OBJECTIVES

In 2003, the University of Missouri-Columbia School of Medicine (MU SOM) initiated an integrated quality improvement-interprofessional collaborative practice (QI-ICP) curriculum as part of a larger curriculum renewal process. While exploring a different case study focused on the content of the curriculum, investigators became intrigued by MU SOM's approach to change, specifically, how complex adaptive systems (CAS) thinking may have supported sustained transformational change in curriculum across multiple health professions programs. The primary aim of this study was to elucidate the aspects of MU's experience with transformation that were grounded in CAS. A secondary aim was to explore the usefulness of a CAS-based management framework for organizational transformation using the case of curricular transformation in health professions education at MU.

METHODS

Data collection involved interviews, with twelve faculty from a variety of programs, and document analysis, including previously published papers and gray literature (websites, organizational charts and planning documents, and faculty development materials).

RESULTS

Using abductive analysis, we found that leadership in the health professions programs at MU, informed by earlier learning about organizational sensemaking and CAS theory, addressed all 9 of the characteristics of CAS presented in the initial framework. Additionally, systematic combining revealed the need to adjust the framework to ensure applicability to health professions education. The analysis of MU's experience also offered key insights into how that transformation happened in practice. The CAS framework adjustments make explicit the importance of common purpose and the concept of leadership as an emergent event and make it easier to apply the framework to a broader set of organizational contexts, including health professions education.

CONCLUSION

The use of the adjusted framework, informed by insights from this specific case, may help health professions education programs evaluate past change efforts or plan for future change.

Objectives: Despite decades of effort, programs continue to struggle to integrate competencies related quality improvement (QI) and interprofessional collaborative practice (ICP) into health professions education. Additionally, while QI and ICP may seem intuitively linked and there exists some examples of a coordinated approach, the literature regarding competencies, including knowledge, skills, and attitudes (KSAs), is still largely focused on QI and ICP as separate fields of knowledge and practice. This study explored distinctions and connections between quality improvement (QI) and interprofessional collaborative practice (ICP) competency domains in health professions education.

Methods: The authors used a qualitative case study approach with an instrumental case, that is, the University of Missouri-Columbia (MU), where QI and ICP were intentionally integrated as part of core curricula in health professional schools and programs. Eleven faculty members from medicine, nursing, pharmacy, and health care administration participated in interviews exploring their teaching choices in either classroom or clinical settings.

Results: Study participants defined the goal of teaching QI and ICP as enabling learners to deliver safe and patient-centered care and described the knowledge and skills required for QI and the attitudes and skills required for ICP. Furthermore, they described the relationship between QI and ICP as one mediated by systems thinking, where ICP is backgrounded as a critical pre-requisite and QI is foregrounded as a vector for developing interprofessional competencies.

Conclusions: The MU case elucidates the potential synergies that occur when faculty address quality improvement and interprofessional collaborative practice competencies with an integrated approach that leverages connections, while also respecting distinctions. For health professions education programs looking to improve the effectiveness and efficiency of their curricular approach to these fields, it may be fruitful to consider ICP as background and QI as foreground, remembering that without each other, ICP risks losing meaning and QI risks losing impact.

Introduction: Previous studies have identified differences in healthcare contacts, needs, and cost of care among persons living with multiple sclerosis (MS). The need for a deeper understanding of factors influencing healthcare contacts has been highlighted. The aim of this study was to explore different levels of healthcare contact frequency among persons living with MS.

Method: Both quantitative and qualitative data were collected, analyzed, and integrated in a parallel mixed-methods approach with data integration through joint display. Data were retrieved from the hospital administrative system, the Swedish national MS registry, and a previously conducted interview study. The population was divided into four segments based on healthcare contact frequency, ranging from Segment 1, with the fewest visits, to Segment 4, representing those with the most frequent contacts. Analyses were conducted using descriptive statistics, statistical tests on differences between segments, multinomial logistic regression, deductive content analysis, and integration.

Results: The mean and median distribution of individual study variables increased or decreased (depending on scale direction) between segments for most variables toward more symptoms, reduced function, and declining experiences of health from the lowest to the highest contact frequency. The probability of belonging to a certain segment was influenced by the explanatory variables age, gender, overall health, and expanded disability status with the different variables playing different roles for each segment. Qualitative findings also suggested increased physical limitations with increased level of healthcare contacts. This was not necessarily due to MS and influence of comorbidities was sometimes expressed. Both requests of less and more healthcare contacts existed and content of healthcare contacts could have more personalized design overall, health care was perceived positively across all segments. Data integration with merged interpretation included eight themes, characteristics of the population, neurological assessment and gait function, symptoms and consequences, fatigue and cognition, perspectives on health, examinations, interactions with health care, and disease duration and future. The merged interpretation confirmed patterns of symptoms, reduced function, and declining experiences of health from the lowest to the highest contact frequency and expanded on individual variation within segments and influenced by comorbidities. Discord in data regarded relations with others, aspects of medication, and knowledge building and type of MS.

Conclusion: The findings on distribution of variables and experiences across segments, were increase in symptoms, loss of function, and deterioration of health experience correlating with increased levels of contact frequency from Segments 1 to 4. The explanatory variables found were age, gender, overall health, and expanded disability. The merged interpretation, expand on individual differences on how symptoms were experienced and influenced by comorbidities. Discord found, regarding for example personal context and aspects of self-care where areas that may be overlooked in healthcare contacts. The explanatory variables identified in this study are suggested to be further explored together with the knowledge of persons living with MS and professionals.

HUVUDBUDSKAP

• Det finns ett stort antal patientrapporterade utfallsmått (PROM). Trots att de behövs som komplement till medicinska mått för en personcentrerad vård används de alltför sällan.
• PROM kan användas för att identifiera vårdbehov, utvärdera behandlingseffekter samt följa förändring över tid.
• Användning av PROM kräver kunskap om varför de behövs, vad de mäter och hur data kan analyseras och användas.
• Integrering av PROM i journalsystemen är avgörande för deras användning i vårdens vardag.
• Det kräver prioritering av PROM vid automatiserad överföring från 1177.se till patientjournal vid insamling av hälsodata inom Nationell kunskapsstyrning samt lösning av juridiska och tekniska hinder för deras användning i kvalitetsregister.

PROMs provide valuable information from patients about their health and health-related problems. These measures complement medical measures and are critical for developing optimized, co-produced and person-centred healthcare, as they add important perspectives, offering a holistic view of health. Valid and reliable PROMs have been developed since a long time and are increasingly used in research. Digital PROMs are today available at 1177.se but seldom utilized in clinical practice. To utilize PROMs in clinical care, healthcare professionals need to understand their value and how to analyse data and use results. Therefore, to support the increased interest to implement PROMs, this knowledge needs to be disseminated among all professionals. In order to effectively use PROMs in improvement work, we also need to address significant technical and legal obstacles. Integrating PROM data into electronic medical records should be prioritized in the ongoing development of infrastructure for health data collection.

Objective

This study aims to provide a deeper understanding of what persons with lived experience and professionals with experience of patient safety, suicide research, and investigations consider to be most important in investigations of healthcare before suicide to learn and improve the care of suicidal patients.

Method

This is a qualitative study based on 15 semistructured interviews with persons with lived experience of suicidality and professionals. Thematic analysis was used.

Results

The persons with lived experience and the professionals agreed that a holistic approach to the investigations is crucial. They should embrace a longer period of time, involve family and significant others, integrate the perspective and expectations of the patient, and analyze factors of significance for suicidality, suicide prevention, and safety. There is a need to improve the investigations through the involvement of all stakeholders and actors, securing competence in the investigation team and prioritizing cases to investigate.

Conclusions

Substantial changes in the approach and performance of investigations of suicide in healthcare are needed to make these investigations valuable for increasing the safety of the care of suicidal patients. A holistic perspective during the analysis is crucial for understanding the suicidal process, the interacting factors, and the care process preceding suicide. Competencies in suicidality, suicide prevention, and patient safety must be included in the analysis team to ensure high quality and relevance. To improve the value of these investigations, we suggest establishing a template based on current knowledge to ensure attention to variables of significance for a safe care of suicidal patients.

Background: When the 21 Swedish county councils decided to collaborate in the creation of a national system for knowledge-based management, patient participation was mandatory. Patient and next-of-kin representatives (PR) co-produced person-centred and cohesive clinical pathways together with healthcare professionals (HPR). Research on co-production in healthcare at the national level is scarce. The aim of this study is to explore experiences of patient participation from the perspectives of both PRs and HPRs when co-producing clinical pathways within the Swedish nationwide healthcare system for knowledge-based management. Methods: A qualitative study was conducted. A strategic sample of nine PRs and eight HPRs were interviewed individually between August 2022 and January 2023 using a semi-structured interview guide. We analysed data using an inductive content analysis. Results: Three main categories were identified: (1) Finding appropriate patient representativeness; (2) Working methods that facilitate a patient perspective; and (3) Influence of the patient perspective in the clinical pathways. Conclusions: The study demonstrates the importance of patient and next-of-kin participation in the construction of clinical pathways at the national level. The results provide a platform for further research on patient participation on the national level and add to studies on if and how patient participation on this level has an impact on how the clinical pathways are put into practice at the micro level, and the support provided at the meso level. The study contributes to the growing body of literature studying patient participation and co-production. Trial registration: Region Örebro County ID 276,940. An advisory opinion was obtained from the Swedish Ethical Review Authority (2021-05899-01).

OBJECTIVE: The decline in suicide rates has leveled off in many countries during the last decade, suggesting that new interventions are needed in the work with suicide prevention. Learnings from investigations of suicide should contribute to the development of these new interventions. However, reviews of investigations have indicated that few new lessons have been learned. To be an effective tool, revisions of the current investigation methods are required. This review aimed to describe the problems with the current approaches to investigations of suicide as patient harm and to propose ways to move forward.

METHODS: Narrative literature review.

RESULTS: Several weaknesses in the current approaches to investigations were identified. These include failures in embracing patient and system perspectives, not addressing relevant factors, and insufficient competence of the investigation teams. Investigation methods need to encompass the progress of knowledge about suicidal behavior, suicide prevention, and patient safety.

CONCLUSIONS: There is a need for a paradigm shift in the approaches to investigations of suicide as potential patient harm to enable learning and insights valuable for healthcare improvement. Actions to support this paradigm shift include involvement of patients and families, education for investigators, multidisciplinary analysis teams with competence in and access to relevant parts across organizations, and triage of cases for extensive analyses. A new model for the investigation of suicide that support these actions should facilitate this paradigm shift.

HIGHLIGHTS

• There are weaknesses in the current approaches to investigations of suicide.
• A paradigm shift in investigations is needed to contribute to a better understanding of suicide.
• New knowledge of suicidal behavior, prevention, and patient safety must be applied.

Introduction: The Esther Network (EN) person-centred care (PCC) advocacy training aims to promote person-centred attitudes among health practitioners in Singapore. This study aimed to assess the relationship between the training and practitioners’ PCC attributes over a 3-month period, and to explore power sharing by examining the PCC dimensions of “caring about the service user as a whole person” and the “sharing of power, control and information”. Methods: A repeated-measure study design utilising the Patient-Practitioner Orientation Scale (PPOS), was administered to 437 training participants at three time points – before training (T1), immediately after (T2) and three months after training (T3). A five-statement questionnaire captured knowledge of person-centred care at T1 and T2. An Overall score, Caring and Sharing sub-scores were derived from the PPOS. Scores were ranked and divided into three groups (high, medium and low). Ordinal Generalised Estimating Equation (GEE) model analysed changes in PPOS scores over time. Results: A single, short-term training appeared to result in measurable improvements in person-centredness of health practitioners, with slight attenuation at T3. There was greater tendency to “care” than to “share power” with service users across all three time points, but the degree of improvement was larger for sharing after training. The change in overall person-centred scores varied by sex and profession (females score higher than males, allied health showed a smaller attenuation at T3). Conclusion: Training as a specific intervention, appeared to have potential to increase health practitioners’ person-centredness but the aspect of equalising power was harder to achieve within a hierarchical structure and clinician-centric culture. An ongoing network to build relationships, and a supportive system to facilitate individual and organisational reflexivity can reinforce learning.

Healthcare is in constant change with fast development in knowledge, new technology and varying needs and expectations from patients, citizens, management, and politicians. There is a challenge in balancing the involved actors´ focus, needs, preferences, and resources for healthcare improvement. Improvement of healthcare is an ongoing activity, sometimes managed and controlled, often not. A key ingredient for success is competence where the need for competence varies with perspectives of the improving actors. Actors in healthcare improvement are professionals, patients, politicians, management, citizens, researchers, research foundations and others. In this report a review of frameworks in healthcare improvement are presented together with management myths and questions around needs for healthcare improvement competence and capabilities currently on the agenda.

Most improvement initiatives of some size have substantial parts of IT and have had so for a considerable time. This rather long experience of more and less successful IT implementation and use is transparent and useful in all kinds of healthcare improvement. One important issue in this report is what has real impact is the actual understanding and use of innovations and artefacts by healthcare actors in a broad sense for healthcare improvement (e.g., new clinical evidence, clinical guidelines, process changes, information systems and more). The aim in this report is to review frameworks which can be useful in healthcare improvement as well as in the study of healthcare improvement.

Conclusions concern what is found to be important to study and understand healthcare improvement, considering the presented frameworks. Improvement of healthcare is present in all the frameworks but in different ways and what is emphasized concerning scope and focus. Improving healthcare take place in the interaction of at least two parts, one of which is healthcare professionals, and another is the patient/next-of-kin. Professionals and patient populations interact in processes of social networks and structures. Actors and context are useful concepts for understanding action (use) and its social contexts. The actual use of innovations is best understood in terms of integration into clinical activities and processes – actors’ interaction, coordination and communication activities and processes.

Theoretical implications are that there is a need for more research concerning meso and macro perspectives on methods for healthcare improvement, and the interplay of perspectives regarding the understanding of improvement in healthcare. Of course, a challenge is that the objects of improvement are complex adaptive systems of healthcare is not easily to catch in simple rules. They are genuinely difficult both to change and evaluate changes. Practical implications of the report support design and contents of education programs in improvement of healthcare, in better understanding usefulness, practice, use, and experience base. To help the understanding of the need and usefulness of integrating different perspectives for successful healthcare improvement, e.g., micro, meso, and macro perspectives, use of mixed methods and more. 

INTRODUCTION: Blended learning has taken on new prominence in the fields of higher and continuing education, especially as programs have shifted in response to teaching in a global pandemic. The faculty at the Jönköping Academy's Masters in Quality Improvement and Leadership program has been offering a blended learning curriculum, based on four core design principles, since 2009. We studied key features of the enacted curriculum to understand conditions that can support an effective blended learning model. METHODS: We used a case study approach underpinned by interactive research. Document analysis, a focus group, individual interviews, and stimulated recall interviews were used for data collection. Themes were identified through qualitative content analysis and data reduction, data display, and conclusion drawing. RESULTS: We grouped data into six emergent themes that clarify the enacted curriculum of an established Master's program: focusing on a common purpose, developing technical and relational knowledge and skills, linking theory and practice in the workplace, leveraging collaboration for mutual benefit, concentrating on leadership and coaching, and applying a blended and interprofessional learning model. CONCLUSION: Educators faced with increased demands to be flexible and to offer opportunities for distance education can learn from this case example of effective teaching of quality improvement and leadership in a blended format.