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Brandrud et al. BMC Health Services Research (2017) 17:648 DOI 10.1186/s12913-017-2454-2

RESEARCH ARTICLE Open Access Domains associated with successful quality improvement in healthcare – a nationwide case study Aleidis Skard Brandrud1*, Bjørnar Nyen2, Per Hjortdahl3, Leiv Sandvik4, Gro Sævil Helljesen Haldorsen5, Maria Bergli1, Eugene C. Nelson6 and Michael Bretthauer7

Abstract Background: There is a distinct difference between what we know and what we do in healthcare: a gap that is impairing the quality of the care and increasing the costs. Quality improvement efforts have been made worldwide by learning collaboratives, based on recognized continual improvement theory with limited scientific evidence. The present study of 132 quality improvement projects in Norway explores the conditions for improvement from the perspectives of the frontline healthcare professionals, and evaluates the effectiveness of the continual improvement method. Methods: An instrument with 25 questions was developed on prior focus group interviews with improvement project members who identified features that may promote or inhibit improvement. The questionnaire was sent to 189 improvement projects initiated by the Norwegian Medical Association, and responded by 70% (132) of the improvement teams. A sub study of their final reports by a validated instrument, made us able to identify the successful projects and compare their assessments with the assessments of the other projects. A factor analysis with Varimax rotation of the 25 questions identified five domains. A multivariate regression analysis was used to evaluate the association with successful quality improvements. Results: Two of the five domains were associated with success: Measurement and Guidance (p = 0.011), and Professional environment (p = 0.015). The organizational leadership domain was not associated with successful quality improvements (p = 0.26). Conclusion: Our findings suggest that quality improvement projects with good guidance and focus on measurement for improvement have increased likelihood of success. The variables in these two domains are aligned with improvement theory and confirm the effectiveness of the continual improvement method provided by the learning collaborative. High performing professional environments successfully engaged in patient-centered quality improvement if they had access to: (a) knowledge of best practice provided by professional subject matter experts, (b) knowledge of current practice provided by simple measurement methods, assisted by (c) improvement knowledge experts who provided useful guidance on measurement, and made the team able to organize the improvement efforts well in spite of the difficult resource situation (time and personnel). Our findings may be used by healthcare organizations to develop effective infrastructure to support improvement and to create the conditions for making quality and safety improvement a part of everyone’sjob. Keywords: Quality improvement, Learning collaboratives, Continual improvement, Conditions for change, Context

* Correspondence: [email protected]; [email protected] 1Quality Department, Vestre Viken Health Trust, Wergelandsgate 10, Postbox 800, 3004 Drammen, Norway Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Brandrud et al. BMC Health Services Research (2017) 17:648 Page 2 of 9

Background Since 1994, and in spite of a limited underpinning of sci- Healthcare is suffering from serious unsolved problems entific evidence, the continual improvement method has that are threatening lives, increasing costs, and making been spread worldwide by thousands of improvement col- the care unpredictable to the patient [1–7]. Improve- laboratives [13, 27–29]. Relatively little of that work is re- ment of quality in health care, is probably one of the ported in the biomedical literature [30]. Systematic greatest challenges of modern healthcare leadership. reviews and single studies of quality improvement efforts Quality improvement strategies sometimes fail to focus that are reported, indicate that a systematic and know- the changes on clinical, patient oriented improvements, ledge based approach is not enough to succeed without and to involve the frontline healthcare professionals at the presence of certain conditions for improvement, also an early stage of the change process [8–10]. described as context factors [13, 14, 16, 31]. To meet these The role of qualified improvement guidance has challenges, additional improvement approaches, including received little attention in the quality improvement instruments for evaluating the underlying conditions for literature [11–15]. A recent analysis of 35 systematic improvement, have been described [12, 17, 32]. In 2004 a reviews explored the influence of context on the systematic review recommended further research on fac- effectiveness of different quality improvement strategies. tors that tend to produce adoptable changes in healthcare Improvement guidance was not found among a broad organizations [33]. A recent umbrella review of 35 system- range of associated contextual factors that contribute to atic reviews of the influence of context factors on the ef- successful improvement. The analysis organized the fectiveness of (any) quality improvement intervention findings based on the Model for Understanding Success recommend further research to report the context factors in Quality (MUSIQ) model [16, 17]. The MUSIQ model in a systematic way to better appreciate their relative itself was based on a systematic review that included importance [16]. continual improvement interventions, but did not cover The present study explores the conditions for improve- the role of improvement knowledge guidance [14, 17]. A ment in the context of 189 Norwegian clinical improve- cluster-randomized trial aimed to compare clinic-level ment projects initiated by the learning collaboratives of coaching with other learning collaborative components, The Norwegian Medical Association. We asked partici- found coaching to be equally effective with interest circle pating clinicians to identify factors that may promote or calls (group telephone conferences) in achieving clinical inhibit quality improvement. Referring to the studies outcome improvements, but coaching was more cost- above, two of the unanswered questions are (1) “What effective [18]. Godfrey did also find positive effects of combination of what factors tend to produce “adoptable” systematic clinic-level coaching [19, 20]. improvement innovations?” [33]. (2) How is the effective- In a case study of 182 improvement teams Strating ness of the continual improvement method? (The contin- found that creating measurable targets is a crucial task ual improvement method is described in Additional file in quality improvement [21]. In a systematic review of 1: Supplement 1). The purpose is to identify domains as- quality measurement. Thor et al. found statistical sociated with success, as this knowledge may be used to process control (SPC), to be a useful method for those develop an infrastructure and culture that promotes who mastered the technique [22]. This underscores the continual improvement in healthcare, without the help importance of good measurement guidance. from a learning collaborative. Many healthcare organizations do not have a basic infrastructure to support improvement, and contextual Methods factors generally receive scant attention in the current Summary literature on quality improvement strategies [13, 14, 16, The method of the present study had four steps. First we 22, 23]. Kringos et al. found that the availability and developed a questionnaire for improvement teams. The functionality of information technology and facilitated instrument was based on a qualitative study of the con- data collection improved the effectiveness of quality im- ditions for change among 19 participants of the learning provement intervention, as well as the involvement of collaboratives of the Norwegian Medical Association multidisciplinary improvement teams [16]. (Sub study I, published in 2011) [23]. Second, we submit- Little evidence is found that leadership support is asso- ted the questionnaire to the 189 improvement teams of ciated with successful quality improvement [24–26]. the same learning collaboratives. Third, we analyzed the This may be typical for external initiated learning collab- data by comparing the reported conditions for improve- oratives, because we found a few studies where the ment in the organizations of the successful projects ver- frontline leaders have been directly included in the sus the other (comparator) projects. We already knew project planning and improvement guidance, with a the success level of the 189 projects from the validation positive leadership influence on the effectiveness of the of a Change Process and Outcome Scale instrument improvement efforts [16, 18–20]. which was published in 2015 (Sub study II) [32]. Brandrud et al. BMC Health Services Research (2017) 17:648 Page 3 of 9

The learning collaboratives and enabled us to develop a validated questionnaire reflect- Between 1998 and 2011 The Norwegian Medical Associ- ing the most interesting conditions for change reported by ation sponsored eight hospital related improvement col- clinicians telling their improvement project stories from laboratives to support quality and safety improvement their own organizations, after participating in a learning efforts in clinical environments (Table 1). The improve- collaborative of the Norwegian medical association. ment collaboratives were based on the Breakthrough Series model of the Institute for Healthcare Improve- Data collection ment, aiming to accelerate improvement beyond what The questionnaire was submitted to former improve- had been achieved by traditional educational approaches ment team leaders between 2 and 4 years after the end [34]. The model has two dimensions: the learning col- of each improvement collaborative. We had access to laborative method (national level), and the systematic their e-mail addresses from the improvement collabora- approach to continual improvement (organizational tive participant list. A link to an on-line questionnaire level) [11, 22, 35–42] (described in Additional file 1: was e-mailed to the improvement team leaders. They Supplement 1). Each collaborative lasted from 6 to were asked to think back on their improvement project 9 months and engaged clinicians from 15 to 30 health- and the promoting and inhibiting conditions for quality care organizations who met to learn from each other improvement that they encountered, and to show their and from recognized experts in specified topic areas level of agreement with the focus group comments that (Table 1). The participating improvement teams sent 2– were included in the questionnaire. 4 representatives from different disciplines involved in If a Word-version of the questionnaire was preferred, the topic (at least one physician) to three collaborative the respondents returned their filled-in questionnaires learning sessions, where the relevant subject matter ex- by e-mail or “surface mail”. In cases of non-response perts of the collaborative (medicine, nursing, psychology, from team leaders, we contacted other participants from etc.) demonstrated the quality gaps within the topic to the same team. In 36% of the teams, late responses lead the participants. A team of 10–15 improvement know- to more than one response from the same team. Because ledge experts (coaches) guided the improvement teams the responses from team members mostly reflected dif- at, and in between the learning sessions. ferent professions, and the inter-rater reliability of the same team ranged from poor to strong, we decided to Instrument development let each team be represented by the average ratings of its The questionnaire was developed to identify the activ- responding members. ities and conditions associated with successful quality improvement initiatives, and to study the effectiveness Project evaluation of the continual improvement method (Additional file 1: This study is neither an experiment, nor a study of the Supplement 1). The instrument and its development is experiments of others, aiming to bring evidence to the described in details in Additional file 1: Supplement 2. success of the projects in our material. This is a study of the conditions for making successful changes. The aim Sub study I is to learn from healthcare professionals in the improve- The first sub study was published in 2011 [23], and ment teams of those projects who have been able to provided us with a large amount of relevant comments, document improvements.

Table 1 The eight hospital-related improvement collaboratives of the Norwegian Medical Association Year Topic Number of projects Examples of the measurable aims of the single projects within each Improvement collaborative 1999 Cesarean Section 23 Reduce the cesarean sectio rate to para 0 by 20%. 2000 Intensive Care 15 Reduce the duration of mechanical ventilation by 20% by an optimization of the sedation; reduce length of ICU stay by 10%. 2001 The Use of Restraints 18 Reduce the use of mechanical restrains in psychiatric therapy by 25%. 2003 Serious Affective Disorders 23 Reduce the MADRS score by 50% and the length of stay by 50%. 2004 ADHD 33 Reduce the time from admission to diagnosis by 30% 2005 Quality & Efficacy in 30 Increase the quality of the preliminary feedback to the primary care Psychiatric Outpatient Clinics physician by 50% 2006 Substance Abuse 24 Increase the quality of the admission process by 50% 2011 Early Intervention in 23 Reduce the days between first time referrals by 50%, and the age Psychiatric Disorders of the patients by 25%. Brandrud et al. BMC Health Services Research (2017) 17:648 Page 4 of 9

Sub study II improvement teams. Of the 132 responding projects, 54 The second sub study was published in 2015 [32]. Seven (41%) had documented improvements in their final re- improvement experts from different healthcare profes- ports by recognized measure methods, and 78 (59%) had sions alternated in participating in a four-person review not been able to do so within the time frame of the team. The reviewers were two physicians (BN and TSH), learning collaborative (Table 2). The results of the 54 three nurses (GSH, ASB, and EA), one psychologist successful projects are presented in Additional file 1: (LdG) and one bioengineer (AS). The improvement ex- Supplement 3, not as a result of this study, but to illus- perts were not involved in the evaluation of projects they trate the relationship between the changes they have had participated in with coaching or other kinds of sup- made, and the conditions for change reflected in our port. In this study we explored the final reports of the findings. improvement teams. We developed a checklist to struc- ture the study according to the recommended improve- ment method (Plan- Do-Study- Act-cycles) [38], to make Research question I: “What combination of what factors it easier to discuss our observations an reflect on our tend to produce “adoptable” improvement innovations?” different assessments of the project. The criterion to be First, in a logistic regression analysis of the answers to classified as successful was to document significant im- the 25 questions of the questionnaire (Additional file 1: provements by recognized measurement methods, based Supplement 2) we identified the variables which were on a clear linkage between vision, aims, change efforts significant associated with success. Two variables were and measurements. found in the final model: (Q12) Good guidance & help We found that 72 projects (38%) were successful, ran- with measurement, and (Q7) Someone in the improve- ging from 17 to 60% within each of the eight collabora- ment team enjoyed working with measurement (Table 3). tives. A majority (78%) presented their outcomes as a shift Second, to disentangle what combination of variables in the level in the desired direction on a control chart. are underpinning successful improvement efforts, we performed a factor analysis of the 132 responses to the Data analysis 25 questions. This analysis produced five domains: Do- We analyzed the association between the assessments of main I: “Measurement and Guidance” (nine variables), the improvement teams (responses to 25 selected Domain II: “Leadership engagement”(five variables), Do- questions) and the success level of their projects. First, a main III: “Professional environment” (seven variables), logistic regression analysis was used to analyze the asso- Domain IV: “Group process” (two variables), and Domain ciation between success and each of the 25 questions. V “Leadership impact” (two variables) (Table 4). Second, a factor analysis with Varimax rotation was used Third, we studied the quartiles of the domains in the to identify the underlying structure of the 25 question- successful projects and compared the scores from the 54 naire items. Domains were extracted with an Eigen value successful projects with the 78 comparator projects greater than one. Kendall’s-tau-b correlation revealed within the five domains. Two domains were significantly that the conditions for a principal component analysis associated with success: Domain I Measurement & (PCA) were present. Third, when analyzing the multi- Guidance (p = 0.002) and Domain III Professional envir- variate associations between the five domains and onment (p = 0.002), (Table 5). success. Logistic regression analyses were performed, Finally, we made a logistic regression analysis of the with success as the dependent variable, and the success five success domains. As shown in Table 6, two domains domains as independent variables. Only domains which were found in the final model: “Measurement and Guid- were significant in a bivariate analysis (defined as ance” and “Professional environment”, confirming the p < 0.05) were included in the multivariate regression findings of the crude analyses displayed in Table 5. analyses. The results from the regression analyses are presented as odds ratios with 95% confidence intervals Table 2 Projects, completed questionnaires and response and corresponding p-values. A significance level of 5% rate per success level was used. All statistical analyses were performed using Projects per Filled-in questionnaires Response rate the software package IBM-SPSS version 21. success level per success level per success level Successful 72 (38%) 54 (41%) 75% Results projectsa Our results are based on the answers to the 25 variables Other 117 (62%) 78 (59%) 67% of the questionnaire from the successful versus the other projects projects. The questionnaires were returned by 53 physi- Total 189 (100%) 132 (100%) 70% cians, 56 nurses, 38 psychologists, and 51 other health- aThe successful projects have documented improvements by recognized care professionals, representing 132 (70%) of the 189 measure methods in their final reports Brandrud et al. BMC Health Services Research (2017) 17:648 Page 5 of 9

Table 3 Bivariate and multivariate logistic regression analysis for scoring on the positive side of the scale (4 + 5) to each detection of variables significantly associated with success, (with variable. the 25 questions as independent variables and success as The first success domain “Measurement & Guidance” dependent variable) cover the two success variables from the first regression Bivariate analysis Multivariate analysis analysis: Good guidance & help with measurement, and OR 95% CI P value OR 95% CI P value Someone in the improvement team enjoyed working with Q12: Good 3.17 1.82 5.52 <0.001 2.58 1.49 4.45 0.001 measurement. In addition the findings suggest it was guidance & help with measurement easier for the successful projects to get hold on their coach when needed (Q10), an availability they assessed Q7: Enjoying to work 3.03 1.45 6.25 0.003 2.35 1.07 5.13 0.003 with measurement as important to succeed (Q11). Further, did the control The table shows the independent variables in the final model, their odds charts appear to be easy to communicate to their peers ratio (OR) associated with one point increase on a 5 point Likert scale, in the site (Q20), assessed as important when trying to P 95% confidence intervals (CI) and values make successful improvements (Q21). The second success domain “Professional environment” The complexity of our findings is displayed in Table 7 indicate the importance of presenting patient focused presenting the combination of variables that are under- aims when trying to engage of the professional environ- pinning the two success domains, illustrated by the ment in the improvement efforts (Q16), and the import- proportion of successful and comparator projects ance of presenting measurement to maintain motivation

Table 4 Rotated component matrix (Varimax with Kaisers normalization)

*One of four negative variables that are turned to positive in the other tables Brandrud et al. BMC Health Services Research (2017) 17:648 Page 6 of 9

Table 5 The proportion of scores from the 54 successful projects in the five questionnaire domains Domain Domain I. Domain II Domain III Domain IV Domain V Number of projects Measurement Leadership Professional Group Leadership & Guidance engagement environment process impact Quartilea Percent Percent Percent Percent Percent n I 27.3% 36.4% 25% 36% 45.8% 54 II 26.7% 35% 29.4% 37.5% 30.3% 54 III 42.9% 33.3% 57.7% 52.6% 51.2% 54 IV 64.7% 55% 52.5% 41.7% 35.5% 54 P valuea 0.002 0.134 0.002 0.675 0.260 54 vs 78 aThe quartiles represent the successful projects, and the p-values represent a Chi-square test of the 54 successful versus the 78 other projects

(Q23). Regardless of their success level, 83% reported education and training. A system of mentoring was they had been able to organize their improvement developed to enable experienced coaches to support the efforts well, in spite of a limited resource situation novice coaches (Additional file 1: Supplement 4). (Q5) (Table 7). Our findings support measurement for improvement as a Research question 2: How is the effectiveness of the cornerstone of the project continual improvement method? The present study highlights the importance of using Our findings reflect the intellectual underpinnings of the measurement to understand and reflect on the variations continual improvement method presented in Additional in current practice, and to monitor the target process file 1: Supplement 1. High performing professional envi- continually to maintain motivation for change. Learning ronments were successfully pursuing patient-centered from the final reports of the improvement projects, the quality improvement if they had access to a combination sub study indicate that successful results are connected of: (a) knowledge of best practice, provided by profes- to a clear linkage between vision, aims and proper mea- sional subject matter experts, (b) knowledge of current surements, clear and understandable improvement practice provided by simple measurement methods, efforts, and the ability to communicated this all to others learned from (c) improvement knowledge experts who in an understandable way [32]. Our findings support the provided good guidance and help with measurement, findings of others indicating that by measuring and and made the team able to organize the improvement ef- monitoring variation and change with control charts, it forts well in spite of the difficult resource situation (time is easier to understand and manage performance from and personnel). week-to-week, communicate progress, and motivate colleagues to sustain the improvements [43–48]. Discussion Our findings support improvement knowledge guidance Our findings indicate common Interprofessional interest Our study underscores the power of good guidance and in the patients’ welfare help with measurement. In contrast to most learning Our The glue for interprofessional collaboration is a collaboratives abroad, The Norwegian Medical Associ- common interest in the patient’s welfare, which has been ation invested in a team of 10–15 improvement know- emphasized as crucial by others [49]. We found that ledge experts (coaches) to guide their improvement 92% of the 198 responding physicians, nurses, psycholo- teams [23]. The coaching team met regularly for gists and other members of the improvement teams found patient-centered targets of “great” or “very great” Table 6 Bivariate and multivariate logistic regression analysis of importance for engaging their colleagues in quality the five domains of the underlying questionnaire structure, improvement (Q16 Table 7). (with the 5 domains as independent variables and success as dependent variable) Our findings call for an infrastructure for improvement in Unadjusted analysis Adjusted analysis healthcare Domain OR 95% CI P value OR 95% CI P value We have found that successful quality improvement I: Measurement & 3.13 1.51 5.52 0.002 2.64 1.25 5.61 0.011 efforts depend on certain conditions for change in the Guidance participating organizations that to a certain degree have III: Professional 3.20 1.55 6.62 0.002 2.57 1.20 5.48 0.015 environment been facilitated by the national learning collaborative. The table shows the two results domains, their odds ratio (OR) associated However, if continual improvement efforts are to with one point increase, 95% confidence intervals (CI) and P values become part of everyone’s work in healthcare, an Brandrud et al. BMC Health Services Research (2017) 17:648 Page 7 of 9

Table 7 Variables of the two success-domains and the proportion reflection, and (c) provides qualified improvement guid- of evaluated projects scoring on the positive side of the scale ance to frontline clinical improvement teams [23]. (4 & 5 on a scale from 1 to 5) to each variable Proportion of projects scoring on the positive side of the scale (score 4 Methodological considerations and 5) to each of the variables of the success factors A significant part of the overall spectrum of healthcare Domain I: Measurement & Guidance Successful Comparator problems constitutes matters that are not principally n =54 n =78 biological. For this reason, it is essential to know how Q7: Someone in the improvement team 87 56 enjoyed working with measurement the philosophies of the social sciences and the biological sciences differ. One does not erroneously use the criteria Q10: We got hold on our coach when 74 57 needed between the Learning for one area to judge another. The social sciences differ sessions (LS) from the biological sciences in two aspects: They entail Q11: Is the availability of the coach 83 54 greater elements of overt interpretation that often enter between the LS of any importance to into the collection of data. In many cases, a research make successful improvements? result is an understanding, not an explanation. The dif- Q12: We had good guidance and help 81 50 with measurements ference between explanation and understanding however, is not as distinct as many believe [50], and in Q13: Is good guidance and help with 59 73 measurements of any importance this study, we are including both. to succeed with the improvement work? The present study is exploring the conditions for mak- Q18: The improvement team learned SPC 77 46 ing desired changes in healthcare. We are not reporting Q19: Is the measure method SPC of any 76 57 on a scientific experiment aiming to bring evidence to importance to succeed with the success of the services and projects in our material. improvement efforts? This study has been developed with the prerequisite of Q20: The control-charts were easy to 78 51 the known outcome of the learning collaborative pro- communicate to our peers in the site. jects of the Norwegian Medical Association. Q21: Is it of any importance for successful 67 53 changes that the control-charts are Learning from high performers stems from a growing easy to communicate to the peers number of “positive deviance” approaches to quality im- in the site? provement [50–53]. The aim of the present study is to Domain III Professional environment Successful Comparator learn from healthcare professionals in the improvement n =54 n =78 teams of those projects who have been able to document Q16: We based the improvement efforts 94 91 improvements based on a clear linkage between vision, on patient-focused aims aims, change efforts and measurements. Q17: Are patient-focused aims of any 94 90 Process and outcome evaluation by improvement ex- importance to engage the healthcare professionals in the improvement efforts? perts and improvement teams can illuminate the strat- (No negative scores found) egies and processes responsible for the improvement of Q1: Referring to the senior expert team 75 76 the target process. In so doing, the process and outcome made our change ideas more feasible evaluation from sub study II [32], makes a relevant and to the peers in the site important contribution to the development of potentially Q6: The project was well grounded in the 74 67 professional environment successful strategies to make positive changes in patient care [12]. Q5: We organized the improvement efforts 83 83 well in spite of the difficult resource It is a limitation that 75% of the projects covered by situation (time and personnel) our research are from the psychiatric sector and one Q22: We presented measurements 83 71 may conclude that the results are limited to this field. continually to maintain motivation. (Table 1) The general theoretical framework that we Q23: Is it of any importance to present 74 72 have used (see Additional file 1: Supplement 1), the find- measurements continually ings of others (see the Background section), and the maintain motivation? matching conditions for improvement reported by the improvement teams from the non-psychiatric settings however, does not support this limitation [23]. infrastructure for improvement that at least is providing It is a strength that the items used in the questionnaire similar conditions for change in the local context is es- was based on a data collection method that invites re- sential. The infrastructure should include: (a) a system spondents to share their point of view, rather than re- that promotes leadership’s engagement at every stage of spond to researcher-initiated questions [54]. We the improvement work, (b) provides easy access to clin- designed the questionnaire to be large enough to cover ical data needed for improvement measurement and the most important comments, and short enough to get Brandrud et al. BMC Health Services Research (2017) 17:648 Page 8 of 9

a decent response rate. As described in Additional file responsible for planning and conducting the entire study. She has an 1: Supplement 2, this implied a step-wise reduction of intimate knowledge of the database and its content, and is main responsible for the data analysis and the manuscript. BNY collected data from one of the the material from 233 (partly overlapping) comments focus groups, participated in the development of the two instruments, to a final selection of 17. In spite of our systematic ap- participated in the evaluation of the improvement projects, has an intimate proach, we may unintentionally have excluded import- knowledge of the database and its content, assisted in the data analysis and participated in writing of the manuscript. PHJ supervised the planning and ant comments in this process that should have been data collection part of the study, has an intimate knowledge of the database included in the study. The eight additional questions and its content, and participated in writing of the manuscript. LSA assisted in regarding the importance of the most critical incidents planning the research process, has an intimate knowledge of the database and its content, supervised the statistical analysis of the data, and are meant to compensate for this limitation (Additional participated in the writing of the manuscript. GSH collected data from one file 1: Supplement 2). of the focus groups, participated in the development of the two instruments, participated in the evaluation of the improvement projects, and in the final preparation of the manuscript. MBE has an intimate knowledge Conclusion of the database and its content, assisted in the analysis of the data and the Our findings suggest that quality improvement projects literature review, and in the final preparation of the manuscript. ECN assisted with good guidance and a sharp focus on measurement in planning the research process, in outlining the contents of the article and in editing and reading the manuscript. MBR is the main supervisor of the for improvement, have an increased likelihood of success. study, has an intimate knowledge of the database and its content, assisted The two success domains are well aligned with contin- in the data analysis and participated in writing of the manuscript. ual improvement theory. High performing professional Ethics approval and consent to participate environments were successfully pursuing patient- The dissertation proposal was evaluated by the regional ethics committee of centered quality improvement if they had access to a South-East Norway 4 Oct 2012 and waived from formal approval according to combination of: (a) knowledge of best practice, provided Norwegian law due to the fact that it did not involve patient interventions. Later, the study was approved by the Data Protection Authority of Oslo University by professional subject matter experts, (b) knowledge of Hospital as required by Norwegian law. Informed consent was obtained from all current practice provided by simple measurement informants of this study before enrolment. The thus, all necessary approval has methods, learned from (c) improvement knowledge been in place. experts who provided good guidance and help with Competing interests measurement, and made the team able to organize the The authors declare that they have no competing interests. improvement efforts well in spite of the difficult resource situation (time and personnel). Publisher’sNote Our findings may be useful for healthcare organiza- Springer Nature remains neutral with regard to jurisdictional claims in tions in the development of an effective infrastructure published maps and institutional affiliations. for improvement and thereby create necessary condi- Author details tions for making quality and safety improvement a part 1Quality Department, Vestre Viken Health Trust, Wergelandsgate 10, Postbox of everyone’s job. 800, 3004 Drammen, Norway. 2Municipality of Porsgrunn, Porstbox 128, N-3901 Porsgrunn, Norway. 3Department of Family Medicine, Faculty of Medicine, University of Oslo, PO Box 1130, Blindern, NO-0318 Oslo, Norway. Additional file 4Oslo Center for Biostatistics and Epidemiology, Research support Services, Oslo University Hospital, Sogn Arena, Klaus Torgaards vei 3, 0372 Oslo, 5 Additional file 1: Supplement QI Success Domains. (DOCX 350 kb) Norway. South Eastern Norway Regional Health Authority, PO Box 404, 2303 Hamar, Norway. 6The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, 30 Lafayette Street, Acknowledgements Lebanon, NH, USA. 7Department of Health and Society, Faculty of Medicine, The Norwegian Medical Association Quality Assurance Fund for Quality and University of Oslo, PO Box 1130, Blindern, NO-0318 Oslo, Norway. Safety provided partial funding for the first part of the data collection of this study (2006-2008). The authors thank Lill de Grève (LdG), Ada Schreiner (AS), Received: 16 October 2015 Accepted: 17 July 2017 Tordis Sørensen Høifødt (TSH) and Ellen Andersen (EA) for their participation in the evaluation of the 189 projects. The authors thank H. Asbjørn Holm, Ole Tjomsland, and Lars Strauman for their help and support with this study. References 1. Havik OE. A general model for psychological reactions in somatic disease. Funding How can we understand and care for the patients’ psychological needs? Vestre Viken Health Trust (research team leader), South Eastern Norway Nordisk Psykologi. 1989;41:161–76. Regional Health Authority funding our statistical support by the Oslo Center for 2. Institute of Medicine (US) Committee on Quality of Health Care in America. To Biostatistics and Epidemiology, Research support Services (co-supervisor). Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson Norwegian Cancer Society and Research Council of Norway (main supervisor). MS, editors. Washington (DC): National Academies Press (US) 2000. 3. Institute of Medicine (US) Committee on Quality of Health Care in America. Availability of data and materials Crossing the quality chasm: a new health system for the 21st century. Anonymised datasets are available from the corresponding author on request. Washington (DC): National Academies Press (US); 2001. 4. Nelson EC, Batalden PB, Huber TP, Mohr JJ, Godfrey MM, Headrick LA, Authors’ contributions Wasson JH. Microsystems in health care: part 1. Learning from high- ALL authors read and approved the final manuscript, agreed to be performing front-line clinical units. Jt Comm J Qual Improv. 2002;28:472–93. accountable for all aspects of the work in ensuring that questions related to 5. Deilkås ET. Report from a national medical record review using the global the accuracy or integrity of any part of the work are appropriately trigger tool. In: Report from the Norwegian knowledge Centre for the investigated and resolved. ASB was the research team leader and main Health Services (editor); 2011. Brandrud et al. BMC Health Services Research (2017) 17:648 Page 9 of 9

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The Continual improvement method of the learning collaborative is a combination of Professional knowledge and Improvement knowledge. Improvement knowledge (Suppl.1, Figure 1) implies: (1) knowledge of the system (e.g. the particular context of the place where the patient meet the provider, and the patterns of their interactions). (2) Understanding variation (with time as a variable, e.g. on a control chart). (3) The psychology of work and change (e.g. peoples’ judgements and choices). (4) Theory of knowledge (the differences in the perspectives of the people involved and how they learn). Continual improvement also implies several improvement methods and tools >22, 23, 34, 37, 39, 41, 42, 44, 45@.
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Prior to the present study, critical incident data were collected in focus groups conducted by a research team of four experienced improvement advisors: one physician, two nurses, and one bioengineer. The Critical Incident Technique (CIT) was used as the data collection method, and the result was published in 2011[23]. A critical incident is one that makes a significant contribution, either positively or negatively, to an activity.[50] When seated around the table, the respondents were asked: “Think about the time when you were participating in the BTSC and the time after the project ended. What did you experience as promoting and/or inhibiting elements during and after the BTSC?” The first focus group also wanted to discuss positive spin-offs from their BTSCs. The subsequent groups were thus asked to do the same. The story telling moved around the table several times with minimal interruption by the data collectors. Their task was to support the process using active listening techniques, confirming what the respondents meant without asking other questions or providing explanations.[23, 50] The data collectors summarized the critical incidents on flipcharts in dialogue with the respondents who assessed the accuracy of the recorded information. The focus groups lasted about 45 minutes, and each respondent reported from 5 to 20 critical incidents and positive spin offs (comments) with a mean of 12 per respondent and a total of 233 comments. A Canadian-Norwegian journalist translated the comments into English.

 
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Utøya island in Lake Tyri, Norway (photograph: Frode Johansen, with permission)

The Utøya area in Southern Norway. Sundvolden hotel was established as the triage and information center. Ringerike Hospital was the local emergency care center (Google Maps)

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The hospital was well structured with an appropriate, well-known and readily available (written) emergency preparedness plan, revised by tactical management a few weeks before July 22 2011, and well known by every manager. Good crisis management requires good management skills and medical expertise. The tactical management team must be able to understand the needs of the organization during such an event. The management were confident that the staff was competent and that they were well trained by the BEST-principle. Therefore, they could concentrate entirely on managing the over- arching situation. +&*&
 
The logistics revolved around patients, family, personnel, and equipment.

 
   The emergency preparedness plan was followed regarding the composition of one team around each patient. The doctors met in reception and other personnel met at their respective departments. Personnel that were needed for transport and/or other treatment tasks were summoned from their respective departments by the disaster coordinator. Each department appointed a coordinator, usually the one that was proposed in the local plan on an action card, or the nurse who had the best knowledge of the departments’ routines. The coordinator distributed tasks within the department and was contactable via the phone number specified in the plan.

Because of the large number of patients, the hospital’s ordinary trauma team was replaced by teams tailored to the trauma of the individual patient, with at least one physician for each team. For example, teams were summoned from the surgical department to attend the most seriously injured patients. Each patient who required surgery, alternatively stabilizing treatment, was followed all the way by a team consisting of a nurse anesthetist, a surgical or an ER nurse, and a physician (when necessary) until the initial treatment was completed. As described by Waage & Poole:

When the first patients arrived, three of five surgical consultants and one of two surgical residents were available to lead the trauma teams. One of the five consultants performed triage, and one was sent to the scene. The surgical resident on-call was unable to treat any patients owing to the greatly increased organizational duties from the mass casualty incident. Incidentally, there was only one regular acute admission from 15.00 hours until noon the next day. Two orthopedic consultants and four orthopedic residents were present. Of the four anesthetists present, one was sent out to the scene. In addition, there were 11 doctors from the medical department, and gynecologists were also available. Non-surgical personnel took care of the less badly injured patients. Patients with minor injuries were sent to the outpatient department staffed by medical doctors, and moderately to severely injured patients were sent to the emergency department. Owing to a lack of general surgeons, who normally would assess all injured patients, those with apparently isolated extremity injuries were taken care of by an orthopedic surgeon, while patients with head and torso injuries were placed under the care of a general surgeon. (….) Anesthetists were prioritized to the most severely injured patients and to patients requiring immediate surgery.AE

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The importance of information is under appreciated. Much of the outcome of a crisis management situation depends on how well the information flows, both internally and across the various external stakeholders, such as next of kin and media.

 


Documentation was related both to individual patients and to the progression of work during the disaster. The work was documented "real time". This is why the hospital had a comprehensive overview of how the disaster was handled, and find areas for improvement in retrospect. This task was initially taken care of by tactical management and then by a secretary who was fed the information.

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 Because of the high pace in the emergency entrance, the patients could not be identified at that time and many of the patients were not able to identify themselves. Therefore, patients were registered with continual numbers in the emergency-web that followed the patients through the system. This is how strategic management could monitor patient flow.

In addition, tactical management needed a detailed list of how many patients were in the hospital at any time, the seriousness of the patients’ injuries and other important information about the patient. This was not easy. A patient list was therefore created in Excel where the number from the disaster web was as quickly as possible linked with a verified identity. The list consisted of the patients’ social security number, home municipality, information about their injuries, and other relevant information that was regularly updated. The patient list was regularly printed out and given to the police liaison and the secretary who answered the external telephone requests. Tactical management were challenged on the legality of this list in terms of confidentiality, but chose to use it in light of the extraordinary situation.

The patient list was also used at a meeting in the intensive ward at midnight, where operating staff, anesthesia staff, and disaster management gathered to plan the night's operations (e.g., who would be sent to other hospitals, etc). The list was systematically checked.

The patient list proved to be particularly useful when it came to identifying all patients with gunshot wounds, also patients who had been sent out of the hospital due to unverified information that the perpetrator may have prepared the projectiles with poison.

The next day, the patient list was used to determine which of the patients came from the same municipality and probably knew each other, so they could stay in the same room. The patients were very happy to be with friends who had been through the same experience.

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Management placed an emphasis on ensuring quick information to next of kin. None of the patients that were admitted had working cellphones. Employees were constantly reminded that establishing contact with next of kin via the hospital's telephone was a high priority. Disaster management also established a phone line where next of kin could call for information. Tactical management continually delivered an updated patient list here. The load was much greater than expected because many of those who called were relatives of those who subsequently proved to be among the dead. The number of inquiries was therefore much higher than the number of patients.

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  Tactical management had two staff members that circulated, monitoring different processes and giving feedback on bottlenecks which then could be addressed. This helped management feel confident that things were running smoothly and they could concentrate on other things.


 Tactical management consisted of a tactical leader and a tactical management team. Clear and visible leadership is important in general, but particularly in a crisis. The tactical leaders moved around a lot and talked to people; they encouraged them, listened to what they were concerned about, and gave information.

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The psychosocial support for next of kin, the uninjured and lightly injured was well attended. It is easy to forget those who are more severely injured and therefore could not receive the same help. They were recently operated upon, perhaps influenced by painkillers, and staff mainly focused on the somatic injuries. Tactical leaders went around to all the patients the day after and caught up with their needs. This mainly revolved around finding out what had happened to those they knew, and establishing contact with surviving friends, and of course next of kin.

 " $ The disaster plan is an essential tool for the organization to run smoothly and efficiently. Nevertheless, there will always be need for creative ad hoc solutions beyond what can be conveyed in the plan. When creating such solutions, it is essential that key personnel are informed so that systems do not work against each other. Information flow and clear management is therefore essential.

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1. Major incident preparedness and competence

"What is most important about experience is that you have the knowledge and skills you get by training. It makes you able to tolerate extreme situations and make quick decisions. Ringerike hospital has activated the trauma team many times, and with valuable debriefings afterwards. This reinforces the value of experience, making you able to tolerate more".

"Then we brought out the red emergency preparedness manual and the action cards [a role & task description so that no details were missed], and I was able to repress my own feelings and concentrate on the job".

“We need a plan anyhow, and action cards to « keep on track». We saw they were clinging to their action cards in a way that some cards were worn out”.

“The same multidisciplinary team followed the same patient thorough the entire care process, from triage to the general or psychiatric ward, and did not let go of the patient before it was justifiable"

“Proximity to the mental healthcare unit and a written emergency cooperation plan was crucial.”

"Knowledge is important, but we need to be trained. If anyone in the team is un-trained, it helps that some have trained and can lead/help the others along”.

“Hole Municipality had a trained crisis team”.

“The police were an important part of the emergency service. They cleared the path for the healthcare workers, and their lifesaving efforts at Utøya were great. They were applying direct pressure to gunshot wounds to stop the bleeding”.

2. Crisis management and leadership

“I would not have been able to lead over 200 persons without good structure as foundation. Neither would I have been able to manage the major incident without enough human resources at hand”.

“We knew we could trust the competence of our trained personnel, thanks to our monthly simulation and team-training system. Knowing this, tactical management was able to concentrate on other issues”.

“Fortunately, an experienced senior manager was available to take the responsibility as ambulance commander".

“There was progress all the way; good flow, well directed by the (hospital) medical commander, and people did what was expected from them”.

“We endeavored to bring together the right professionals, forming good, multidisciplinary teams”.

“Crisis management must understand the real time needs of the organization and what needs can be expected in the next sequences of events”.

?B

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“Tactical management went around talking with the health professionals, encouraging and listening to their concerns and stories, and provided information”.

“The information we collected was both related to each patient (patient list), and to the consecutive events (Event log). A successful outcome depended to a large degree on the quality of the information flow, internal to the healthcare leaders, coordinators, and workers and external to the attached families and to the press”.

“The interaction between the police liaison and tactical health care leadership worked perfectly”.

3. Empowerment of the multi-professional networks

“Cooperation, and that we knew each other well, helped us manage the situation. It would have been very difficult to be alone. We needed each other in making the right decisions”.

“Then we spoke to the youngsters for hours. Their stories were heart-breaking, and we knew that we must not lose each other if we [were to] be able to withstand this”.

“When the hospital was blocked by the police due to a terror threat, those who did not have patient contact were scared. We who worked with the patients were not scared”.

"Life-saving that the ambulance/prehospital expertise was that great".

"We knew you were coming, (anesthesiologist arriving at the support center) and were aware of your presence. It was very important to have someone with your expertise among us”.

“The presence of such a versatile expertise was reassuring to me. I would not be able to do my part of the job otherwise”.

4. Ability to improvise based on structure and competence

“Easier to improvise because we have regular training, both as individuals and together with the others in the team. Enough to understand each other and to know where we had to improvise.”

“The action cards freed up mental capacity to improvise. E.g., when the police closed the road to Oslo, we established a second support center in cooperation with primary care services, taking care of the families being shut out from the main support center. This was useful”.

"We regularly provided updated patient lists to the police through the entire evening. Never felt this could be wrong".

“The support center at the hotel constituted a solid and comforting environment for providing psychosocial support.”

“Structure and competence makes room for improvisation”.

"Three helicopters landed about the same time with severely injured patients, two landed on the hospital’s helipad (meant for one) and the third in front of the main entrance.“

"Thanks to the updated patient list, tactical management was soon able to identify patients from the same municipality and placed them together in the same room (at the ward). They were pleased to come together with friends sharing the same experiences".

?C

Errata list Name of candidate: Aleidis Skard Brandrud

Title of thesis: Learning about the conditions for improvement and excellent care from high performing clinical networks.

Abbreviations for different types of corrections: Cor – correction of language, (Cpltf – change of page layout or text format)

Side Line Foot- Original text Type of Corrected text note correction

5 7 eight learning collaborative Cor eight learning collaboratives

5 11 (…) were found, (included in Cor (…) were found (included in condition 1, 5 and 6 below). condition 1, 5 and 6 below).

5 15 Five focus groups covering Cor Five focus groups covering 29 30 of the 31 most important of the 31 most important roles (…) roles (…)

5 19 (…) teams and networks has Cor (…) teams and networks have been collected. been collected.

5 22 (…) and additional studies, Cor (…) and additional studies, This PhD project (…) this PhD project (…)

5 28 , easy available plans (…) Cor , readily available plans (…)

5 32 , patient and family, creating Cor , patients and families to good solutions, rescue create good solutions and patients (…) rescue patients (…)

5 33 (…) an event, and allowing Cor (…) an event, allowing the the team to be able team to be able (…)

5 37 (…) the data appear Cor (…) the data appear simultaneous (e.g. training simultaneously, (e.g. training

sessions). sessions).

1

(…) where sustainability and Cor (…) where sustainability and resilience is paradoxically resilience are paradoxically 5 43 working together. working together.

(…) where sustainability and Cor (…) where sustainability and resilience is paradoxically resilience are paradoxically 22 9 working together. working together.

25 14 McDonald (2009) Cor McDonald (2016)

25 25 McDonald 2009 Cor McDonald 2016

25 26 McDonald 2009 Cor McDonald 2016

47 12 3.3.2. New Public Cor 3.3.2. New Public Management and Corporate Management and Corporate governance Governance

47 14 (…) approaches (e.g. Cor (…) approaches (e.g. Corporate governance) (…) corporate governance) (…)

, which could turn in lower 47 24 Cor , which could result in lower cost, cost,

, establishing short-term 47 26 Cor , establishing short-term labor contracts, develop labor contracts and corporate (…) developing corporate (…)

(…) the goals and intention 47 28 Cor (…) the goals and intentions that agencies are (…) that agencies are (…)

52 5 (…) control approach, has (…) Cor (…) control approach, experts have (…)

59 24 (…) does not necessary mean Cor (…) does not necessarily (…) mean (…)

eg 60 18 Cor e.g.

2

eg 60 20 Cor e.g.

Centreline 60 21 Cor Centerline

Carey and Lloyd Nelson et al. 61 1 Cor Wheeler 2003 and Nelson et 2007 are proposing al. 2007 are proposing

(…) Normalization process 63 1 Cor (…) Normalization Process theory (…) Theory (…)

(…) and utility; and by socially 63 4 Cor (…) and utility as well as by defined (…) socially defined (…)

(…) what the change means 63 7 Cor (…) what the change means in to practice (…) practice (…)

(…) the Model for 63 18 Cor (…) the Model for Improvement (…) improvement (…)

, and Demings three 63 19 Cor , and Deming’s three fundamental questions (…) fundamental questions (…)

(…) refering to (…) 66 1 Cor (…) referring to (…)

(…) a varieties of (…) 69 16 Cor (…) a variety of (…)

However the review (…) 78 9 Cor However, the review (…)

(Waage et al. 2013). A study 89 25 Cor (Waage et al. 2013), a study

Blackbourne 92 142 Cor Blackburn

Nothern 97 4 Cor Northern

(…) adopted by at Ringerike 97 7 Cor (…) adopted at Ringerike hospital (…) hospital (…)

3

(…) where sustainability and 112 10 Cor (…) where sustainability and resilience is paradoxically resilience are paradoxically working together. working together.

Therefore the (…) 116 23 Cor Therefore, the (…)

(…) where sustainability and 122 25 Cor (…) where sustainability and resilience is paradoxically resilience are paradoxically working together. working together.

The Norwegian law of privacy 127 1 Cor The Norwegian law of privacy was unclear at this point. was unclear regarding patient lists.

, easy available plans (…) 129 13 Cor , readily available plans (…)

, patient and family, creating 129 17 Cor , patients and families to good solutions, rescue create good solutions and patients (…) rescue patients (…)

(…) an event, and allowing 129 18 Cor (…) an event, allowing the the team to be able team to be able (…)

(…) the data appear 129 22 Cor (…) the data appear simultaneous (e.g. training simultaneously, (e.g. training sessions). sessions).

(…) where sustainability and 129 38 Cor (…) where sustainability and resilience is paradoxically resilience are paradoxically working together. working together.

(…) 45 were brought to 132 14 Cor (…) 43 were brought to Vestre Viken (…) Vestre Viken (…)

Of the 45 patients (…) 132 16 Cor Of the 43 patients (…)

(…) discussed in this thesis, 143 5 Cor (…) discussed in this thesis that they will not (…) that they will not (…)

4

143 14 Ringerike hospital has since Cor Ringerike hospital has, since the mid-nineties had a strong the mid-nineties, a strong focus on the patient focus on the patient’s perspective of the care as a perspective of the care as a process, process,

(…) the Microsystem 143 15 Cor (…) the microsystem movement. movement.

“Early intervention in 143 22 Cor “Early intervention in Psychiatric disorder”- psychiatric disorder” collaborative (…) collaborative (…)

(…) learning collaborative 150 17 Cor (…) learning collaborative innovator, In spite of (…) innovators. In spite of (…)

From Compliance & control 160 9 Cor From Compliance & Control to Learning & Interaction to Learning & Interaction

researchers from related 161 15 Cor researchers from related cultured (…) cultures (…)

(…) because of 168 25 Cor (…) because of a communication (…) communication (…)

(…) a limitation influences (…) 171 12 Cor (…) a limitation influencing (…)

(..) excellent care, It was (…) 176 6 Cor (..) excellent care, it was (…)

This was b\made to (…) This was made to (…) 177 7 Cor

( se examples Chapter (…) (see examples Chapter (…) 177 24 Cor

179 10 factor loadings ≥5 Cor factor loadings ≥.5

183 31 , easy available plans (…) Cor , readily available plans (…)

5

184 1 , patient and family, creating Cor , patients and families to good solutions, rescue create good solutions and patients (…) rescue patients (…)

184 2 (…) an event, and allowing Cor (…) an event, allowing the the team to be able team to be able (…)

184 6 (…) the data appear Cor (…) the data appear simultaneous (e.g. training simultaneously, (e.g. training

sessions). sessions).

Clarifying the number of informants and their roles in the local trauma care network.

The total number of roles in the psychosocial and trauma care network from Utøya to discharge from Ringerike hospital was 35, of which 31 roles were considered particularly important. Of the 30 professionals participating as informants, 26 met in 5 focus groups. Four single interviews were made with those who were not able to meet in their focus group. The 30 informants covered 29 of the 31 most important roles. The material of paper 3 was based on the statements of these 30 informants. A fifth single interview was made with informant number 31, because he was replacing a member of the internal expert team who suddenly died from a heart attack (see Paper 3, page 814). Informant 31 is one of the architects behind the trauma system (see Figure 5 and Chapter 7.2.1.). He is an expert on role 30, and has a perspective on trauma care that is crucial to understand the cultural, historical and theoretical underpinnings of the trauma system that are focused in this thesis. Because he did not participate in the local medical response, his interview was not included in the material of Paper 3. He was, however, participating as one of the co-authors of the paper.

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