospital rankings, which are part of the market-based system, are used internally by
hospital boards as a strategic tool to weaken the position of medical professionals
and to take up their responsibility with regard to quality. The information drawn
from indicators is used in a similar way.

Throughout the years you step in earlier (…). That helps. Because there is more infor-
mation, we now at least have the HSMR [Hospital Standardized Mortality Rate], well
we did not have those eight years ago.
Hospital director

The layered institutional arrangement does not only help hospital boards to take up
their responsibility with regard to quality but also poses new problems for them.
Working in an Institutionally Layered System on Patient Safety and Quality 83

Being in an institutionally layered arrangement means having to relate to many

external actors who all want, slightly different, information. First, they have to relate
to market parties such as patient organisations and insurers. Hospital boards do not
always see the added value for quality of this.

They poor out this bureaucracy all over you and you have to comply with that. So that
keeps your organization busy. And subsequently the health care purchaser [insurer]
comes by and you just talk about money.
Hospital director

Second, they have to relate to quality demands of the professional associations that
are active in the self-regulatory regime. Third, they have to relate to state legislation
and the Inspectorate who, as shown earlier, are also increasingly involved in quality
issues. Especially because government takes action in an incident-driven way this
causes problems according to respondents since this formalisation and fragmentation
prevents them to work on quality in a structured manner. Moreover, the fact that these
external actors rely heavily on formal systems in which hospitals have to account for
their quality work, makes it hard for hospital boards to incorporate more informal
quality assurance activities, such as visiting wards and having informal conversations
with staff. These informal activities are, according to respondents working in hospi-
tals, highly important to govern quality. However, they are hard to give account of
to external parties. This causes the formalistic tools used by external parties and the
need for situated informal approaches to be increasingly disconnected.
In response to these challenges, hospital boards perform institutional work in
order to try to influence the institutional context they are in. One strategy they use
is to refuse to comply with external demands when boards feel they are of no extra
value to quality of care. They argue that they have to prioritise certain demands over
others to keep the pressure manageable and try to regain control over the quality
agenda (see also Quartz et al. 2012).

They [a hospital] made an inventory about the number of guidelines, regulation etc.
they had to follow and they came to the number of 1400. His [director of the hospital]
proposition is that you have to make a well argued choice about what you focus your
attention on, because 1400 subjects is a pointless exercise (…) that you pick ten themes
and as Board of Directors you decide to work on those.
Healthcare Inspectorate

Hospital boards also try to deal with quality more proactively in an attempt to
reshape and (re)gain control over quality. They do so, for instance, by building qual-
ity systems which pay attention to both formal and informal aspects of quality gov-
ernance, in this way overcoming the overly formalistic approach used by outside
actors. Last, by actively contributing to national discussions on quality and develop-
ment processes of quality instruments, hospital boards and professionals also try to
influence the external demands put on them through the mechanisms of the associa-
tional order. These examples show that institutional work can help actors to influence
their position in relation to the institutional context.
84 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

CONCLUSIONS: LESSONS FROM THE DUTCH CASE

The institutional context of healthcare organisations impacts their quality and safety
work and the power relations of the organisation vis-à-vis external parties as well
as of hospital boards vis-à-vis professionals in their organisations. When analysing
quality and safety work, it is therefore important to pay attention to this institutional
context.
In healthcare, these institutional contexts have become increasingly complex due
to the twin introduction of market mechanisms, such as patient choice and transpar-
ency and an increasing influence of the state, which have complemented professional
self-regulation. This increased complexity can also be seen in the Nordic countries
(Deilkås et al. 2015; Lehman et al. 2015; Øvretveit et al. 2015). In this chapter, we
focused on the complexity of these governance arrangements, its consequences and
how hospitals relate to these by using the concepts of institutional layering and insti-
tutional work. We used Dutch healthcare as a case study. The specifics of the layered
arrangements will be different across countries. For instance, in the Nordic countries
historically a consensual mode of decision-making has been more dominant than
in other countries, which will impact the implementation of new policies (van de
Bovenkamp et al. 2011). However, this does not mean that we cannot draw lessons
from this chapter for other healthcare systems.
First, an important lesson is that how reforms such as the introduction of market
mechanisms in healthcare work out will depend on their interaction with existing
institutional arrangements (see also Dent 2003; Kodate 2010; Pollit and Boackaert
2011). The effects of these reforms partly depend on the local dynamics created by
the history of the healthcare system. We therefore need comparative studies between
countries to understand these dynamics and effects better. This insight also provides
a lesson for policymakers and analysts who need to think about and reflect on the
interactions between arrangements and the effects certain reforms create.
Second, we can learn that actors working in hospitals (or other healthcare organ-
isations affected by layering) have to deal with the effects of institutional layering
such as fragmentation of quality demands. Our case study offers important insights
into how they can do this, namely, by using the new institutional arrangements to
change power relations (e.g. between hospital boards and professionals) or to influ-
ence new institutional frameworks by using pre-existing ones (such as we saw in the
attempts of hospitals to influence and negotiate external demands).
The chapter shows that having to relate to an institutionally layered context can
be both enabling and disabling for actors working on quality in healthcare organisa-
tions, in our case hospital boards. On the one hand, it has given them the opportunity
to strengthen their position on quality internally and also given them the instru-
ments to better govern quality within the hospital organisation. Hospital boards can
therefore also use the layered context to further their end. On the other hand, it has
provided them with additional challenges to work on quality effectively. It has been
shown before that layering can have a burdening effect (Van der Heijden 2011). Our
case supports this conclusion since having to relate to external actors involved in
healthcare quality can result in working on quality in an ad hoc manner because of a
politics of incidents, a high registration burden and a strong focus on accounting for
Working in an Institutionally Layered System on Patient Safety and Quality 85

one’s actions which draws attention away from the informal activities that are needed
for actors to take up their role. We have also seen, however, that actors engage in
institutional work to reshape their institutional context in order to work on quality
more effectively (Lawrence et al. 2011). Working in a layered institutional arrange-
ment is therefore not only a struggle for actors, but it also offers potential to use and
play with layers in order to get a grip on healthcare quality and safety.
In order to use this potential, insight into the specifics of layering of a certain
­system is highly relevant. The same goes for the specifics of how actors can try
to influence their institutional context, which may differ between countries. This
insight is highly relevant since healthcare organisations and policymakers alike can
use it to govern quality more effectively. ‘Archaeological’ studies into layering and
studies into the institutional work of actors can help in gaining such insights.

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Section II
Contemporary Nordic
Research – Macro-Level Issues
 6 Centralisation Efforts
to Improve the
Quality of Care and
Reduce the Costs in
Healthcare Systems
Pia Kjær Kristensen and Søren Paaske Johnsen

CONTENTS
Introduction............................................................................................................... 89
Scale Effects..............................................................................................................90
Definition of Volume............................................................................................90
Outcomes............................................................................................................. 91
Scale Effects across Different Diseases............................................................... 91
Is There a Linear Scale Advantage?.......................................................................... 93
Patient Selection...................................................................................................94
Quality of Care.....................................................................................................94
Clinical Skills....................................................................................................... 95
Hospital Organisation...........................................................................................96
Interpreting the Volume–Outcome Relationship.......................................................96
Volume Threshold................................................................................................96
Implications...............................................................................................................97
Future Research........................................................................................................ 98
References.................................................................................................................99

INTRODUCTION
Efforts to improve the quality of healthcare and reduce costs in healthcare systems
often focus on centralising care in high-volume hospital units. Worldwide hospital
consolidation has increased over the last few years; in the United States, it is pre-
dicted that 20% of all hospitals will seek a merger in the next 5 years (Creswell and
Abelson 2013). In some Nordic countries (e.g. Denmark), some level of centralisation
has already occurred; but in other countries, this process has been less pronounced to
date, due to challenges like isolating geography or long distances between h­ ospitals
(e.g. Norway).

89
90 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

Several studies have investigated whether the number of patients treated in a

department (or the number of specific procedures performed) was associated with
patient outcome. This association, called the volume–outcome relationship, has
received increasing interest over the decades, due to the hypothesis that ‘practice
makes perfect’ and an expectation that centralised care may lead to more cost-­
effective care, due to the economics of scale. Indeed, large enterprises generally gain
cost advantages, because fixed costs can be spread out over more units of output;
therefore, the cost per unit of output decreases with increasing volume.
This chapter describes the current literature on the volume–outcome relationship,
including a discussion on the methodological issues related to interpreting reported
data. Furthermore, we will describe potential mechanisms underlying this associa-
tion, including the quality of delivered care, clinical skills, patient selection and hos-
pital organisation. Finally, we will discuss interpretations of the data available on
the volume–outcome relationship and the implications of healthcare centralisation,
particularly for Nordic countries.

SCALE EFFECTS
A large number of studies have investigated the volume–outcome relationship
across a wide range of clinical conditions. This relationship has been most fre-
quently studied with regard to surgery and cancer care, but some studies inves-
tigated this relationship with regard to patients with acute and chronic medical
conditions. In the following review, we will analyse the current understanding of
the volume–outcome relationship across different diseases to assess potential scale
effects. The scale effect most often pertains to cost-effectiveness, but it may also
pertain to quality of care improvements, due to increased routine and specialisa-
tion in the organisation.

Definition of Volume
Volume can be defined both as the cumulative number of patients ever treated (e.g.
as in a learning curve for a surgeon learning a new technique) and as the number
of patients that must be treated per time period to maintain proficiency in a skill
or procedure. Later, we will focus on the latter definition. Moreover, the literature
distinguishes between the volume pertaining to a single physician and the volume
pertaining to a hospital. Thus, the ‘physician volume’ is the experience required for
an individual physician to provide satisfactory quality of care with a given technique
or procedure (e.g. a surgeon that performs a few procedures per year is likely per-
form surgery less effectively than a surgeon that performs several procedures per
week). In contrast, the ‘hospital volume’ reflects the hospital’s overall experience
with a procedure (e.g. high-volume units may be more likely to have teams that work
effectively together, systems in place to identify complications early and efficient
mechanisms for responding to complications).
It is likely that the provider (e.g. physician) volume and hospital volume interact,
but few studies have examined both types of volume simultaneously. One of those
Centralisation Efforts to Improve the Quality of Care in Healthcare Systems 91

studies found a multiplicative effect; thus, better outcomes were observed when
­high-volume physicians practised in high-volume hospitals (Hannan et  al. 1991).
However, other studies have not confirmed that effect (Lindenauer et al. 2006).
Very few studies have investigated patient volume as a continuous variable. In
contrast, most studies had used fixed categories of patient/procedure volume. Due to
the different organisations found among healthcare systems internationally, a variety
of volume categories have been used. Consequently, volume that may be defined
as high in one study may correspond to a low volume in another study. Therefore,
caution is necessary when making comparisons across studies.

Outcomes
Mortality is the most frequently examined outcome. Few studies have examined
the risk of complications, length of hospital stay or risk of readmission (Halm et al.
2002). However, the possible association of volume with these outcomes is impor-
tant, because they represent aspects of healthcare other than mortality. For many
conditions, such as patients undergoing knee and hip arthroplasties, mortality is not
a useful outcome measure, due to the very low mortality risk (Glassou et al. 2014).
Complications, such as the revision rate, might be a more appropriate measure,
because it is a frequent outcome after hip/knee replacement surgery, and it may more
directly reflect the quality of provided care. However, for many studies, the follow-
up period is too short to detect all relevant complications. In addition, the length of
hospital stay and readmission rate reflect both in-hospital care and care transitions
between hospitals and primary care.

Scale Effects across Different Diseases

Many studies have linked a high patient volume with low mortality, particularly for
patients that require advanced surgical and invasive procedures (Halm et al. 2002,
Koelemay and Vahl 2007, Post et al. 2010, Ross et al. 2010, Joynt et al. 2011, Zevin
et  al. 2012). For example, patients with cancer of the oesophagus, liver and pan-
creas appear to have better survival rates when they are admitted to high-volume
units or treated by high-volume physicians than when they are treated at low-volume
units or by low-volume physicians (Begg et al. 1998, Gordon et al. 1999). The same
association was observed in patients that underwent treatments for cardiovascular
diseases, such as percutaneous coronary intervention, surgery for abdominal aor-
tic aneurysms, thrombolytic therapy for myocardial infarction, paediatric cardiac
surgery or bypass surgery (Halm et al. 2002, Koelemay and Vahl 2007, Post et al.
2010, Joynt et al. 2011). Patients that receive organ transplantation or bariatric sur-
gery at high-volume hospitals also appear to have better survival rates than patients
admitted to low-volume hospitals (Zevin et al. 2012). However, evidence that sup-
ports a relationship between volume and outcome is quite limited and inconsistent
for many relatively simple surgical procedures and conditions, for example, ortho-
paedic procedures (Halm et  al. 2002, Franzo et  al. 2005, Kristensen et  al. 2014).
Although surgical procedures have received more attention than medical treatments,
there is some evidence to suggest that patients with acute myocardial infarction,
92 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

breast cancer, stroke or HIV infections benefit from physicians that have treated
more patients with those conditions (Bennett et al. 1989, Sainsbury et al. 1995, Ross
et al. 2010, Svendsen et al. 2012). One study that focused on common medical condi-
tions, including pneumonia, showed no difference in mortality between low-volume
and high-volume hospitals (Lindenauer et al. 2006).
Overall, existing studies have indicated that a high volume may be associated
with low mortality among patients that undergo advanced surgery or invasive proce-
dures and among patients with complex medical conditions. In contrast, no consistent
association has been found for patients that undergo relatively simple, standardised
surgical procedures.
The association is less clear between patient volume and other outcomes, includ-
ing length of stay and readmission rates. Among patients with hip fractures and
patients with pneumonia, a high volume has been associated with a longer length of
stay (Lindenauer et al. 2006, Kristensen et al. 2014), but in other patient groups, such
as stroke, high volume has been associated with a shorter length of stay (Svendsen
et al. 2012). This variation in findings is striking. One potential interpretation is that
patients undergoing advanced invasive procedures or patients with complex medi-
cal conditions benefit most from high-volume facilities; however, the results may
have been skewed by unmeasured factors, such as differences in discharge policies.
Alternatively, an association between a high volume and a short length of stay could
also arise from the reverse relationship, because a shorter length of stay would result
in more beds available and thus a larger volume of patients.
A few studies have examined readmission as an outcome. Of these, some found
that among patients undergoing major surgery, increased volume was associated with
reduced readmission rates (Nguyen et al. 2004, Tsai et al. 2013); however, others could
not confirm this relationship (Goodney et  al. 2003, Borenstein et  al. 2005). To our
knowledge, only one study has examined the association between volume and read-
mission among medical patients. In that study, hospitals with low volumes had lower
standardised readmission rates than hospitals with high volumes (Horwitz et al. 2015).
In conclusion, there does not seem to be a general association between volume
and outcome across diseases, even when considering different outcomes, including
mortality, length of stay and readmission. Nevertheless, there is an indication that
patients undergoing advanced invasive procedures or patients with complex medical
conditions may benefit most from a facility with a high patient volume.
Existing studies have had a number of methodological limitations, including the
risk of bias, inadequate control for mixed cases, lack of hierarchical modelling to
account for clustering (not taking into account that patients within the same hos-
pital and unit are correlated) and moderate statistical precision. All studies have
used an observational design; therefore, it is important to consider the selection pro-
cedures and risk adjustments for differences in illness severity and co-morbidity,
also called the case mix. Although case-mix adjustments may improve the likeli-
hood of fair comparisons between hospitals, there may be unknown biases that are
impossible to adjust for; therefore, the results should be interpreted with caution.
Lacking hierarchical modelling in the statistical analysis to account for clustering
can produce spuriously significant effects, because clustering affects the sampling
variance. Moreover, statistical precision can be a problem. Patient samples may be
Centralisation Efforts to Improve the Quality of Care in Healthcare Systems 93

too small to achieve statistically significant differences, or even when significant, the
volume–outcome relationship may not show sufficient strength for clinical relevance
(i.e. large sample sizes may produce results that are statistically significant, but the
absolute differences may only be minor).

IS THERE A LINEAR SCALE ADVANTAGE?

In addition to the substantial heterogeneity in findings between studies, variation
is also observed in findings within individual studies. For example, some patients
admitted to low-volume hospitals may experience excellent outcomes, and patients
admitted to high-volume hospitals may experience poor outcomes. Furthermore, the
effect of volume may be reduced over time, as procedures become well established.
These inconsistencies could indicate that the volume of patients is not a mecha-
nism in itself, but rather a contextual descriptor, which is not directly related to
outcome (Jha 2015). Several potential mechanisms may underlie a volume–­outcome
relationship. In a report from the Institute of Medicine, entitled ‘Interpreting the
Volume-Outcome Relationship in the Context of Health Care Quality’ (Hewitt
2000), a conceptual model was drafted to explain the contextual mechanisms that
can influence the relationship between volume and outcome. A modified version of
that model is presented in Figure 6.1.
The model illustrates important contextual mechanisms that influence the
­volume–outcome relationship. Outcome is associated with patient selection, includ-
ing disease severity and co-morbidity, the processes of care and the skills that pertain
to both hospitals and clinicians; all of these factors may be affected by volume. In the
following sections, we will describe the elements in the model and their ­relationships
to volume.

Skills of clinicians

Specific processes of care

Patient Patient
volume outcome
Hospital
organization

Patient
selection

FIGURE 6.1  Contextual mechanisms that influence the volume–outcome relationship.

(Based on Hewitt, M.E., Interpreting the Volume-Outcome Relationship in the Context of
Health Care Quality: Workshop Summary, Institute of Medicine, Washington, DC, 2000.)
94 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

Patient Selection
Different types of patients may be admitted to low-volume and high-volume hospi-
tals. A study by Liu et al. (2006) found substantial differences in the characteristics of
patients admitted to hospitals with different volumes. They showed that, in general,
blacks, Asians, Hispanics, patients that receive Medicaid (a federal programme in
the United States that provides assistance with medical costs to people with limited
income and resources) and uninsured patients were less likely to go to high-volume
hospitals. Because these patients may have higher levels of disease severity and co-
morbidities, patients admitted to low-volume hospitals may have a worse prognostic
profile than patients admitted to high-volume hospitals (Liu et al. 2006). In contrast,
another study reported that high-volume surgeons were more likely to perform inap-
propriate carotid endarterectomies than low-volume surgeons; that finding indicated
that patients at high-volume units may have a higher risk profile than patients at low-
volume units (Brook et al. 1990). In some cases, patients with a high-risk profile may
be referred to high-volume units for specialist treatment; however, in other cases,
patients with a high-risk profile might be transferred to low-volume units for end-
of-life care (e.g. after specialised treatments have failed). Another type of patient
selection that can influence the volume–outcome relationship is known as selective
referral. In this case, more referrals are directed to excellent physicians and hospitals
with a good reputation for achieving better outcomes; thus, a high volume may be
associated with better outcomes.
Varying attention has been directed towards adjusting for disease severity and
co-morbid conditions. The methods used for these adjustments may affect patient
outcome evaluations. In addition, the quality of patient information may affect
whether an adjustment for case mix is performed. For example, high-volume hospi-
tals are more research intensive, and therefore, they may have collected more patient
information on a routine basis. Thus, high-volume hospitals may have greater capa-
bilities in adjusting for patient-related risk factors. This notion was supported by
findings in a review by Halm et al. (2002). They stated that studies that included risk
adjustments based on clinical data were less likely to report significant associations
between patient volume and mortality than studies that adjusted for risk based on
administrative data. They noted that administrative data validity could vary across
different patient volumes; thus, administrative data provided better case-mix adjust-
ments at high-volume hospitals than at low-volume hospitals (Halm et al. 2002).

Quality of Care
Most studies lack an examination of the mechanisms and specific processes involved
in how volume might directly influence outcome. However, the association between
volume and quality of care has been examined in a limited number of studies.
In studies where high-volume units were associated with better outcomes, the
association appeared to be mediated through high-quality care. In a study on patients
with acute myocardial infarctions, the differential use of treatments recommended by
guidelines, including treatments that were proven effective (thrombolytics, aspirin,
beta blockers and angiotensin-converting enzyme inhibitors), could explain about
Centralisation Efforts to Improve the Quality of Care in Healthcare Systems 95

one-third of the survival benefit attributable to high-volume hospitals (Thiemann

et al. 1999). They showed that patients at high-volume hospitals were more likely to
receive treatments recommended by guidelines, including effective pharmaceutical
treatments, compared to patients treated at low-volume hospitals. Another study on
patients that underwent rectal cancer surgery found that high hospital volumes were
associated with improved global quality scores and low 30-day mortality (Leonard
et al. 2014).
In other studies, where high-volume units were associated with poor outcome,
the association appeared to be mediated by low-quality care. In a study of patients
with hip fractures, a higher patient volume was associated with higher 30-day
mortality, longer length of stay and a lower quality of in-hospital care (Kristensen
et  al. 2014). In addition, admission to a low-volume unit was associated with a
higher probability of receiving the treatment recommended by guidelines. Thus,
the different effects of volume on 30-day mortality appeared to be partly explained
by differences in the quality of in-hospital care, due to greater adherence to guide-
lines (Kristensen et al. 2014). This association between patient volume and provid-
ing the care recommended by guidelines was also observed in a study of patients
with pneumonia. Lindenauer et al. (2006) found that, as unit volume increased,
the risk of delay in antibiotics administration also increased. Consistent with that
finding, another study in emergency departments found that increases in the total
number of emergency department visits were associated with decreases in adher-
ence to guideline-recommended diagnostic tests; thus, higher numbers were asso-
ciated with a higher risk of exacerbation among patients with pulmonary disease
(Tsai et al. 2009).
Quality of care, reflected by whether patients receive the recommended care
­processes, seems to be an important intermediate factor for the volume–outcome
association. However, not all studies have found this association.
A study on patients that received coronary artery bypass surgeries found that
controlling for quality of care differences did not have any impact on the associa-
tion between volume measures and mortality. However, adherence to process quality
measures was associated with improved mortality rates, independent of hospital or
physician volume (Auerbach et al. 2009). In another study on patients with strokes,
a higher patient volume was associated with improved quality of care and reduced
hospital bed day use, but it was not associated with mortality. Adjusting for dif-
ferences in care quality had no major influence on mortality or on the bed day use
(Svendsen et al. 2012).
These studies indicated that other aspects of care or other mechanisms that were
not investigated may have contributed to the outcomes obtained. Several underly-
ing mechanisms might explain the volume–outcome relationships, including clinical
skills and hospital organisation.

Clinical Skills
Different levels of skills possessed by treating physicians may also be associated with
patient outcomes. For example, in surgical procedures, surgeon dexterity is often a
critical factor in minimising trauma to adjacent tissues; that is, an inexperienced
96 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

surgeon may cause more surgical trauma than an experienced surgeon (Palm et al.
2007, Liu et al. 2015). Furthermore, cognitive skills may be important in producing
high-quality outcomes, such as the ability to recognise uncommon signs of medical
conditions and take appropriate, timely action. In addition, we could hypothesise that
adherence to current guidelines is also related to clinical skills (Hwang et al. 2013).
For instance, team members that are familiar with the disease treatment guidelines
may be predisposed to recommending the appropriate treatment, because they utilise
the guidelines on a regular basis.

Hospital Organisation
A third possible mechanism that can complicate the interpretation of the volume–
outcome relationship includes system-level factors, such as hospital organisation.
Organisational skills, including the ability of the system to facilitate effective care
(e.g. multidisciplinary coordination and the ability to respond effectively to compli-
cations), may contribute to patient outcome (Bates and Gawande 2003). Furthermore,
high-volume hospitals may be more likely to have state-of-the-art equipment that can
contribute to avoiding errors (e.g. sophisticated computerised reminder systems and
advanced diagnostic equipment). In addition, high-volume hospitals may have the
financial capacity to employ teams specialised in home-based follow-up or patient
education programmes, which may improve outcome (Swart et  al. 2015). On the
other hand, the high activity levels present in the large, complex environments of
high-volume hospitals may pose a challenge to implementing and perfecting funda-
mental care.

INTERPRETING THE VOLUME–OUTCOME RELATIONSHIP

The absence of a consistent positive relationship between high volume and quality
of care suggests that the benefits associated with greater disease experience in busy
hospitals could be outweighed by the challenges of implementing and perfecting
care in large, complex environments. Furthermore, we cannot exclude the existence
of publication bias, which would diminish the likelihood of identifying studies that
failed to find a volume–outcome association.

Volume Threshold
An interesting question is whether there might be a volume threshold for the
­volume–outcome relationship. In other words, there may be a volume range that
shows the effect, but once a certain volume is reached, increasing the volume
would no longer be associated with better outcomes.
Indeed, for medical conditions, one study identified an annual volume threshold,
above which, increases in annual volume no longer significantly affected outcome
(Ross et al. 2010). That study showed that the curves representing the association
between volume and risk-adjusted mortality began to level out at different thresh-
olds for different conditions. The annual volume thresholds were 610 patients for
myocardial infarction, 500 patients for heart failure and 210 patients for pneumonia.
Centralisation Efforts to Improve the Quality of Care in Healthcare Systems 97

Those results suggested that the benefit of an increased patient volume would be
most pronounced at hospitals with fewer than 100 cases of a given condition. The
same pattern was observed in studies on how the volume of patients with hip frac-
tures was related to 30-day mortality in countries where some centralisation had
already occurred (Franzo et al. 2005, Kristensen et al. 2014). In those studies, a high
patient volume was defined as greater than 352 patients with hip fractures per year.
They showed that high volumes were associated with higher 30-day mortality. In
other patient groups, such as patients with stroke, a graph suggested that the advan-
tages of high volume were most evident in stroke units that treated up to 300–400
patients annually (Svendsen et al. 2012).
The finding of a volume threshold may arise from the fact that the volume effect
may be diminished or even reversed in large-scale institutions. Large-scale institu-
tions may have several disadvantages that counteract the benefits of volume, includ-
ing deficient coordination, increased bureaucracy and an unrestricted access to
expensive but not necessary relevant technology, due to specialisation (Posnett 1999,
Kristensen et al. 2010).

IMPLICATIONS
The volume–outcome relationship has been one of the key arguments for centrali-
sation of healthcare, despite the weak evidence to support an association for many
medical conditions. Most volume–outcome studies have been performed on data
collected prior to 2000, when hospital consolidation had only occurred to a lim-
ited extent in many settings. Therefore, it is uncertain whether we should generalise
those study findings to the current healthcare systems, which may have substantially
higher levels of centralisation. In particular, there appears to be a lack of evidence to
support a positive association between increasing patient volume and improved out-
come among patients with common medical conditions that require low-risk invasive
procedures. The literature has also indicated that volume thresholds may exist; thus,
increasing the volume may not be associated with improved outcomes or may even
lead to worse outcomes.
In addition, there is limited evidence regarding the relationship between very
high volumes and cost. The association between volume and cost has been investi-
gated, but as mentioned earlier, it is not known whether a potential threshold exists
(Bardach et al. 2004, Slattery et al. 2004, Losina et al. 2009, Tsugawa et al. 2013,
Albornoz et al. 2014). One potential hypothesis might be that some organisational
elements, such as surgical teams and emergency department teams, would be bet-
ter utilised in high-volume institutions, which would reduce the average cost per
patient. However, it is possible that high-volume hospitals might stimulate an unwar-
ranted high level of healthcare utilisation, due to the easy access and the high capac-
ity for advanced treatment and care (Fisher et al. 2000). A study from the United
States found that hospital consolidation over a 17-year period was associated with
increased healthcare utilisation among patients with heart disease (Hayford 2012).
One interpretation of that finding might be that, when patients must travel farther for
treatment, they might require more intensive treatment and it may result in higher
mortality. Another interpretation could be that larger hospitals have easy access to
98 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

advanced, costly equipment and procedures, and consequently, they are more likely
to use these tools, though not always indicated, which would lead to inefficient care
and overtreatment.
There is no conclusive evidence to demonstrate a general relationship between the
patient volume and the quality of care. Furthermore, the quality of care should be
balanced against other aspects of care, including patient satisfaction, the availability
of healthcare and the possibility of involving caregivers.
In Nordic countries, there is an ongoing debate about the potential impacts of cen-
tralised healthcare on geographic availability and equality in healthcare. Although
all the Nordic countries have brought into a common set of economic and social
policies, often termed the ‘Nordic model’, which is characterised by a combination of
free market capitalism and a comprehensive welfare state, there are also important
differences between countries (Andersen et al. 2007) regarding the healthcare system.
To some extent, different Nordic countries have implemented different strategies for
centralising healthcare. For example, extensive centralisation has occurred at the hos-
pital level over the last few decades in Denmark; however, to date, other countries (e.g.
Norway) have insisted on a more decentralised healthcare system at both the hospital
and community levels (Olejaz et al. 2012). The different strategies for centralisation
that are implemented across the Nordic countries may reflect political and historical
differences but also differences in geography (e.g. the length of Norway is more than
fivefold larger than that of Denmark). It remains unclear what role travel distance to
the nearest hospital should play in considering the most appropriate level of centrali-
sation. Treatment delays caused by transporting patients over long distances should
be weighed against the potentially more effective treatment offered at highly special-
ised centres. This trade-off was illustrated by the dilemma involved in selecting the
most effective transportation strategy for patients with acute myocardial infarction
(Andersen et al. 2003). Furthermore, although the most effective strategy can be iden-
tified for some acute medical conditions, those results are not necessarily generalis-
able to other disease areas. For example, in chronic conditions, where a long-term
patient-centred care programme requires participation of the family, a long distance
to the hospital may have potentially important adverse effects on care delivery.

FUTURE RESEARCH
Further research is clearly warranted on the differences in quality of care between
high- and low-volume hospitals. Moreover, more data are required on differences in
hospital organisations and the possible existence of volume thresholds. Examining
the relationships between patient volume and potential mediating mechanisms will
provide a better explanation of why outcome differences exist between low- and
high-volume physicians and healthcare units. Advancing research in this area could
also provide knowledge for improvement by identifying the factors lacking in poor-
performing providers, in both low-volume and high-volume cases. As the processes
of high quality are identified, it will be important to investigate how readily they can
be applied to other hospital contexts. For example, some processes related to a better
outcome, such as mobilising patients with hip fractures within 24 h postoperatively,
can be readily shared with other hospitals. Alternatively, other processes, such as
Centralisation Efforts to Improve the Quality of Care in Healthcare Systems 99

full-time geriatric service in an orthopaedic department, may be difficult for other

hospitals to implement, due to an insufficient level of clinical activity to justify that
level of organisation. Therefore, organisational practices should also be studied.
The volume threshold is an important area that merits further study, because hos-
pital consolidation is likely to increase in the future. Therefore, a hospital consid-
ered large by today’s standards may be considered small in the future. Continuous
research will be needed to ensure that our understanding of the interplay between
patient volume, quality of care and treatment outcomes remain up to date.

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 7 National Clinical
Registries
Ten Years of Experience
with Improving Quality
of Care in Denmark
Søren Paaske Johnsen, Jan Mainz and Paul D. Bartels

CONTENTS
Setting and National Public Registries................................................................... 104
History of Danish Clinical Registries..................................................................... 104
Current Status.......................................................................................................... 105
Data Collection and Validity................................................................................... 106
Data Reporting........................................................................................................ 107
Role of Clinical Registries in Quality Improvement.............................................. 108
Targets for Quality of Care..................................................................................... 108
Clinical Registries and Research............................................................................ 109
Future Perspectives................................................................................................. 110
Conclusion.............................................................................................................. 112
References............................................................................................................... 112

Information on the patterns of healthcare performance is an essential component of

well-functioning and efficient healthcare systems. Healthcare data help to identify
and locate

1. Problems in the provision of care

2. Regions, areas and healthcare systems that lag or lead in delivering high-
quality and efficient care
3. The causes of unwarranted variation
4. The magnitude of public benefit, if problems in care were remedied

Still, most countries lack a system of healthcare surveillance that could identify
what problems occur and where and that could monitor progress towards healthcare
improvement (Corallo et  al., 2014). Clinical registers represent a solution to these
challenges as they contain systematically collected data related to clinical observa-
tions, diagnostic procedures, treatments and outcomes within the context of patient

103
104 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

pathways of specific diseases or health-related interventions (Agency for Healthcare

Research and Quality, 2014). Many countries plan to establish clinical registers and
therefore look towards countries with experience within this area. The Nordic coun-
tries and, in particular, Sweden and Denmark have a long tradition for working with
clinical registries and therefore have extensive experience with both the strengths
and limitations of the registries (Ekman et al., 2014; Vårdanalys, 2014). In this chap-
ter, we report on the Danish experience with using clinical registries as a central
pillar in the national strategy for improving the quality of care. The authors have
played an active role in establishing and running clinical registries in Denmark in
the last two decades and can consequently not be considered to be neutral. However,
the first-hand experience and observations made over the years may hopefully still
be of value for readers with an interest in clinical registries.

SETTING AND NATIONAL PUBLIC REGISTRIES

Denmark has approximately 5.6 million inhabitants who are served by a publicly
funded healthcare system granting free and equal access to visits at general prac-
titioners, admissions and outpatient visits at hospitals for all residents (Indenrigs-
og Sundhedsministeriet SFDR, 2011). The country has a long historic tradition for
establishing population-based registries covering many aspects of public life.
The existence of a 10-digit personal identification number, which follows each
Dane from cradle to grave and is used in all public registries, allows for unambigu-
ous linkage between the various registries. Because of the existence of a wide range
of nationwide, population-based registries, data on healthcare (e.g. contacts with
general practitioners, hospital admissions and filled prescriptions at the pharmacies)
can be combined with the data of a more general nature (e.g. place of living and vital
status) as well as detailed socio-economic information including individual-level
data on education, occupation and income.

HISTORY OF DANISH CLINICAL REGISTRIES

Clinical registries have for more than 20 years constituted a central tool for quality
improvement work in the Danish healthcare system. The pioneer within this area was
the Danish Breast Cancer Cooperative Group, which was established by the Danish
Surgical Society in 1976 with the aim of ensuring optimal diagnostic procedures and
treatment of breast cancer (Moller et al., 2008). The group has since then prepared
evidence-based national guidelines regarding diagnostic procedures and treatment
(surgery, radiotherapy and systemic therapy). These have continuously been devel-
oped and evaluated in randomised trials and quality control studies. Furthermore, a
clinical registry was established at the same time as the guidelines. Departments of
pathology, surgery and oncology have since 1976 systematically reported informa-
tion about diagnostics, treatment and follow-up. Notably, these activities were initi-
ated 10 years prior to systematic quality improvement being accepted as a necessary
activity of a modern healthcare system.
The key elements in the development of the role and organisation of clinical reg-
istries in Denmark are presented in Table 7.1. The registries moved from the pioneer
National Clinical Registries 105

TABLE 7.1
Clinical Registries in Denmark: Development 1975–2015
1975–1995 1993–1999 1999–2011 2011–2015
Bottom-up Let a thousand • National quality programme Universal framework and
research flowers bloom: • Position paper, law and requirements for clinical
registries • National clinical administrative order, basic registries:
registers as a tool requirements for clinical • One umbrella support
for monitoring quality databases organisation (Danish
the effect of a • National Indicator Project Clinical Registries)
national quality and three competency • Stable standardised
improvement centres for clinical quality reporting and public
strategy + databases disclosure (monthly/
professional • Interdisciplinarity yearly)
quality • Cross-sectoral registries • Uniform access for
improvement/ • Involvement of organisation researchers
research and management • Management information
• Public disclosure of results • Danish Multidisciplinary
Cancer Groups

phase to be a recognised element of the national quality strategy in 1993. Since then,
a number of changes within and around the registries have occurred leading up to the
current status. However, the fundamental principle of professional responsibility and
ownership of the contents of the registries still remain as a core value in the ongoing
work with the clinical registries.

CURRENT STATUS
According to Danish law, clinical registries are defined as public registries
which contain individual-level information about well-defined patient groups
(Sundhedsdatastyrelsen, 2016). To be approved as a clinical registry, the primary
objective of the registries should be to facilitate surveillance and improvement of
quality of care. However, it is also an important part of the mission of the reg-
istries to facilitate accountability and transparency in healthcare (e.g. to ensure
that clinicians and administrators are accountable for the provided care and when
relevant to facilitate informed patient choices regarding preferred place of care).
Furthermore, there is increasing awareness of the potentially important role of
the registries in the national research infrastructure (i.e. the registries represent
large unselected patient cohorts with detailed clinical information and often com-
plete follow-up, which makes them highly relevant for clinical and epidemiologi-
cal research) (Table 7.2).
The registries are required to fulfil a set of national criteria regarding organ-
isation, functionality, data safety and reporting. Once a registry is approved by
the national health authority overseeing the registries (Statens Serum Insititut,
2015), reporting of all relevant patients to the database is mandatory by law for the
106 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

TABLE 7.2
Mission for Danish Clinical Registries
Improvement Improving prevention, diagnostics, treatment and rehabilitation
Management/accountability Documentation for clinical governance and organisational priority setting
Transparency Information for citizens and patients
Innovation Research infrastructure

hospitals and clinics treating the patients. The approved clinical quality databases
are exempted from the requirement of obtaining the patients consent to collect rel-
evant data.
There are currently approximately 70 approved nationwide clinical registries
in Denmark, including 5 registries which are in the process of being established.
The registries cover more than 80 clinical areas, with the majority covering specific
disease entities. Other clinical registries cover a specific disease-related procedure
(e.g.  bariatric surgery or hip replacement), while a third category of databases
covers a broader range of procedures such as treatment at intensive care units or
anaesthetic procedures. The highest density of registries is found within cancer,
major chronic diseases, orthopaedic surgery and obstetrics and gynaecology.
Most of the registries cover only secondary and tertiary care. However, collabora-
tion with the primary healthcare sector has been established for five selected chronic
diseases.
The individual registries each have a board with representation of relevant medical
specialities and in many cases also other health professionals (e.g. nurses, occupa-
tional therapists, physiotherapists and dieticians). The activities of the clinical regis-
tries have since 2011 been coordinated through the umbrella organisation, the Danish
Clinical Registries which is a national quality improvement programme responsible
for the activities in the nationwide clinical registries. The registries receive support
from competency centres, which provide epidemiological, IT and quality improve-
ment support, including coordination of continuous contact between hospitals
and clinics as well as the administrative and political level. The Danish Clinical
Registries is governed by a secretariat referring to a board representing the Danish
regions, health authorities, professional and patient organisations. The ­registries are
almost exclusively publicly financed.

DATA COLLECTION AND VALIDITY

Primary collection of detailed patient-level data may require substantial time and
resources, which are not always available among overloaded clinicians in busy
clinical settings. Restricting the requirements for primary data collection, that is
defined as data that are collected and reported specifically to the clinical registries
and not otherwise used in the care of the patient, has therefore been a focus for the
Danish Clinical Registries in recent years. The aim is to reduce the workload for
National Clinical Registries 107

the health professionals and at the same time still obtain the required data with
high validity for the clinical registries. Record linkage to existing administrative
and healthcare registries is therefore increasingly used as a way of re-using rel-
evant data that are already being collected for other purposes. More than half of
all variables in the clinical registries in Denmark now come from other existing
public registries, and this trend is expected to continue and even accelerate in the
coming years with the increasing availability of obtaining data directly from elec-
tronic medical record systems. The use of data from existing data sources has in
general been successful; however, incorporating these data in the clinical registries
is a demanding process, which requires substantial efforts from all stakeholders.
As an example, using administrative hospital discharge data may imply challenges
with a tradition of low prioritisation of correct coding and high prioritisation of
diagnosis-related group coding, lack of timely reporting of data from the hospitals
and time delays in processing the data in local and central administrative informa-
tion systems.
A high completeness of the registration of relevant patients is a key aim in the
clinical registries in order to ensure that the individual registry is representative of
the entire patient population in Denmark. Consequently, a criterion for receiving
legal approval and funding is that at least 90% of all relevant patients are captured by
the database. This criterion is fulfilled by the large majority of the registries within
1–2 years after establishment.
In addition to the completeness of the patient registration, the completeness and
quality of the recorded data for the registered patients are also essential. The clini-
cal registries are required by the Danish Clinical Registries and the national health
authority to have detailed data definitions and to address problems with data collec-
tion at the annual audits, including local variation in data registration practice. These
approaches support a uniform and valid registration practice; however, challenges
remain with the data quality in some registries and continuous attention is therefore
required.

DATA REPORTING
All Danish clinical registries are required by law to produce an annual report in
which the boards of the individual registries provide epidemiological and clinical
interpretation of the results and make recommendations for quality improvement
(Sundhedsdatastyrelsen, 2016). The reports are made publicly available at Sundhed.
dk (2016). Furthermore, over the last years, a development towards more timely
reporting of the data to both health professionals and administrators has accelerated
following demands from the regions in Denmark, which are responsible for running
the hospitals. This has been done in order to support continuous monitoring and
quality of care improvement work. Results from more than 60% of the registries are
now delivered monthly to the regions’ management information systems, and the
development has reached a point where it is the capacity of the receivers rather than
the sender that restricts the access to data.
108 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

ROLE OF CLINICAL REGISTRIES IN QUALITY IMPROVEMENT

The clinical registries represent in many ways a prototype for data-driven quality
improvement. Simple one-way presentations for the organisation, including man-
agement and health professionals, only rarely have effect in relation to quality
improvement (Agency for Healthcare Research and Quality, 2015). If data should
have an effect, they must be selected in a way that they are both relevant and valid.
This is done by the boards of the individual clinical registries, which represent
the practical experience in the clinical field supplemented by high-level exper-
tise in clinical epidemiology, biostatistics and data management ensuring credible
methodology.
In relation to the clinical registries in Denmark, it has been our experience that
it is an important strength that members of the boards of the clinical registries are
strongly involved in the writing of clinical guidelines and the construction of clinical
pathways. This ensures that the clinical registries and the clinical guidelines mutu-
ally support each other and that the registries can be used as a tool for supporting the
implementation of the recommendations in the clinical guidelines.
There is currently an increasing recognition of the importance of the context for
quality improvement based on quality indicator data. The detailed data of the clini-
cal registries in relation to both the patients (e.g. the severity of the disease of the
individual patient) and the provided care (e.g. details about the procedures and treat-
ments) make it possible to ensure that the data are both meaningful and credible in
different contexts. This has ensured clinical ownership and facilitated a reflective
use of the data.
Substantial improvements in the quality of care have been observed, in particular
within the last decade, for the majority of the medical areas in Denmark covered by
clinical registries. The improvements include both processes of care and clinical out-
comes (Møller et  al., 2013; Nakano et  al., 2013; Rosenstock et  al., 2013; Tøttenborg
et al., 2013; Jørgensen et al., 2015). A causal association between the quality improve-
ment work driven by the data from the clinical registries and the observed improve-
ments in care is difficult to document; however, given that the indicator monitoring and
systematic auditing based on the clinical registries has been the most consistent quality
improvement activity in Denmark during the period, it is probably reasonable to assume
that the clinical registries have played an important role for the changes in care that have
occurred over the years.

TARGETS FOR QUALITY OF CARE

A particular important factor making the observed improvements in care possibly
appear to have been the increasing involvement of the entire organisation in using
the data from the clinical registries for managerial support for professional-led qual-
ity improvement. This involvement has to a large extent been based on targets or
standards for the quality of care, which has been defined by the health professionals.
An example could be that at least 90% of the patients with acute stroke should be
admitted or transferred to a specialised stroke unit or that at least 90% of the patients
with systolic heart failure should receive an angiotensin-converting enzyme inhibitor
National Clinical Registries 109

or angiotensin II blocker. This is from an international perspective a unique feature

of the Danish clinical registries (Agency for Healthcare Reaserch and Quality, 2014;
Ekman, 2014). Target values are defined via available evidence or in the absence of
this via a formalised process of expert consensus. Initially, the target construction
was described in 1999 by an expert group commissioned by the Danish medical
societies and hospital owners and implemented in the Danish Indicator Project. In
2005, the concept of indicator plus standard was codified in the approval form issued
by the National Board of Health for mandating Danish clinical registries.
The targets have in many ways been successful as aids for improvement, gov-
ernance and accountability by national clinical registries in Denmark. Since they
are, at least in principle, legitimated by science and professionals, they have been
accepted throughout the healthcare system making it easier for the organisations
and the surrounding society to identify areas where improvements are warranted.
Although the approach has had a positive impact, in particular on structural changes
in the healthcare system (e.g. establishment of specialised stroke units and heart
failure clinics), it also appears to be areas where the original intention of the targets
has not been followed. This development reflects that the demonstration of actual
evidence for best practice coupled with the standards is quite weak for many medical
conditions. Furthermore, the professional definition of standards for best practice has
been highly variable ranging from ideal goals to thresholds ranging from acceptable
to unacceptable. This variation obviously has major implications for the interpreta-
tion of the targets. However, it is noteworthy that perception of the standards at the
management level appears to have been consistent across the clinical registries (i.e.
the targets have all been interpreted as evidence based and reflecting ideal goals).
These discrepancies have to be resolved if the targets shall continue to be a tool for
quality improvement and governance. A simple solution would be to ensure that the
targets are classified according to their context. Thus, we need to clearly distinguish
between best practice internationally, nationally derived targets and targets reflect-
ing acceptability.

CLINICAL REGISTRIES AND RESEARCH

The first generation of clinical registries in Denmark was primarily established for
research purposes, and clinical motivation and acceptance for participation in the
work with the clinical registries is still to some extent conditioned by the possibility
of using the collected data for research purposes. Although the involvement of other
stakeholders in the clinical registries has increased dramatically over the years and
has had major impact on the mission of the registries, the academic activities remain
essential for the development of the registries.
The clinical registries come with a number of methodological strengths that make
them viable from a research perspective. First, they make it possible to conduct
­population-based studies on large cohorts of patients with usually close to complete
data of the study population including follow-up. Additional advantages include the
fact that data are collected independently of any research question, which reduces
the risk of information bias, for example recall bias and impact of decision on diag-
nosis and therapy because of the awareness of an ongoing study. The fact that data
110 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

are already collected also means that the cost of research in clinical quality data-
bases is usually low compared with clinical studies based on primary data c­ollection.
However, limitations still exist and should be acknowledged. The data collection is
not controlled by the researcher, and patient characteristics may be poorly measured
or even lacking. Still, most clinical registries contain more detailed clinical data than
alternative data sources, in particular administrative health registries. In addition,
data from the clinical registries can be complemented through linkage with other
registries and data from medical records.
During the last decade, data from the Danish clinical registries have been used
in a wide range of research. This includes traditional clinical epidemiological stud-
ies on patient prognosis focusing on determining the outcome of specific groups of
patients, identification of prognostic factors or prognostic models. Another group of
studies have focused on medical care variation and have tried to identify and explore
unwarranted variation in medical care defined as differences in the performance of
healthcare systems, rather than in population needs or preferences (Corallo, 2014).
Examples have been studies on disparities in quality of care according to age, sex,
socio-economic status or time of admission. Another important research area has
been comparative effectiveness research, which can be defined as direct comparison
of existing healthcare interventions to determine which works best for which patients
and which pose the greatest benefits and harms in routine clinical settings (Sullivan
and Goldmann, 2011). As an example, the Western Denmark Heart Registry has been
used as platform for a series of pragmatic clinical trials comparing different types
of coronary stents in patients with coronary heart disease (Christiansen et al., 2013;
Maeng et  al., 2014). In addition, the registries have also provided data for health
delivery research, which is also known as translation research or implementation
­science (Pronovost and Goeschel, 2011).
Finally, the clinical registries have participated in international studies, in partic-
ular collaboration studies between the Nordic countries. This type of collaboration
is facilitated by the close similarities of the political systems in the Nordic countries
and the comprehensive tax-financed healthcare systems covering entire populations.
As an example, Mäkelä et al. (2014) used data from the Nordic Arthroplasty Register
Association which combine data from Sweden, Norway, Finland and Denmark to
demonstrate that the survival of cemented implants for total hip replacement was
higher than that of uncemented implants in patients aged 65 years or older.

FUTURE PERSPECTIVES
When the clinical registries have been able to continuously contribute to the develop-
ment of patient care in the Danish healthcare system over a long time period, it is to
a large extent due to an innovative clinical practice that has taken advantage of exist-
ing trends (technological, organisational and attitudinal) in the healthcare system.
Throughout the last decades, there have been several major changes in the strategy
for the clinical registries. These changes have been driven both by clinicians and
by other stakeholders. The last major change occurred in the period between 2009
and 2011, but new changes are already underway. The most important element is
an increasing recognition and acceptance of the need to give more priority to direct
National Clinical Registries 111

patient involvement in the management of the healthcare system. This is particularly

important within the area of quality of care, which in Denmark so far has been very
focused on the formal role of the involved stakeholders. However, there are already
experiences with clinical registries that have been proactive in taking patient prefer-
ences and needs into account in relation to data-driven quality improvement (e.g. the
Danish Biologics database (DANBIO) – a national registry for rheumatologic patients
treated with biological drugs).
It has already been demonstrated that it is possible to integrate patient-reported
data on outcomes and experiences into quality of care work based on clinical reg-
istries (Baker et al., 2012). In addition, there are positive experiences from Sweden
with involvement of patients in the selection of relevant areas for quality improve-
ment, interpretation and communication of data (Ekman, 2014). This means that one
of the key focus areas for the Danish clinical registries will be increased involvement
of patients in prioritisation and interpretation of the quality of care data as well as
large-scale use of patient-reported data within relevant areas.
Another focus area will be timely reporting of data to ensure that clinical reg-
istries can facilitate a dynamic and ongoing clinical practice in which data-driven
quality improvement work is an integrated part of everyday practice and not a once-
a-year procedure aimed at retrospectively explaining data. Targeted communication
aimed at the individual stakeholders (general population, patients, decision-makers,
management, health professionals) will be important.
The current clinical registries cover very different areas (e.g. from the quality of care
of a specific procedure to lifelong courses of chronic diseases, which covers numerous
hospital departments and providers in the healthcare system). The current technological
development in relation to the electronic medical records will imply that ‘simple’ sur-
veillance of specific procedures can be monitored directly using the electronic medical
record. This will require that the electronic medical record can include all data elements
that form the basis for the registry and hereafter report directly to the locally involved
clinicians. It is therefore expected that it will be possible to monitor these areas with
less resources in the future. In contrast, the complex courses of diseases experienced
by patients with cancer and chronic diseases will continue to require the full set-up of a
clinical registry, and these areas will consequently be given high priority.
Finally, there is a need for the clinical registries to play an even more active role
in the generation of new knowledge about the performance of healthcare system.
Although there have been examples of health services research studies based on clin-
ical registry data, much more is needed in order to take advantage of the information
potential, which is currently not exploited given the substantial human and financial
resources invested in the clinical registries. A more active and systematic approach
is therefore needed in order to ensure that important differences in the quality of care
are revealed, the causes of unwarranted variation are identified and programmes
intended to improve healthcare are evaluated. To obtain a broader picture, analyses
across clinical registries will be needed.
It is expected that the clinical registries by measuring avoidable variation may
help identifying misused resources that can be reallocated to achieve better value
without sacrificing equity. Better public transparency and research on variation
in healthcare performance may potentially accelerate improvements in care with
112 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

benefits to patients while reducing costs. In contrast, the absence of data will blind
patients, physicians, healthcare managers and policymakers from the information
needed to understand and improve care. Data gathering, data access and independent
data analysis are essential to the national provision of high-value healthcare.
Initiatives are currently underway to further strengthen the role of the clini-
cal registries in the national research infrastructure in Denmark. The Program for
Clinical Research Infrastructure is a national initiative aiming at improving inte-
gration across clinical registries, other public administrative and healthcare regis-
tries and biobanks in the healthcare sector to facilitate data analysis and to integrate
research findings into daily clinical work by building bridges between research and
clinical practice. Focus will also be on the development of novel methods for ana-
lysing large data sets due to the growing amount and complexity of the information
available within healthcare (e.g. medical and administrative databases, electronic
medical records and biobanks).

CONCLUSION
In conclusion, the Danish clinical registries have played a central role in the data-
driven quality improvement work in Denmark over the last decades and in particular
within the last decade. The key element in this development has been an early deci-
sion to make clinical registries the backbone of the national quality improvement
strategy and subsequently to involve all stakeholders in the work. The efforts have
been strongly facilitated by legislation, which regulates the registries and ensures that
requirements for institutions and hospital owners, in particular mandatory reporting
of all relevant patients to the registries, are given high priority. Furthermore, trans-
parency and accountability through target setting and public disclosure of all perfor-
mance data at the unit level have stimulated professional engagement and interest.
Finally, technical aspects including a strategy to ensure uniform software solutions
and standardisation of the formats for output/reporting have been important. The
Danish clinical registries face a number of still unsolved challenges; however, the
elements mentioned earlier will most likely remain central also in the years ahead.

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 8 Side Effects of
Overdoing It
Lessons from a
Comprehensive Hospital
Accreditation Programme
Carsten Engel and Henning Boje Andersen

CONTENTS
Introduction............................................................................................................. 115
Interview Survey of Practitioners’ Experience and Views of Accreditation........... 118
Overimplementation of Standards.......................................................................... 120
Outline of a Programme Theory for Accreditation................................................. 120
Discussion............................................................................................................... 123
Conclusion.............................................................................................................. 125
References............................................................................................................... 125

INTRODUCTION
Healthcare accreditation programmes have been developed and implemented in
many countries based on the expectation that they will improve patient safety and
quality of healthcare. Accreditation is not a new phenomenon, having a history of
almost 100 years in the United States and Canada and was launched in Australia
more than 40  years ago (Scrivens, 1995). While it maintains its importance in
these countries, a steep increase in the number of accreditation programmes in
operation began in the 1990s and amounted to 44 in 2009, some of which were
operating in several countries (Shaw et al., 2013). In Denmark, accreditation was
adopted as a national strategy in 2005 but has been partially discontinued in
2015 (see Box 8.1). In the other Nordic countries, it has never gained a foothold,
although there are ­isolated examples of hospitals choosing to go for accredita-
tion or ISO certification (e.g., Hasman, 2012; Lie and Bjørnstad, 2015; Norén and
Ranerup, 2015).

115
116 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

BOX 8.1  THE DANISH HEALTHCARE QUALITY PROGRAMME

The Danish Healthcare Quality Programme (DDKM – Den Danske Kvalitets­
model) was established in 2005 by the Danish Government and the five Danish
regions (the regions run about 98% of all hospital services, financed over state
taxes). The intention was to create a common national system for the assessment
of quality in healthcare to promote better patient pathways, transparency of quality
and continuous quality improvement (QI). At the outset, the programme covered
only public hospitals, but step by step all publically financed healthcare has been
included and now covers private hospitals, pharmacies, prehospital care, some
aspects of municipality-based primary care as well as, from 2015 and onwards,
programmes for all practice-based healthcare (GPs, physio-/ergotherapists, chiro-
practors) are being launched.
The two main components of the programme are the accreditation standards,
setting the criteria against which the performance of the hospitals is assessed
and the external survey conducted once every 3 years, where a team of surveyors
assess the hospitals against the standards. The surveyors are hospital employees
(senior clinicians or managers), trained for the purpose, and working as sur-
veyors for 2–3 weeks per year. A large hospital will be assessed by a team of
6–8 ­surveyors for 5 days. The focus, in particular in the second cycle, has been
on implementation of good working practices, judged by interviewing front-line
staff and cross checking with documentation, such as patient records, and on a
systematic approach to QI. Processes are assessed for their ability to deliver the
expected outcome, rather than merely on compliance with formal specifications
in written policies. The findings during the survey are presented in a published
report and are the basis for the decision of which level of accreditation to award.
By the end of 2015, two cycles of accreditation had been completed
for all public hospitals in Denmark and the programme for public hospitals
was terminated. The Ministry of Health has indicated that the two cycles of
accre­ditation have improved quality, especially organisational quality, and
patient safety, but that the time has come to replace accreditation with other
means of QI. Hospital accreditation is now perceived as entailing a burden of
bureaucracy, excessive registration and documentation and a focus on detailed
specification of processes, all of which are not meaningful to front-line staff
(Danish Ministry of Health, 2015). Accreditation programmes will continue in
private hospitals and pharmacies, GP practices and specialist physician practices.

The International Society for Quality in Health Care proposed that accreditation
may be defined as follows:

An act of granting credit or recognition by an external evaluation organisation of the

achievement of accreditation standards, demonstrated through an independent external
peer assessment of that organisation’s level of performance in relation to the standards.
ISQua (2013a)
Side Effects of Overdoing It 117

While the intentions behind the considerable efforts involved in implementing and
­running accreditation programmes certainly are based on a desire to improve safety
and quality, the evidence for actual improvement is scant or non-existent (Hinchcliffe
et  al., 2012; Brubakk et  al., 2015). Still, several studies (Braithwaite et  al., 2010;
Schmaltz et al., 2011; Falstie-Jensen et al., 2015a,b; Bogh et al., 2015) have addressed
the link between accreditation and safety and quality, but we wish to focus on
another issue, namely the side effects of accreditation in terms of overimplementa-
tion of standards and the drift towards bureaucratisation. This has been elucidated in
­investigations of professionals’ attitudes (Verstraete et al., 1998; Paccioni et al., 2008;
Hinchcliffe et al., 2012), and we wish to dig deeper into this problem in this chapter.
An important background for our discussion is the well-known difficulties in design-
ing studies to assess the effectiveness of complex interventions (Craig et  al., 2008).
Accreditation is clearly not a standardised intervention; there are important differ-
ences between accreditation programmes, and not least between the contexts in which
they operate and in the ways in which they are understood and implemented by the
organisations undergoing accreditation. Thus, it is doubtful if the findings of even a
well-designed randomised controlled study could be translated to other accreditation
programmes in other settings. To understand the usefulness and challenges in accredi-
tation we must explore the mechanisms by which it is supposed to exert a beneficial
effect; this might be formulated as a programme theory (Davidoff et al., 2015) – see
also Chapter 4. The value of a programme theory is not only in evaluation but also in
implementation. Improving the function of complex systems is a complex venture. If
based on a too simple and inexplicit theory, side effects may occur that might have been
avoided, had the expected mechanisms and causal relations been spelled out in advance.
One key assumption behind accreditation programmes is that standardisation
of procedures will improve quality and safety (https://www.accreditation.ca/why-
accreditation-matters; Roberts et al., 1987; Shaw, 2000; Rozich et al., 2004). This
assumption is plausible, but we argue that this hypothesis can be interpreted too
simplistically and that standardisation by way of accreditation is liable to bureaucra-
tisation and staff resistance. We will explore our claim by presenting a brief outline
of a more refined programme theory, based on the science of complex systems, and
then compare this to the assumptions that have determined the actual implementa-
tion of an accreditation programme. We will do so by reviewing the comprehensive,
nation-wide accreditation programme for public hospitals that ran in Denmark for
10 years until 2015. In our review, we will mainly focus on the perceptions and expe-
rience by hospital staff and healthcare decision and therefore also on the reasons for
the eventual dismantlement of the hospital accreditation programme (see Box 8.1).
When the Danish accreditation initiative was launched for the Danish ­hospitals
in 2008 (the Danish Healthcare Quality Programme, see Box 8.1), the then
Managing Director Europe for Joint Commission International, Carlo Ramponi,
offered this warning:

If the bureaucratic approach is prevailing, much energy will be used to demonstrate

formal compliance with standards, but there will be no real willingness to change and
improve patient safety.
Mandag Morgen (2008)
118 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

It is this drift towards bureaucratisation and excessive weight on documenting and

demonstrating compliance – which can be summarised as ‘overimplementation’ –
that we will review and discuss in this chapter. Our aim is, first, to document and
describe how the original aims of the accreditation programme became overshad-
owed by bureaucratisation and compliance seeking – as perceived by key stakehold-
ers and in particular clinical staff – and, second, to discuss how the drift towards
bureaucratisation of QI programmes may be curtailed. In short, we seek to draw
out lessons learned from the 10-year old and now terminated history of the Danish
Healthcare Quality Programme for public hospitals.

INTERVIEW SURVEY OF PRACTITIONERS’ EXPERIENCE

AND VIEWS OF ACCREDITATION
The IKAS institute (Institut for Kvalitet og Akkreditering i Sundhedsvæsenet) is
responsible for developing and managing the Danish Healthcare Quality Programme
(see Box 8.1) and carried out a series of 17 focus group interviews, May to September
2014, in order to gather users’ and other key stakeholders’ requirements and wishes to
prepare version 3 of the healthcare quality programme for ­hospitals. Thus, the inter-
views were an opportunity for eliciting experiences (positive and negative) of clinical
staff with the programme including the way in which it had been implemented.
The IKAS interviews covered 12 focus group interviews with hospital and
hospital quality managers on several levels (including clinical leaders) across the
country and 5 with healthcare safety and quality societies and public agencies.
The total number of informants amounted to 140. Results of the interviews are
described in a short report published January 2015 (IKAS, 2015b). The study
shows that participants and especially clinical staff have a number of critical
views of the programme, but the summaries of interviews do not show a uni-
formly negative picture, and it should be kept in mind that the emphasis was on
features that participants would like to see changed in the planned subsequent
version of the Programme.
The standard set is divided into 82 standards, each of which describes require-
ment for a particular activity, such as quality surveillance or safe surgery.
Compliance is assessed by 471 measurable elements, in DDKM called indicators.
Other accreditation programmes use a number of different terms for the DDKM
indicators, such as measurable elements or criteria.* Indicators are also used by
hospitals implementing DDKM to operationalise the content of the standards,
although a self-assessment is expected to reveal that the hospital is in compliance
with most indicators so that action is only required for a subset. Two areas of con-
cern that were addressed in interviews are of particular interest for the themes of
this chapter, namely the nature of standards contained in the programme and the
implementation of the standards, that is the selection of indicators and derived
requirements to, for instance, documentation.

* http://www.achs.org.au/field-review-of-the-draft-equip6-standards,-criteria-and-elements/; http://
www.jointcommissioninternational.org/jci-accreditation-standards-for-primary-care-centers/.
Side Effects of Overdoing It 119

While hospital managers stated that in their view the programme has had a very
beneficial influence on quality and safety, most other interviewees including, in
­particular, clinical staff shared a critical view on several aspects of the programme
standards. In summary, in their view, the standards:

• Are in a number of instances too far removed from daily clinical work
• Have too much focus on the organisation, infrastructure and the hospital
operation
• Do not clearly distinguish between requirements that are dictated by legis-
lation and those that are imposed on the basis of quality concerns
• Are too static and do not seem to allow that standards, once their fulfilment
has been demonstrated, may no longer require a continuous level of organ-
isational attention
• Fail to include the quality assurance departments themselves, whose activi-
ties have a significant influence on the conditions under which the clinical
departments can work

Similarly, participants had critical views on the implementation of standards – in

contrast to the contents of the standards as earlier mentioned, and they are particu-
larly concerned with the tendency to go beyond the requirement of the standards
and engage in what we characterise as ‘overimplementation’. A large proportion of
participants hold that implementation:

• Has been appropriated and more or less taken over by the central regional
and the hospitals quality departments with little involvement of clinical
departments
• Sets the bar much higher in terms of the level, detail and scope of indicators
than is justified by the contents of the standard
• Led to a proliferation of guidelines that inflate the intentions behind the
quality programme
• Has led to an emphasis on passing the accreditation ‘exam’ with no critical
comments at all, that is with no recommendations for improvement
• Has led to the use of performance measures that some participants refer to
as a ‘control culture’ and a ‘checklist culture’
• Has failed to involve sufficiently clinical department in defining indicators
and their level and scope and hence their involvement in interpreting the
standards in a clinically meaningful way

In summary, key stakeholders find that standards do not sufficiently reflect the clini-
cal work context and that current practices of demonstrating and verifying compli-
ance have been captured by an over-reliance on documentation and a search for
compliance errors.
Results similar to those of the IKAS survey were also uncovered in another and
independent survey carried out in 2014–2015 by the Danish Institute for Local and
Regional Government Research and published in a comprehensive report in May
2015 (Holm-Petersen et al., 2015).
120 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

The results of the surveys did not come as a surprise. In recent years, a ­growing
and often very explicit disenchantment with ‘documentation load’ has been expressed
and described in the medical weeklies and in the general media and has been a
theme for heated debate at meetings in healthcare quality and safety societies. Thus,
a campaign to recruit support against growing demands for documentation in 2011
managed to collect signatures among a fifth of all hospital physicians in the capital
and received extensive press coverage (Rasmussen, 2011).

OVERIMPLEMENTATION OF STANDARDS
As we have seen, hospital staff have experienced an exaggerated emphasis on docu-
mentation and in general overimplementation of standards. An important source of
overimplementation, as suggested in the quote in the first section by Carlo Ramponi, is
a shift in the mind of the management of the organisation from identification of oppor-
tunities for improvement to demonstration of compliance with standards (‘obtaining
a clean certificate’). Instead of seeing the accreditation survey as an opportunity to
gain new insight into the modus operandi of the organisation, it becomes important
to managers to guard themselves against surprises and to assure a satisfactory out-
come of the award of status. To achieve this, a quality bureaucracy is set up and
made accountable for delivering unblemished accreditation. To match expectations,
the ‘qualitocrats’ need to be assured of process compliance. Thus, while satisfactory
result of the assessment a survey should obviate the need for continuous supervision
by creating confidence in the ability of the processes to perform as desired, instead,
paradoxically, a tight system of internal control is established, associated with exten-
sive demands for documentation, including documentation of non-actions.
In addition to the misunderstanding of the intention to standardise, assuming
that the aim is to ‘standardise everything’, you arrive at what might be called the
­perverted quality cycle:

• Describe in details how everything should be done.

• Require everyone to document every action in details.
• Check if documented actions correspond to prescribed actions.
• Impose sanction if this is not the case.

We will further develop this proposed explanation (ex post facto) of the bureaucra-
tisation of the use of standards by formulating a sketch of a programme theory of
accreditation and comparing with examples of accreditation gone awry, taken from
experiences with DDKM.
Before we describe the sources behind the possible defences against overimple-
mentation, it will be helpful to consider the role of accreditation in a strategy for QI.

OUTLINE OF A PROGRAMME THEORY FOR ACCREDITATION

While the promotion of QI is an explicitly stated purpose of accreditation (ISQua,
2015), accreditation should not be viewed as a complete QI intervention but as an
evaluation tool, used by the organisation itself and by external evaluators. Through
Side Effects of Overdoing It 121

evaluation, the organisation identifies opportunities for improvement and is thereby

provided with a direction for the QI efforts of the organisation. Thus, accreditation
is a component of a QI strategy, but the total strategy is more than a set of accredita-
tion standards and an assessment methodology. And very importantly, the strategy
can usually not be determined and controlled entirely by the accreditor. As for any
approach to QI, the way in which the organisation imbeds accreditation in its total
management strategy is of paramount importance (Dixon-Woods et al., 2014).
The assessment inherent in accreditation results not only in a set of suggested
improvements but it also entails that when an accreditation is awarded it must be
reviewed at regular intervals (ISQua, 2013a,b). Failure to achieve the desired status
can have serious consequences for an organisation. Accreditation and other forms of
external assessment can be seen as an external pressure towards QI. While positive
associations between external assessment and hospital outputs can be demonstrated
(Sunol et al., 2009), external pressure to obtain accreditation can also have a negative
impact. This is not a new insight (McMillen et al., 2008).
The key element of a programme theory for accreditation is in our context that
healthcare organisations and systems should be considered as complex systems
(Dekker, 2011). This is a short statement with profound implications. A complex sys-
tem cannot be totally predetermined by procedures and to accommodate unforeseen
variations in context and individual differences judgement must be exercised (see
also Wears, 2015a,b).
A programme theory should address in more details the way in which the organ-
isation manages quality and risk. Suffice to say that we do not think that quality
management will include detailed and continuous documentation and monitoring
of compliance with process specifications. Also, the role of the external evaluation
component should be clarified: What is evaluated? By what means? What kind of
credit will it provide? How will it compare to other ways of identifying opportunities
for improvement? (Cf. the definition of accreditation in ISQua, 2013a).
Standardisation is thus one of the several mechanisms used in accreditation.
However, while accreditation standards when used as evaluation tools may reveal a
need for standardisation, they should not be translated directly into written opera-
tional procedures without due consideration of what should be standardised.
How this works in practice can be illustrated with some examples, taken from our
experience with the Danish Healthcare Quality Programme.

Example 8.1: Mistaking an Artefact for a Goal: Focus Shift

from Outcome to Poorly Chosen Performance Indicator

Accreditation standards may include a criterion such as ‘Results of diagnostic test

(lab, x-ray, etc.) should be signed off’. The meaning of this is not that a signature
on a piece of paper or in an electronic patient record makes any real difference.
The criterion is shorthand for ‘There should be a process in place to ensure that
test results are seen by a competent person in a timely manner, are acted upon
appropriately, and are then signed off. When a signature is missing this is then
liable to alert another person to the fact that the test result has not been seen’.
This is a process well suited for standardisation, although even with a process
122 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

as generic as this, one should not assume that one process description can fit
everywhere in a complex healthcare provider organisation. But the real caveat is
that you should not focus too much on the readily observable artefact, the signa-
ture. Accreditors should evaluate compliance by checking by interviews if there
is a common understanding of the work process among involved workers. Some
patient records should be checked as verification, but the assessors should not
hunt for an example of a missed signature. Even more importantly, the organisation
should be very careful to avoid collecting data on the presence of signatures. This
may shift focus from acting timely to getting the signature right, leading to absurd
undertakings such as having junior doctors signing off old and now obsolete test
results in assembly line fashion. The expected outcome is the absence of events
due to missed test results, but measuring outcome by counting non-occurrences
of rare events is problematic. If there is a perceived problem, time might be better
spent doing an in-depth analysis of the workflow, to understand why it works most
of the time, but still fails too often (Hollnagel, 2014). As part of an improvement
project it may be warranted to track the frequency of signing for a limited period.
The example can be generalised: use of checklists promotes safety in certain
circumstances and as part of a more comprehensive intervention (Dixon-Woods
et al., 2011), but monitoring quality by monitoring documentation for completed
checks will in most cases not be useful and will alienate professionals.

Example 8.2: Standardisation on the Wrong Level

Our second example illustrates how standardisation becomes overimplemented

by being taken it too far. It is well documented that malnutrition is not rare among
certain patient groups (Kondrup et  al., 2002). It therefore makes good sense to
screen patients at risk for malnutrition, and simple tools for this are available
(Danish Health and Medicines Authority, 2008). One such tool entails asking four
simple questions; a scoring matrix then enables one to decide whether there is
reason to initiate further investigations, or if it can safely be assumed that the risk
is minimal and no further action required.

The apparent simplicity of the screening procedure has led some quality managers
and some healthcare professionals with a special interest in nutrition to suggest that
every patient should be screened. We note first that this is in contrast to the logic in
other types of screening; for example, while it is clearly possible that a woman aged
25 years has a yet undetected mammary cancer, screening is reserved for much older
women, where the risk is considerably higher. Second, we observe that is not that
easy to determine what we mean by ‘every patient’. Should we screen at every patient
admission? Should we also screen patients visiting outpatient clinics? Some of them
might certainly be at risk. Should we screen everyone once or every week or month?
If so, how do we keep track of who needs a screening? Maybe we need not screen
everyone. It is stated in the Danish accreditation standards for hospitals that nutri-
tional screening is for patient groups with a potential nutritional risk (IKAS, 2012).
But if we try to make an exhaustive definition of who these patients might be, that
is standardising on total patient population level, who should be screened, then our
best guess is that this can never be defined satisfactorily, and it might become more
cumbersome to determine whether a screening is needed than performing the actual
Side Effects of Overdoing It 123

screening. If on top of this we add mistaking means for the end and want to monitor
whether we have actually screened as prescribed, then the staff may face a require-
ment to document not only screenings that have been performed but also whenever
it has been assessed that a nutritional screening is not needed.
If instead we standardise at the patient pathway level, things look very differ-
ent. Now, we see nutritional screening as a standardised building block: Whenever
we see a need to do a nutritional screening, we perform and document it in a stan-
dardised way. And whenever we design a patient pathway, we consider whether nutri-
tional screening should be part of it. This approach emphasises that nutritional care
is not an isolated fragment but an integral part of total care.
Incidentally, patient pathways illustrate the principle that in some cases standardi-
sation does not provide us with a final answer, but a common point from which to set
off. Not all patient journeys will fit into standardised patient pathways. But whenever
nutrition is deemed to be an issue by the relevant clinician, a standardised screening
tool is available for use.
We should emphasise that the intention is not that screening again should be
left to the discretion or the memory of the individual clinician. But standardisation
should be at the level of specific patient pathways. It may require an effort to make
healthcare professionals aware that the risk for malnutrition is one of the many issues
they should consider, when designing a pathway or facing a patient not captured by
a specific pathway, and it may be that a clever design of an electronic patient record,
making a screening tool readily available, would promote this awareness.

DISCUSSION
One might wonder why overimplementation occurs. In his analysis of how evalu-
ation is used in the modern society, Dahler-Larsen (2012) demonstrates a series
of three socio-historic epochs: the modern society, the reflexively modern soci-
ety and the audit society. The latter is characterised by being obsessed with
a desire to verify and check in order to avoid risk and anything falling below
standards. This leads to the rise of evaluation machines: ‘Mandatory procedures
for automated and detailed surveillance that give an overview of organisational
activities by means of documentation and intense data concentration’ (op. cit.,
p. 176). Accreditation can easily be made to fit into this image, and this will then
generate the very examples of excessive procedures illustrated earlier. The gen-
eral trend towards the audit society, which manifests itself in a multitude of other
evaluation machines, will ensure that accreditation drifts in this direction, unless
actively countered. Similarly, in his comprehensive review of the bureaucratisa-
tion of safety, Dekker (2014) describes and documents from a large and varied set
of studies how the formalisation of safety standards has led to serious negative
side effects, in particular a one-sided focus on compliance and a control culture
that hampers innovation in QI efforts.
What could accreditors do to counteract the tendency to overimplementation?
There is an inherent tension in a system aimed both at demonstrating opportuni-
ties for improvement to an organisation and at issuing a certificate to provide
124 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

assurance to commissioners and service users. This is reinforced by the fact that
the accreditation process in many jurisdictions, including Denmark, is com-
pletely transparent, whereas traditionally the detailed report and a failure to
obtain accreditation have been confidential information. Transparency is a condi-
tion in a publically financed healthcare system. There is another handle, though.
Nowadays, the external assessment is the final step after a prolonged phase of
preparations. This seems to be contradictory to viewing the assessment as a start-
ing point for improvement activities.
There are a number of misconceptions that the accreditors could and should address
clearly.
First, standards should not be considered as rules such as, for instance, building
regulations. It is not that every standard or – every measurable element – requires a
specific action. The frequent use of the phrase ‘implementing standards’ may actu-
ally inadvertently induce this misperception and should possibly be avoided. The
standards should be seen as a guidance, that is an opportunity for reflection, an
assessment tool and a tool for structuring quality and risk management. Any action
taken is a result of the organisation’s own process of assessment against the stan-
dards, not a bureaucratic consequence of the standards per se. In this process, a
holistic view of the standards should be taken.
Second, the programme theory behind accreditation should be articulated and
communicated clearly. It cannot be assumed to be apparent from the standards. This
includes comprehensive communication of the view on standardisation.
Finally, attention must be taken to the design and format of specific accreditation
standards. In the two published versions of the Danish hospital accreditation stan-
dards (IKAS, 2011, 2012), the measurable elements were organised into four steps to
reflect the quality cycle (plan–do–study–act):

• Step 1: Guiding documents

• Step 2: Implementation of guiding documents
• Step 3: Quality surveillance
• Step 4: Quality improvement

This was devised for a didactic purpose but turned out to have unintended conse-
quences. In the first version, requirements for quality surveillance were specified
in the standards and were to a large extent of the process compliance type. In the
second version, this specification of quality surveillance was largely removed, but
since quality surveillance was still coupled to individual processes, it turned out to
be difficult for hospitals to move to a more outcome-oriented and holistic approach
to quality surveillance.
Taken together, the stepwise construction and the approach to quality surveillance
have biased the use in the direction of ‘the perverted quality cycle’ and created the
impression that QI begins with the writing of guidelines. This has been changed in
special versions, including the one intended for use in the Faroese hospital system
(IKAS, 2015). In versions for use by general practitioners and specialist physicians
(IKAS, 2014, 2016), the need for written documentation has been heavily toned down.
Side Effects of Overdoing It 125

CONCLUSION
We have reviewed how the Danish Healthcare Quality Programme has led to a
proliferation of control requirements and, in general, a gap between, on the one
hand, what is perceived as meaningful clinical quality assurance and improvement
activity and, on the other hand, the requirements for control of compliance and
documentation. In our opinion, if accreditation is done smartly it may offer a way
of replacing ceaseless control with trust, based on an assessment of whether the
system ‘has what it takes’. Such an assessment will pay attention to professional
judgement and variations in culture rather than rigid compliance with inflexible and
static standards.

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Section III
Contemporary Nordic
Research – Meso-Level Issues
 9 A Multidisciplinary and
Multifactor Approach
to Falls Prevention
The RFPNetwork
Tarja Tervo-Heikkinen, Marja Äijö
and Arja Holopainen

CONTENTS
Introduction............................................................................................................. 132
Falls and Fall-Related Accidents........................................................................ 132
Research on the Subject in Brief........................................................................ 132
Fall-Related Development Work and Education................................................ 134
Methods................................................................................................................... 134
Background for the Network.............................................................................. 134
Development Work: How to Start the Operation of the Network...................... 135
Agenda for the First Meeting............................................................................. 135
Network Meetings from the Second Meeting Onwards..................................... 136
Operational Area of the Regional Fall Prevention Network.............................. 136
Hotus – Preventing Fall-Related Accidents through Knowledge Sharing
and Collaboration............................................................................................... 137
Results..................................................................................................................... 137
Systematic Follow-Up of Falls........................................................................... 137
Regional Process Description of Fall Prevention............................................... 139
Implementation of the Falls Prevention Process................................................ 139
Forming Subnetworks........................................................................................ 139
Collaboration in the Regional Fall Prevention Network – How Do the
Subnetworks Operate?....................................................................................... 140
Educational Development Work......................................................................... 141
Discussion............................................................................................................... 142
Success Factors for Multiprofessional RFPNetwork......................................... 142
References............................................................................................................... 142

131
132 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

INTRODUCTION
This chapter describes a project aimed at clarifying and unifying practices related
to the prevention of falls in different contexts. Fall-related accidents are increasing
especially among elderly people, and these accidents have both human and financial
side effects (WHO, 2007; Stevens et al., 2006; Hartholt et al., 2012; Gill et al., 2013).
Therefore, interventions were developed during this network project to prevent falls
among the elderly living at home, in hospital or other contexts.

Falls and Fall-Related Accidents

Globally, falls and fall-related accidents are a serious health issue, especially among
elderly people (WHO, 2007). Falls can cause both fatal (e.g. head traumas) and non-
fatal (e.g. decreased functioning injuries) (Stevens et  al., 2006; Korhonen, 2014).
In addition, falls cause significant costs for healthcare. For example, falls increase
hospitalisations and long-term nursing home admissions among elderly people after
a hip fracture (Hartholt et al., 2012; Gill et al., 2013).
The age-standardised hip fracture rate has declined in western countries, but the
incidence of hip fractures has increased numerically (Korhonen, 2014). When look-
ing at gender differences, we found hip fractures to be more common among women
than men, whereas some injuries, such as skull fractures, are more common among
men (Orces, 2010; SotkaNET, 2015). In addition, there is significant variation in hip
fracture rates among women from different nations (Litwic et al., 2012; Sosa et al.,
2015). Among European women the highest fracture rates are seen in Scandinavia.
One explanation can be vitamin D insufficiency, which is common in Scandinavian
countries. It should be noted that incidence rates can vary widely even within the
same country (Litwic et al., 2012). For example, some ethnic differences (e.g. bone
material properties and bone mass) may partly explain the higher tendency for frac-
tures in Norwegian women than in Spanish women (Sosa et al., 2015).
Falls, slips and trips are the most common reasons for accidental deaths in
Finland. These accidents also cause more than 90% of hip fractures and more than
half of brain injuries (Current Care Guidelines, 2008, 2011). According to Finnish
statistics (SotkaNet, 2015), periods of care due to fall-related accidents are much
more common among people aged 65 years and older than among younger people.
The number of people over 65 years who sustain a hip fracture every year in Finland
is almost 8000 (SotkaNet, 2015). Even though the incidence of hip fractures has
declined in the new millennium in many western countries, including the Nordic
countries (Kannus et  al., 2006; Abrahamsen and Vestergaard, 2010; Stoen et  al.,
2012; Nilson et al., 2013), the absolute number of hip fractures has increased (Leslie
et al., 2009; SotkaNet, 2015).

Research on the Subject in Brief

A lot of research on fall-related subjects has been conducted over the last decade
globally (Joanna Briggs Institute, 2010; Cameron et al., 2012; Gillespie et al., 2012),
as well as in Finland (Table 9.1). A common finding in all research is that fall-related
A Multidisciplinary and Multifactor Approach to Falls Prevention 133

TABLE 9.1
Examples of Finnish Fall-Related Studies from 2007 to 2014
References Setting, Material Main Results
Hartikainen Systematic review (N = 29 The main group of drugs associated with an
et al. (2007) studies) concerning increased risk of falling: psychotropics,
medications as a risk factor antiepileptics and drugs that lower blood pressure.
for falls or fall-related
fractures.
Panula (2010) Population-based study, Hip fractures: most commonly among women,
N = 461, surgically treated occurred indoors and in institutions. Twenty-five
hip fracture (1999–2000) per cent of patients had a previous fracture.
patients. Incidence, Age-adjusted mortality was higher in men than in
morphometry, medication, women. Fracture prevention, indoor safety
mortality and cause of death measures and treatment of chronic lung diseases
were analysed. should be encouraged.
Karinkanta RCT. N = 199, aged Twelve-month resistance and balance-jumping
(2011) 70–78 years old women. training, especially in combination, prevented
Four training groups. The functional decline by improving muscle
supervised training was performance and dynamic balance as well as
three times a week for self-rated physical functioning.
12 months. Eighty-one per
cent continued to the
subsequent 1-year follow-up
measurements (24-month
assessment).
Piirtola (2011) The incidence and predictors Three hundred seven (26%) persons sustained
of fractures, functional altogether 425 fractures of which 77% were
decline and excess mortality women. Reduced handgrip strength and BMI < 30
due to fractures. N = 1177 in women and a large number of depressive
(41% men) aged ≥ 65. symptoms in men were independent predictors
Twelve years’ follow-up. of fractures.
Salonoja RCT multifactorial fall Twenty-five per cent used regularly psychotropic
(2011) prevention study, 12 months, drugs, counselling and instructions decreased the
community-dwelling aged regular use by 22% which had an effect to falls.
people 65 years and older, The multifactorial prevention was successful in
N = 591. decreasing the incidence of falls in depressive or
multiple fallers.
Korhonen Register study. The The incidence of hospital-treated fall-induced
(2014) epidemiology and trends in injuries of older Finns rose from 1970 to 1990, but
fall-induced deaths and then the injury rates have declined. Incidence of
injuries of older adults in severe head injuries and cervical spine injuries
Finland during 1970–2012 increased. The number of fall-induced injuries will
and predict the injury rates increase during the coming decades.
until the year 2030 by linear
regression models.
134 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

accidents are caused by many factors. Therefore, their prevention also calls for
­different kinds of activities and multiprofessional actions in order to be effective.

Fall-Related Development Work and Education

It is important that professionals understand how they can prevent fall-related acci-
dents; collaboration with educational organisations is therefore crucial. Theoretical
background in this collaboration is integrative pedagogy which connects four ele-
ments of expertise. On an individual level, these elements are theoretical knowledge,
practical expertise, self-regulation skills development and sociocultural information,
which are manifested on a wider scale in the workplace (Tynjälä, 2008). This phi-
losophy has previously been used in development work related to practical training
situations in healthcare among healthcare students (Koskinen and Äijö, 2013; Äijö
and Sirviö, 2012).
Integrative pedagogy integrates theory and practice. Theoretical knowledge
includes information and facts about fall prevention, and the learning methods
used are traditional, such as teaching using lessons and research articles. It is the
responsibility of healthcare professionals to put this theoretical knowledge into
action in their workplaces. Among students, integrative simulation situations at uni-
versities and vocational colleges and authentic learning experiences from practice
placements or inter-professional falls prevention campaigns combine theoretical,
practical and reflective elements of learning. Combining practical and theoretical
information requires that students and professionals have self-regulation informa-
tion. Self-regulation information includes a person’s own learning habits, awareness
of competence needs and one’s own operational models with patients, for example,
how to recognise and discuss risk of falling with patients in different kinds of situ-
ations and settings. Sociocultural knowledge consists of the unwritten rules of the
work placement as well as the tools and equipment used. (Tynjälä, 2008.)
The purpose of this paper is to describe the development of the Regional Fall
Prevention Network (RFPNetwork) and the actions implemented in it.

METHODS
Background for the Network
Interaction between people and organisations can be organised in three different
ways: by forming hierarchies, markets and/or networks (Podolny and Page, 1998;
Järvensivu et al., 2010). In a network, the distribution of tasks is resolved through
flexible consultation and is based on trust. The network way to act is good when there
is a need for innovative and flexible solutions (Järvensivu et al., 2010).
In Finland, the Ministry of Social Affairs and Health conducted a large healthcare
project (2009–2011) called Attractive and Health Promoting Health Care. One part of
the project was implementation of evidence-based nursing practices as well as devel-
opment of different networks. This marked the beginning of fall prevention work in
Kuopio University Hospital (KUH) and also the beginning of the collaborative proj-
ect of KUH and the Nursing Research Foundation (Hotus) aimed at fall prevention
A Multidisciplinary and Multifactor Approach to Falls Prevention 135

in  hospitals. One of the results of the project was the need to establish a regional
network to promote fall prevention throughout the KUH region (Tervo-Heikkinen,
2011a,b). The need for the network arose from the Finnish national action plan for
nursing management, where one of the aims was development of the management of
nursing care by creating specific regional co-operation structures for healthcare prac-
tice, education and research (Ministry of Social Affairs and Health, 2009). The need
for a multiprofessional network arose from the risks of falling and from the need of
fall prevention, which requires multiprofessional work in order to succeed.

Development Work: How to Start the Operation of the Network

The Regional Fall Prevention Network (later RFPNetwork; AKE in Finnish) began its
operation in May 2012 in the region of KUH district which covers, among others, the
districts of North Savo, Central Finland and North Karelia, where the RFPNetwork
operates in 2015. KUH is responsible for specialised medical care for almost one
million people in Eastern and Central Finland. The RFPNetwork is a multiprofes-
sional group with the aim of promoting prevention of falls and fall-related accidents
in the whole area by supporting the introduction of evidence-based and consistent
practices and guidelines. The main objective is that the number of fall accidents will
not increase in the area. These goals are pursued through consistent and evidence-
based instruction, good practices and education.
In Finland, specialised medical care hospitals are responsible for organising
training courses for the staff in their region. Because of that obligation, the KUH
organised a course in fall prevention before setting up the network. Afterwards, a
leader for the network was appointed and organisations interested in the topic were
identified. In the autumn of 2015, the network has grown to comprise 30 members
from 11 organisations or groups of organisations.

Agenda for the First Meeting

Network co-operation adheres to the overall development cycle: planned activities,
work, evaluation activities and acting as the basis for assessment (http://asq.org/
learn-about-quality/project-planning-tools/overview/pdca-cycle.html). The fact that
the establishment of the network has a legitimate reason does not mean that the
network is efficient. It is essential for the operation of the network that it works flex-
ibly and actively (Järvensivu and Möller, 2009; Järvensivu et al., 2010). Interaction
between network members is based on genuine dialogue, based on the following
principles: respect for others, listening to others, bringing up one’s own voice and
refraining from making hasty conclusions (Isaacs, 1999).
What are the tasks at the network’s first meeting?

1. Familiarising the network members with each other.

2. Collecting all members’ thoughts, expectations and wishes regarding the
operation of the network.
3. Gathering information about practices that best serve the network’s mem-
bers and the organisations involved.
136 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

4. Gathering information about the measures or monitoring procedures that

are used in the member organisations.
5. What expertise is required in addition to what is already included?
6. Agreeing on the issues that should be addressed at the next meeting.
7. Agreeing on meeting practices, such as frequency and length of meetings.

How did we do this in the RFPNetwork? The group that participated in the first
meeting consisted of 12 representatives from five organisations. The spectrum of
occupational groups has widened significantly after the first meeting. The objective
has been to bring together professional groups whose activities can have the greatest
influence on falls prevention.
At the first meeting, the convener made a presentation on falls and fall preven-
tion for discussion by using research-based knowledge on the subject of falls and
fall prevention. In brief, we had a uniform idea what the RFPNetwork should do and
what its priorities were, as well as what further expertise we needed to complete the
network. The RFPNetwork decided to meet four times a year. Between meetings,
the network operates by e-mails and in small groups, if needed.

Network Meetings from the Second Meeting Onwards

Once all basic practicalities had been settled, it was time to focus on action:

1. The group had been supplemented with new expert members.

2. Any new organisations interested in the operation of the network could
join in.
3. Formulated the network action plan: ideas, expectations and wishes formed
the basis for an action plan.
4. Prioritisation of tasks.
5. The network had to be open to new ideas and tasks.
6. Agreement that all members of the network had to do their part.

As described earlier, the RFPNetwork recruited new expert members from old and
new organisations. Although it is important to complement the expertise of the net-
work, it is not optimal for the network to grow too much or too rapidly. The network
approach means making decisions together with shared understanding. In a fast-
growing network, a lot of time has to be spent on grouping the members; and as a
result, decisions do not get made (Järvensivu et al., 2010).

Operational Area of the Regional Fall Prevention Network

The goal for the network was to have an impact in the whole region. In the autumn
of 2015, there were 30 members from 11 organisations or organisation groups in the
RFPNetwork. They represented different kinds of hospitals, health centres, nursing
homes, homecare or educational organisations in the area. Network members also
represented many professions, such as physicians, geriatricians, nutrition therapists,
lecturers, researchers, physiotherapists, patient safety managers, registered nurses,
A Multidisciplinary and Multifactor Approach to Falls Prevention 137

osteoporosis nurses, nursing managers, pharmacists, clinical nurse specialists, emer-

gency field directors and development managers. Some of the members joined the
network because of their own interest in the subject and the desire to improve patient
safety. Others had been invited to join the network because they have valuable exper-
tise on the topic. The important thing was to identify the network’s needs and the
benefits of multidisciplinary actions (Järvensivu and Möller, 2009). In autumn 2015,
the members represented a geographically large area, as can be seen in Figure 9.1.
In the RFPNetwork, this means that all member organisations use the same con-
sistent falls prevention practices, procedures and guidelines and that the educational
organisations teach these to the students, for example to nurses, physiotherapists,
practical nurses and medical students. The RFPNetwork is an example on how dif-
ferent professionals with a background from education and clinical practices can
develop practices together. In addition, students from different educational organisa-
tions and professions are key actors and developers in this kind of network together
with healthcare professionals and teachers.

Hotus – Preventing Fall-Related Accidents through

Knowledge Sharing and Collaboration
The goal of the Nursing Research Foundation (Hotus) is to disseminate evidence-
based guidelines and information about evidence-based practices to healthcare pro-
fessionals. A good example is the falls prevention project in the KUH region where
Hotus and the RFPNetwork have been co-operating partners.
Hotus is one of the partners involved in disseminating this network model nation-
ally. With the goal of applying best practices at the regional level, beyond individual
­hospitals or healthcare centres, this project has brought together a variety of h­ ealthcare
and educational organisations in the RFPNetwork.

RESULTS
In the RFPNetwork, ideas and expectations of all members are brought together.
These ideas and expectations include consistent education and training, consistent
instructions and recommendations, guidelines and educational materials, monitor-
ing of accidental falls from different registers and, later, increasing visibility of the
RFPNetwork. The network made an action plan for 2 years at a time. The first thing
was to draw up consistent good practice recommendations that are suitable to all
organisations and units. It was clear that the recommendations would have to be
evidence based. The next task was to find out what kind of instructions about fall
prevention were available to the general public and what might be needed. As a
result, we started to draw up the ‘Stay Up!’ guide, published in Finnish, Swedish and
English. In the same way, we also produce different types of material for practice.

Systematic Follow-Up of Falls

The work of the network has to be monitored. The topic of the RFPNetwork is
very multidimensional, and monitoring the impact of its operations is challenging.
 138
Researching Patient Safety and Quality in Healthcare: A Nordic Perspective
Regions of the
organisations
participating in
the network in
RFPNetwork autumn 2015
RFPNetwork member organisation
RFPNetwork’s member MML 2014
organisation with own subnet
RFPNetwork subnet member

FIGURE 9.1  The RFPN operation area in 2015, the participating hospital regions in Finland and RFPNetwork member organisations and subnetworks
with their members.
A Multidisciplinary and Multifactor Approach to Falls Prevention 139

However, at the onset of work, the RFPNetwork agreed on a common follow-up of

fall-related accidents on organisational and national level. It was decided that organ-
isational level follow-up would be performed every year from the Reporting System
for Safety Incidents in Health Care Organizations (HaiPro) (http://awanic.com/haipro/
eng/). The organisations that do not use HaiPro record accidents in accordance with
their own registers. The visibility of the network will also be monitored by surveys.

Regional Process Description of Fall Prevention

One of the tasks for the RFPNetwork was the description of the regional fall preven-
tion process. The process of description begins in the home, that is the place with
the first opportunity to have a preventive effect on falls prevention. The process goes
through falls prevention planning in different organisations, from homes to hospital
and back. It includes all RFPNetwork tools to measure and prevent the risk of falling
and instructions on what to do if someone actually does have a fall.
All completed materials have been included in the process description, which will
be supplemented as and when new material is completed. The material is distributed
electronically to members of the network. We have also had an opportunity to share
open materials via the Hotus homepages (http://www.hotus.fi) and, as of May 2015,
the KUH website (http://www.psshp.fi/ake in Finnish and in English pages http://
www.psshp.fi/rfpnetwork)

Implementation of the Falls Prevention Process

Once the basics for the fall prevention process and network are in place, the process
has to be implemented into practice. It is important to understand that the basic net-
work cannot function and grow endlessly. That is why this kind of network needs
subnetworks. Subnetworks can operate within an organisation which, for example,
brings together different units at a hospital or health centre so that implementation
is made possible. Every unit needs a key person in order to ensure implementation.
The key person is familiar with the phenomenon, instruments and materials, so she/
he is able to guide colleagues.
The advantages of the regional network to implementation are

1. Uniform processes
2. Uniform instructions and checklists
3. A uniform and systematic follow-up system, for example concerning falls
in the area
4. The use of uniform tools, such as fall risk assessment tools
5. Uniform guidebooks to the general public

Forming Subnetworks
As noted earlier, it is important to complement the expertise of the network, but it
is not optimal for the network to grow too much or too rapidly. The network needs
different types of expertise, but the implementation of consistent practices and
140 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

Expert Key
members person
members

Expert
Key members
person of SN
members
The main network
Members with
Members with subnetwork (SN)
subnetwork in
(SN) in larger area Members with
their own subnetwork (SN)
organisation in their own
organisation
Key Expert
Expert
person members
Key members
members of SN
person of SN
members

FIGURE 9.2  Forming a large network with subnetworks.

guidelines also requires more than the input from the regional network. There has to
be actors who are closer to practice than the main network.
The RFPNetwork organisations have therefore set up subnetworks. A subnet-
work can operate within one organisation or, more widely, for example, within a
municipality or an even larger district. For example, Hoivakoti Aurinkopuisto is a
private nursing home with a subnetwork on one organisation level. Siilinjärvi, on
the other hand, is a municipality and has a subnetwork that brings together different
parts of social and healthcare services. The establishment of a subnetwork to the
RFPNetwork has been initiated at the Central Finland Health Care District, compris-
ing 21 municipalities (Figure 9.2).
If all these members belonged to a single network it would suffocate the operation
of the network. Subnetworks and practical actors, which we call key persons, are
also needed for implementation. It must, however, be ensured that the voice of the
key persons is heard in the main network as well.

Collaboration in the Regional Fall Prevention

Network – How Do the Subnetworks Operate?
The municipality of Siilinjärvi has been involved in the RFPNetwork from the
beginning and their subnetwork actions are promising. Very early on, they formed a
subnetwork of their own. It consists of representatives from different areas of social
and healthcare and various professions. This subnetwork has a fixed meeting sched-
ule, and they are working actively to bring RFPNetwork’s consistent practices and
materials to the workplace.
A Multidisciplinary and Multifactor Approach to Falls Prevention 141

The Siilinjärvi subnetwork has drawn up a plan for the years 2015 and 2016.
One of the tasks of the RFPNetwork is to increase the visibility of the network and
to raise people’s awareness of their own opportunities to exert influence on falls
prevention. Information directed at the general public has also been added to the
municipality’s homepage; they have organised an ‘Elderly week’ on the topic of falls
prevention and worked together with different actors to arrange a series of lectures
entitled ‘Your Health’.

Educational Development Work

Falls prevention work has strengthened the collaboration between educational
organisations and workplaces. This collaboration enables students’ learning through
a variety of development tasks, theses and research. Students have carried out falls
prevention campaigns and, at the same time, learned about project planning, imple-
mentation and evaluation. The project design also promotes the development of
project management skills, increases theoretical knowledge of falls prevention and
supports conversation skills with customers or patients. Data collected from differ-
ent campaigns of falls prevention and development work give students material for
their theses.
The consistent practices, procedures and instructions developed by the
RFPNetwork form key contents for teaching. These good practices are taught
and practised, for example, in simulated situations at educational organisations.
Familiarity with practices and forms, for example Falls Risk for Older People
(FROP-Com Screen, Russell et  al., 2008) or RFPNetwork’s checklist for fall
prevention, and training in their use, contributes to students’ skills to work with
patients and clients. In addition, knowledge of falls prevention activities and pre-
vention process contributes to correct guidance of patients and the use of forms
during the students’ clinical practice periods. This has increased students’ knowl-
edge and skills to work with patients and as part of multidisciplinary teams during
training periods.
Teaching simulation situations can be highlighted, and they contribute to the
development of falls prevention work. For example, polypharmacy, sedating medi-
cations and orthostatic hypotension have been identified as risk factors among
people who have fallen at home or in hospital (Ambrose et al., 2015). When signifi-
cant risk factors are recognised, healthcare professionals are able to use preventive
methods to reduce the risks. This increases readiness to detect the risks and prevent
falls. Issues relating to the safety of elderly patients’ treatment and rehabilitation
also comprise the emphasis on teaching, for example, advice and guidance relat-
ing to safe movement in patients’ homes as well as in hospitals and nursing homes.
The Stay Up! Guide has already been in use in teaching situations, among ­others.
Development work focusing on good practices and teaching increases students’
expertise and professional skills to implement fall prevention measures, particu-
larly among the elderly. In addition, healthcare professionals need to update their
knowledge and skills as well. Lifelong learning is key in carrying out and support-
ing fall-related preventive work among healthcare professionals and local residents
in the whole area.
142 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

DISCUSSION
The current period of the project will end in December 2015, and the RFPNetwork’s
task for the rest of the year is to draw up an action plan for the next 2 years. Ideas
and needs have already been submitted to the network from subnetworks, expert
members and key persons. Regular monitoring and follow-up will continue. New
statements are already on the stocks, and new ideas will continue to be received.
It is also important to highlight the visibility of the network’s actions by writing
articles, through p­ articipation in conferences, and by working actively with differ-
ent organisations, such as universities. University students in different professions
and at different levels can write theses on topics related to falls prevention and fall-
related issues.
In the future, promotion and research is one part of the collaboration between the
network organisations. This also promotes follow-up and visibility of the network.
Implementation data will be collected from healthcare professionals and people living
in the operation area. In this project, we used falls as an example in simulation and
integrative pedagogy. One of the topics for future research is healthcare students and
their learning experiences from simulation and integrative pedagogy.

Success Factors for Multiprofessional RFPNetwork

1. Multidisciplinary experts are involved – commonly agreed objectives and
measures.
2. Network operation organised by an influential organisation.
3. Network convened by experts on the topic.
4. The participants and organisations involved are committed to the network.
5. The network is supported by the management of the organisations involved.
6. Management ensures the availability of network’s resources.
7. The network has uniform aims and has planned how to monitor progress
(aims and outcomes).
8. In order to be successful, implementation calls for
a. Key personnel at the units.
b. Consistent and regular education.
c. Uniform good practices suitable for different areas in the healthcare
context (measurement, monitoring and reporting).
d. Uniform education materials for the general public and staff.
9. Visible and open sharing within the network.
10. Multiprofessional, encouraging and supportive co-operation.

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 10 Coordination of
Discharge Practices
for Elderly Patients in
Light of a Norwegian
Healthcare Reform
Heidi Helen Nedreskår and Marianne Storm

CONTENTS
Introduction............................................................................................................. 145
Methodology........................................................................................................... 147
Ethics.................................................................................................................. 147
Context............................................................................................................... 148
Results..................................................................................................................... 149
Implementation of New Agreements................................................................. 149
Organisation and Information Flow................................................................... 151
When Is a Patient Ready for Discharge from Hospital?.................................... 152
Competence and Experience.............................................................................. 154
Discussion............................................................................................................... 155
Development of Agreements: Management Continuity..................................... 155
Information Flow Has Significance for Coordination: Informational
Continuity........................................................................................................... 157
The Vulnerable Patient: Relational Continuity.................................................. 157
Limitations of the Study......................................................................................... 158
Conclusion.............................................................................................................. 158
References............................................................................................................... 159

INTRODUCTION
Hospitals and municipalities expect their healthcare personnel to conform to differ-
ent values and professional traditions. Hospitals focus on treatment, whereas munic-
ipalities focus on care, function and coping. These different tasks are performed
separately, rather than in collaboration, even when such collaboration would be the
best solution for the patient (Danielsen and Fjær 2010; Glouberman and Mintzberg
2001). Many studies have revealed the lack of coordination when discharging older

145
146 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

patients from hospital to home as a significant problem (Aase et  al. 2013; Dahl
et  al. 2014; Laugaland et  al. 2011, 2012). Hospital discharge is a critical phase in
patient recovery, and shorter hospital stays and rapid discharge require coordination
between health personnel across organisations to ensure adequacy of services and to
avoid readmissions (Storm et al. 2014). Elderly patients with both physical and cog-
nitive health challenges represent a significant proportion of health service users in
both hospitals and municipalities. Because Norway has a twofold healthcare system
and because the two services have different legally mandated tasks, it will be these
elderly patients who are most often moved between hospital and municipality health
services (Tjora and Tøndel 2012). Coordination of health services is essential for
these patients to receive proper treatment and care.
Øgar and Hovland (2004) defined coordination as ‘the information exchange,
knowledge transfer, and assignment of responsibilities and duties to safeguard
patients’ needs, and the overall health policy objectives and regulatory requirements
that apply to health services’ (p. 166). Haggerty et al. (2003) have studied the concept
of continuity in healthcare services. Continuity of care is a multidimensional concept
closely related to coordination and comprising the following dimensions: informa-
tional continuity, management continuity and relational continuity. ‘The importance
attached to each type differs according to the providers and the context of care,
and each can be viewed from either a person focused or disease focused perspec-
tive’ (Haggerty et  al. 2003, p. 1220). Better coordination follows from continuity
(Haggerty et al. 2003).
Management continuity is a structural dimension characterised by political
healthcare guidelines and financial arrangements for the patient’s daily care (Hellesø
2012). According to Haggerty (2003), management continuity is achieved when
multiple services are delivered in a complementary and timely manner. Sharing of
management plans or care protocols facilitates management continuity and helps
both patients and healthcare personnel to secure future care. An important aspect of
management continuity is flexibility in adapting care to changes in patients’ needs
(Haggerty et al. 2003).
Continuity of information means that the healthcare personnel responsible for
a given patient are also in possession of adequate information about that patient.
Additionally, the patient should possess adequate information about treatment, prog-
nosis and future plans for both specialist health services and the municipality’s care
services (Hellesø 2012). Haggerty (2003) described informational continuity as ‘the
use of information on past events and personal circumstances to make current care
appropriate for each individual’ (p. 1220).
For a healthcare system to legitimately claim continuity of service, the patient must
experience care as integrated, connected and coherent in relation to his/her medical
and personal needs (Haggerty et al. 2003). Relational continuity implies ‘an ongoing
therapeutic relationship between a patient and one or more providers’ (Haggerty et al.
2003). It means that healthcare personnel are familiar with the patient and his/her
medical history, that all parties agree on the plan for care and that the patient knows
about prospective services. ‘The experience of continuity may differ for the patient and
the providers, posing a challenge to evaluators’ (Haggerty et al. 2003, p. 1221).
Coordination of Discharge Practices for Elderly Patients 147

The purpose of this study is to investigate how healthcare and administrative per-
sonnel perceive coordination of health services between hospital and municipality
in two healthcare trusts and their respective municipalities in Norway, as well as to
explore how personnel coordinate healthcare services at discharge from hospital to
short-term municipal placements. The study focuses on discharge to ordinary, short-
term placements and to a transitional ward established with the purpose of receiving
patients ready for discharge.
The following research questions will be answered:

1. How does coordination between hospital and municipality take place when
implementing new discharge agreements?
2. How do healthcare personnel and administrative personnel characterise
coordination of discharge practices for elderly patients?

METHODOLOGY
A qualitative study was conducted using individual interviews (Kvale and
Brinkmann 2009) of a strategic selection of healthcare personnel and adminis-
trative employees at a university hospital and a county hospital, as well as with
personnel in some of the respective municipalities. The aim was to understand
informants’ subjective experiences of events in relation to discharging patients
from the hospital and transferring them to short-term placements or transitional
ward at a nursing home.
Informants’ employers asked employees whether they wished to participate in an
interview, and interviews were conducted at the workplace. Before the interviews,
informants received information about the study and notification that participa-
tion was voluntary (Kvale and Brinkmann 2009; Thagaard 2010). Informants were
also asked to describe their experiences of the flow of information from hospital to
municipality upon patient discharge to short-term facilities. Interviews were tape-
recorded and transcribed verbatim.
Five of the interviews were conducted in October 2012 and 11 of the interviews
in the spring of 2013. The interviews were conducted in two different counties, in
two small rural municipalities affiliated to a county hospital and in a large munici-
pality affiliated to a university hospital (Table 10.1).
A qualitative content/text analysis was performed (Graneheim and Lundman
2004). After reviewing the tape recordings and the transcribed interviews, the data
were systematised and analysed, resulting in four themes. Both authors participated
in the analysis.

Ethics
The study is part of the research project ‘Quality and safety’ (Aase et al. 2013). The
project was certified by the Regional Committees for Medicine and Health Research
Ethics on October 19, 2011 (ref. no. 1978). All informants provided written consent
to participate in the study.
148 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

TABLE 10.1
Informants’ Age, Gender, Place of Work and Job Title at the Time of the
Interviews
Study
Informants Municipalities Hospitals
Age 38–62 years 40–61 years
Gender 8 women 7 women, 1 man
Educational Bachelor of nursing, bachelor of physiotherapy Bachelor of nursing, master of
background specialist training in geriatrics, palliative care social science, master degree and
and management and master degree specialist training in management
Work 13–34 years 14–33 years
experience
Workplace Nursing homes, Patient Service Unit Surgical and medical wards,
coordination section
Positions Ward leader, head of nursing home, patient Employees and leaders at
coordinator, secretary for receipt of request coordination section, ward leader,
from hospital administrative nursing leader

Context
This study was conducted in two counties in Norway, located within the same regional
health authority. The urban hospital is affiliated to 18 municipalities, and the county
hospital is affiliated to 21 municipalities. Many of Norway’s municipalities have small
populations (Romøren et al. 2011) and are geographically far from a hospital.
The Norwegian healthcare system is divided into two separate organisational
­levels: primary care and specialised secondary. Local municipalities are responsible
for primary care including nursing homes, home care, public health nursing, phys-
iotherapy, ergo therapy and general practice. Specialised healthcare is provided in
state-owned hospitals and organised by four regional health authorities. These two
levels act according to different laws, regulations, goals and tasks (Laugaland 2015).
The introduction of the Coordination Reform in 2012 required of hospitals and
municipalities a greater degree of formalised cooperation (Law of Primary Health
and Care Services 2011; Law of Specialist Care 2009; Report to Parliament [No. 47]
2008–2009). The intention of the reform is to ensure that healthcare services improve
continuity and coordinated services (Report to Parliament [No. 47] 2008–2009).
The Coordination Reform and the Coordination Agreement (Samhandling­
savtaler) require hospitals and municipalities to provide an explicit address for
inquiries about patients and service users (Coordination Agreement 2012 and Report
to Parliament [No 47] 2008–2009). The term ‘Coordinating Unit’ is used by both
municipal and specialist services. The Coordinating Unit responds to inquiries, pro-
vides administration and secures continuity of service provision between the primary
and specialist healthcare (Det kongelige Helse- og Omsorgsdepartementet Meld.
St. 16 (2011–2015), Helsedirektoratet 2012). The Coordination Reform stipulates a
preference for electronic communication between hospitals and municipalities when
Coordination of Discharge Practices for Elderly Patients 149

exchanging health information regarding patients (Report  to Parliament [No. 47]

2008–2009). Electronic message exchange (EME) among hospitals, municipalities
(e.g. home care, nursing homes, Patient Service Units) and general practitioners is in
an initial phase, and there are major differences among practitioners in their use of
the new technology. Electronic communication will be fully developed in all hospi-
tals and municipalities in the coming years (Bergmo et al. 2013).
The Coordination Reform and related laws require specialist health services and
municipalities to form binding agreements in order to contribute to cooperation and
coordination between levels of administration and care, ensuring better continuity
of care and coordinated services (Det kongelige helse- og Omsorgsdepartementet
Meld. St. 16 (2011–2015); Law of Primary Health and Care Services 2011; Law of
Specialist Care 2009; Report to Parliament [No. 47] 2008–2009). Sub-agreements
and one overarching agreement have been produced according to the law in all
municipalities and for specialist services in Norway. Agreements are binding for
both parties and describe the tasks appropriate to the respective organisations.
Breach of agreements results in a written notice of deviation and, possibly, sanctions.
This study is concerned with one sub-agreement, which deals with allocation of
tasks/duties and responsibilities regarding somatic patient stays in and discharges
from special health services to municipal health services. According to this sub-
agreement, the municipality is financially responsible for patients ready to discharge.
If a municipality does not immediately receive patients ready for discharge, it must
pay a penalty fee to the hospital. Should the patient receive services from the munici-
pality, the hospital must notify the municipality about admittance within 24 hours
(early notification). According to the sub-agreement, written notice must also be pro-
vided in cases where patients have completed treatment before discharge. The ready-
to-discharge notice designates a patient’s completion of treatment, and written notice
is sent from the hospital to the municipality.

RESULTS
The results are presented according to the four themes revealed through data analysis:
implementing new agreements, organisation and information flow, when is a patient
ready for discharge from hospital? and competence and experience in health personnel.

Implementation of New Agreements

The introduction of the agreements of the Coordination Reform in 2012 required
comprehensive training of employees in hospitals and municipalities. For effective
coordination, the employees of both organisations need adequate knowledge of the
agreements and of how to put them into practice when transferring patients.
Informants from the hospitals and in the municipality experienced that the
work related to the agreements is anchored by management and is executed by
managers at different levels of the organisation. The work is described as encom-
passing and time-consuming. Informants at both hospitals and in the municipality
explained that a range of different methods are used to develop and implement
the agreement.
150 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

Findings show that there are several similarities between the urban and the rural
approach to implement the agreements. Both have engaged administrative and
healthcare personnel in working groups together with the management to come to an
agreement for both municipalities and hospitals. Management in both hospitals and
urban and rural municipalities was concerned with providing information to employ-
ees during the process of implementing the agreements. The Internet and newsletters
were used to gather and disseminate information. The rural hospital and municipali-
ties had a specific project group focusing on the discharge agreement, because they
expected this agreement to represent a difficult task for both organisations. They
arranged a meeting with personnel from both the hospital and the municipalities
where personnel completed a questionnaire about their experiences of the discharge
agreement. The county hospital and the rural municipalities also had user represen-
tative in the group implementing the discharge agreement.
The urban hospitals have established coordination contacts (nurses with extra
knowledge of the functions and services in the municipalities) to improve coordina-
tion with the municipalities. To improve coordination, the urban hospital continued
with and strengthened the mutual practical consultant arrangements they already
had in place with municipal doctors and nurses.
Informants from the Coordination section at the urban hospital related that they
previously had agreements about patients ready for hospital discharge with many
local authorities, but that now these agreements are legally mandated. Informants
stated that the employees have been involved in coordination work in varying ways
with virtually all sub-agreements, just not with the overarching agreement. They
described the agreement on discharge-ready patients as a detailed distribution of
work for service providers at both levels. Informants perceived the concrete nature of
the agreement as an advantage. The agreement, they said, is easier to follow through
and practice when smaller matters are left to the judgement of healthcare personnel.
The informants reported that their organisations had given significant attention to
new routines for notifying municipalities of patients who have completed treatment.
They said that healthcare personnel are drilled in the agreement-specified proce-
dures related to patient discharge from hospital.
The informants from the county hospital mentioned that, previously, coordination
between the two service levels had been characterised by many small, uncoordinated
municipalities and large hospital, which gave the hospitals power. The hospitals are
affiliated to many municipalities and, prior to the agreement, the municipalities had
each negotiated separately with the hospital, leaving them with less power than the
hospitals. One participant was of the opinion that this had changed for the better
under the coordination agreement:

The coordination environment changed … This is the idea of the Coordination Reform,
to give greater equitability. And it was a very good process, and I found that we were
fortunate to have the agreement and a sense of equality emerged.
Coordination section, county hospital

Many of the informants said that when the municipalities stand together, they become
a greater power. Although some municipalities are quite small, coordination gives
Coordination of Discharge Practices for Elderly Patients 151

the municipalities a strengthened position, which also reflects in specific, tangible

cooperation at the departmental level.
According to the informants, there is a greater focus on coordination in the organ-
isations, and the sub-agreement leads to earlier and more frequent contact between
hospital and municipality on discharge of patients. Municipalities now have few or
just one telephone number, which the hospitals use when planning for discharge of
patients, and there are prepared checklists and standard forms for contact between
organisations.

Organisation and Information Flow

According to the informants, Coordinating Units are organised in different ways
among municipalities. In the urban municipality, the Patient Service Unit func-
tions as the Coordinating Unit. There are four units serving the entire municipality.
Patients seeking healthcare services are referred to the Patient Service Unit, where
each is assigned a permanent patient coordinator. The Health and Social Service
head is the top manager and professional responsible for the decisions taken. One of
the informants at the Patient Service Unit enlarged on the role:

First and foremost it is to coordinate services to users … to see that they get the appro-
priate help. We enter into dialogue with next of kin, have home visits to patients, see
how it goes and think further. With changes in need the idea is to see the whole, make
a few summaries, and be available.
Patient Service Unit, urban municipality

The strength here, according to this informant, lies in the fact that one gains an early
oversight of the patient’s needs and can make a plan in conjunction with other help
agencies and with next of kin. Informants from the two rural municipalities reported
that they also used the term ‘Coordinating Unit’, but the units were differently organ-
ised and the daily activity functioned differently. Both had telephone numbers that
hospital personnel could call. The person who answered the phone could vary, they
reported, and the call could then be passed on to the duty telephone at the nursing
home or directly to the home care nurse. In both municipalities, the ward leaders at
nursing homes played a key role in servicing the contact phone line, even though calls
often concerned patients that were not being discharged to the nursing home. Findings
from the rural municipalities indicate that those communicating with the hospital on
transfer of patients were not always familiar with the patients but had the opportunity
to refer them on to familiarised health personnel to better secure information continu-
ity. Informants from rural municipalities said they knew many of their users, and it
appears that a smaller environment resulted in better familiarity among staff, patients
and next of kin. One participant, a ward leader, explained the process:

I can receive a telephone call about a patient ready for discharge, or a 24-hour warning.
It can arrive at reception or to the homecare nurse. If reception receives the call during
the day they then place the call to the individual they think is the best receiver.
Ward leader, nursing home, rural municipality
152 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

According to the informants, there is a great need for reliable communication between
hospital and municipalities in connection with discharge of patients. They stated that
communication occurs in different ways. Telephone, fax and EME were used. EME is
a system enabling hospital and municipality to exchange patient information electroni-
cally. EME was in place between the university hospital and the urban municipality.
The rural municipalities and the county hospital had not yet taken EME into use and
instead used faxes for written dissemination of patient information. Information could
be sent by telephone and fax, but when EME was not in place, organisations were
dependent on documentation from the hospital being sent directly along with patients,
to ensure that late changes were included. Informants from both rural municipalities
described this process. Informants from the county hospital and associated munici-
palities largely believed that coordination and information flow worked well, and they
observed that, as an extra security, they delivered information with the patient, some-
times with the help of next of kin, in addition to fax and telephone.
In the large municipality, lines of communication were somewhat simpler, because
all notices of discharge-ready patients went to a Patient Service Unit. When a patient
was discharged to a ‘transition ward’, there was additional contact between the
department and the hospital. The results reveal that there are differences in how the
flow of information proceeds between the hospital and the municipality, and these
differences depend on the organisation and on whether EME has been taken into use.
In the three municipalities, Coordinating Units functioned differently, and EME was
only available in the urban municipality and at the urban university hospital. This has
consequences for how healthcare personnel communicate with each other.
Figure 10.1 presents information flow between the two hospitals and municipali-
ties, including obligatory notifications in accordance with the sub-agreement regard-
ing hospital discharge of patients. There is a difference between municipalities with
and without a Patient Service Unit.

When Is a Patient Ready for Discharge from Hospital?

It is the hospital’s obligation to determine when a patient is ready for discharge to
the municipal health service, according to the agreement on discharge of somatic
patients. The doctor at the ward is responsible, but result shows that the decision
is taken in collaboration with the nurses. A participant from the county hospital
reported engaging in discussion with the doctor to arrive at agreement about when
the patient is ready for discharge. The doctor considered the patient’s medical sta-
tus, and the nurse evaluated the patient’s level of functioning and need for training
with reference to the municipality. Nurses decided whether notification of completed
treatment was provided in accordance with the agreement.
Should a hospital fail to comply, the municipality could protest, and there have
been cases where the hospital has had to retain the patient an extra day because of
lacking notice or for failure to conform to notice requirements. In individual cases,
disagreement can arise between the municipality and the hospital about whether the
patient’s treatment is complete, and this can lead to conflict regarding whether the
municipality is obliged to pay for the patient while still being hospitalised in accord
with the agreement. Informants observed that it could be difficult to decide when the
Coordination of Discharge Practices for Elderly Patients 153

Flow of information between hospital and municipality

in connection with discharge of patients
Patient admitted to Notification: In progress notice Ready to discharge notice Patient discharge
hospital 24-hour notice hospital

Via telephone,
fax and EME

Switchboard
Contact phone to the
– Home care nurse
rural municipalities
– Nursing home
– Other
Duty telephone,
municipality Patient service unit

Notification
about new
Nursing home short term Transit ward
patient

Arrows indicate dialogue

from hospital to municipality

FIGURE 10.1  Flow of information between hospital and municipality in connection with
discharge of patients.

patient’s treatment is complete, because the health condition of the patient changes.
Complications can arise which change the date of discharge, and the hospital needs to
remain in regular dialogue with the municipality to keep the discharge date updated.
Informants noted that next of kin are important. Because of illness, medication,
cognitive impairment and impairments of vision and hearing, older people often
wish next of kin to be thoroughly informed of the condition of their health, because
they are important assistants in the follow-up of services and of further medical
help. Informants pointed to patients with dementia or cognitive impairment as the
most vulnerable to rapid hospital admittance and discharge and to transfer between
departments and organisations. According to the informants, discharge from hospi-
tal to short-term wards can occur quickly.
Our findings indicate that employees in administrative and managerial positions
viewed the patient coordinator of the Patient Service Unit as important for both patient
and next of kin and for the hospital and nursing home. The informants observed that
quick transfers could make the patient uncertain and insecure about the situation and
about further services and care. The patient coordinator has an important and chal-
lenging role in cooperating with the hospital to ensure coordination of services so that
patients experience predictability. A number of informants cited examples of working
across departments in order to find good solutions for the patients.
There have been some especially vulnerable patients that have been moved twice. First
been moved to the transition ward and then moved further to the intended place … but
we have spoken about this, we have an oral agreement in a sense … that especially
vulnerable patients shall be moved the fewest times possible.
Coordinating section, urban hospital
154 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

The capacity of the municipality to receive patients on completion of treatment has

significantly improved since the Coordination Reform was instituted, according
to all informants. Informants from both hospitals wondered how this was possible.
Their experience was of sending patients off earlier than previously.

Previously they stayed perhaps ten to twelve days after they were finished and received
their rehabilitation time in here, and so you are healthier when you leave. But now
notice is given immediately when they are ready.
Administrative nursing leader, county hospital

Informants from all municipalities confirmed the attitude that patients ready to
discharge should be received. In cases of very sick patients where it is not ethically
or professionally defensible to move the patient to a temporary location (transition
ward, urban municipality), but where the patient must be transferred directly to the
correct placement, the municipality may pay for the patient to remain in hospital.
In some cases, the hospital also defers registering the patient as fully treated to
spare the patient an extra transition. This occurs in collaboration with the munici-
pality when the municipality can make a suitable offer within a short time. As a
rule, responsibility for payment follows governing agreements, but collaboration to
safeguard the rights of especially vulnerable patients occurs regularly, according
to informants.
To avoid penalty fees, the urban municipality organised a transit ward to receive
patients when ready to discharge. The rural municipalities sometimes took two
patients in one room rather than one, and they used rooms not planned for patients
to avoid paying fees.
There is a major convergence of views from the informants in hospitals and
municipalities that economy is a concern for both organisations; financial concerns
influence the hospital’s decision to indicate discharge readiness, and for the munici-
pality’s decision to notify discharge readiness before the payment requirement would
come into effect.

Competence and Experience

Most of the informants were nurses working in different management or admin-
istrative positions in hospitals or municipalities. They reported that nurses in dif-
ferent positions were occupied within coordination work internally and across
organisations.
Experienced healthcare personnel are important to achieve continuity of care
and service with regard to discharge of patients, according to informants. One
of the informants from the county hospital, who had the responsibility for dis-
charge of patients, noted that adequate time, experience, competence and stabil-
ity among nurses are important factors contributing to secure discharges that
safeguard continuity of services. Several nurses at the county hospital had been
at the department for more than 20 years. As a result, their superiors felt secure
that the nurses knew the requirements and followed them while also maintaining
clinical professionalism.
Coordination of Discharge Practices for Elderly Patients 155

The informants from a small rural municipality that was often in communication
with the hospital about discharge of patients explained how important it was to be
able to ask the right questions to hospital staff, to form a correct picture of patients
and to clarify health conditions and level of functioning. She related the following:

We have these forms we use, so when I pick up the telephone I am very concentrated.
So I think that this can be irritating for them when they get me in conversation … they
know then it is thorough. There must not be much room for doubt afterwards.
Ward leader, rural municipal nursing home

The informant from the transition department in the urban municipality, which received
all its patients from the hospital, was very concerned with the competence of those in
dialogue with the hospital. The facility used specially trained nurses in these roles.
The ward recognised the importance of clinical skills in properly caring for patients
coming from hospital. The participant’s experience was that good communication and
clinical skills are necessary to ensure continuity of services for patients. Informants
mentioned that cooperation between health personnel in different organisations is
time-consuming and complex work. At both hospitals, informants stated that lack of
time is most often the cause of deficiencies at discharge. They also observed that direct
work with patients should be prioritised ahead of planning and discharge work. In busy
periods, work is done using overtime or performed less thoroughly.
Informants in different hospital wards and municipalities told of a fast work tempo
and of expectations for a good patient flow through the system. For the municipali-
ties, this meant receiving patients ready to discharge immediately after they finished
with hospital treatment. Informants from all municipalities observed that the need
to provide for the patient’s best interests, while at the same time meeting economic
demands and ensuring patient flow, could be a conflictual experience. On the one
hand, the employer desires efficiency in the use of resources, but the wishes of the
patient and the next of kin may contradict this aim.

DISCUSSION
This study reports that the new agreements between the hospital and municipality health
services have improved coordination between the organisations. There are concerns
about shorter hospital stays and quicker transfers of patients from hospital to munici-
palities due to the discharge agreement and, in particular, about the consequences for
elderly patients. There are differences between rural and urban municipalities and hos-
pitals in how they have organised service coordination, their systems for information
exchange and in the extent to which they have implemented EME. Experienced health
personnel are important to ensure coordination and continuity of care.

Development of Agreements: Management Continuity

Management continuity involves both political health guidelines and the organisa-
tion of daily care for the patient (Hellesø 2012). Informants’ satisfaction with dis-
charge agreement is evidenced in the interviews. According to the informants, a
156 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

more explicit delegation of tasks now occurs alongside established routines, leading
to increased and earlier dialogue between the organisations. They believed the agree-
ments provide predictability and guiding limits. A clearer delegation of work tasks
between the administrative levels following implementation of the Coordination
reform was also reported by Martens and Veenstra (2015).
It is demanding to negotiate new agreements and implement them in large organ-
isations like hospitals and municipalities. Our results show that a thorough job has
been done in this respect by disseminating information on the agreements and how to
put them into practice in the organisations. Although work with agreements has been
initiated and managed at the system level, work has been done to involve managers
and personnel in different kinds of work groups. Findings indicate that, with the
implementation of the new agreements, a feeling of greater equity emerged between
the hospital and the municipality. Both parties experienced an evening out of the bal-
ance of power because of work with the agreements. Respect for co-workers, good
structures of coordination and a balance of power are important factors that affect
coordination (Øgar and Hovland 2004).
Coordination of services between health personnel in different organisations and
units of care is a comprehensive and demanding task for nurses (Hellesø et al. 2005).
Research has shown that when patients are moved, it is largely the nurses who are
in contact with each other across and within organisations (Kirsebom et al. 2012;
Moore 2012; Olsen et al. 2013). The way in which nurses solve problems involved in
transfers from hospital to municipality healthcare service can make a difference in
patients’ experience of continuity (Hellesø 2012).
According to the informants in this study, nurses in hospitals and municipali-
ties have an important coordinating task. Orvik (2006) referred to nurses as the
glue of the organisations. Nurses contribute to holding a complex system together,
a task other health professions take for granted. Nurses’ many organisational tasks
can compromise their time for patient contact, undermining the opportunity for the
development of professional competence in their own clinical areas (Orvik 2006).
The nurses interviewed here noted that coordination across organisations was time-
consuming and that this had increased with the new agreements and consequences
thereof, especially the obligatory notification and more frequent dialogue between
the hospital and the municipality. The data do not give grounds for claiming that there
are differences between rural and urban hospitals regarding increased workload.
Haggerty (2003) stated that management continuity is very important for
patients with chronic or complex diseases that require services from several
providers as well as for older persons discharged to short-term stays in nursing
homes. According to Haggerty (2003), continuity is achieved when services are
delivered in a complementary and timely manner. Informants in all municipali-
ties reported that they were concerned about penalty fees for discharge-ready
patients because rapid discharges can threaten the continuity of service due to lack
of time for discharge planning. The economic incentive seems to work in accord
with the purposes of the Coordination Reform. Informants noted that they had
almost no patients ready to discharge in hospital. Starting in January 2012, change
came about quickly. Municipalities have followed the requirements and taken on
patients. This is in line with the intention emphasising the economic responsibility
Coordination of Discharge Practices for Elderly Patients 157

of the individual enterprise (Report to Parliament [No. 47] 2008–2009). However,

shorter hospital stays and rapid hospital discharges can be a particular challenge
for the older patients (Martens and Veenstra 2015).

Information Flow Has Significance for

Coordination: Informational Continuity
The findings show a variation in how information flows between the hospital and the
municipality depending on the organisation and on whether EME has been taken into
use. The rural municipalities still had neither EME in hospitals nor a well-functioning
Coordinating Unit, informants said. By contrast, the urban hospital and municipality
had both in place. Informants from both the county hospital and the rural municipali-
ties were optimistic about reduced workload in relation to exchange of information
and more secure flow of information after the introduction of EME. Simple access to
and exchange of relevant information is decisive for achieving good coordination and
to ensure secure, proper treatment of patients (Hellesø 2012; Jeffs et al. 2013).
Continuity of information means that the healthcare personnel responsible for
the patient are adequately informed about treatment, prognosis and further plans
for treatment/care in both organisations, and the patient must also be so informed
(Haggerty et al. 2003). Written information on the transfer of patients to short-term
placements is a requirement in accordance with sub-agreement on discharge of
patients, whether by fax or EME (Report to Parliament [No. 47] 2008–2009). When
older patients are discharged from the hospital, documentation tends to focus on
medical conditions, but it is also important to share knowledge of the patient’s val-
ues and preferences (Haggerty et al. 2003). Our data do not support the claim that
patients in small municipalities lack documentation to a greater extent than those
in larger ones when discharged to short-term nursing home care, even though these
small municipalities have no EME.
Informants related that patient and next of kin often bring along information from
the hospital and are thereby messengers between the different organisations and
responsible for safeguarding the continuity of information (Hellesø 2012; Hellesø et al.
2005). That the information exchange is performed in a number of different ways cre-
ates challenges, in particular for the hospitals that must deal with different procedures
in different municipalities, as well as for both types of organisation where the use of
fax and telephone is found to be cumbersome and laborious. Healthcare personnel in
hospitals and municipalities maintained that they used a lot of time on information
exchange (written and conversations) in order to ensure continuity of information.

The Vulnerable Patient: Relational Continuity

Relational continuity refers to the personal relationship between an individual
patient and professionals, built on shared experience and interpersonal trust (Guthrie
2008; Haggerty et al. 2003). Elderly patients with chronic diseases traverse organ-
isations, going from specialist to primary healthcare, which involves many different
professionals. As primary healthcare has grown, the primary healthcare team has
expanded, especially with nurses, who have also extended their roles (Guthrie 2008).
158 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

The informants involved with the Patient Service Unit reported that this system
secures cooperation and continuity of care. The patient coordinator can become
familiar with the patient and next of kin as they follow them through the different
phases of illness and changing needs. Care for the individual and care delivered
over time by the same healthcare professionals both ensure relational continuity
(Haggerty et al. 2003). A good relationship to the patient coordinator, according to
interview informants, facilitates provision of appropriate services and contributes to
the patient’s greater confidence in the system.
Relational continuity can lay the ground for how patients experience the quality
of services. In this study, we do not have the voice of the patients and do not know if
the patients experience relational continuity. Haggerty (2003) states that the experi-
ence of continuity may differ for the patients and the providers, which is a challenge
in the evaluation of continuity.
In the smaller rural municipalities, services are not organised with a patient ser-
vice unit and patient coordinators. In order to receive fax and telephones from the
hospital, they use their existing services in nursing home, home care and switch
board. In the smaller rural municipalities, people are more acquainted to each other,
and often there are just one or two nursing homes, with which both the patients and
the next of kin feel familiar. When patients and next of kin know or are familiar with
healthcare personnel, they can have a sense of predictability and security, despite
having no permanent healthcare personnel/patient coordinator to which to relate. In
contexts where there is little expectation of establishing relationships with multiple
healthcare personnel, as in nursing home care services, a stable core of personnel
can give the patient a sense of stability and predictability (Haggerty et  al. 2003).
Informants in the rural municipalities indicated that they knew many of the patients
personally, and this may lead to a sense of stability and predictability for the patients.

LIMITATIONS OF THE STUDY

Informants in this study were administrative personnel and managers. Managers
have been involved in producing, disseminating and implementing the agreements
at the departmental level. Administrative personnel and managers can be loyal to
management and feel that they represent the service system; they may therefore find
it difficult to express negative views in an interview (Glouberman and Mintzberg
2001). Had nurses been interviewed who experienced daily patient contact, differ-
ent views on the coordination and transfer of elderly patients to the municipality
healthcare service may have emerged. Further research focusing on the perspective
of patients and next of kin will contribute valuable viewpoints on their experiences
with continuity and coordination of care.

CONCLUSION
This study has investigated healthcare personnel’s perceptions of coordination of
healthcare services between the hospital and the municipality, especially when
older patients are discharged to municipal short-term placements, in two counties in
Norway. Data analysis revealed four themes of importance for the coordination of
Coordination of Discharge Practices for Elderly Patients 159

health services: implementing new agreements, organisation of services and infor-

mation flow, when is a patient ready for discharge from hospital? and competence
and experience in health personnel. The work with implementation of new agree-
ments has involved managers, administrative personnel and clinical personnel at
different levels of the organisations, as well as a range of different work methods.
The agreement has led to a more explicit delegation of tasks and earlier dialogue
between the organisations. There is variation among organisations regarding how
they organise for coordination and how information flows between the hospital and
the municipality. Nurses in hospitals and municipalities have an important, but time-
consuming, role in coordinating services across organisations.

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 11 Leading Quality
and Patient Safety
Improvement in
Norwegian Hospitals
Inger Johanne Bergerød and Siri Wiig

CONTENTS
Introduction............................................................................................................. 161
Theoretical Approach.............................................................................................. 162
Methodological Approach....................................................................................... 164
Leading Quality and Safety Improvement in Hospitals.......................................... 164
Structural Challenge................................................................................................ 165
Political Challenge.................................................................................................. 165
Cultural Challenge.................................................................................................. 167
Educational Challenge............................................................................................ 167
Emotional Challenge............................................................................................... 169
Physical and Technological Challenge................................................................... 169
Contextual Challenge.............................................................................................. 170
Senior Leadership Challenges................................................................................. 171
Lessons Learnt about Quality and Safety Leadership Processes............................ 171
Acknowledgements................................................................................................. 174
References............................................................................................................... 174

INTRODUCTION
The Norwegian healthcare system is undergoing significant reform including an
increasing focus on ‘quality’, of which safety is an important component (IOM, 2001;
Wiig et al., 2014). The government’s priority is to build a high-quality and patient-­
centred healthcare service that has a better distribution of power and influence between
the system and the patient. In addition to strengthening the user role, the government
has three focal areas to enhance quality and safety: (1) creating and establishing bet-
ter systems, (2) strengthening leadership engagement and (3) building a reporting
and learning culture to reduce adverse events (Ministry of Health and Care Services,
2008–2009, 2011–2012, 2012–2013; The Norwegian Directorate of Health, 2005).
As part of this increased attention to quality and safety, Norway launched its
first national patient safety campaign in 2011, followed by a permanent patient

161
162 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

safety programme in 2014. Leadership is one of the top priorities of the programme.
Leadership and hospital boards play an important role in the coordination of com-
plex hospital organisations and are often considered key links in these systems
(Donaldson et al., 2000; Goeschel et al., 2010; Künzle et al., 2010). Research shows
that implementation and maintenance of new methods are a demanding undertak-
ing that requires comprehensive leadership, engagement, prioritising and enthusiasm
(Bate et al., 2008; Frankel et al., 2008). Despite increased research into the role of
leadership, there is still limited knowledge on how and in what ways leadership
affects quality and safety in healthcare systems (Hockey and Bates, 2010; Levey
et al., 2007).
The aim of this chapter is to explore the role of leadership in organisational and
cultural factors related to quality and safety in hospitals. We compare the organising
and leadership processes in two Norwegian hospitals. The following research ques-
tion guided this study: How is leadership influencing quality and patient safety work
in two Norwegian hospitals?
The study is part of the Norwegian case study in the European FP7-funded proj-
ect ‘Quality and Safety in European Union Hospitals: A research-based guide for
technical implementing best practice and a framework for assessing performance’,
QUASER, 2010–2013 (Robert et al., 2011).

THEORETICAL APPROACH
To understand how hospitals are organising for quality and safety, and the role of
leadership in this process, we applied Organising for Quality (Bate et  al., 2008)
as our theoretical framework. The evidence-based framework uses case studies in
seven prominent hospitals in the United States and Europe to identify six challenges
to achieving and sustaining quality of care. The original framework illustrates an
integrated leadership perspective. In this chapter, we added two more challenges –
the contextual challenge and the senior leadership challenge that were also identified
in the QUASER study (Fulop et al., 2012).
The eight challenges applied in the theoretical framework are as follows:

1.
Structural – organising, planning and coordinating quality efforts
2.
Political – addressing and dealing with the politics of change surrounding
any quality improvement effort
3.
Cultural – giving ‘quality’ a shared, collective meaning, value and signifi-
cance within the organisation
4.
Educational – creating a learning process that supports improvement
5.
Emotional – engaging and mobilising people by linking quality improve-
ment efforts to inner sentiments and deeper commitments and beliefs
6.
Physical and technological – designing physical systems and technological
infrastructure that support and sustain quality efforts
7.
Contextual – responding to social, political and contextual factors outside
and inside the organisation
8.
Senior leadership – evaluating all leadership challenges in the framework
related to quality and patient safety (Figure 11.1)
Leading Quality and Patient Safety Improvement in Norwegian Hospitals 163

1. The structural
challenge

8. The senior
2. The political
leadership
challenge
challenge

7. The contextual 3. The cultural

challenge challenge

6. The physical 4. The

and
educational
technological
challenge challenge

5. The emotional
challenge

FIGURE 11.1  Eight leadership challenges. (Based on Bate, P. et al., Organizing for Quality:
The Improvement Journeys of Leading Hospitals in Europe and the United States, Radcliffe,
Oxford, U.K., 2008.)

The integrative leadership perspective in our theoretical framework implies a variety

of approaches and priorities to meet the challenges. Within the structural challenge,
we find strategic leadership involving a strong vision, strategic goals and discipline
around the focus on quality and safety. Within the political challenge, we find politi-
cally credible leadership in which leaders with authority, negotiating skills and abil-
ity respond to quality and patient safety challenges with seriousness and conviction.
Clinical empowerment is important in this challenge as is the ability to align mes-
sages to the medical specialties in the hospital. In the cultural challenge, we find
value and symbol-based leadership in which leaders cultivate a culture that is dedi-
cated above all to quality and patient safety. In the educational challenge, we find
educational leadership of people who work with best practice, learning and devel-
opment in quality and patient safety. The emotional challenge focuses on inspira-
tional leadership where enthusiastic leaders see quality and patient safety as a ‘goal’
or a project. They suggest ideas, methods and motivations for the implementation
and maintenance of quality and safety improvement throughout the o­ rganisation.
The  physical design and technology challenge is related to technological-based
164 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

leadership, where leaders understand the importance of building a culture of func-

tional, ethical, clinical and informational technologies based on patient and user
experiences. In this challenge, the systematic use of quality data (e.g. quality indica-
tors), physical environment or architecture is considered an important part of quality
and safety improvement work. The contextual challenge relates to the way in which
management handles external requirements and environmental demands, balanced
against internal factors such as the organisation’s size, structure and ability to deliver
in terms of budget, quality, safety and patient satisfaction. The last challenge, senior
leadership challenge, is an overall assessment of leadership attention towards organ-
ising for quality and patient safety.

METHODOLOGICAL APPROACH
This chapter is based on the Norwegian QUASER study of two hospitals (Bergerød,
2012; Bergerød and Wiig, 2015; Wiig et al., 2013, 2014). The Norwegian hospitals
were selected on the basis of performance on five national quality indicators (aver-
age over the last 3  years). Hospital A was designated as ‘high performing’ and
Hospital B was designated as ‘developing’ based on the selected indicators (Burnett
et al., 2013; Wiig et al., 2011). Both hospitals were studied at the meso (organisa-
tional) and micro (ward) levels. The study included two areas at the micro level in
Hospital A (maternity, cancer) and one area at the micro level in Hospital B (mater-
nity). The research project was approved by the Norwegian Social Science Data
Services (5 May 2011, Ref. 26636), and all respondents provided informed written
consent prior to their participation in the study.
Data collection at the meso and micro levels (April 2011 to April 2012) con-
sisted of semi-structured interviews (97), focus group interviews (2), interview
with patient representatives and patient Ombudsman (Hospital B), shadowing of
healthcare professionals and observation (45 h) and documentary analysis (strate-
gies, mission documents, board reports, user committee reports, method books).
A common interview guide was developed based on the theoretical framework
(Figure 11.1).
All interviews were transcribed and uploaded in Nvivo and analysed accord-
ing to a predefined codebook according to the eight challenges in our theoretical
framework (structure, politics, culture, emotions, education, physical and tech-
nical, external demands and leadership) (Robert et  al., 2011; Wiig et  al., 2014).
In this chapter, we focus on the leadership aspect related to the eight challenges
(Bergerød, 2012).

LEADING QUALITY AND SAFETY IMPROVEMENT

IN HOSPITALS
In the following, we will present results from the Norwegian QUASER study accord-
ing to the eight leadership challenges (Figure 11.1). Under each challenge, we pro-
vide examples in the form of quotes from Hospitals A and B. Table 11.1 gives an
overview of main contextual factors for the two hospitals.
Leading Quality and Patient Safety Improvement in Norwegian Hospitals 165

TABLE 11.1
Contextual Factors for the Two Case Hospitals
Context Hospital A Hospital B
Location Small town in rural Norway Large city in Norway
Population 110,000 inhabitants 260,000 inhabitants
Hospital Central hospital University hospital
Small hospital Large hospital
Treats 140,000 patients annually Treats 600,000 patients annually
Employees 2,200 employees 11,500 employees
Annual budget 1.4 billion NOK 8.4 billion NOK

STRUCTURAL CHALLENGE
Hospital A is a small hospital with a hierarchical organisational structure. Hospital B
is a large teaching hospital with a flat organisational structure. Formal responsibil-
ity for quality and safety relies in the management line organisation. Both hospitals
have established a mandatory quality committee and a patient safety committee.
Hospital A’s quality committee is highly respected, and all division directors and top
management sit on it. The latter is a senior management decision made to pinpoint
the role of leaders in working on quality and safety. As a consequence, Hospital A’s
quality committee is active in quality improvement. In contrast, Hospital B’s quality
committee is characterised as a ‘sleeping’ committee. It has rather little prestige, and
none of the committee members are clinicians with authority.
Organisational support for line managers, with regard to the efforts to improve
quality and safety, differs significantly. Hospital A has a small number of quality
staff to support the line managers in improvement efforts and projects. All improve-
ment projects follow the same methodological approach. The rationale for the small
staff and the one improvement method is to make the line managers responsible
for ensuring quality and safety in their own department. Responsibility should not
be handed over to staff outside the unit, but it can be supported by professionals who
are well versed in the common improvement method. Hospital B has a relatively
large patient safety section with the expertise and educational resources to support
the managers across the hospital. This organisational section is central in support-
ing the line managers in working on quality and safety improvement. It acts as an
internal knowledge centre with dedicated educational resources. The result shows
that the patient safety section is successful in helping line managers exercising their
formal responsibility for quality and safety within their department (Table 11.2).

POLITICAL CHALLENGE
The senior management at both hospitals works politically but in different ways to
enact change. Hospital A’s senior managers combine ‘top-down’ and ‘bottom-up’
approaches to quality and safety improvement and change. In practice, our result
166 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

TABLE 11.2
The Structural Challenge
Hospital A Hospital B
About a common improvement method for About the importance of formal quality and safety
working on quality and safety improvement: committee:
We aim for good results in all the improvement This committee [the quality committee] has been
projects included in the improvement ‘sleeping’. It has been argued that the top
program. We also aim for developing a management group should be included in committee
comprehensive methodology that has (Administrative staff, Patient safety section).
organization wide support. Our The patient safety committee is constituted by highly
methodological approach takes employees qualified clinicians holding a high credibility
seriously and we use them as strategic across professional disciplines. The participants
consultants towards the goal of securing are very competent and represent different
equal rights to high quality health care professional disciplines. They meet on a monthly
services (Document: Application to be a pilot basis and receive cases from the patient safety
hospital for improvement programme). department (Administrative staff, Patient safety
section).

shows that ‘top-down’ leadership seems to work well in small organisations. This is
evident in Hospital A because senior managers are aware of their own role in quality
and safety improvement and of long-term organisational development that is atten-
tive to building a shared organisational cultural within the hospital. These senior
managers do not think that they need to spend time persuading employees to par-
ticipate in improvement activities or to support changes imposed from the external
environment. The senior management trusts the organisational culture to assist with
the adoption and implementation of changes.
In Hospital B’s flat organisational model, clinical empowerment is a key in the
bottom-up leadership approach to quality and safety improvement processes. Senior
managers argue that the clinical empowerment is necessary to enlist employees in
improvement efforts. Moreover, the senior managers need the managerial skills to
deal with power issues and negotiations of change. The latter implies that the senior
managers spend much time ‘selling the message’ to get key clinicians on board as
part of the change process.
The political challenge of change is present in both hospitals. For example, the
maternity wards underwent structural changes to cut costs. Hospital A merged
the maternity and gynaecology departments. Hospital B downsized its staff at the
expense of obstetrical care. The changes created resistance and power conflicts
in both hospitals, because healthcare staff was given new tasks in Hospital A
(midwives and nurses were assigned tasks across maternity and gynaecology) and
because the staff resources and expertise were transferred between wards and
allocated to patients with the highest risk potential in Hospital B (from training
in breastfeeding in the post-natal ward to emergency situations on the mater-
nity ward). Despite resistance, both hospitals accepted the imposed changes
(Table 11.3).
Leading Quality and Patient Safety Improvement in Norwegian Hospitals 167

TABLE 11.3
The Political Challenge
Hospital A Hospital B
About the consequences of merging the maternity About amending processes and economics:
and gynaecology departments:
I assume that responsibility is imposed on us and we Currently we talk about economy, yes, we still
have a feeling of not being sufficiently competent. talk about that, but not economic aspects only.
We are constantly striving. I feel it is assumed that We talk a lot about professional development,
we as nurses can work anywhere, but this is not the patient quality, patient safety, how to improve
case. The demands on us are large in terms of both patient pathways in an efficient manner and
quality standards and knowledge needs. Should a how to solve the targets specified in the letter
doctor go from the general department to the of assignment, such as waiting lists, priorities
surgical department and make his rounds there? such as deadlines related to discharge
This striving is very challenging (Nurse). summaries (Senior manager).

CULTURAL CHALLENGE
The two hospitals have different cultural traits. Hospital A is characterised by a
coherent, open and non-punitive culture. Healthcare professionals show a collective
commitment to the provision of high-quality and safe healthcare services. The organ-
isation is relatively small and characterised by oversight and short distance between
the shop floor and the senior managers. Senior managers are committed to building
a common culture through language adjusted to the language used by the staff at the
micro level.
Hospital B has a culture with strong professional groups and a strong professional
identity. This implies that it can be difficult for the staff that is not leading clini-
cians to talk about incidents or to speak up, either formally or informally. Under-
reporting is perceived to occur frequently. A central cultural feature in the maternity
ward at Hospital B is that healthcare staff (doctors/midwives) ‘defines’ quality for the
patients (mother and baby), to give birth vaginally rather than through caesarean sec-
tion. Patient experience is usually not on the agenda, and the culture is characterised
by an informal professional competence hierarchy (Table 11.4).

EDUCATIONAL CHALLENGE
The hospitals differ in the ways in which senior managers work in relation to learn-
ing and education of healthcare professionals. Hospital A has had great challenges to
meet the demands from the inner and outer context on how to educate and train its
employees. Due to a difficult staffing situation with few specialists, there are limited
opportunities to send employees to courses, conferences and professional develop-
ment. Hospital A is very systematic in its handling of adverse events or incidents,
despite a limited number of staff that works directly with such cases. All adverse
events are reviewed by the quality staff and discussed in the quality committee in
order to promote system-wide learning from adverse events.
168 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

TABLE 11.4
The Cultural Challenge
Hospital A Hospital B
About creating a common culture through About informal hierarchy in the department:
language:
I am not so dandy that I have to use all If you are «in» you can come away with anything, and
these fancy terms and concepts. So, I think people don’t argue. Then, there is always someone who
we have to create our own language and can’t say a thing without being corrected. I think we
use our own words. The underlying have to improve the culture, especially among the
meaning is the same (Senior manager). doctors … I think it is very difficult to be in the specialist
An action plan is easier to understand than training program at this hospital. It is a long way to
a project directive. Those are the things work your way up in this hierarchy. I have said it a
we are talking about (Senior advisor). number of times … I am so glad I did not get my
specialist training at this hospital (Physician).

Hospital B is characterised by an academic tradition and research environment

where the staff has a strong focus on learning both from within the organisation
and from the international research community. Senior managers in Hospital B
emphasise the recruitment advantages of strong research traditions and being in
the forefront of research. The patient safety section is central to learning from
adverse events.
The role of professional education of nurses/midwives is a hallmark of the
learning processes in both hospitals. They contribute to professional development
and updating of procedures and organise simulation sessions to offer training in
technical skills as part of the ordinary work on the wards, when time permits
(Table 11.5).

TABLE 11.5
The Educational Challenge
Hospital A Hospital B
About difficulties in prioritising education and About professional development as part of the
training activities: recruitment strategy:
The manager tells us that we can attend scientific We do have many that graduate for a PhD degree
conferences. But the problem is that we can’t go here … it is a part of our policy to educate our
because of the staffing situation. There are often own employees. That is why we try to facilitate a
too few of us here. Sometimes it is almost work situation allowing for doing a PhD while
impossible to run the department when key being employed here. This is part of our
personnel are gone (Senior physician). recruitment strategy (Senior manager).
The quality improvement work will always
compete with other tasks taking place in a
hospital (Senior advisor).
Leading Quality and Patient Safety Improvement in Norwegian Hospitals 169

TABLE 11.6
The Emotional Challenge
Hospital A Hospital B
About senior management enthusiasm: About competence as a driving force:
Look to Jønkøping [a city in Sweden]» it said, and … this department is considered a very good
I thought, what…? Why not look to this county? department with high professional status that
What was so special about Jønkøping? Nothing! prioritizes professional expertise. Professional
They did not do anything fabulous, but they did expertise trumps everything. (Senior physician)
what they did in a systematic way and then they
created a culture (Senior manager, Hospital A).

EMOTIONAL CHALLENGE
The two hospitals show different abilities to instil positive feelings, inspiration and
commitment to quality and safety. Despite external pressure for cost efficiency, merg-
ers and downsizing and even threats of shutdown, the employees and the managers
show a mobilising response to the ‘ghost of change’. The merger of the maternity
and gynaecology departments in Hospital A was not only frustrating for employees
but also elicited a consistent striving and a collective enthusiasm for the delivery
of high quality and safety. They wanted to show the outside world that they deliv-
ered sound services with high quality. Professional pride, idealism and professional
enthusiasm characterise Hospital B, where improvement is driven by ‘bottom-up’
leadership. Opportunities for financing quality improvement projects from regional
health trust and participation in national patient safety campaign are key contextual
factors that created enthusiasm and awareness of quality and safety work in both
hospitals (Table 11.6).

PHYSICAL AND TECHNOLOGICAL CHALLENGE

Both hospitals pay close attention to collecting and using various types of data to
improve the quality and safety of their services. Hospital A began its systematic
quality and safety work in 2005 by collecting, analysing and presenting relevant
quality data in order to prevent what the senior manager perceived as a ‘culture of
assumptions’ in which professionals and managers assumed they knew the quality
performance of their organisation, but with no facts or evidence to support these
assumptions. The senior manager appointed a dedicated person with strong ana-
lytical skills and Hospital A started systematising data on quality indicators and
established mandatory reporting on specified quality domains. Based on this effort,
Hospital A is earning top scores on the established national quality indicators devel-
oped by the Directorate of Health.
Hospital B’s managers and staff experience physical infrastructure in terms of
buildings and localities as a challenge to the provision of high quality and safety
within the maternity section. For example, the lack of space in the maternity section,
170 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

TABLE 11.7
The Physical and Technological Challenge
Hospital A Hospital B
About the lack of tools and methods for user About physical location as obstacle to high quality:
involvement and collecting patient experiences:
I have a very bad conscience when I am thinking The least satisfying thing about working here is
about user involvement in quality improvement. the conditions we offer to the women on the
We are really bad at it and we know it. I really post-natal ward. We do not provide them with a
want to do something about it in practice and single room and they can’t bring the father to stay
not just on paper. The regional health trust has with them. We don’t have a family-room
developed an IT tool for the user survey and the here – which we are actually obligated to have.
purpose is that we are going to implement it It is very unsatisfactory (Head of department).
here (Senior manager).

poor facilities for mothers and infants and a lack of co-location between maternity
and children’s clinic are physical challenges that interfere with the provision of
maternity care services according to current quality standards. Both staff and hospi-
tal managers agree that the need to transport the newborns, which required intensive
care, from the maternity section to another building located in the children’s clinic,
poses a serious quality and safety challenge. The co-location of these services has
been discussed for years. Both hospitals lack the competence and tools to collect and
use patient experience to improve service quality and safety (Table 11.7).

CONTEXTUAL CHALLENGE
Governmental and political attention to quality and safety has increased in Norway
over the last decade, in terms of national strategies, patient safety campaign and
programme, regulation and targets affecting senior managers in both hospitals. The
increased external demands and targets related to mangers’ attention to quality and
safety, in addition to the increasing requirements of reporting on national quality
indicators, all contribute to legitimising managers’ strategic effort to improve quality
and safety. One of the most important external conditions for both hospitals is the
link to the regional health authority (RHA). The RHAs are responsible for the deliv-
ery of the services within the health region. Every year, each of the four RHAs hands
over a letter of assignment to the local health trust within the regions. The RHA
contributes with providing courses, organising conferences and collaboration in rela-
tion to the national patient safety campaign. Hospital A takes advantage of this col-
laboration as it contributes to developing the organisations’ professional competence
within improvement work. Within the area of patient experience, the RHA supports
the hospitals in developing tools to document patient experiences. Such measures
are requested by both hospitals and illustrate the need for competence and support to
take advantage of patient experiences as an important input for the improvement of
quality and safety (Table 11.8).
Leading Quality and Patient Safety Improvement in Norwegian Hospitals 171

TABLE 11.8
The Contextual Challenge
Hospital A Hospital B
About long-term attention towards national About external governing principles:
quality indicators:
If I go back in time and read reports from For all health care professionals, professional
2006–2007 and look at time of discharge pride and performing high quality practice
summary before we established the new way of according to professional standards appear as
reporting, the figures were in the range of 40%, keys. Earlier, these standards were set by health
20%, 60%. Today’s figures show 80% and some care professionals themselves. Currently, this has
departments have 100%. I do not think we would changed and the standards for sound
have achieved this goal without the new way to professional practice are defined by bureaucrats
using data and establish requirements of and politicians (Clinical director).
reporting (Senior manager).

SENIOR LEADERSHIP CHALLENGES

Senior managers at both hospitals ensure quality and safety by putting the topic
on their agenda. This sets a clear and strategic direction for the hospital staff and
underpins the message that quality and safety are equally important to opera-
tional measures. This contributes to building legitimacy for the required time
and effort in addition to holding managers at all levels accountable for providing
of high-quality and safe services. In Hospital A, the senior managers emphasise
symbolic (quality and safety culture) and technological (systematisation of data)
leadership to improve quality and safety. Since 2005, the senior managers have
worked to build a common culture of continuous monitoring of quality data. This
constitutes an important factor of Hospital A’s commitment to quality and safety.
In Hospital B, senior managers emphasise political and educational leadership as
key factors of success. Here, leaders must have the ability to negotiate, involve
and collaborate with prominent clinicians. Leadership processes within Hospital B
depend on providing the employees with sufficient time for professional devel-
opment and research activities as a key element to improve quality and safety
(Table 11.9).

LESSONS LEARNT ABOUT QUALITY AND SAFETY

LEADERSHIP PROCESSES
Leadership along with other organisational and cultural factors strongly influenced
how quality and safety work was carried out in hospital settings. This study of two
Norwegian hospitals showed that managers and their organisations had differ-
ent responses and actions to overcome challenges in improving quality and safety.
Figure 11.2 summarises the hospitals’ emphasis on the eight leadership challenges
using a score from 1 (low) to 10 (high).
172 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

TABLE 11.9
The Senior Leadership Challenge
Hospital A Hospital B
About leadership philosophy: About leadership philosophy:
We have worked extensively with organizational development, A key characteristic of our
delegation and understanding of roles. I also think this has organization is the large degree of
been important in terms of developing our quality delegation of power. In comparison,
improvement work […]. I think this is important because other comparable hospitals have a
previously we were under the impression that we could just centralized power structure within
sit on the top and makes decisions (Senior advisor). the organizations (Senior manager).

Score from Norway

1 (low) to 10 (high)

Structure
10
External demands 8 Politics
6
4
2
Leadership 0 Culture

Physical and
Education
technological

Emotion

Hospital A Hospital B

FIGURE 11.2  Overall assessment of Hospitals A and B on the eight leadership challenges.

In both hospitals, we find extensive senior manager commitment and a long-

term perspective on quality and safety. Hospital A has integrated quality and safety
improvement as an important part of daily operations without a special use of addi-
tional resources and staff in a quality department. Hospital A has become successful
in creating a common organisational culture. Through a systematic use of quality
data over time, the hospital has managed to achieve among the highest scores on
national quality indicators.
Hospital B also pays considerable attention to the reporting and systematisation
of data but has not scored as well as Hospital A on national quality indicators. This
study makes no conclusion about the relationship between national quality indica-
tors and quality results. However, the study shows that long-term commitment and
involvement from the hospital senior management in quality and safety improvement
are vital for how this is taken care of at the sharp end. Managers in both hospitals
Leading Quality and Patient Safety Improvement in Norwegian Hospitals 173

are sensitive to the outer context (indicators, letter of assignments). In addition, they
are responsible for setting quality and safety on the agenda in the organisation and
for the integration and adaptation of quality and safety improvements to the opera-
tion of the hospital. In other words, our results are similar to those of other studies,
showing the importance of leaders in improving quality and safety (Frankel et al.,
2008; Goeschel et al., 2010; Jha et al., 2010; Künzle et al., 2010; Leape et al., 2009;
Levey et al., 2007). What is missing in the literature on quality and safety in health-
care services is the lack of comprehensive understanding of how different organ-
isational, cultural and leadership factors interact in different clinical settings (Bate
et al., 2008; Hockey and Bates, 2010; Krein et al., 2010). The latter is documented
in this study through the two hospitals’ quality and safety journey and response to
the different leadership challenges, organisational and cultural factors. The study
indicates that success on the leadership challenges cannot be attributed to a narrow
focus on a single challenge such as structure or politics, but rather to a long-term
approach to several challenges (Hospital A: structure, culture, leadership, emotions,
physical/technical aspects; Hospital B: external requirements, leadership, structure,
education).
Organisational size is an important explanatory factor for the successful quality
and safety improvement work in Hospital A. The organisation is transparent with
oversight; there is a short distance from the managers to the healthcare professionals
at the shop floor and a good opportunity to build a common organisational culture.
The cultural challenges differed between the two hospitals (Figure 11.2). The obvi-
ous leadership challenge in Hospital B is to improve a culture that is heavily shaped
and influenced by leading clinicians and their definition of what is considered high
quality and safety in healthcare services. Instruments other than ‘bottom-up’ initia-
tives focusing solely on clinical effectiveness should be implemented. International
research literature (Coulter, 2011; Doyle et  al., 2013; Robert and Cornwell, 2013)
and governmental expectations (Ministry of Health and Care Services, 2011–2012,
2012–2013) point out the need for a culture that recognises the current patient role
and considers patients and their experiences as one of several resources in quality
and safety improvement efforts. This study concludes that involvement of patient or
user experience needs to be given extensive attention by senior managers and other
stakeholders in Norwegian hospitals.
Hospital B scores slightly better than Hospital A on the educational challenge
(Figure 11.2). Although Hospital B has challenges associated with a learning cul-
ture because of strong professional roles, it has succeeded in facilitating professional
development. This is of key importance for the quality and safety improvement pro-
cesses at the hospital. Challenges such as external requirements related to the budget
balance, cost efficiency and downsizing have not threatened the hospital’s ability to
prioritise professional competence development and updating. Through its priori-
tisation of continuous professional development, the hospital has also managed to
establish a recruitment strategy that attracts talented professionals.
Few studies have explored the interactions among organisational, cultural and
leadership factors at different levels in the healthcare system (macro–meso–micro)
and their influence on quality and safety improvement practice in hospitals (Bate
et  al., 2008). The results are not generalisable as they are based on two hospitals
174 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

with different sizes and functions. The results will still be relevant to other hospi-
tals because the manners in which senior managers diagnose and approach different
organisational and cultural factors are keys in ensuring quality and safety. Senior
managers need to address these factors in a systematic process of ‘self-diagnosis’.
The focus and measures to improve practice will depend on organisational size,
culture, competence composition, power relations and physical/technological condi-
tions. The understanding of the organisational and cultural conditions and the role of
leadership within each hospital is thus central, although expectations, requirements
and regulations of the authorities are the same for all hospitals.

ACKNOWLEDGEMENTS
The study, ‘Quality and Safety in European Union Hospitals: A Research-based
Guide for Implementing Best Practice and a Framework for Assessing Performance
(QUASER)’, has received funding from the European Community’s Seventh
Framework Programme (FP7/2007–2013) under grant agreement n° 241724.
We wish to acknowledge the following members of the QUASER project:
Naomi Fulop, Glenn Robert, Janet Anderson, Susan Burnett, Charles Vincent,
Susie Edwards, Heide Poestges, Kathryn Chales and Anna Renz, England; Roland
Bal, Anne Marie Weggelar, Julia Quartz and Hester van de Bovenkamp, the
Netherlands; Karina Aase and Christian von Plessen, Norway; Francisco Nunes,
Sara Gomes and Alexandra Fernandes, Portugal and Boel Anderson Gäre, Johan
Calltorp, Pär Höglund, Tony Andersson, Anette Karltun and Johan Sanne, Sweden.
We wish to thank all of the hospital employees and managers for taking their time
to share their knowledge and experiences with us. Last, but not least, we thank the
site managers at the hospitals who generously helped us organise the data collection.

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Section IV
Contemporary Nordic
Research – Micro-Level Issues
 12 Telecare in Home
Healthcare Services
Implications for
Quality and Safety
Veslemøy Guise, Anne Marie Lunde Husebø,
Marianne Storm, Kirsti Lorentsen Moltu
and Siri Wiig

CONTENTS
Background............................................................................................................. 179
Introduction........................................................................................................ 179
Research on the Quality and Safety of Telecare................................................ 180
Healthcare Staff Perspectives on the Quality and Safety of Telecare................ 180
Aim and Research Question............................................................................... 181
Methods................................................................................................................... 182
Data Collection and Analysis............................................................................. 182
Sample Characteristics....................................................................................... 183
Results..................................................................................................................... 183
Reduced Ability for Clinical Observation.......................................................... 183
Vulnerability of Poor Assessment of Patient Needs........................................... 184
Increased Ability of Closer Patient Contact and Improved Continuation of Care....185
Patient Empowerment and Reduction of Stigma............................................... 187
Discussion............................................................................................................... 187
Conclusions............................................................................................................. 189
Acknowledgements................................................................................................. 190
References............................................................................................................... 190

BACKGROUND
Introduction
Home healthcare services are a growing segment of the Norwegian healthcare
­system. Specialist healthcare services are shifting from the hospital setting to the
community (Sibbald et al., 2007; Helse- og Omsorgsdepartementet, 2009), and many
healthcare services are increasingly expected to be delivered in people’s own homes
(Helse- og Omsorgsdepartementet, 2015). A rapidly growing ageing population,

179
180 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

many with complex healthcare needs, will necessitate changes to traditional forms
of home healthcare provision, such as increased integration of telecare technologies
into service delivery (Koch and Hägglund, 2009; Milligan et  al., 2011). Telecare
solutions can enable healthcare professionals to remotely care for patients living at
home and are therefore seen as a promising solution to some of the challenges fore-
cast for future home healthcare services (Solli et al., 2012). Implementation of new
information and communication technologies (ICT) in healthcare settings is how-
ever complex and is influenced by several factors (Hoonakker, 2012). The attitudes
and experiences of healthcare professionals have been flagged as a potential major
barrier to telecare implementation (Mair et al., 2007; Brewster et al., 2014; Taylor
et al., 2015). A crucial determinant in whether or not healthcare professionals adopt
telecare is evidence of its quality and relative advantages to users (Sheikh et  al.,
2011; Zanaboni and Wootton, 2012). Investigation of healthcare professionals’ views
on quality and safety may be important, therefore, to help determine the success or
otherwise of innovation initiatives like telecare (Brasaite et al., 2014).

Research on the Quality and Safety of Telecare

The study of the quality and safety of telecare is an emerging research field. As a
result, knowledge on adverse events and patient safety risks associated with telec-
are has been lacking and the service quality implications of implementing telecare
solutions in home healthcare are poorly understood (Balka et al., 2007; Black et al.,
2011; Sheikh et al., 2011; Hoonakker, 2012). Emerging evidence seems to suggest,
though, that patient safety risks associated with the use of telecare in home health-
care services may be related to the nature of healthcare tasks, or the characteristics
and capabilities of those providing the care, rather than problems with the technol-
ogy itself (Guise et al., 2014). Evidence on the effectiveness or otherwise of telecare
remains inconclusive in terms of both therapeutic effects and increased efficiency
in the healthcare services (Ekeland et al., 2010). A number of studies do however
report a range of positive outcomes associated with the use of telecare and other ICT-
assisted healthcare services for a variety of patient groups (Bowes and McColgan,
2006; Barlow et al., 2007; Ekeland et al., 2010; Lindberg et al., 2013; Husebø and
Storm, 2014). There is a need for more research to illuminate the quality and safety
implications of using telecare in home healthcare services (Hoonakker, 2012), not
least of all studies on implications for patient experiences and patient–provider rela-
tionships (Ekeland et al., 2010).

Healthcare Staff Perspectives on the Quality and Safety of Telecare

Staff perspectives on quality and safety in healthcare are contingent on their grasp
of professional roles, personal ideas and beliefs (Travaglia et al., 2012; Wiig et al.,
2014a). To gain an understanding of how care quality and safety is perceived and
enacted in day-to-day provision of telecare services, therefore, we need knowledge
of the values, beliefs and professional standards of the healthcare professionals pro-
viding the services (Farr and Cressey, 2015). Previous research on staff perspectives
Telecare in Home Healthcare Services 181

on the quality and safety of telecare use has mainly reported on perceived negative
implications. For example, some healthcare professionals were found to worry about
the adverse consequences of providing care at a distance due to a lack of confidence
in the safety and efficiency of telecare (Hibbert et al., 2003). Others were sceptical
to whether or not a technology-assisted approach is able to satisfy complex patient
needs (Söderlund, 2004), while others again note concern about the impact of tech-
nology on therapeutic relationships (Stanberry, 2001). Furthermore, staff may feel
that telecare is not the most appropriate or preferred use of their professional skills
(Mair et al., 2007, 2008). When telecare is perceived as a threat to care quality and
patient safety, for example due to changes in clinical routines, workload and patient
interactions, healthcare professionals are likely to resist its implementation and any
related changes to the organisation of services (Sharma and Clarke, 2014).
Further understanding of healthcare professionals’ perspectives on the quality
and safety of care (Wiig et al., 2014a; Farr and Cressey, 2015) could help address
potential barriers, risks and resistance to the use of telecare in home healthcare
services (Sharma and Clarke 2014; Zhang et al., 2014) and is therefore likely impor-
tant to aid successful implementation (Hoonakker, 2012¸ Brasaite et al., 2014). The
study reported here addresses this need for more knowledge by focusing on the
perspectives of healthcare staff on the quality and safety of the planned imple-
mentation of virtual home healthcare visits in two Norwegian municipalities. The
rationale for using telecare as part of the delivery of primary healthcare services for
people living at home is a desire to provide safe, high-quality care while enabling
older adults to remain longer in their own homes. Virtual visits, which involve the
use of a secure videophone system that enables real-time audio-visual communica-
tion between staff and patients, can for example be used to assess a patient’s health
status, monitor medication routines, demonstrate or supervise procedures and pro-
vide social contact (Husebø and Storm, 2014). The study is part of Safer@Home –
Simulation and training, an action research project where the overall objective is
to develop, test and evaluate a training initiative to prepare healthcare providers,
patients and their families for taking part in virtual visits (see Wiig et al., 2014b, for
a full study protocol).

Aim and Research Question

The aim of this study was to explore healthcare professionals’ perspectives on qual-
ity and safety implications of implementing virtual home healthcare visits as part
of municipal home healthcare services. The following research question has guided
the study: What are healthcare professionals’ perspectives on potential quality
and safety implications of using virtual visits in the provision of home healthcare
services?
Exploration of the perceptions of healthcare professionals, as key stakeholders in
a proposed new telecare service, on potential quality and safety implications of using
virtual visits, can contribute to a better understanding of what aspects of care quality
and safety that need to be considered prior to implementation, not least in regard to
potential training and support needs.
182 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

METHODS
Focus group interviews were used to explore healthcare professionals’ perspectives
on potential quality and safety implications of introducing virtual visits in home
healthcare services. The focus group method emphasises group interaction and dis-
cussion. It is a particularly apt data collection technique in studies where the aim is to
explore participants’ attitudes, experiences, beliefs and concerns about an issue, as the
group approach taps into a wide variety of frameworks of understanding (Kitzinger,
1995; Kitzinger, 2005). Focus groups have furthermore been recommended when
examining professional responses to organisational changes (Kitzinger, 2005), such
as the planned implementation of virtual visits. A purposive sampling strategy was
used, guided by a desire to include a cross section of health and social care profes-
sionals working in the various municipal health and social care services typically
delivered in the home context in Norway. Thus, eligible participants were health or
social care staff working in different home healthcare or sheltered housing services
in the two municipalities planning to use virtual visits as part of service delivery.

Data Collection and Analysis

The data collection was conducted according to the agreed study protocol (Wiig et al.,
2014b) during 2013 and 2014. Six focus groups took place in five different types of
municipal home health and social care services. Each group consisted of the profes-
sional groupings who usually work together in the respective service types, in order to
take advantage of homogeneity and existing group dynamics (Krueger and Casey, 2000;
Malterud, 2012a). The groups were as follows: three groups with different constellations
of registered nurses, enrolled nurses, healthcare workers and care assistants from home
healthcare services; one group of physiotherapists from physiotherapy services; one
group of occupational therapists from occupational therapist services; and one group of
social care workers from sheltered housing services. The same set of topics was covered
in each focus group interview: technology experience, implementation of virtual visits
in home healthcare services, implications of virtual visits, and training needs. Each of
the groups met once, and each interview lasted between 90 and 120 minutes.
The author VG moderated all six focus groups. One or two other members of the
research team (SW, MS, AMLH, KM) acted as observers in different focus groups,
taking field notes on group dynamics, atmosphere and participant relations (Malterud,
2012a). The degree of participation from the moderator and observers varied across
groups. Mainly, the moderator facilitated the group discussion, while the observers
contributed with clarifications and additional questions. All interviews were tape-
recorded and transcribed verbatim. Data were analysed according to Malterud’s
(2012b) systematic text condensation approach. All authors contributed to the data
analysis. This chapter reports on findings related to ‘implications for quality and
safety’, a code group within the theme ‘Implications of using virtual visits’. The study
has been ethically approved by the Norwegian Social Science Data Services (Ref.
32934, 16 April 2013). Participation was voluntary, and written informed consent was
obtained from all participants. All data have been anonymised and securely stored.
Telecare in Home Healthcare Services 183

Sample Characteristics
A total of 26 professionals participated in the focus groups. Eighteen were from
municipality A (city based, 132.600 inhabitants) and eight from municipality B (rural
based, 10.700 inhabitants). The 26 participants included seven registered nurses,
four enrolled nurses, five occupational therapists, three physiotherapists, three social
workers, one care worker, one social educator, one health worker and one care assis-
tant. There were 23 women and 3 men, aged between 24 and 59 years old (the aver-
age age was 39 years). Participants’ average length of total working experience was
13.75 years (ranging between 1 and 37 years), with an average 8 years of employment
in their respective municipality. Only two participants had previous experience using
videophone technology (Skype) at work, but all had experience using technologies
such as mobile phones, PCs, digital planning tools and electronic patient records as
part of their job.

RESULTS
The analysis revealed that the healthcare professionals perceived both positive and
negative quality and safety implications of using virtual visits in home care services.
Negative quality and safety implications were a reduced ability for clinical observa-
tion and vulnerability of poor assessment of patient needs, while positive quality and
safety implications were an increased ability to monitor and follow-up on patients
and patient empowerment and reduction of stigma.

Reduced Ability for Clinical Observation

There was broad agreement among the participants that implementation of vir-
tual visits through the use of a video communication tool would diminish health
professionals’ ability to conduct proper clinical observations of a patient’s health
status: we need the clinical gaze! (Enrolled nurse, Focus Group (FG) 1). Not only
nurses, in particular, emphasised this aspect, but also the occupational therapists
and physiotherapists expressed the importance of physical presence and ability
to conduct physical examinations. The informants considered the potential loss
of information gained from clinical observations as the most pressing risk factor
associated with virtual visits. Participants’ rationale related to the need to observe
and directly monitor clinical parameters, for example, by observing skin colour,
respiration and ordinary bodily functions, feeling the patients’ temperature or
noticing uncommon smells from the patient or their surroundings. This is illus-
trated in the following exchange:

There is a lot of information you can miss when using such a camera. Because when
you visit the patients [at home], you see if they are all right. You don’t just observe that
the duvet moves up and down, like you would through a camera, but you listen to how
they breathe, and you look at their skin colour.
Registered nurse, FG 1
184 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

You touch them.

Enrolled nurse, FG 1

You feel, you smell, in case they have been sick or have diarrhoea. Yes. So there are a
lot of things we check.
Registered nurse, FG 1

The participants also described how the physical meeting at the patients’ home was
key in their observations of not only the patient’s health status and bodily functions
but also the state of the home environment. One person said: ‘In our profession, we
are experts in observation. When we are inside a home, we observe everything from
ceiling to floor and discover things that we may need to address, and we can lose
that of course’ (Registered nurse, FG 5). Participants described how the home set-
ting in itself could be a potential risk to patient safety in terms of, for example, lack
of cleanliness, poor hygiene, bad air quality and hazards posed by electrical equip-
ment, such as stoves being left on. Healthcare professionals therefore perceived the
reduced ability to conduct direct home observations as a potential risk to the safety
of virtual visits.

Vulnerability of Poor Assessment of Patient Needs

Moreover, some participants stated that virtual visits would potentially be a more
restrictive way of interacting with the patient, with the possible risk of conversa-
tions being too focused on the specific topic of the call only and less about emerging
topics. Healthcare professionals considered the ability to deal with emerging topics
such as patient motivation and deeper personal issues, which often came up during
physical home visits, as important information for the quality of the care process.
The informants also discussed how virtual visits could have negative implications
for relational and communicative aspects of patient care. The informants considered
the professional relationship with the patient as key in collecting vital information
about the patients’ health status and needs. They argued that the virtual visit would
give less room for discussions and elaborations and could be a barrier for the patients
in sharing information necessary for the healthcare professionals to make the best
treatment and care decisions:

I think the relationship between us and the service user is so important. It is often diffi-
cult for them to tell us all they would like to tell us, or express their entire need for help
from us. Therefore, the videophone could be a barrier, because it is a bit impersonal.
But of course, this depends on the user group. For some users I think this would be
great, for others it could be complicated.
Occupational therapist, FG 3

Informants emphasised the importance of patient needs assessments prior to imple-

mentation of virtual visits, to ensure quality of care. The main issues raised by the
participants regarding a needs assessment were related to proper identification of
Telecare in Home Healthcare Services 185

the patient needs that could be addressed via virtual visits without an increased
risk to patient safety, the patients’ capacity to deal with the new technology, and the
patients’ ability to learn how to use the technology. There was agreement among
participants that these are aspects that need to be properly assessed, to be able to
provide sound professional practice via virtual visits: ‘My thought is what are the
patient’s needs? In other words, what are the needs and can we solve everything
over the videophone?… I think what the patients’ needs are and what tasks need to
be solved – those questions should guide the use [of the technology]’ (Occupational
therapist, FG 3).
Some participants also described worries about whether the use of virtual visits
could increase the risk of not getting in touch with patients as scheduled. While it
was acknowledged that there could be several reasons for a video call going unan-
swered, such as the patient simply forgetting the appointment, participants were
firm that alternative means of contacting the patient must always be in place, such
as making an ordinary phone call or arranging for a prompt physical visit to be
carried out:

If they [the patients] do not answer the [video] call in the first fifteen, twenty minutes,
maybe up to an hour, that’s one thing. But if we cannot contact them at all, then we’ll
have to physically drive down [to their home] and see if anything is wrong.
Social worker, FG 6

Another safety practice suggested was the need for an error notification system in
case of technical problems with either the video communication equipment or the
Internet connection. Healthcare professionals stressed that both the user and they
themselves must be made aware of any such faults as early as possible, to avoid
delays in getting in touch with each other and, not least, in carrying out necessary
healthcare procedures.
Furthermore, participants expressed concerns over whether care at a distance
could present a potential risk to healthcare professionals’ ability to correctly handle
patient privacy issues: ‘There could be others nearby who could hear [the conversa-
tion]. For example, users may have the window open. Or they could have visitors that
we do not know of. Which we then do not notice until well into the conversation’
(Social worker, FG 6). Such challenges to the staff’s duty to preserve patient confi-
dentiality were regarded as a possible threat to overall quality of care.

Increased Ability of Closer Patient Contact

and Improved Continuation of Care

The healthcare professionals discussed several positive quality and safety conse-
quences in relation to the use of virtual visits. Participants across all groups agreed
that virtual visits would increase opportunities for more frequent patient contact
and improved continuation of care: ‘You can offer them [patients] more frequent
visits and you can offer them increased follow-up with telecare, that I don’t doubt’
(Physiotherapist, FG 2). Both increased rate and duration of visits were key elements
186 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

that could improve care quality and safety for a range of patient groups, with a poten-
tially better ability for early detection of changes in a patient’s health status, includ-
ing those with a chronic condition like epilepsy: ‘Then we could check on [patients]
more often than the single visit we do now. [They] could just as well have a seizure
right after we get back into the car’ (Registered nurse, FG 1). The same benefits were
seen for recently discharged patients: ‘Often they need that extra security when they
come home after an operation or a short stay [at a nursing home], then they need
more frequent visits. So, yes certainly then’ (Enrolled nurse, FG 5).
In these ways, virtual visits were seen as a useful supplement to traditional home
care visits, allowing for closer patient contact:

If we only used the videophone it would feel like a poorer and more impersonal inter-
action. But if you use it [virtual visits] in addition to the ordinary visits, it would be a
more comprehensive service and that would increase care quality. You could talk with
the patients every day instead of visiting them in their homes only twice a week. You
could continue to visit them [physically] one day a week and talk with them every day.
Occupational therapist, FG 3

This idea of new telecare tools supplementing traditional home care services to
improve its current level of quality and safety was discussed by several participants,
with several participants across the groups being adamant that virtual visits must
not replace physical visits. Some argued that current services were at a minimum or
below acceptable quality level and that healthcare professionals had too little time to
perform expected tasks: ‘The way things are at present, there is no quality at all …
because we are in [the home] for a few seconds, a few minutes maybe and have no
time for anything more. What kind of quality is that?’ (Enrolled nurse, FG 4). The
implementation of virtual visits was thus seen as a way to increase care quality by
freeing up time for patients who may need more contact than is currently provided:
‘It could ease things a bit for us in relation to how it is today. Then perhaps we could
use a little more time on those [patients] who really need it’ (Enrolled nurse, FG 4).
While most participants felt that virtual visits could improve the quality and
safety of home healthcare services by providing increased opportunities for more
frequent patient contact and better continuity of care, the idea of using telecare tools
was quite contentious within one of the focus groups, as is illustrated by the follow-
ing exchange:

I think it is terrible, because they [municipal decision-makers] don’t consider that the
most important thing is after all the person [healthcare professional] who physically
walks through the patient’s door every day to see if they are ok. That is much more
important than all these robots and everything. I think it is absolutely awful. They
don’t think about the social aspect, they don’t think about the human aspect at all.
Care assistant, FG 4

But we can’t stop it [the use of telecare], you know. That’s how service development is.
Enrolled nurse, FG 4
Telecare in Home Healthcare Services 187

Yes, but it’s terrible either way, to think about that development, because these are
people who are stuck in a chair, perhaps all day.
Care assistant, FG 4

How do we treat them [patients] today, though? We are there [at their home] for
two seconds.
Enrolled nurse, FG 4

This discussion clearly shows that while healthcare professionals in general are very
concerned about the safety and quality of the healthcare services they provide, there
are rather differing understandings of how best to achieve safe, good quality care.
While many agreed that the quality and safety of home healthcare could ultimately
be improved by the introduction of virtual visits, not all participants were convinced.

Patient Empowerment and Reduction of Stigma

One quality improvement aspect of implementing virtual visits mentioned by the
participants was the potential for improved patient empowerment. Some felt that vir-
tual visits could be a good way for healthcare professionals to give more responsibil-
ity for own care over to patients: ‘That’s what’s really our problem, we so easily go in
and do things for them, so that’s almost the hardest. And in these cases it may be that
this [virtual visits] could be good’ (Enrolled nurse, FG 5). Some participants also
mentioned how the implementation of virtual visits could improve care quality by
encouraging more self-care practices when patients return home from a healthcare
institution, a time when they are often vulnerable and need close follow-up: ‘In this
phase we are experts in making them helpless. We do everything for them’ (Nurse,
FG 5). ‘Yes, that’s when we could really make use of this [virtual visits] in a positive
way’ (Enrolled nurse, FG 5).
In addition, quality improvement implications were conceptualised as the pos-
sibility of being able to reduce real or imagined stigma of being a care recipient and
having the home care services visibly visiting one’s home several times a day: ‘It
[a virtual visit] is not visible [to others], so then you can [help the patient] in a way
that implies the least amount of visibility to others’ (Occupational therapist, FG 3).
The use of virtual visits was here associated with a less publicly visible approach to
home healthcare provision and was seen as a way of better preserving patient privacy
and enabling services more tailored to patients’ individual preferences, potentially
improving overall care experiences.

DISCUSSION
This focus group study explored healthcare professionals’ perspectives on quality
and safety implications of using virtual visits in home healthcare services. The
findings show that healthcare professionals perceive negative as well as positive
consequences for the quality and safety of the care they provide to patients living
at home. Staff perceptions of both positive and negative implications were found
188 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

to have close links to individual views of ideal and appropriate clinical roles and
task performances, as well as their day-to-day experiences concerning patient inter-
actions and service organisation (Travaglia et  al., 2012; Farr and Cressey, 2015).
There was also some degree of disagreement among participants on the potential
quality and safety implications of virtual visits, which were mainly reflected in
rather contradictory perceptions regarding, on the one hand, a diminished ability to
observe and monitor patients and, on the other hand, an increase in patient contact
and continuity of care.
The main risks to patient safety that participants foresaw were a reduced ability to
sufficiently observe patients’ health statuses and monitor clinical parameters and any
potential hazards in the home environment. In addition, they were concerned about
the potential risk of not being able to adequately detect and assess patients’ needs
during virtual visits. These findings are in line with previous research addressing
real or perceived risks to home healthcare quality and safety associated with the use
of telecare in the Nordic countries (Söderlund, 2004; Nilsson et al., 2008; Wälivaara
et al., 2011; Reierson et al., 2015) and elsewhere (Hibbert et al, 2004; Mair et al.,
2007; 2008; Brewster et al., 2014; Guise et al., 2014; Sharma and Clarke, 2014).
At the crux of these established concerns about negative implications for care
quality and patient safety are apprehensions about the loss of conventional means
of knowing and caring for patients (Nagel et  al., 2013). ‘Knowing the patient’ is
recognised as a core component of safe, high-quality healthcare (Luker et al., 2000;
Zolnierek, 2014). Traditionally, knowing happens through communication and use of
the senses by way of physical presence (Bundgaard et al., 2012), as was described by
our participants. Since the use of telecare implies physical distance between provider
and patient, it suggests fundamental changes to patient–provider interactions, which
for many healthcare professionals do not fit with their view of how to provide safe
and effective care (Sharma and Clarke, 2014). One of the main challenges of sus-
tained telecare usage are current gaps in the knowledge of how to ‘know the patient’
in virtual environments (Nagel et al., 2013). As was suggested by our participants,
thorough and ongoing patient needs assessments both before and during the use of
telecare services can be a way to ensure that patients’ suitability for using these types
of services are regularly monitored and assessed.
Our study also found that healthcare professionals foresee several positive
quality and safety implications of using virtual visits in home healthcare services.
Conceptualisations of positive quality implications are interesting as this is some-
thing that, in contrast to negative quality and safety implications, has been given little
attention in the previous literature. Some of these findings can be seen as a reflection
of ongoing Norwegian healthcare policies and reforms, mainly the move towards
providing more care in community settings (Helse- og Omsorgsdepartementet,
2009, 2015), thus giving municipal primary care services increased responsibility
for growing numbers of vulnerable patients. Study participants believed that virtual
visits could facilitate increased frequency and duration of patient contact, in part by
freeing up more time for longer face-to-face visits than what current service organ-
isation seemingly allows for. Telecare was thus seen to have the potential to improve
the quality and safety of home healthcare by increasing accessibility to professional
care and offering more opportunities for enhanced patient follow-up and monitoring
Telecare in Home Healthcare Services 189

where needed (Nilsson et al., 2010; Sharma and Clarke 2014; Kajander and Storm, in
press). As was noted by some participants, this could be especially valuable for vul-
nerable patients newly discharged from hospital (Hesselink et al., 2012; Laugaland
et al., 2012; Storm et al., 2014). Virtual visits have indeed been found to facilitate
continuous and coordinated care (Husebø and Storm, 2014), as well as quick patient
access to qualified healthcare staff (Kajander and Storm, in press) during periods of
transition from hospital to home-based care.
Another key finding regarding positive implications for care quality was that vir-
tual visits were seen to enable and support increased patient involvement in own care.
Again, the findings here could be explained by recent government policies empha-
sising a substantial strengthening of patient participation and empowerment within
the Norwegian healthcare system as a whole (Helse- og Omsorgsdepartementet,
2013, 2014). Study participants admitted that rather than encouraging patients’ inde-
pendence and self-care, current practice sometimes contributed to helplessness and
dependency. They therefore saw the potential for increasing and upholding patient
participation as a fundamental advantage of virtual visits. Certainly, telecare solu-
tions can offer a flexible and efficient way for professionals to provide advice and
guidance in support of a variety of self-care practices in home-dwelling patients with
long-term conditions (Bond, 2014; Husebø and Storm, 2014; Kajander and Storm,
in press). The fact that new ICT solutions can have a positive impact on patients’
autonomy and independency has furthermore been noted as a crucial incentive to
their being adopted for use by healthcare professionals in the home healthcare ser-
vices in Norway (Gjestsen et al., 2014).
Few participants had practical experience of using either telecare in general or
videophone technology for virtual visits specifically. They were thus speaking only
from the perspective of potential future users of such telecare tools and not as expe-
rienced telecare professionals. The findings reported here should therefore be viewed
in this context, although they do mirror outcomes from a Swedish study where
nurses experienced that the use of telecare increased the quality of home health-
care (Nilsson et al., 2010). It is also important to note that participants’ perspectives
on the implications of proposed virtual visits varied, as has been found elsewhere
(Taylor et al., 2015). Some argued quite strongly that virtual visits did not fit with
their ideals of good quality in healthcare service provision and would be imper-
sonal, dehumanising and increase the distance between the service provider and the
patient. Mair et al. (2008) note similar findings. Others again were very encouraging
and could see a lot of potential for quality improvement through virtual visits. Many
were eager to try out this new way of working and communicating with patients, as
long as it was used with the right group of patients and if staff were given sufficient
information and training beforehand (Zhang et al., 2014; Taylor et al., 2015).

CONCLUSIONS
To ensure safe, purposeful and effective use of telecare services and to aid long-term
implementation and adoption of telecare tools in municipal healthcare settings, it is
important to have knowledge and understanding of healthcare professionals’ views
on implications for care quality and patient safety, not least in regard to potential
190 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

training and support needs. In this study, staff perceptions of possible quality and
safety implications of using virtual visits in home healthcare were explored. While
findings concerning perceived negative implications for quality and safety are simi-
lar to those found in previous research independent of geographical location and
context, the positive quality and safety implications observed here could be related
to current Norwegian healthcare policy. Perceptions of both positive and negative
implications were found to be linked to views on necessary and appropriate clinical
competencies and ideal patient–provider relationships in dynamic domestic settings,
all within the structures imposed by a complex municipal healthcare system. This
study indicates then how multiple contextual factors influence healthcare profession-
als’ conceptualisations of the quality and safety implications of using telecare in the
provision of home healthcare services.

ACKNOWLEDGEMENTS
The Safer@Home – simulation and training study is part of the project ‘Smart
systems to support safer independent living and social interaction for elderly
at home’ (Safer@Home). This project is supported by the Norwegian Research
Council grant number 210799. The authors would like to thank the focus group
participants for their kind contribution. They would also like to thank the funders
and the Department of Health Studies, University of Stavanger, for the opportu-
nity to carry out this research. The authors would also like to thank partners in
the overall Safer@Home project: Lyse; Department of Electronical Engineering
and Computer Sciences at University of Stavanger; Stavanger municipality;
Cisco; DevoTeam; VS-Safety; SINTEF; SAFER/Laerdal Medical and Stavanger
University hospital/SESAM.

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 13 Sensemaking in Specialised
Coping with Complexity

Home Care
Mirjam Ekstedt

CONTENTS
Introduction............................................................................................................. 195
Complexity in Specialised Home Care................................................................... 196
Theoretical Perspective on Sensemaking................................................................ 197
Tentative Model for Sensemaking in Everyday Clinical Work.......................... 198
Empirical Study...................................................................................................... 199
Methods.............................................................................................................. 199
Preparation: Putting Together the Pieces of the Puzzle......................................200
Building Understanding at a Distance...............................................................202
A Shared Mind across Disciplines..................................................................... 203
Keeping Track of a Thousand Pieces.................................................................204
Attentiveness to ‘Small Talk’.............................................................................204
Involving Patients in Understanding..................................................................205
Concluding Reflections...........................................................................................206
Acknowledgements.................................................................................................208
References...............................................................................................................208

INTRODUCTION
Healthcare systems face considerable challenges in the coming years as a consequence
of current demographic changes: a growing and ageing population and new groups of
patients with chronic and complex disorders. Concurrent medical and technical advances
have made it possible to move the administration of potent drugs and the use of complex
medical technology into patients’ homes (Fex et al., 2009). The rapid medical advances
increase professional specialisation, making multiple competencies imperative in assess-
ments and decisions regarding a patient’s care. Optimising safety and continuity of care
in the face of these challenges imposes great demands on healthcare organisations and
requires a radical rethinking of ways to support patients in self-management at home.
In order to understand how safety is created in specialised home care settings, it
is necessary to know more about the cognitive strategies used by professionals at the
sharp end of practice, to manage problem-solving and decision-making in everyday
clinical work (ECW) (Klein, 1998). This chapter aims to contribute to this under-
standing through the lens of sensemaking theory (Weick, 1995; Weick et al., 2005).

195
196 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

COMPLEXITY IN SPECIALISED HOME CARE

Specialised home care in Sweden is provided in a patient’s private home on a 24-hour
basis by an ambulatory multidisciplinary care team, as an alternative to hospital
care. Although most of these specialised home care teams serve patients with can-
cer, the volume and scope of such practices are expected to expand over the next
decade since it will also include patients with multi-morbidity and complex chronic
conditions. The complexity of specialised home care is qualitatively different from
that delivered in institutional settings (Ekstedt and Cook, 2014). The range of patient
illnesses and conditions that a caregiver might encounter is greater than in most
institutional settings. Many specialised professionals from different care providers,
governed by different values and laws (the Social Services Act and the Health Care
Act), are usually involved in the care of a single patient. This, combined with the
underlying patient complexity, makes home care ripe for developing ‘gaps’ in com-
munication and information transfer (Caines et al., 2011; Abraham et al., 2012).
Characteristics of specialised home care organisations are consistent with fea-
tures of complex adaptive systems (CASs) theory (Ciliers, 1998). CASs are open
systems, meaning that it is difficult to frame the boundaries surrounding the system
and that the borders of responsibility, for example, may be blurred. In a complex
system, each component is ignorant of the behaviour of the system as a whole and
does not even know the full effects of its own actions. This means that the interac-
tive relationships surrounding a patient’s care trajectory are dynamic, non-linear,
difficult to foresee and more or less impossible to control (Dekker, 2011). Features
of CAS are adaptation and self-organisation, in the sense that personnel constantly
adjust to the obstacles and messy details that occur in ECW. CAS also has a memory,
in the sense that history – each individual’s and organisation’s former experiences of
what works or not – co-determines self-organisation. Relationships are a key feature
of CAS, which leads us to consider sensemaking as a phenomenon emerging from
iterative reciprocal interactions between agents involved in care.
At the operative point of specialised home care, where decisions and actions affect
patients directly, the physician in charge of the patient and the multidisciplinary
team are generally responsible for planning care and setting goals. Nevertheless, the
work is for the most part conducted by single professionals going individually to a
patient’s home to provide care. Decisions about changes in treatment or other actions
rely on direct observations, patient conversations and physical examinations made
during these regular visits. Laboratory studies require re-planning and coordination
of care, and imaging services will involve moving the patient to an imaging facility.
Thus, single professionals in the multidisciplinary team make countless rapid-fire
decisions on a daily basis, which have an impact on the patients as well as on the
staff’s conditions for care. A previous study documents how practitioners in home
care effectively use tailored responses to uncertainty and disturbances in thought-
ful, inventive, courageous, meaningful, clever, inspired, determined and purposeful
ways (Ekstedt and Cook, 2014). However, there is a paucity of empirical support
regarding how professionals make sense of, and cope with, the complexity in home
care to reach specific goals. The same is true of how the responses to unexpected
situations are transformed into learning and get incorporated into habitual work.
Coping with Complexity 197

The theory of sensemaking provides a useful conceptual link between the individual
and organisational processes of decision-making in this context (Hayes, 2013). This
perspective allows both individual aspects and organisational circumstances to be
integrated into the individual decisions about a road of action. In the following sec-
tions, the theoretical bases of sensemaking will first be described briefly and then
adopted into a tentative framework that will be used for illustrating the empirical
study on ECW in specialised home care.

THEORETICAL PERSPECTIVE ON SENSEMAKING

Clinical cognitive work is devoted to making and sustaining a coherent, purposeful
and relevant understanding of patients and their conditions. Weick (1995) describes
this as sensemaking. Sensemaking is about the interplay of actions and interpre-
tations, which helps individuals or a collective of individuals to build consensus
around a situation and provide a road of action by sharing their unique perspectives.
Sensemaking has diverse theoretical routes and has been explored in a wide
variety of domains and disciplines: organisational (Weick et al., 2005), educational
(Russell et al., 1993; Warren et al., 2001; Jordan et al., 2009) and human–computer
interaction (Savolainen, 1993; Nosek, 2005), to mention just a few. Sensemaking
has also been viewed as a more individual activity. For example, Rings and Rands
defined sensemaking as ‘a process in which individuals develop cognitive maps of
their environment’ (1989, p. 342). More recently, sensemaking has been adopted in
the endeavour to enhance self-management strategies in chronic diseases (Mamykina
et al., 2015). In this view, understanding is the term that describes mutual activity.
Sensemaking is grounded in identity constructions, deriving from the need to
organise flux when the flow of routine actions is interrupted. Sensemaking starts
with noticing and bracketing: individuals examine the situation at hand and try
to classify it in relation to their existing mental models of related phenomena.
Sensemaking is also about labelling: individuals give shape to their lived expe-
riences through verbal descriptions, which allow them to share their meanings
with one another, thereby contributing to the development of common ground.
Sensemaking is retrospective in the sense that individuals construct meaning out
of situations by ‘stepping outside the stream of experience and direct attention to
it’ (Schutz, 1967). This can only be done after they have completed their involve-
ment and can reflect on the outcomes. Sensemaking is about presumption and the
most plausible hypothesis. Sensemaking is social and systemic: an individual’s
sensemaking is shaped by, and in turn shapes, the opinions of others. Considering
the modest amount of empirical work on sensemaking that has been accumulated
so far, this study in out-of-hospital care will fill a gap in understanding of the
largely invisible social processes which not only are taken for granted but also
woven into communication and activities in specialised home care.
In later works, Weick and his fellow researchers state that sensemaking is a pro-
cess that is ‘ongoing, social and easily taken for granted’ (2005, p. 409). The inference
of this statement is that humans under ordinary conditions adapt to a habitual mode of
sensemaking, which is so natural that it is not even thought about. He goes on to state
198 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

that explicit efforts at sensemaking tend to occur ‘when the current state of the world
is perceived to be different from the expected state of the world, or when there is no
obvious way to engage the world’ (Weick et al., 2005, p. 409). Sensemaking means
that ‘the interplay of action and [the fact] that interpretation, rather than the influence
of evaluation of choice, is the core phenomenon’ (Weick et al., 2005, p. 409). These
statements suggest that when gaps of understanding occur, they are triggering explicit
efforts to make sense of the uncertain or ambiguous. This is a contrast to the ongo-
ing habitual mode of sensemaking. Further, they suggest that this explicit mode of
sensemaking is characterised by an interplay of action and interpretation, whether by
making inferences from earlier experiences through an inner communication or by
interaction and communication with others. These cornerstones are adopted into the
tentative model of sensemaking in ECW, further described overleaf.

Tentative Model for Sensemaking in Everyday Clinical Work

The tentative model for sensemaking in ECW presented in the following (Figure 13.1)
is based on the theoretical perspectives of Weick (1995) and Weick et al. (2005) and
inspired by the framework in diabetes self-management created by Mamykina and
co-workers (2015). This model will be used to illustrate and discuss the empirical
findings from specialised home care in this study.

Interpretation

Inference

Sensemaking
mode
Habitual mode

on Ac
epti tio
n
P erc

Gaps Learning

FIGURE 13.1  Tentative model of sensemaking in everyday clinical work. Inner circle,
habitual mode, a ‘default state’ characterised of routine actions, implicit understanding and
use of existing mental models; outer circle, sensemaking mode, characterised of explicit,
mindful and active use of cognitive skills; left corner of the triangle, perception, monitoring
and classification of new information and experiences; upper corner, construction of new
Inferences allow for a certain road of action and interpretation of plausible models in search
for an answer to the question: ‘what is the story?’; right corner, the process of carrying out
ECW in response to new information; perception of gaps in understanding disrupts the flow
of action and initiates sensemaking mode; learning, new understanding is integrated as rou-
tine in the habitual mode.
Coping with Complexity 199

The proposed model suggests that sensemaking in ECW is carried out in one
of two modes: habitual mode (inner circle Figure 13.1) and sensemaking mode
(outer circle Figure 13.1). The model also proposes that both the habitual mode
and the sensemaking mode involve three essential activities (represented by the
three corners in the triangle): (1) perception, which involves the monitoring and
noticing of new pieces of information and cues of situations in ECW; (2) inference,
which implies the activation of relevant patterns of knowledge and experiences in
an active interplay of action and interpretation of mental models in search of the
most ­plausible road of action (inferences and interpretations are made in an inner
communication and/or in interaction with others); and (3) action, which is the pro-
cess of carrying out ECW in response to new information.
The habitual mode is characterised by implicit understanding, use of existing rules
and routines, containing an anticipated flow of actions. Professionals interpret and
respond to the perception of new information so naturally that they do not even think of
this as an effort. In the habitual mode, the perception–inference–action cycle activates
existing experiences and mental models rather than creating a gap in understanding,
and professionals fall into routine actions rather than choosing a new road of actions.
The sensemaking mode is characterised by an explicit, mindful and effortful use
of cognitive skills in which professionals analytically engage and interact with the
new information or situation at hand. Explicit efforts at sensemaking are triggered
when gaps in understanding are identified and when the flow of routine actions
is interrupted (left corner). In sensemaking mode, interpretation and inference of
plausible models interplay in the search for an answer to the question: ‘what is the
story here?’ (top corner). Explicit efforts are made to make the world comprehensive
in order to find the best road of action (right corner). The new understanding that
emerges becomes integrated as routine in the habitual mode and may reshape rou-
tines and lead to organisational learning.

EMPIRICAL STUDY
The chapter is based on an empirical study, conducted over 2 years in three special-
ised (palliative) home care units in the county of Stockholm. The three care loca-
tions were selected in order to increase the geographic and sociodemographic range
of settings and internal routines. The study, which was carried out at the ‘sharp end’
of care, that is, at the point of contact between the patient and the medical system,
explores what professionals actually do to deliver safe and coordinated home care to
patients with complex disorders (Woods, 1993). Specific foci were sensemaking and
communication between members in the multidisciplinary home care teams under
ordinary conditions. The research was approved by the appropriate institutional
review board for human subjects. Methods and settings are briefly described in the
following. For a thorough description, see Ekstedt and Cook (2014).

Methods
We applied an ethnological perspective using several observational techniques, in
order to acquire knowledge ‘from within’ to see how problems were framed and
200 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

understood (Schutz, 1970). The methods, successfully used in other fields (Woods,
1993; Albolino et al., 2007; Arman et al., 2012), provided reliable data on how
work was actually performed. The observational methods included general par-
ticipant observations of ‘places’ of care, and ‘shadowing’ professionals in ECW,
using a semi-structured protocol, field notes, audio recordings and photographs.
The  research team also performed short interviews with key actors (including
patients and family caregivers) to clarify and deepen the observations. During the
field observations, we participated in formal morning meetings, handover situa-
tions and during phone calls and chitchat throughout the day where team members
prepared for home care encounters, shared information and updated their knowl-
edge during the shift. We also followed clinicians during their daily home care
encounters in order to understand the complexity of work done and see how they
made sense of situations and stored and communicated key information. We paid
particular attention to situations where the work tasks prompted patient-centred
or inter-worker communications. Interviews and observations were tape-recorded
and transcribed verbatim. Traces of sensemaking and actions taken were anal-
ysed by the use of thematic analysis and process-tracing methodologies described
by  Woods (1993). The goal in these methods is to map out how an incident
unfolded, including available cues, in both the immediate and the larger context.
The observations have been integrated with interview and field notes. The main
findings from the analysis on sensemaking in ECW are presented and illustrated
with quotations and cases.

Preparation: Putting Together the Pieces of the Puzzle

ECW in home care is exposed to an infinite stream of events and inputs that surround
the professionals. Decisions rely on each expert’s pre-understanding of a patient’s most
recent status and likely trajectory. Ordinary clinical work is made up of periods of
attention to different tasks. Interruptions are common, and each interruption requires a
shift of attention to a different focal point. Every shift of attention from a patient or task
to an interrupting issue and back again requires a process of understanding. So com-
mon is this activity that it goes almost completely unnoticed by clinicians themselves.
Conversations that went on during the preparations for the day were characterised by
isolated sentences or short calls that could not be understood by an outsider, but for
those involved made up the pieces of the puzzle needed to perform ECW.

Case 13.1 Morning Preparation

Before the morning meeting: A team of nurses and assistant nurses prepare for
the day ahead by reading medical charts on the computer, printing to do-lists and
talking in smaller groups. Random sentences are overheard:

• Automatic infusion pump, but it doesn’t say what it is, what should be in
it … It just says ‘50 mg furo’ [i.e. furosemide, diuretic] …
Coping with Complexity 201

The phone rings and a nurse answers. Her side of the conversation is as follows:

• The doctor said that everything connected to x-rays, you should contact
the oncologist … they are the ones that are supposed to check up on you
and they should write the referral.
• I’ll leave a message for M/the doctor. She’ll be back next week, so she’ll
know there’s been a problem.
• Okay, well, I’ll pass that along …

During the morning meeting: The doctor asks for feedback on a prescription
given earlier. The nurse, who knows the patient, explains and gives a few small
comments on what should be observed when they visit the patient.
The doctor: I haven’t seen the results of the tests that were supposed to be done
on XX yesterday.
The nurse: Yeah, but we were wondering if they could be done on Friday, when
we have a visit there.
The doctor: NO, this cannot wait until then. CREA [i.e. Serum-creatinine, an
important indicator of renal health] was very high and we have to do the test
today, there’s a risk of complications in the kidneys.
Field note: It turned out that one nurse had never seen the dialysis equipment
that a patient had at home. Various people tried to explain how it worked. The
other nurses tried to explain the various connections, and the end result is that
staff ‘traded’ patients with each other.
Short interview after the morning meeting:
The morning meetings can seem chaotic, but I think it’s great that we go over
everything. It’s enough to say the name of someone you’re going to see to jog
your memory and if you have any questions and … Just saying the names is
enough – it can mean many things, for instance if the assistant nurse is seeing the
same patient and sometimes we can coordinate – for instance if I’m just deliver-
ing medication and they are going anyway, they can do that, so I don’t have to
rush. And then … You can’t remember everything, maybe you haven’t written
everything down … Then you can say: ‘don’t forget this and remember that’. It’s
hard to write everything down …

This case illustrates how ‘order’ is constructed through the use of spoken and written
‘words’. By naming patients, prescriptions or work tasks aloud, an interactive pro-
cess of sensemaking started in a variety of ways that had real consequences for the
choice of actions. Decisions were made for structuring workflow, avoiding mistakes
and creating continuity of care.
The morning preparation case also showed how new or deficient information
created gaps in understanding, triggering efforts at sensemaking. The perception of
the missing lab revealed brittleness in routines and highlighted gaps in the transfer
202 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

of information and a discrepancy between the nurse’s and the physician’s view
about the urgency of the test. In habitual work, nurses coordinate routine blood
tests with their ordinary patient visits. However, in this instance, the nurse  was
not aware that the test should have led to an extra visit to the patient, resulting in
a discussion and interactive interplay between professionals (sensemaking mode).

Building Understanding at a Distance

Although specialised home care is surrounded by a multidisciplinary team, the
observations revealed that ECW to a large extent is performed in ‘professional
silos’. We observed how single professionals built their understanding of a patient
in their first few minutes of a home care encounter. During the short encounter, the
nurse notices changes in the patient’s status, makes inferences in relation to what is
expected and tries to identify vital signs of change for closer attention. During this
initial state of sensemaking, the nurse tries to get a sense of: what is going on here?
The following case illustrates how the nurse becomes aware of vital signs that are at
variance with the person’s ‘normal’ conditions. Attaining this initial understanding
is critical because it sets the stage for everything that happens afterwards. The fol-
lowing example is from an interview with nurses.

Case 13.2 Sensemaking at a Distance

Nurse 1: No, but all these assessments where you feel pretty much alone …
this is mostly about us capturing stuff.
Interviewer: How do you do that?
Nurse 4: Well, I try to keep in mind that it’s my job to do a full workup in
so far as possible. If the patient is in pain, we’ll discuss that for a while
to find out more. What kind of pain is it, where and so on …
Nurse 2: Then I’ll report all my observations to a doctor. Then it’s more
about … Okay, have I really remembered everything and asked everything
that the doctor might ask about. And then I’ll think that it’s not my task to
determine what it is, only to report what the patient says, what the patient
experiences and what I see. And then I’ll just insert a needle or extract a
certain number of blood samples. Maybe a urine sample as well. Because
I know they’ll say: ‘go back and get a …[blood sample], whatever that is’.
Interviewer: So you’ve learned to cover your back, in order not to have to
go back again?
Nurse 4: Yeah, exactly. That’s usually the way it is, that that’s what they’ll
ask for. Or if I’ve been with a patient and done a thorough workup,
maybe I’ll have some medicine that I’ll leave with the patient and the
patient can start treatment once I’ve checked with the doctor.
Nurse 1: I guess that’s the way it is, you become more humble in this job
the longer you do it, as you realize how little you understand. It used to
be that you were very quick to think that you were right and you would
Coping with Complexity 203

deliver the workup that led to that conclusion. If you didn’t have a good
enough doctor, asking questions beyond what I had thought of, then the
end result might be incorrect …

The experienced nurses’ mindful processing of vital signs resulted in a road of

action that had to be communicated and interpreted with other professionals.
Another round of explicit efforts of sensemaking would take form when the nurses
in this case communicated their observations and actions back to the physician.

A Shared Mind across Disciplines

Clinicians’ decisions rely heavily on nurses’ abilities to monitor patient symptoms
and make inferences about what they hear and see and label and report their observa-
tions back to the physicians in ways that predispose them to find common ground. On
the other hand, professionals’ domain-specific knowledge must be shared with team
members operating at the sharp end ‘two steps away’. Specific characteristics of home
care are that the ‘ward’ is distributed over a large geographic area and that the physi-
cians cannot easily observe and diagnose, which raises concerns: ‘How do we ensure
that what I see is also what the other person sees?’ This was expressed as follows:

Of course, we always wear different lenses thanks to our differing experiences. Here,
[in home care settings] I just see the patients that the nurses think I should see. The oth-
ers I don’t really know much about. And the way this operation is structured, it depends
on that competence in order to work. There is always a risk that they don’t observe
things in the same way that we would if we were to see the patients – you don’t get
the same monitoring and quick decisions that you get if a patient is admitted to a unit.
Doctor, interview

This was also a concern among professionals within the same discipline:

The hard part of it is that when we give furix, [i.e. furosemide, diuretic] there are many
of us doing it and it doesn’t always have that much of an effect – they can remain above
their goal weight for weeks and then it’s important that someone reflects on it not seem-
ing to have any effect.
Nurse, interview

Collective sensemaking is a product of an interactive process where each profession-

al’s knowledge, experiences, values and preferences are communicated and a com-
mon ground is developed. Case 13.2 illustrates how the nurse developed a ‘shared
clinical eye’ with the physician but was still aware of, and grounded in, her identity as
a nurse. In this specific situation, being the ‘extended eyes and ears’ of the physician,
she was able to take the physician’s view and effectively bracket out essential symp-
toms, label them in a comprehensible way and articulate her observations back to the
physician as a basis for decision-making. This is a product of sensemaking which
204 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

takes time to develop within a team and also a marker of maturity in an organisation.
Newly graduated nurses were aware that they had not yet achieved a ‘shared mind’
and compensated for that in different ways: ‘I like to be on time and haven’t developed
the clinical eye for safety that the more experienced people have. So for me, it takes
longer. I have to double check and use checklists a lot, so I am often quite late’.

Keeping Track of a Thousand Pieces

In ECW, artefacts are commonly used to share information and awareness of goals,
plans and details that no single individual can grasp (Nemeth et al., 2004). An arte-
fact could be as simple as a note on a piece of paper during a patient visit, a white-
board in clinical areas, a worksheet, an individual nursing plan for the day-to-day
work or a notebook entry during rounds. All of these are examples of artefacts
used briefly, usually for a few hours, to hold and represent critical details of clini-
cal work. Artefacts were both collective and individual, more or less ­tailored to the
needs. As illustrated later, the selection of information for inclusion in the artefact
attests to its importance and either contributes to or constrains sensemaking.

We have the double documentation: the chart and our daily to do-list. Sometimes
there’s a risk that when you copy information and things are changed in the chart …
who follows up on that in the to do-list? It’s not that you write down exactly what to
administer or what it’s called or whatever … You just jot down a note on the to do-list,
so you can go back and check the chart.
Depending on which nurse is handing out the medications, different individual
solutions are used to ensure and clarify which medications are actually handed out – if
they have been replaced with a generic drug, a different strength, if they’re in a pill
organizer or a bag on the side. There may be post its or color coded markings on the
medication lists. I use color coding, but that’s just me.

Throughout the data material, it was striking that what made work hard for healthcare
personnel was not encountering severely ill patients and their next of kin, handling potent
drugs or technical devices. What created frustration and could make things go wrong
were all the ‘thousand small things’ surrounding patient care. These menial tasks include
ordering, storing and managing medication, providing materials to patients’ homes,
securing that backpacks were filled with the essentials in case of unexpected situations
and documentation. This plenitude of convergent things ‘to do’ was captured and stored
in professionals’ minds during their shifts, noted down on pieces of paper or handed over
in quick conversations with colleagues. Interruptions and multitasking consume memory
space and cognitive ability, impeding sensemaking. Faced with complex, ambiguous and
emotionally laden circumstances (cognitive overload), a person will tend to ignore data,
simplify tasks and make hasty decisions and stick to rules of thumb and stereotypes
rather than explore the full range of what is seen and heard. With increased complexity,
the need for artefacts that facilitate sensemaking becomes pressing.

Attentiveness to ‘Small Talk’

Sensemaking in home care is an ongoing process, a swift interplay of actions
and  interpretation in search for an answer to the question: ‘what is the story?’
Coping with Complexity 205

(Weick, 1995). Paying attention to other views and openly sharing information opens
for the equally important question: ‘what shall we do about it?’ Sensemaking puts
cognition and action together and the following case shows the ability to catch tran-
sient moments. Just being around and attentively grasping the ‘small talk in the air’
was of significance for the larger pattern of understanding.

Case 13.3 Attentiveness to ‘Small Talk’

Mary, the coordinating nurse, makes a routine call to Mr. Carlsson to remind him
to take his medication. The medical doctor, who passes by occasionally, cannot help
overhearing the telephone conversation. The medical doctor, who had recently got the
medical report from specialist care, is holding that paper in her hand when she passes
by and the following conversation takes place between the nurse and the physician:
• ‘I couldn’t avoid overhearing what you said in the phone call, are
we talking about the same patient?’ [showing the epicrisis]
• ‘Yes, I just talked to him and reminded him to take his medication.’
• ‘But he has just been to the specialist and he should stop taking this
medicine now that the treatment is complete.’
• ‘Oh, so he shouldn’t take it anymore … Should I call him back?’
• ‘You can call the hospital (the specialist) and check if he’s been given
more information …’
The nurse calls the hospital and gets new information with another perspec-
tive on the patient’s condition. Mary then calls Mr. Carlsson back to present the
information she got from the specialist and tells him that he will get a letter sent
home with more information.
This case shows how sensemaking is an issue of language, talk and commu-
nication and how engaging in sensemaking requires the ability to not only reflect
and examine but also to act upon concrete situations.

Involving Patients in Understanding

In home care, patients and their next of kin are the hosts of care. Healthcare professionals
are literally guests in a person’s private home, while still having the full responsibility
for medical care. Ethical dilemmas with respect to decision-making came to light in the
observations. For patients living with chronic illnesses, it can be highly demanding to
understand and communicate symptoms, disabilities and effects of complex regimens at
home. Effectively functioning in the role of self-manager, particularly when living with
one or more chronic illnesses, requires a high level of knowledge, skill and confidence.
The following example illustrates how a common understanding between the nurse and
the patient was achieved during a home care encounter.

Patient: What’s this blue one and the white one? When you get the pills like
this, you just don’t know.
206 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

Nurse: Do you take those?

Patient: I have.
Nurse: Okay, but you’ve got them on the side.
Patient: Yeah, in a pot.
Nurse: Well, we can remove that now, because that’s the Lasix. [a medication
containing furosemide, i.e. diuretic]
Patient: Yeah, I was just wondering what the difference is.
Nurse: No, those are the same, though they can look different. This one might
be green.
Patient: Yeah, I’ve had that one before – I just thought that was the difference,
the color … That’s the thing when you get medicines like this, you don’t
know anything. That’s my collection (the nurse is looking at pills in a bag).
I collect them over time and then I toss them. You have to keep track of
things yourself, you know, otherwise you don’t know anything …

This dialogue recognises that patients manage their health on their own most of the
time, making decisions daily that affect their health. The goal of healthcare was thus
to achieve not merely compliance or adherence to treatment and routines but also
sensemaking and common grounds for decision-making.

CONCLUDING REFLECTIONS
This paper highlights six features of ECW in specialised home care, where sensemak-
ing is a critical activity in order to cope with complexity and create safe care. These
features are ‘preparation, putting together the pieces of the puzzle’, ‘building under-
standing at a distance’, ‘a shared mind across disciplines’, ‘keeping track of a thousand
pieces’, ‘attentiveness to the small talk’ and ‘involving patients in understanding’.
The significance of sensemaking in the preparation of ECW in home care is
nicely illustrated in the morning preparation (Case 13.1). Sensemaking is the core
activity for putting together pieces of information retrieved from team members,
medical records and artefacts (e.g. notes, whiteboards) and to make ‘order’ out of
what to an outsider could seem like ‘chaos’ (Weick, 1995). In order to make decisions
in interaction with all these sources of information, people had to verbalise how they
think about things, do things or understand things. These activities of noticing and
bracketing out ‘what is going on here?’ with respect to a single patient’s care helped
the professionals reduce the plausible meanings of information and prioritise the
most essential goals (Weick, 1995).
The interactions as exemplified in Case 13.1 were also imperative to exposing
flaws in information transfer, to discover misconceptions between human actors as
well as technical or organisational factors and to coordinate care. Perception of gaps
(left corner in Figure 13.1) is central to the process of sensemaking, triggering the
interplay of interpretations, inferences and actions to make the world more com-
prehensible. In this study, gaps are not always apparent, nor are appropriate bridg-
ing reactions always clear. The subtlest hints, like a question at a morning meeting
(Case 13.1) or a spoken word that someone catches ‘in the air’ (Case 13.3), could be
the triggers that reveal a gap present in an individual’s care. This is consistent with
Coping with Complexity 207

Weick and co-worker’s (2005) view on how the order of organisations is constructed
as much by the momentary and small things as by the conspicuous, large structures
of, for example, written general rules.
Sensemaking goes beyond mere communication and transfer of information. It
is about patterning, constructing plausible interpretations and interacting in pursuit
of mutual understanding (Weick et al., 2005) (top corner of the triangle, Figure 13.1).
The study shows how sensemaking rapidly switched between a habitual mode and
a collective sensemaking mode when the expected and well known became unin-
telligible in some way. During the day, as seen in Case 13.2, sensemaking was
­characterised by ongoing noticing and bracketing of information in an inner dia-
logue. During this process, professionals built up an overall understanding of a
patient’s condition and a sensitivity to plausible roads of action. The nurses kept
track of a thousand pieces of information in a clever way, using cognitive notes and
artefacts, although the technical devices hindered rather than facilitated their under-
standing. For expert nurses, this process was guided by deep domain knowledge
and existing mental models that had been acquired through work, training and life
experience (Ekstedt and Cook, 2014), while less experienced nurses in this study
described a more effortful use of cognitive skills and artefacts to make decisions
on their ECW. The overall understanding of the state of patients (and the systems)
which individual nurses acquired during their shift is analogous to what pilots define
as ‘situational awareness’ or with the more practical expression of the U.S. Navy:
‘having the bubble’. This means that they have sufficient expertise to see patterns and
small anomalies that arise so that problems can be anticipated before they develop
(Hayes, 2013). These ‘bubbles’ of understanding have to be shared within the team,
and we found that this, much like what has been described within intensive care units
(Albolino et  al., 2007), was accomplished in conversations at ‘rounds’, handovers
and morning or afternoon meetings. All personnel focused on creating a coherent,
nuanced and useful understanding of the work world, its hazards, what it is possible
to do and what might be the outcomes of various roads of action.
Creating collective sensemaking across disciplines is one of the most important
challenges for decision-making and the development of expertise (Salas and Klein,
2001). Sensemaking is grounded in identity construction, which refers both to disci-
plinary identity and to the culture and history of each individual, which shape their
thinking (Weick et al., 2005). However, the danger of blind spots in the assessment
of a patient’s needs in home care is increased by the fact that care, in most cases,
is performed ‘two steps away’, making collective sensemaking even harder. There
is also a delicate balance between ‘shared mind’ (Epstein and Street, 2011) in the
sense of becoming attenuated and maintaining the ‘professional eye’ that is unique
for each discipline. Both deep domain knowledge and different views are needed to
perform care in complex home care settings.
In this study, the process of sensemaking was also demonstrated between the
healthcare system and the patient. Several studies conclude that patients are unpre-
pared for the self-management activities that follow hospitalisation (Moore et  al.,
2003; Fuji et al., 2013; Toscan et al., 2013), which requires high levels of understand-
ing (Bodenheimer et al., 2002). A growing body of evidence shows that an active
and informed patient (and family caregivers) is in most cases a basis for adherence
208 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

to treatment (Stenberg et al., 2012; Flink, 2014; Wibe et al., 2014). Thus, the goal of
home care organisations must be to involve patients and their next of kin in sense-
making and decision-making in the real sense of the word.
Although the organisational level was not the focus of this study, organisational
learning strategies were demonstrated through the active perception–inference–
action–interaction in sensemaking mode, within individual professionals and in the
team. The notion of gaps is central to this process. The proposed model of sensemak-
ing offers a link between individual and organisational learning in a dynamic (non-
linear) fashion (Figure 13.1). The model suggests that management systems that offer
opportunities for sensemaking and encourage people to talk about gaps in under-
standing foster a permissive learning atmosphere. New understanding that emerges
when people interact in efforts of sensemaking during ECW becomes integrated in
routines, not only on an individual professional level but also on an organisational
level. This remains to be tested empirically.

ACKNOWLEDGEMENTS
The author would like to thank the Swedish Council for Health, Working life and
Welfare, FORTE, for financing this project; Marlene Lindblad for her part in data
collection, and Richard Cook for valuable theoretical discussions.

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 14 Administration of
Intravenous Medication
Process Variation across
Hospital Wards
Eija Kivekäs, Kaisa Haatainen,
Hannu Kokki and Kaija Saranto

CONTENTS
Background............................................................................................................. 211
Smart Pumps: Use and Challenges......................................................................... 212
Reporting Medication Errors’ Adverse Events: Reporting Technology................. 213
Methods................................................................................................................... 214
Setting................................................................................................................ 214
Design................................................................................................................ 214
Data Collection and Analysis............................................................................. 215
Results..................................................................................................................... 217
Discussion............................................................................................................... 220
Conclusion.............................................................................................................. 221
References............................................................................................................... 221

BACKGROUND
Intravenous drug administration is a more risk-prone clinical process than almost
any other procedure taking place in hospital settings (Kaushal et al. 2001, Gonzales
2010). There are numerous strategies that can contribute to reducing the risk for
medication errors and patient harm in the hospital drug administration processes
(AAMI 2010, EU 2015). These strategies include good clinical practices, adequate
training and optimal use of technologies. While literature reviews suggest that com-
puterised infusion devices, such as smart pumps (also called smart infusion pumps
or intelligent infusion devices), can contribute to the risk reduction of medication
errors in healthcare settings, data supporting this manner of risk reduction in the
field remain limited (Black et al. 2011, Ohashi et al. 2014).
Computerised patient infusion devices, infusion pumps, include features for pre-
venting medication administration errors. According to earlier studies, over 90%
of intravenous medications involve some type of an error (Husch et  al. 2005). In
Finland, a study by Ruuhilehto and her associates (2011) showed that 51% of 64,405

211
212 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

web-based incident reports were concerned with medication, and the most common
incidents were errors in documenting, dispensing and administering medications.
Valentin and colleagues (2009) found out that the administration of parenteral medi-
cation was a vulnerable area in patients’ safety in intensive care. Their results were
based on data from 113 participating units from all over the world (27 countries) and
illustrated that this problem could not be attributed to suboptimal care in a few indi-
vidual units but, instead, represented a common pattern. The most frequent errors
were related to wrong time of administration and missed medication, followed by
wrong dose, wrong drug and wrong route of administration. The authors stated that
most medication errors occurred in routine care situation, not in extraordinary situ-
ations (Valentin et al. 2009).
Medication safety in hospitals is dependent on the successful execution of a com-
plex system of scores of individual tasks, namely prescribing, preparing, dispens-
ing and transcribing a medication and monitoring the patient’s response. Many of
these tasks lend themselves to technological devices. Patient safety is a matter of
major concern. Emerging technologies, such as smart pumps, can diminish medica-
tion errors (Ohashi et al. 2013) as well as standardise and improve clinical practice,
resulting in the subsequent benefits for patients (Rothschild et al. 2005, Manrique-
Rodríguez et al. 2014, Mason et al. 2014).
Härkänen (2014) demonstrated that adverse outcomes due to medication-related
factors were common. The use of combination of methods revealed information that
was more diverse than what was previously known regarding medication-related
problems in hospital setting and that can be used to increase safety in the medication
process (Härkänen 2014). In incident reports and observational data, the adminis-
tration errors were the most common, followed by documenting errors, while in
Global Trigger Tool data, the prescribing errors were the most frequently appar-
ent (Härkänen 2014). Technology may provide the key for reducing medical errors.
Technological applications such as electronic health records (EHR), barcoding tech-
nology for medication administration and smart infusion pumps are widely held as
providing solutions for patient safety (Bates and Gawande 2003, Wulff et al. 2011,
Ohashi et al. 2014).
This chapter presents the findings of a study conducted in a Finnish tertiary hospi-
tal in 2014. The findings are a part of a developing process based on an international
collaboration with David W. Bates and Brigham and Women’s Hospital, Boston. The
design section includes a description of the development project, and the results sec-
tion will report on the preliminary results of a more extensive project (before–after
study). The research questions focus on the following issues: what are the frequen-
cies and types of intravenous medication errors with infusion pumps, what are the
frequencies and types of intravenous medication errors within a medication process
and how much variability is there by frequency and type in the settings.

SMART PUMPS: USE AND CHALLENGES

The term ‘smart pump’ was originally coined by the Institute for Safe Medication
Practices in the United States to describe an infusion pump with an inbuilt drug
library that contains correct parameters for all the medications to be delivered by the
Administration of Intravenous Medication 213

pump (ISMP 2010, Quinn 2011). Smart pump technology has progressed over the
past 5 years (Ohashi et al. 2014), and the built-in safety features of the smart pump
technology provide an additional double-check system for medication administra-
tion (Carayon 2010, Mason et al. 2014). The proper use of the smart pump technol-
ogy yields benefits that include enhanced workflow for nurses and error reduction in
medication administration (Carayon et al. 2010).
Technology provides error reduction capabilities in medication via programmed
dose limit alerts with audio-visual feedback to staff regarding erroneous orders,
improper dose calculations or programming errors. Ohashi and colleagues noted
in their literature review lower compliance rates of using smart pumps, overriding
soft alerts, non-intercepted errors and the possibility of using the wrong library.
Rothschild et  al. (2005) evaluated a very early version of the pumps and found
that smart intravenous pumps with decision support capabilities had the capacity
to intercept many dangerous medication errors. Manrique-Rodrigues et  al. (2014)
demonstrated that the implementation of smart pumps proved effective in preventing
infusion-related programming errors from reaching patients. A study in a German
hospital showed that smart pumps prevented potentially dangerous overdoses. In a
before–after study on patient-controlled analgesia, the use of a smart pump resulted
in a significant 22% decrease in adverse drug events recorded by an automated sur-
veillance system, and voluntary report events also decreased significantly by 72%
(Kastrup et al. 2012).
The introduction of smart pump technology provides a technology-based final
check of an infusion rate that creates a safe environment for care. Modern infusion
devices are much more than mere pumps and are currently often regarded as part of
the organisation’s information technology capability. However, only a small reduc-
tion in dosing errors has been found, while a greater reduction occurred in pump-
related errors. Nine out the 10 post-intervention pump programming errors occurred
because users did not use the pump software correctly (Adachi 2005, Ohashi et al.
2014). Previous studies have shown poor caregivers compliance with the drug library
and users frequently ignoring the drug library when selecting a drug (Ohashi et al.
2014). Creation of a safe and effective customised drug library is essential for the
proper utilisation of smart pumps. A drug library should include at least all high-
alert drugs with standard concentrations as well as soft and hard stops to various
dosage limits. Drug libraries must also be maintained and updated constantly.
Wireless communication technology in an organisation’s infrastructure allows easier
adjustment or updating of drug libraries, which otherwise would require manually
updating each pump separately (ISMP 2010).

REPORTING MEDICATION ERRORS’ ADVERSE

EVENTS: REPORTING TECHNOLOGY
The World Health Organization has presented Draft Guidelines for Adverse Event
Reporting and Learning System, and a European Council Recommendation
(2009/C 151/01) has also advised European countries on the establishment and
revision of reporting systems (EU 2009). The European Council Recommendation
mentions that there are big differences between reporting systems in the EU
214 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

Member States. There are both mandatory and voluntary reporting systems in the
Member States, and variety in the types of incidents that can be reported varies.
However, a broad definition allows the reporting of any concerns, including near
misses and ‘no harm’ incidents providing a rich resource for learning and systems
improvement (EU 2009).
The HaiPro system is intended for reporting patient safety incidents on the
organisational level in Finland. The main properties of HaiPro are anonymity,
confidentiality and freedom from sanctions. The HaiPro approach incorporates a
system model that takes into consideration the features of natural human behav-
iour and the pathway of diverse events development. The local incident reporting
system is meant to prevent adverse events of treatment through the improvement
of operational procedures. At present, data are collected only at the level of the
organisation and not sent forward to or nor aggregated or analysed on regional
and national level (Doupi 2009). In this study, reports from the HaiPro system
illustrated one perspective of the administration of intravenous medication in the
hospital, and the wards were studied.

METHODS
Setting
The study was conducted in a Finnish tertiary hospital, which has 800 beds and pro-
vides specialised medical care to 860,000 inhabitants. Around 90,000 in patients
are treated in the hospital annually (PSSHP 2015). Computerised physician order
entry has been in use in the hospital since 2009, and a barcoding system is used in
its pharmacy. Smart pumps were in use in the intensive care unit and cardiac care
unit, and a drug library was customised for each unit. The studied wards included
a coronary care unit, an adult intensive care unit, an oncology unit and a cardiotho-
racic surgical ward. The pilot data were collected at a maternity ward, where the
appropriateness of the questions was also tested for Finnish hospital.

Design
This is a descriptive retrospective pre–post study conducted in three phases over
the course of 36 months in total (2014–2016, Figure 14.1) based on a similar study
implemented in the United States (Bates 2012). During the first year, the quality and
quantity of reported adverse events were screened in order to acquire baseline data
concerning safety incidents (including HaiPro) in the wards. This was followed by
an observational study where a multidisciplinary team of investigators prospectively
compared the actual medication, its dose and the infusion rate of the infusion pump
with the prescription in the medical record. Subsequently, during the second year
(2015), these results were analysed. A consensus process including a face-to-face
meeting with users and decision-makers took place in order to evaluate the types
of events and to develop an intervention. After a run-in period, the effectiveness of
intervention will be tested during the third year of the study (2016) to produce a set
of evidence-based recommendations.
Administration of Intravenous Medication 215

Year 1 Year 2 Year 3

Phase 1 Phase 2 Phase 3
1. Obtain a statement of the 1. Observation data analysis 1. Second measurement of
committee on research ethics intravenous medication errors
2. Development of data 2. Face-to-face meeting for 2. Data analysis
collection form developing recommendations
3. Observer training 3. Interventions to reduce 3. Face-to-face meeting for
intravenous medication errors developing recommendations
4. Initial measurement of 4. Publication of a final report
intravenous medication errors

FIGURE 14.1  The study phases based on Bates’ study protocol, 2012.

This study was approved by the University of Eastern Finland Committee on

Research Ethics in 2014. Participants in the study were voluntary and aimed at
patients aged 18 years or older.

Data Collection and Analysis

The observation data were collected by four researchers. The observation data
collection is based on methods employed by Husch and colleagues (2005). Key
elements, required to capture all kinds of intravenous medication errors, were
identified using methods by Ohashi and colleagues (2013). In assigned inpatient
units, using a ‘prospective point prevalence’ approach, all data from intrave-
nous medications at patient bedside were collected with the standardised form.
Observers compared the infusing medication dose and infusion rate on the
pump with the prescribed medication, the dose and rate in the medical record.
All orders were obtained from both EHR and handwritten paper-based medical
records, and all intravenous fluids were classified as medication. The availability
of correct patient identification band and name verification was recorded for each
patient. Labelling of the infusing medication, according to medication policy,
was assessed.
Observations on the intravenous medication administration processes were made
over 4 days, 8 hours per day in March 2014 in each of the four units. All epidural,
patient-controlled analgesia and general use of intravenous infusion pumps on
inpatient care units were included in the investigation. To capture data, two to four
observers (registered nurses and pharmacists) went to a ward and conducted observa-
tion on patients. The observer entered a patient room; he or she introduced himself
or herself and explained the purpose of the study. In order to confirm the presence
of an error (Table 14.1), the observers had to agree that an error had been made.
If such an error was identified, that had the potential to cause harm, the staff nurse
caring for this particular patient was discreetly informed about the incident so that
he/she could correct it.
The main study outcomes will be the intravenous medication error rate and the
serious medication error rate. All errors were classified for every administered
medication. Serious errors were rated by NCC MERP index (National Coordinating
Council for Medication Error Reporting and Prevention) (Table 14.2).
216 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

TABLE 14.1
Medication Error Types in the Study
Error Type Definition
1. Wrong dose The same medication but the dose is different from the prescribed order.
2. Wrong rate A different rate is displayed on the pump from that prescribed in the
medical record. Also refers to weight-based doses calculated
incorrectly including using a wrong weight.
3. Wrong concentration An amount of a medication in a unit of solution that is different from
the prescribed order.
4. Wrong medication A different fluid/medication as documented on the IV bag label is being
infused compared with the order in the medical record.
5. Known allergy Medication is prescribed/administered despite the patient had a known
allergy to the drug.
6. Omitted medication The medication ordered was not administered to a patient.
7. Delay of rate or An order to change medication or rate not carried out within 4 hours of
medication/fluid change the written order per institution policy.
8. No rate documented on Applies both to items sent from the pharmacy and floor stocked items
label per institution policy.
9. Incorrect rate on label Rate documented on the medication label is different from that
programmed into the pump. Applies to items sent from both the
pharmacy and floor stocked items.
10. Patient identification Patient either has no ID band on wrist or information on the ID band is
error incorrect.
11. No documented order Fluids/medications are being administered but no order is present in
medical record. This includes failure to document a verbal order.

Source: Ohashi, K. et al., Evaluation of intravenous medication Errors with smart infusion pumps in an
Academic Medical Center, AMIA, ed. in: Proceedings of the AMIA 2013 Annual Symposium,
16–20 November 2013, AMIA, Washington, DC, pp. 1089–1098.

TABLE 14.2
The Severity of Medication Errors according to NCC MERP Harm Index
(A) Capacity to cause error
(B) An error occurred but did not reach the patient
(C) Errors unlikely to cause harm despite reaching the patient
(D) Errors that would have required increased monitoring to preclude harm
(E) Errors likely to cause temporary harm
(F) Errors that would have caused temporary harm and prolonged hospitalisation
(G) Errors that would have produced permanent harm
(H) Errors that would have been life-threatening
(I) Errors that would likely have resulted in death

Source: NCC MERP, NCC MERP index, Homepage of National Coordinating Council for Medication
Error Reporting and Prevention, 2001, Online, available at: http://www.nccmerp.org, accessed
29 January 2014.
Administration of Intravenous Medication 217

All factors collected in each participating ward included the report of patient
safety incidents at the organisational level (HaiPro), the institutional policies and
procedures around medication administrations. The data were analysed and then
presented at each ward. The meetings were hosted by the multidisciplinary team.
Written memorandums from each meeting were analysed by content analysis, and
these data will be utilised in the recommendations.
The preliminary data were used as material in a meeting with physicians, nurses,
pharmacists and a patient safety manager. In the meeting, data of the use of intrave-
nous infusion pumps and medication administration workflow were reviewed. Based
on the data and the summary of the meeting, the multidisciplinary team developed
an intervention that may improve the safety of intravenous drug administration at
the wards.

RESULTS
The HaiPro reports from between 2011 and 2013 indicated that adverse events had
increased in each unit. In particular, the incidence of near misses has increased,
which illustrates that the preventative meaning of reporting has been emphasised.
Most of the incidents were related to medication or information management. The
majority of the reported incidents consisted of detected errors; recently, reports on
near misses had increased (Figures 14.2 and 14.3).
During the data collection period, 194 inpatients in four inpatient wards were
included in the study, and 492 medication procedures were observed (Table 14.3).
These consisted of 355 intravenous medication infusions and 137 fluids infusions.
Out of these, infusion pumps were used in 56% of cases.

3000

2500

2000
Number

1500

1000

500

0
2011 2012 2013
Near misses (medication) 217 355 695
Detected errors (medication) 452 507 729
All incidents 1592 2021 2713

FIGURE 14.2  Reported incidents of detected- and near-miss medication and intravenous
medication–related errors (2011–2013) in the hospital.
218 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

400
350
300
250

Number
200
150
100
50
0
2011 2012 2013
Medication- or
intravenous-related
incident reports 96 121 170
Detected 78 81 126
Near misses 18 39 43
All incidents 208 265 344

FIGURE 14.3  Reported incidents of detected- and near-miss medication and intravenous
medication–related errors, 2011–2013, in the studied wards (excluding the pilot ward).

TABLE 14.3
Study Participants and Type of Medication
Maternity The The The The Summary
Ward Oncology Medical Cardiothoracic Surgical (without
(a Pilot) Unit ICU Surgical Ward ICU Pilot)
Patient 9 71 18 25 80 194
  Patients who refused 1 1 2 2 5
Infusion 9 144 29 25 294 492
 Medication 100% 58% 41% 80% 82% 355
 Fluid 61% 59% 20% 18% 137
  Infusion pump 11% 34% 83% 16% 83%
  No infusion pump 89% 60% 17% 84% 10%
  Empty medication ‘bag’ 6% 20%

The use of an identification band is imperative to ensure that the right patient
receives the right care. Information on the identification band has to correspond
with details recorded on the patient’s medicine chart, and this should be confirmed
whenever medications are administered. Remarkable variety between wards was
found in the first phase of this study (Table 14.4). Misidentification of patients
and administering medicines intended for another patient to these patients are
real dangers.
Stating patients’ allergies is key hospital policy. One aim of the EHR is to improve
recording patients’ allergies and raise awareness of high-risk products among staff.
Administration of Intravenous Medication 219

TABLE 14.4
Differences between Wards in the Use of
Identification Bands and Documentation of Allergies
Observation Target Wards (%/Ward)
Availability of identification band 4%–100%
Information on allergy was documented 33%–56%

TABLE 14.5
Variety between Wards in Labelling Status
Observation Target – Labelling Wards (%/Ward)
Patient’s name 2%–89%
Name of preparer (nurse or pharmacist) 0%–89%
Drug 100%
Dose or content of drug 75%–100%
Composition of infusion (volume) 8%–89%
Date/time 50%–89%

The lack of information on allergies was a surprising finding in the study (Table 14.4).
Violations of medication policies regarding labelling were the most frequent error
types. The details of the information missing on the labels varied between wards
(Table 14.5). The most common error was the lack of information on the label of the
drug to be infused. There were also the differences in the way in which medications
were prescribed, and medication orders were documented. Regardless of the fact that
in some wards, all prescriptions were available in the EHR, the wards used several
overlapping documentation forms and a paper-based form to manage medication
information.
Each error in observation data was rated using the NCC MERP harm index. Data
collection in the four study units further indicated that errors were rated as A–B, indi-
cating that there was potential for an error (A) or an error occurred but did not reach
the patient (B). Indeed, in spite of the EHR system, several overlapping documentation
forms were in use, and medication processes varied significantly across the units.
In summary, the work processes at each studied ward differed, even though
the organisation’s policy was well known. There was a lot of variety in the use of
identification bands between wards, and allergies were infrequently documented.
Missing allergy information was recognised as a risk in the EHR. According to
the organisation policy, medication and fluid prescriptions should be documented
in the EHR system. A lot of room for development was found in connection to
the labels of intravenous medication, because their contents varied between wards.
The use of medical technology, such as infusion pumps, smart pumps and drug
library of devices, should be increased. The staff was highly interested in improv-
ing their competences in using technology.
220 Researching Patient Safety and Quality in Healthcare: A Nordic Perspective

DISCUSSION
The results of the first phase of this intervention study show the significance for the
hospital to improve patient safety. There was a positive development in the volun-
tary reporting of patient incidents, and especially reporting near-miss incidents had
increased every year. These illustrate that the preventative importance of reporting had
been emphasised. Members of staff were very interested in investing in their compe-
tence in using technology and were aware of the possibilities provided by technology.
In this study, the most common error was the lack of information on medication
labels thus increasing the risk of administering wrong intravenous medication to
patients. Previous studies have also demonstrated similar tendencies in medication
errors (Keohane et  al. 2005, Ohashi et  al. 2013). Documentation of allergy was the
information found missing most frequently. The allergies of only 56% of the patients
had been recorded in the EHR system. Differences in identifying patients in the studied
wards were a further significant finding. Through the course of this study, such violation
errors of hospital policy were found, which could potentially put patients at risk.
Traditional infusion pumps were in common use. Smart pumps were used mainly
in cardiac care and intensive care units in this study. There was clearly a need to
develop the use of technology in patient’s care. However, it has already been dem-
onstrated that until barcode pumps are integrated with other systems within the
medication administration process, the role of smarts pumps in enhancing patient
safety will be limited (Trbovich et al. 2010, Ohashi et al. 2014). Regardless of the
technology, careful planning of care processes will ensure proper patient identifica-
tion prior to any medical intervention and provide safer care with significantly fewer
errors (Upton and Quinn 2013). In the future, more interest must be focused on the
work processes. The work processes at each studied ward differed even though the
organisation policy was well known.
The main strength of an observation and medical chart review evaluation is that
the observers directly perceived the use of medical devices in clinical environ-
ments. The advantages of observation include obtaining data on authentic surround-
ings (Elias and Moss 2011, Sinivuo et al. 2012). The most remarkable preliminary
result of this study was the high variability in the medication processes in the
­different studied units. Several types of errors were detected related to intravenous
medication administration. These may increase the risk for administering wrong
­intravenous medications. The discussions in the first face-to-face meeting with the
staff from the wards were productive. The staff was aware of the hospital’s instruc-
tions concerning intravenous medication, but each ward had and followed their own
­procedures. The tendency of nurses to ignore safety software in infusion devices
where manufacturers have made it optional to use these is one of the obstacles for
the research efforts attempting to demonstrate and quantify an increase in patient
safety (Rothschild et  al. 2005). The temptation to follow so-called workarounds
must be resisted if potential benefits to patients and health professionals are to be
realised (McAlearney et al. 2007).
In the meetings with wards staff, the significance of the problem was recognised,
and deeper commitment to hospital policy was stated. Overlapping documentation
and ward-specific systems were highlighted, and there were lively discussions on
Administration of Intravenous Medication 221

the recommendations. Collaboration in the hospital was emphasised. It is the prime

responsibility of the prescriber to ensure that the patient’s information is checked for
allergies before any prescriptions are written. Other staff responsible for dispensing,
administrating and monitoring medicines can help prevent potential incidents by
identifying the patient’s allergy status.
The results of discussion with the staff have condensed into four recommenda-
tions: (1) the identification band should be used according to the organisation policy;
(2) allergy status should be documented for all patients, including the lack of an
allergy (‘No known medicine allergy’); (3) medication and fluid orders should be
prescribed on the EHR system according to the organisation policy and (4) the label
of intravenous medication has to be filled as instructed.
There are limitations to our study. The small sample size of the studied wards
limits the generalisability of the results. The study focused only on one tertiary
­hospital. However, as they are in use all over healthcare institutions, the safe use of
infusion pumps is a shared challenge for healthcare organisations.
The first observations on intravenous medication errors identified the key issues
related to the use of infusion pumps and smart pumps. This will support to the devel-
opment of strategies to allow improving the prevention of intravenous medication
errors. The utilisation of staff meetings will increase commitment to develop strate-
gies for improving the prevention of intravenous medication errors. Support gained
from hospital management and their commitment to improve patient safety was a
facilitator for this study.

CONCLUSION
The most important preliminary result of this first observation study was the high
variability in the medication processes in the studied wards. The hospital policy con-
cerning intravenous medication has a central role in improving patient safety. The
staff appeared to be well motivated to develop the medication processes and their
own competence in using technology. Future challenges associated with the hospital
policy especially to intravenous medication and increasing the use of medical tech-
nologies in patient care and in healthcare in general.

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Index
A E
Accreditation programmes e-health, 52
accreditation definition, 116 Elderly patients discharge practices
Danish accreditation initiative, 116 agreements implementation, 149–151
history, 115 competence and experience, 154–155
interview survey, 118–120 content/text analysis, 147
misconceptions, 124 continuity of care, 146
programme theory, 117 Coordinating Unit, 148
element of, 121 Coordination Agreement, 148
examples, 121–122 Coordination Reform, 148–149
external assessment, 121 discharge to municipal health service,
nutritional screening, 122–123 152–154
standardisation, 121, 123 EME, 149
quality surveillance, 124 ethics, 147
socio-historic epochs, 123 information continuity, 146, 157
standards overimplementation, 120 interviews, 147–148
Agency of Healthcare Research and Quality, 44 management continuity, 146, 155–157
Attractive and Health Promoting Health organisation and information flow, 151–153
Care, 134 relational continuity, 146, 157–158
research questions, 147
C Electronic message exchange (EME), 149,
152, 157
Centralisation processes, 3 Empirical fields, 7–8
Complex adaptive systems (CASs) theory, 196 European societal culture, 58
Evidence into practice translation, 11–12
D
F
Danish Biologics database (DANBIO), 111
Danish clinical registries Falls prevention
advantages, 109 Attractive and Health Promoting Health
comparative effectiveness research, 110 Care, 134
DANBIO, 111 education, 134
data collection and validity, 106–107 fall-related accidents, 132
data reporting, 107 Finnish fall-related studies, 133
definition, 105 integrative pedagogy, 134
feature of, 109 KUH, 134–135
history of, 104–105 Nursing Research Foundation (Hotus),
indicator plus standard concept, 109 134–135, 137
medical care variation, 110 RFPNetwork
mission for, 105–106 educational development work, 141
objective, 105 first meeting, 135–136
population-based studies, 109 focus on action, 136
professional-led quality improvement, 108 history of, 135
in quality improvement, 108 ideas and expectations, 137
secondary and tertiary care, 106 implementation of, 139
Danish Healthcare Quality Programme, 116 objective, 135
Data extraction tool, 6 operational area, 136–138

235
236 Index

regional process description, 139 patient safety, 212

subnetworks, 139–141 patients’ allergies, 218–219
success factors, 142 smart pumps, 211–214, 220
systematic follow-up, 137, 139
Framework for Patient Safety Research, 6–7 K

G Kuopio University Hospital (KUH), 134

Global Trigger Tool, 212 M

H McDonaldization, 58
Measurements and indicators development and
HaiPro system, 214, 217 testing, 9
Hazards identification and mitigation, 13 Mixed methods, 8
Healthcare-associated infections monitoring, 11 Multi-stage strategy, 4
High Reliability Organisations (HRO) theory, 62
Home healthcare services, see Telecare N
Hospital standardized mortality rate (HSMR), 82
National clinical registries
I Danish clinical registries, 104–112
setting, 104
Information and communication technologies National quality development plan, 2
(ICT) tools, 9, 11 NCC MERP harm index, 216, 219
Institutional layering New public management (NPM), 32
definition, 75 Nordic region population, 2–3
in Dutch healthcare Nordic welfare model, 3
civil society arrangement, 78–79 Norwegian healthcare system, 148
competition and closing contracts, 78 contextual challenge, 162, 164, 170–171
Healthcare Inspectorate, 80 contextual factors, 164–165
HSMR, 82 cultural challenge, 162–163, 167–168
market-based system, 78 educational challenge, 162–163, 167–168
market parties, 83 emotional challenge, 162–163, 169
national safety programme, 80 evidence-based framework, 162
quality demands, 83 national patient safety campaign, 161
regulated competition system, 82 Norwegian QUASER study, 164
self-regulation by professional overall assessment of leadership challenges,
community, 77–79 171–174
state regulation of quality, 78 permanent patient safety programme,
summary of, 81 161–162
top-down state regulation, 79–80 physical and technological challenge,
transparency, 78–81 162–163, 169–170
governing mechanisms, 76 political challenge, 162–163, 165–167
International Health Policy survey, 38 senior leadership challenge, 162–164, 171–172
Intravenous drug administration structural challenge, 162–163, 165–166
adverse outcomes, 212 Norwegian Patient Rights Act (1999), 33
detected-and near-miss medication, 217–218
Finnish tertiary hospital O
barcoding system, 214
Bates’ study protocol, 214–215 Organisational characteristics and outcomes, 14
data collection and analysis, 215–217
fluid prescriptions, 219 P
identification band, 218–219
labelling status, 219 Paternalistic care models, 27
medication errors, 212–214, 217–218 Patient and public involvement (PPI), 48–49
medication procedures, 217–218 Patient-centred care
NCC MERP harm index, 219 chronic conditions, self care, 38
parenteral medication administration, 212 complaints and redress, 36
Index 237

definition, 28 Research programmes and policy

direct proactive involvement, 29 Agency of Healthcare Research and
doctor–patient relationships, 38 Quality, 44
easy access to information, 37 collaborative synthesis, 45
end-of-life care, 38 contextual changes, 47–48, 50–51
healthcare setting, 28 degree of specialisation, 48
health information, 33–34 level of interest, 45–46
health legislation, 37 linear to complex safety models, 45
health professionals education and patient safety and quality conceptualisation,
training, 28 46–47, 49–50
high-quality care, 28 PPI, 48–49, 51–52
information gaps, 38 randomised controlled trial designs, 45
International Health Policy survey, 38 Review process, 5–6
IOM report, 28 RFPNetwork, see Regional Fall Prevention
paternalistic care models, 27 Network
patient choice, 32–33 Root cause analysis (RCA), 62–63
patient experience surveys, 35–36 ‘0-7-90-90’ rule, 33
patient organisations, 30–31
patient rights, 31–32 S
policies, 29–30
primary care provider choice, 37 Safety culture assessing and improvement, 12–13
shared decision-making, 28 Safety science theories
social and psychological factors, 28 decision-making perspective, 62
therapeutic alliance, 28 energy and barrier perspective, 61
Plan–Do–Study–Act (PDSA) cycle, 65 HRO theory, 62
Program for Clinical Research information processing perspective, 62
Infrastructure, 112 learning and reporting, 63
Perrow’s theory of normal accidents, 62
Q RCA, 62–63
resilience engineering perspective, 62–64
Qualitative methods, 8, 52 Swiss Cheese model, 62–63
Quality improvement theories Search methods, 4–5
PDSA cycle, 65 Situation–Background–Assessment–
policing, punishing and rewarding, 66 Recommendation, 9
Six Sigma, 65 Skillrule-knowledge model, 68
SPC methods, 66 Smart pumps, 211–214, 220
structure–process–outcome framework, Specialised home care
64–65 cognitive strategies, 195
system-wide multi-model approaches, 66 complexity, 196–197
technical–empirical approach, 64 domain-specific knowledge, 203
Quantitative methods, 8 label and report, 203
morning preparation, 200–201
R nurse and patient understanding, 205–206
observational methods, 200
Regional Fall Prevention Network (RFPNetwork) sensemaking
educational development work, 141 collective sensemaking, 203
first meeting, 135–136 definition, 197
focus on action, 136 explicit mode, 198
history of, 135 information selection, 204
ideas and expectations, 137 initial state, 202
implementation of, 139 interruptions and multitasking, 204
objective, 135 labelling, 197
operational area, 136–138 menial tasks, 204
regional process description, 139 small talk, 204–205
subnetworks, 139–141 tentative model, 198–199
success factors, 142 Statistical process control (SPC) methods, 66
systematic follow-up, 137, 139 Swiss Cheese model, 62–63
238 Index

T V
Telecare, 52 Virtual visits
definition, 180 closer patient contact,
healthcare staff perspectives, 180–181 185–187
patient–provider interactions, 188 continuation of care, 185–187
quality and safety, 180 data collection and analysis, 182
research question, 181 degree of disagreement, 188
self-care practices, 189 patient empowerment, 187
virtual visits reduced ability for clinical observation,
closer patient contact, 185–187 183–184
continuation of care, 185–187 reduction of stigma, 187
data collection and analysis, 182 sample characteristics, 183
degree of disagreement, 188 vulnerability of poor assessment,
patient empowerment, 187 184–185
reduced ability for clinical observation, Volume–outcome relationship
183–184 clinical skills, 95–96
reduction of stigma, 187 contextual mechanisms, 93
sample characteristics, 183 definition, 90
vulnerability of poor assessment, 184–185 hospital organisation, 96
Theoretical domains framework (TDF), 61 patient selection, 94
Theory quality of care, 94–95
development of, 59 scale effects
example, 59 case-mix adjustments, 92
grand theory, 60 complications, 91
Meleis’ definition, 59 mortality, 91–92
mid-range theory, 60 readmission rates, 92
Nordic influence survival rates, 91
Hollnagel’s work, 68 volume, 90–91
Jönköping Quality Program, 68 volume threshold, 96–97
Rasmussen’s ideas, 66–67
Swedish scholar John Ovretveit’s role, 68–69
programme theory, 60
quality improvement theories, 64–67 W
safety science theories, 61–64
structural equation model, 59 Western Denmark Heart Registry, 110
TDF, 61 World Health Organization (WHO), research
Treatment delays, 98 priorities, 44