Background
Theoretical foundation
Methods
Data collection
Analysis
Ethical considerations
Results
Professional category | Number of informants | Number participating in improvement groups | Number of leaders |
---|---|---|---|
Physician | 9 | 4 | 4 |
Nurse | 7 | 5 | 3 |
Secretary | 2 | 0 | 1 |
Administrators (project support) | 2 | 2 | 1 |
Total | 20 | 11 | 9 |
Identifying a need to change
The people behind the project believed that patients had not been given the opportunities that might be expected and that, as a consequence, the system had to be changed. (Middle manager, in project group)
Within the organization, there was a desire to try to improve the flow of patients. The disagreement was about how it was to be done, and whether it was possible. (Middle manager, in project group)
Facilitating system wide improvement
The main concerns have been, first, to ensure broad participation, and second, that the project should be based at the frontline level. (Respondent from project support unit, in project group)When we get everybody involved together, the surgeon, the orthopedic specialist, the nurse, and the porter, and set them around the table to chart out the process and draw a process map, then something emerges. I think it has something to do with ownership. (Middle manager, in project group)
Everyone explained their workday and where they saw improvement potential. (Respondent, in project group)You got to sit in a group with the doctor, the nurse, the director, and the porter, and look at all the problems. It’s not only about my challenges in dealing with a patient scheduled for an operation in an hour. There is actually an entire surrounding complex that has to function. (Middle manager, in project group)
The way it used to be, in many areas the big picture fell apart; work was so fragmented. (Doctor, in project group)Each separate section had its own record books, and everybody tried to plan their operation schedules based on these. But there was no coordination: nothing brought things together in terms of the resources available on the ward as a whole. (Nurse, in project group)
You see more than your own little task, and you see how you can become a bottleneck for other people’s tasks without even knowing it. I think that seeing the whole process, and seeing that you actually are one link in a long chain, helps people to see things more holistically. (Respondent from project support unit, in project group)The most important thing I think we’ve learned is that it was very easy to sit and just look at your own sphere when working out procedures and general standards for patient scheduling. When we all sat down together and tried to create something, it required a mental readjustment so that we had to think, ‘This isn’t just about my area. It also affects others.’ (Doctor, in project group)Things are much better now because everyone has to finish their job on the spot. Now we have procedures that require us not to release a patient with, for instance, a heart problem, on to an anaesthesiologist before they’ve been assessed by a cardiologist.
There were several information meetings along the way. People were supposed to make suggestions; they could write suggestions on pieces of paper, which were posted on the wall. They could say what they thought about the various stages in the process. (Doctor, not in project group)I only see the patients when they’re with me, but I depend on their having completed the other services they need to go through before they come. So it’s easy to see the importance of a systematic plan for what the patients need to get through. (Doctor, not in project group)
When the head of surgery looked at the clinic waiting lists, it became clear that there was an ocean of things that needed to be tackled. And these are things that we didn’t know about before because the system hadn’t been transparent. (Middle manager, in project group)Now we see the big picture with regard to the operation schedule, and this means that we now discover ahead of time if two patients are scheduled for procedures that require the same instruments, and thus resterilization. This used to cause unnecessary waits. (Nurse, in project group)
We drew the whole patient flow chart as it was, and then we drew a new one that illustrated what we wanted to achieve. (Respondent, participating in project group)
Leader involvement and support
Those with expertise in project and improvement measures took part throughout the preliminary investigation stage and knew exactly what had occurred before, what had been decided, and what the plans for the future were. (Middle manager, in project group)You may have really good project support, but if you don’t have really good ideas, good staff, creative staff, then all you’ll get are minor adjustments or copies of what others do. (Project support, in project group)
I’ve learned that involving the relevant staff is not enough. Unfortunately, we need those enthusiasts [enthusiastic middle managers] too. This has not been a success simply because of involvement, post-it notes, and conclusions. If that were the case, we would not have progressed a single step. And that is something I think that improvement theorists need to take more seriously: that is, that the project itself is only 5 percent, or 10 percent. Ninety percent is consistent follow-up. And that is generally extremely unpleasant. (Middle manager, in project group)We thought that if people had been told how to do something, they understood it. Our experience is that you almost have to be there with them and show them how we think it should be done. They need to make it their own before they can do it right. (Nurse, in project group)I’ve learned that things take time. When many people are involved, you have to include them all. It’s important to talk to everyone involved and to take them seriously and try to explain why you’re doing something. Everything is connected, and we need for all the links in the chain to work. (Respondent, in project group)
Discussion
Our findings
Our findings in relation to the MUSIQ framework
MUSIQ framework categories | Contextual factors identified from our case |
---|---|
External environment
| • Input from patients about quality problems |
• External motivators
| • Cancellation rate as a national quality indicator |
• Circulating ideas on patient-centered care | |
Organization
| • An organizational improvement strategy that provided a foundation for the improvement work by emphasizing: |
• Quality improvement (QI) leadership
| |
o Involvement of frontline clinicians | |
• Maturity of organizational QI
| o Improvement by changing the clinical system |
• Culture supportive of QI
| |
Quality improvement
| • Guidance about improvement techniques and project support for the improvement teams |
support and capacity
| |
• Data infrastructure
| • Expedient use of information technology |
• Resource availability
| |
Microsystem
| • Communication with and involvement of clinicians outside the improvement teams |
• Quality improvement leadership
| |
• Middle managers’ role in following up and securing context-sensitive implementation of interventions | |
• Motivation to change
| |
• Middle managers as role models participating in daily work | |
• The shared belief that change was needed among hospital employees | |
Quality improvement team
| • A meeting place for sharing information |
• Team diversity
| • Participation from all of the relevant professional groups in improvement teams, including physicians |
• Physicians’ involvement
|