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1.  Improving the quality of palliative care for ambulatory patients with lung cancer 
BMJ : British Medical Journal  2005;330(7503):1309-1313.
Problem Most patients with advanced lung cancer currently receive much of their health care, including chemotherapy, as outpatients. Patients have to deal with the complex and time consuming logistics of ambulatory cancer care. At the same time, members of staff often waste considerable time and energy in organisational aspects of care that could be better used in direct interaction with patients.
Design Quality improvement study using direct observation and run and flow charts, and focus group meetings with patients and families regarding perceptions of the clinic and with staff regarding satisfaction with working conditions.
Setting Thoracic oncology outpatient clinic at a Norwegian university hospital where patients receive chemotherapy and complementary palliative care.
Key measures for improvement Waiting time and time wasted during consultations; calmer working situation at the clinic; satisfaction among patients.
Strategies for change Rescheduled patients' appointments, automated retrieval of blood test results, systematic reporting in patients' files, design of an information leaflet, and refurnishing of the waiting area at the clinic.
Effects of change Interventions resulted in increased satisfaction for patients and staff, reduced waiting time, and reduced variability of waiting time.
Lessons learnt Direct observation, focus groups, questionnaires on patients' satisfaction, and measurement of process time were useful in systematically improving care in this outpatient clinic. The description of this experience can serve as an example for the improvement of a microsystem, particularly in other settings with similar problems.
PMCID: PMC558209  PMID: 15933354
2.  Patient experiences with interventions to reduce surgery cancellations: a qualitative study 
BMC Surgery  2013;13:30.
Background
The cancellation of planned surgery harms patients, increases waiting times and wastes scarce health resources. Previous studies have evaluated interventions to reduce cancellations from medical and management perspectives; these have focused on cost, length of stay, improved efficiency, and reduced post-operative complications. In our case a hospital had experienced high cancellation rates and therefore redesigned their pathway for elective surgery to reduce cancelations. We studied how patients experienced interventions to reduce cancellations.
Methods
We conducted a comparative, qualitative case study by interviewing 8 patients who had experienced the redesigned pathway, and 8 patients who had experienced the original pathway. We performed a content analysis of the interviews using a theory-based coding scheme. Through a process of coding and condensing, we identified themes of patient experience.
Results
We identified three common themes summarizing patients’ positive experiences with the effects of the interventions: the importance of being involved in scheduling time for surgery, individualized preparation before the hospital admission, and relationships with few clinicians during their hospital stay.
Conclusions
Patients appreciated the effects of interventions to reduce cancellations, because they increased their autonomy. Unanticipated consequences were that the telephone reminder created a personalized dialogue and centralization of surgical preparation and discharge processes improved continuity of care. Thus apart from improving surgical logistics, the pathway became more patient-centered.
doi:10.1186/1471-2482-13-30
PMCID: PMC3750692  PMID: 23924167
Quality improvement; Surgery; Cancellations; Patient centered; Qualitative
3.  Experiences with global trigger tool reviews in five Danish hospitals: an implementation study 
BMJ Open  2012;2(5):e001324.
Objectives
To describe experiences with the implementation of global trigger tool (GTT) reviews in five Danish hospitals and to suggest ways to improve the performance of GTT review teams.
Design
Retrospective observational study.
Setting
The measurement and monitoring of harms are crucial to campaigns to improve the safety of patients. Increasingly, teams use the GTT to review patient records and measure harms in English and non-English-speaking countries. Meanwhile, it is not clear as to how the method performs in such diverse settings.
Participants
Review teams from five Danish pilot hospitals of the national Danish Safer Hospital Programme.
Primary and secondary outcome measures
We collected harm rates, background and anecdotal information and reported patient safety incidents (PSIs) from five pilot hospitals currently participating in the Danish Safer Hospital Programme. Experienced reviewers categorised harms by type. We plotted harm rates as run-charts and applied rules for the detection of patterns of non-random variation.
Results
The hospitals differed in size but had similar patient populations and activity. PSIs varied between 3 and 12 per 1000 patient-days. The average harm rate for all hospitals was 60 per 1000 patient-days ranging from 34 to 84. The percentage of harmed patients was 25 and ranged from 18 to 33. Overall, 96% of harms were temporary. Infections, pressure ulcers procedure-related and gastrointestinal problems were common. Teams reported differences in training and review procedures such as the role of the secondary reviewer.
Conclusions
We found substantial variation in harm rates. Differences in training, review procedures and documentation in patient records probably contributed to these variations. Training reviewers as teams, specifying the roles of the different reviewers, training records and a database for findings of reviews may improve the application of the GTT.
doi:10.1136/bmjopen-2012-001324
PMCID: PMC3488702  PMID: 23065451
Audit
4.  Sustainability of healthcare improvement: what can we learn from learning theory? 
Background
Changes that improve the quality of health care should be sustained. Falling back to old, unsatisfactory ways of working is a waste of resources and can in the worst case increase resistance to later initiatives to improve care. Quality improvement relies on changing the clinical system yet factors that influence the sustainability of quality improvements are poorly understood. Theoretical frameworks can guide further research on the sustainability of quality improvements. Theories of organizational learning have contributed to a better understanding of organizational change in other contexts. To identify factors contributing to sustainability of improvements, we use learning theory to explore a case that had displayed sustained improvement.
Methods
Førde Hospital redesigned the pathway for elective surgery and achieved sustained reduction of cancellation rates. We used a qualitative case study design informed by theory to explore factors that contributed to sustain the improvements at Førde Hospital. The model Evidence in the Learning Organization describes how organizational learning contributes to change in healthcare institutions. This model constituted the framework for data collection and analysis. We interviewed a strategic sample of 20 employees. The in-depth interviews covered themes identified through our theoretical framework. Through a process of coding and condensing, we identified common themes that were interpreted in relation to our theoretical framework.
Results
Clinicians and leaders shared information about their everyday work and related this knowledge to how the entire clinical pathway could be improved. In this way they developed a revised and deeper understanding of their clinical system and its interdependencies. They became increasingly aware of how different elements needed to interact to enhance the performance and how their own efforts could contribute.
Conclusions
The improved understanding of the clinical system represented a change in mental models of employees that influenced how the organization changed its performance. By applying the framework of organizational learning, we learned that changes originating from a new mental model represent double-loop learning. In double-loop learning, deeper system properties are changed, and consequently changes are more likely to be sustained.
doi:10.1186/1472-6963-12-235
PMCID: PMC3532388  PMID: 22863199
Quality improvement; Organizational learning; Learning theory; Sustainability
5.  A new pathway for elective surgery to reduce cancellation rates 
Background
The cancellation of planned surgeries causes prolonged wait times, harm to patients, and is a waste of scarce resources. To reduce high cancellation rates in a Norwegian general hospital, the pathway for elective surgery was redesigned. The changes included earlier clinical assessment of patients, better planning and documentation systems, and increased involvement of patients in the scheduling of surgeries. This study evaluated the outcomes of this new pathway for elective surgery and explored which factors affected the outcomes.
Methods
We collected the number of planned operations, performed operations, and cancellations per month from the hospital’s patient administrative system. We then used Student's t-test to analyze differences in cancellation rates (CRs) before and after interventions and a u-chart to analyze whether the improvements were sustained. We also conducted semi-structured interviews with employees of the hospital to explore the changes in the surgical pathway and the factors that facilitated these changes.
Results
The mean CR was reduced from 8.5% to 4.9% (95% CI for mean reduction 2.6-4.5, p < 0.001). The reduction in the CR was sustained over a period of 26 months after the interventions. The median number of operations performed per month increased by 17% (p = 0.04). A clear improvement strategy, involvement of frontline clinicians, introduction of an electronic scheduling system, and engagement of middle managers were important factors for the success of the interventions.
Conclusion
The redesign of the old clinical pathway contributed to a sustained reduction in cancellations and an increased number of performed operations.
doi:10.1186/1472-6963-12-154
PMCID: PMC3465216  PMID: 22686475
Quality improvement; Process redesign; Cancellation of surgery; and Health information technology

Results 1-5 (5)