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author:("frommel, Mats")
1.  How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren Children's hospital, Stockholm, Sweden 
There is growing interest in applying lean thinking in healthcare, yet, there is still limited knowledge of how and why lean interventions succeed (or fail). To address this gap, this in-depth case study examines a lean-inspired intervention in a Swedish pediatric Accident and Emergency department.
We used a mixed methods explanatory single case study design. Hospital performance data were analyzed using analysis of variance (ANOVA) and statistical process control techniques to assess changes in performance one year before and two years after the intervention. We collected qualitative data through non-participant observations, semi-structured interviews, and internal documents to describe the process and content of the lean intervention. We then analyzed empirical findings using four theoretical lean principles (Spear and Bowen 1999) to understand how and why the intervention worked in its local context as well as to identify its strengths and weaknesses.
Improvements in waiting and lead times (19-24%) were achieved and sustained in the two years following lean-inspired changes to employee roles, staffing and scheduling, communication and coordination, expertise, workspace layout, and problem solving. These changes resulted in improvement because they: (a) standardized work and reduced ambiguity, (b) connected people who were dependent on one another, (c) enhanced seamless, uninterrupted flow through the process, and (d) empowered staff to investigate problems and to develop countermeasures using a "scientific method". Contextual factors that may explain why not even greater improvement was achieved included: a mismatch between job tasks, licensing constraints, and competence; a perception of being monitored, and discomfort with inter-professional collaboration.
Drawing on Spear and Bowen's theoretical propositions, this study explains how a package of lean-like changes translated into better care process management. It adds new knowledge regarding how lean principles can be beneficially applied in healthcare and identifies changes to professional roles as a potential challenge when introducing lean thinking there. This knowledge may enable health care organizations and managers in other settings to configure their own lean program and to better understand the reasons behind lean's success (or failure).
PMCID: PMC3298466  PMID: 22296919
2.  Understanding the context of balanced scorecard implementation: a hospital-based case study in pakistan 
As a response to a changing operating environment, healthcare administrators are implementing modern management tools in their organizations. The balanced scorecard (BSC) is considered a viable tool in high-income countries to improve hospital performance. The BSC has not been applied to hospital settings in low-income countries nor has the context for implementation been examined. This study explored contextual perspectives in relation to BSC implementation in a Pakistani hospital.
Four clinical units of this hospital were involved in the BSC implementation based on their willingness to participate. Implementation included sensitization of units towards the BSC, developing specialty specific BSCs and reporting of performance based on the BSC during administrative meetings. Pettigrew and Whipp's context (why), process (how) and content (what) framework of strategic change was used to guide data collection and analysis. Data collection methods included quantitative tools (a validated culture assessment questionnaire) and qualitative approaches including key informant interviews and participant observation.
Method triangulation provided common and contrasting results between the four units. A participatory culture, supportive leadership, financial and non-financial incentives, the presentation of clear direction by integrating support for the BSC in policies, resources, and routine activities emerged as desirable attributes for BSC implementation. The two units that lagged behind were more involved in direct inpatient care and carried a considerable clinical workload. Role clarification and consensus about the purpose and benefits of the BSC were noted as key strategies for overcoming implementation challenges in two clinical units that were relatively ahead in BSC implementation. It was noted that, rather than seeking to replace existing information systems, initiatives such as the BSC could be readily adopted if they are built on existing infrastructures and data networks.
Variable levels of the BSC implementation were observed in this study. Those intending to apply the BSC in other hospital settings need to ensure a participatory culture, clear institutional mandate, appropriate leadership support, proper reward and recognition system, and sensitization to BSC benefits.
PMCID: PMC3080822  PMID: 21453449
3.  Application of statistical process control in healthcare improvement: systematic review 
Quality & Safety in Health Care  2007;16(5):387-399.
To systematically review the literature regarding how statistical process control—with control charts as a core tool—has been applied to healthcare quality improvement, and to examine the benefits, limitations, barriers and facilitating factors related to such application.
Data sources
Original articles found in relevant databases, including Web of Science and Medline, covering the period 1966 to June 2004.
Study selection
From 311 articles, 57 empirical studies, published between 1990 and 2004, met the inclusion criteria.
A standardised data abstraction form was used for extracting data relevant to the review questions, and the data were analysed thematically.
Statistical process control was applied in a wide range of settings and specialties, at diverse levels of organisation and directly by patients, using 97 different variables. The review revealed 12 categories of benefits, 6 categories of limitations, 10 categories of barriers, and 23 factors that facilitate its application and all are fully referenced in this report. Statistical process control helped different actors manage change and improve healthcare processes. It also enabled patients with, for example asthma or diabetes mellitus, to manage their own health, and thus has therapeutic qualities. Its power hinges on correct and smart application, which is not necessarily a trivial task. This review catalogues 11 approaches to such smart application, including risk adjustment and data stratification.
Statistical process control is a versatile tool which can help diverse stakeholders to manage change in healthcare and improve patients' health.
PMCID: PMC2464970  PMID: 17913782
4.  Coordination in networks for improved mental health service 
Well-organised clinical cooperation between health and social services has been difficult to achieve in Sweden as in other countries. This paper presents an empirical study of a mental health coordination network in one area in Stockholm. The aim was to describe the development and nature of coordination within a mental health and social care consortium and to assess the impact on care processes and client outcomes.
Data was gathered through interviews with ‘joint coordinators’ (n=6) from three rehabilitation units. The interviews focused on coordination activities aimed at supporting the clients’ needs and investigated how the joint coordinators acted according to the consortium's holistic approach. Data on The Camberwell Assessment of Need (CAN-S) showing clients’ satisfaction was used to assess on set of outcomes (n=1262).
The findings revealed different coordination activities and factors both helping and hindering the network coordination activities. One helpful factor was the history of local and personal informal cooperation and shared responsibilities evident. Unclear roles and routines hindered cooperation.
This contribution is an empirical example and a model for organisations establishing structures for network coordination. One lesson for current policy about integrated health care is to adapt and implement joint coordinators where full structural integration is not possible. Another lesson, based on the idea of patient quality by coordinated care, is specifically to adapt the work of the local addiction treatment and preventive team (ATPT)—an independent special team in the psychiatric outpatient care that provides consultation and support to the units and serves psychotic clients with addictive problems.
PMCID: PMC2948678  PMID: 20922065
coordination; integrated care planning; mental health care
5.  Supported local implementation of clinical guidelines in psychiatry: a two-year follow-up 
The gap between evidence-based guidelines for clinical care and their use in medical settings is well recognized and widespread. Only a few implementation studies of psychiatric guidelines have been carried out, and there is a lack of studies on their long-term effects.
The aim of this study was to measure compliance to clinical guidelines for treatment of patients with depression and patients with suicidal behaviours, two years after an actively supported implementation.
Six psychiatric clinics in Stockholm, Sweden, participated in an implementation of the guidelines. The guidelines were actively implemented at four of them, and the other two only received the guidelines and served as controls. The implementation activities included local implementation teams, seminars, regular feedback, and academic outreach visits. Compliance to guidelines was measured using quality indicators derived from the guidelines. At baseline, measurements of quality indicators, part of the guidelines, were abstracted from medical records in order to analyze the gap between clinical guidelines and current practice. On the basis of this, a series of seminars was conducted to introduce the guidelines according to local needs. Local multidisciplinary teams were established to monitor the process. Data collection took place after 6, 12, and 24 months and a total of 2,165 patient records were included in the study.
The documentation of the quality indicators improved from baseline in the four clinics with an active implementation, whereas there were no changes, or a decline, in the two control clinics. The increase was recorded at six months, and persisted over 12 and 24 months.
Compliance to the guidelines increased after active implementation and was sustained over the two-year follow-up. These results indicate that active local implementation of clinical guidelines involving clinicians can change behaviour and maintain compliance.
PMCID: PMC2832625  PMID: 20181013
6.  Implementing clinical guidelines in psychiatry: a qualitative study of perceived facilitators and barriers 
BMC Psychiatry  2010;10:8.
Translating scientific evidence into daily practice is complex. Clinical guidelines can improve health care delivery, but there are a number of challenges in guideline adoption and implementation. Factors influencing the effective implementation of guidelines remain poorly understood. Understanding of barriers and facilitators is important for development of effective implementation strategies. The aim of this study was to determine perceived facilitators and barriers to guideline implementation and clinical compliance to guidelines for depression in psychiatric care.
This qualitative study was conducted at two psychiatric clinics in Stockholm, Sweden. The implementation activities at one of the clinics included local implementation teams, seminars, regular feedback and academic detailing. The other clinic served as a control and only received guidelines by post. Data were collected from three focus groups and 28 individual, semi-structured interviews. Content analysis was used to identify themes emerging from the interview data.
The identified barriers to, and facilitators of, the implementation of guidelines could be classified into three major categories: (1) organizational resources, (2) health care professionals' individual characteristics and (3) perception of guidelines and implementation strategies. The practitioners in the implementation team and at control clinics differed in three main areas: (1) concerns about control over professional practice, (2) beliefs about evidence-based practice and (3) suspicions about financial motives for guideline introduction.
Identifying the barriers to, and facilitators of, the adoption of recommendations is an important way of achieving efficient implementation strategies. The findings of this study suggest that the adoption of guidelines may be improved if local health professionals actively participate in an ongoing implementation process and identify efficient strategies to overcome barriers on an organizational and individual level. Getting evidence into practice and implementing clinical guidelines are dependent upon more than practitioners' motivation. There are factors in the local context, e.g. culture and leadership, evaluation, feedback on performance and facilitation, -that are likely to be equally influential.
PMCID: PMC2822755  PMID: 20089141
7.  Contextual adaptation of the Personnel Evaluation Standards for assessing faculty evaluation systems in developing countries: the case of Iran 
Faculty evaluations can identify needs to be addressed in effective development programs. Generic evaluation models exist, but these require adaptation to a particular context of interest. We report on one approach to such adaptation in the context of medical education in Iran, which is integrated into the delivery and management of healthcare services nationwide.
Using a triangulation design, interviews with senior faculty leaders were conducted to identify relevant areas for faculty evaluation. We then adapted the published checklist of the Personnel Evaluation Standards to fit the Iranian medical universities' context by considering faculty members' diverse roles. Then the adapted instrument was administered to faculty at twelve medical schools in Iran.
The interviews revealed poor linkages between existing forms of development and evaluation, imbalance between the faculty work components and evaluated areas, inappropriate feedback and use of information in decision making. The principles of Personnel Evaluation Standards addressed almost all of these concerns and were used to assess the existing faculty evaluation system and also adapted to evaluate the core faculty roles. The survey response rate was 74%. Responses showed that the four principles in all faculty members' roles were met occasionally to frequently. Evaluation of teaching and research had the highest mean scores, while clinical and healthcare services, institutional administration, and self-development had the lowest mean scores. There were statistically significant differences between small medium and large medical schools (p < 0.000).
The adapted Personnel Evaluation Standards appears to be valid and applicable for monitoring and continuous improvement of a faculty evaluation system in the context of medical universities in Iran. The approach developed here provides a more balanced assessment of multiple faculty roles, including educational, clinical and healthcare services. In order to address identified deficiencies, the evaluation system should recognize, document, and uniformly reward those activities that are vital to the academic mission. Inclusion of personal developmental concerns in the evaluation discussion is essential for evaluation systems.
PMCID: PMC2680845  PMID: 19400932
9.  An approach to measure compliance to clinical guidelines in psychiatric care 
BMC Psychiatry  2008;8:64.
The aim of this study was to measure six months compliance to Swedish clinical guidelines in psychiatric care after an active supported implementation process, using structured measures derived from the guidelines.
In this observational study four psychiatric clinics each participated in active implementation of the clinical guidelines for the assessment and treatment of depression and guidelines for assessment and treatment of patients with suicidal behaviours developed by The Stockholm Medical Advisory Board for Psychiatry. The implementation programme included seminars, local implementation teams, regular feedback and academic visits. Additionally two clinics only received the guidelines and served as controls. Compliance to guidelines was measured using indicators, which operationalised requirements of preferred clinical practice. 725 patient records were included, 365 before the implementation and 360 six months after.
Analyses of indicators registered showed that the actively implementing clinics significantly improved their compliance to the guidelines. The total score differed significantly between implementation clinics and control clinics for management of depression (mean scores 9.5 (1.3) versus 5.0 (1.5), p < 0.001) as well as for the management of suicide (mean scores 8.1 (2.3) versus 4.5 (1.9), p < 0.001). No changes were found in the control clinics and only one of the OR was significant.
Compliance to clinical guidelines measured by process indicators of required clinical practice was enhanced by an active implementation.
PMCID: PMC2525637  PMID: 18657263
10.  Requirements for effective academic leadership in Iran: A Nominal Group Technique exercise 
During the last two decades, medical education in Iran has shifted from elite to mass education, with a considerable increase in number of schools, faculties, and programs. Because of this transformation, it is a good case now to explore academic leadership in a non-western country. The objective of this study was to explore the views on effective academic leadership requirements held by key informants in Iran's medical education system.
A nominal group study was conducted by strategic sampling in which participants were requested to discuss and report on requirements for academic leadership, suggestions and barriers. Written notes from the discussions were transcribed and subjected to content analysis.
Six themes of effective academic leadership emerged: 1)shared vision, goal, and strategy, 2) teaching and research leadership, 3) fair and efficient management, 4) mutual trust and respect, 5) development and recognition, and 6) transformational leadership. Current Iranian academic leadership suffers from lack of meritocracy, conservative leaders, politicization, bureaucracy, and belief in misconceptions.
The structure of the Iranian medical university system is not supportive of effective academic leadership. However, participants' views on effective academic leadership are in line with what is also found in the western literature, that is, if the managers could create the premises for a supportive and transformational leadership, they could generate mutual trust and respect in academia and increase scientific production.
PMCID: PMC2374778  PMID: 18430241
11.  Organizational role stress among medical school faculty members in Iran: dealing with role conflict 
Little research has been conducted to investigate role stress experienced by faculty members in medical schools in developing countries. This becomes even more important when the process of reform in medical education has already taken place, such as the case of Iran. The objectives of this study were to investigate and assess the level and source of role-related stress as well as dimensions of conflict among the faculty members of Iranian medical schools. Variables like the length of academic work, academic rank, employment position, and the departments of affiliation were also taken into consideration in order to determine potentially related factors.
A survey was conducted at three different ranks of public medical schools. The validated Organizational Role Stress Scale was used to investigate the level of role stress and dimensions of role conflict among medical faculty members. The response rate was 66.5%.
The findings show that role stress was experienced in high level among almost all faculty members. All three studied medical schools with different ranks are threatened with relatively the same levels of role stress. Specific differences were found among faculty members from different disciplines, and academic ranks. Also having permanent position and the length of services had significant correlation with the level of role stress. The major role- related stress and forms of conflict among faculty members were role overload, role expectation conflict, inter-role distance, resource inadequacy, role stagnation, and role isolation.
The most role-related stressors and forms of conflict among faculty members include too many tasks and everyday work load; conflicting demands from colleagues and superiors; incompatible demands from their different personal and organizational roles; inadequate resources for appropriate performance; insufficient competency to meet the demands of their role; inadequate autonomy to make decision on different tasks; and a feeling of underutilization. The findings of this study can assist administrators and policy makers to provide an attractive working climate in order to decrease side effects and consequences of role stress and to increase productivity of faculty members. Furthermore, understanding this situation can help to develop coping strategies in order to reduce role-related stress.
PMCID: PMC1892550  PMID: 17535421
12.  Suffering in silence: a qualitative study of second victims of adverse events 
BMJ Quality & Safety  2013;23(4):325-331.
The term ‘second victim’ refers to the healthcare professional who experiences emotional distress following an adverse event. This distress has been shown to be similar to that of the patient—the ‘first victim’. The aim of this study was to investigate how healthcare professionals are affected by their involvement in adverse events with emphasis on the organisational support they need and how well the organisation meets those needs.
21 healthcare professionals at a Swedish university hospital who each had experienced an adverse event were interviewed. Data from semi-structured interviews were analysed by qualitative content analysis using QSR NVivo software for coding and categorisation.
Our findings confirm earlier studies showing that emotional distress, often long-lasting, follows from adverse events. In addition, we report that the impact on the healthcare professional was related to the organisation’s response to the event. Most informants lacked organisational support or they received support that was unstructured and unsystematic. Further, the formal investigation seldom provided adequate and timely feedback to those involved. The insufficient support and lack of feedback made it more difficult to emotionally process the event and reach closure.
This article addresses the gap between the second victim's need for organisational support and the organisational support provided. It also highlights the need for more transparency in the investigation of adverse events. Future research should address how advanced support structures can meet these needs and provide learning opportunities for the organisation. These issues are central for all hospital managers and policy makers who wish to prevent and manage adverse events and to promote a positive safety culture.
PMCID: PMC3963543  PMID: 24239992
Safety Culture; Leadership; Adverse Events, Epidemiology and Detection; Crisis Management

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