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Decentralisation in health care has been proposed as a way to make services more responsive to local needs and by that improve patient care. This study analyses how the senior management team conceptualised and implemented a decentralised management model within a large public health care delivery organisation.

Data from in-depth interviews with a senior management team were used in a directed content analysis. Underlying assumptions and activities in the decentralisation process are presented in the logic model and scrutinised in an a priori logic analysis using relevant scientific literature.

The study found support in the scientific literature for the underlying assumptions that increased responsibility will empower managers as clinical directors know their local prerequisites best and are able to adapt to patient needs. Top management should function like an air traffic control tower, trust and loyalty improve managerial capacity, increased managerial skills release creativity and engagement and a system perspective will support collaboration and learning.

To the authors’ knowledge this is the first a priori logic analysis of a decentralised management model in a healthcare delivery organisation in primary and community care. It shows that the activities consist with underlying assumptions, supported by evidence, and timely planned give managers decision space and ability to use their delegated authority, not disregarding accountability and fostering necessary organisational and individual capacities to avoid suboptimisation.

The purpose of this paper is to examine the outcomes and evolution over a five‐year period of a Swedish university hospital quality improvement program in light of enduring uncertainty regarding the effectiveness of such programs in healthcare and how best to evaluate it.

The paper takes the form of a case study, using data collected as part of the program, including quality indicators from clinical improvement projects and participants' program evaluations.

Overall, 58 percent of the program's projects (39/67) demonstrated success. A greater proportion of projects led by female doctors demonstrated success (91 percent, n=11) than projects led by male doctors (51 percent, n=55). Facilitators at the hospital continuously adapted the improvement methods to the local context. A lack of dedicated time for improvement efforts was the participants' biggest difficulty. The dominant benefits included an increased ability to see the “bigger picture” and the improvements achieved for patients and employees.

Quality measurement, which is important for conducting and evaluating improvement efforts, was weak with limited reliability. Nevertheless, the present study adds evidence about the effectiveness of healthcare improvement programs. Gender differences in improvement team leadership merit further study. Improvement program evaluation should assess the extent to which improvement methods are locally adapted and applied.

This case study reports the outcomes of all improvement projects undertaken in one healthcare organization over a five‐year period and provides in‐depth insight into an improvement program's changeable nature.

This paper seeks to explore critical factors that may obstruct or advance integration efforts initiated by the clinical management following a hospital merger. The aim is to increase the understanding of why clinical integration succeeds or fails.

The authors compare two cases of clinical integration efforts following the Karolinska University Hospital merger in Sweden. Each case represents two merged clinical departments of the same specialty from each hospital site. In total, 53 interviews were conducted with individuals representing various staff categories and documents were collected to check data consistency.

The study identifies three critical factors that seem to be instrumental for the process and outcome of integration efforts and these are clinical management's interpretation of the mandate; design of the management constellation; and approach to integration. Obstructive factors are: a sole focus on the formal assignment from the top; individual leadership; and the use of a classic, planned, top‐down management approach. Supportive factors are: paying attention to multiple stakeholders; shared leadership; and the use of an emergent, bottom‐up management approach within planned boundaries. These findings are basically consistent with the literature's prescriptions for managing professional organisations.

Managers need to understand that public healthcare organisations are based on competing institutional logics that need to be handled in a balanced way if clinical integration is to be achieved – especially the tension between managerialism and professionalism.

By focusing on the merger consequences for clinical units, this paper addresses an important gap in the healthcare merger literature.

The purpose of this paper is to identify opportunities for improving primary care services for people with chronic illnesses by comparing how Sweden and US services use evidence-based practices (EBPs), including digital health technologies (DHTs).

A national primary healthcare center (PHCC) heads surveys in 2012-2013 carried out in both countries in 2006.

There are large variations between the two countries. The largest, regarding effective DHT use in primary care centers, were that few Swedish primary healthcare compared to US heads reported having reminders or prompts at the point of care (38 percent Sweden vs 84 percent USA), despite Sweden’s established electronic medical records (EMR). Swedish heads also reported 30 percent fewer centers receiving laboratory results (67 percent Sweden vs 97 percent USA). Regarding following other EBPs, 70 percent of Swedish center heads reported their physicians had easy access to diabetic patient lists compared to 14 percent in the USA. Most Swedish PHCC heads (96 percent) said they offered same day appointment compared to 36 percent in equivalent US practices.

There are opportunities for improvement based on significant differences in effective practices between the countries, which demonstrates to primary care leaders that their peers elsewhere potentially provide better care for people with chronic illnesses. Some improvements are under primary care center control and can be made quickly. There is evidence that people with chronic illnesses in these two countries are suffering unnecessarily owing to primary care staff failing to provide proven EBP, which would better meet patient needs. Public finance has been invested in DHT, which are not being used to their full potential.

The study shows the gaps between current and potential proven effective EBPs for services to patients with chronic conditions. Findings suggest possible explanations for differences and practical improvements by comparing the two countries. Many enhancements are low cost and the proportionate reduction in suffering and costs they bring is high.

The purpose of this paper is to describe and explain a clinician‐led improvement of a hip fracture care process in a university hospital, and to assess the results and factors helping and hindering change implementation.

The paper has a mixed methods case study design. Data collection was guided by a framework directing attention to the content and process of the change, its context and outcomes.

Using a multiprofessional project team, beneficial changes in the early parts of the care process were achieved, but inability to change surgical staff work practices meant that the original goal of operating patients within 24 hours was not reached. After three years, top management introduced a hospital‐wide process improvement programme, which “took over” the responsibility for improving hip fracture care.

A clear vision why change is needed and what needs to be done, which is well communicated by a respected clinical leader, can motivate personnel, but other influences are also needed to bring about change. Without a plan agreed and supported by top management, changes are likely to be limited to parts of the process and improvements to patient care may be minimal. These and other findings may be applicable to similar situations in other services.

This case study is an illustration of both the strengths and the weaknesses of a “bottom‐up, clinician‐champion‐led improvement initiative” in a complex university hospital.

Organizational culture is a determinant for quality improvement. This paper aims to assess organizational culture in a hospital setting, understand its relationship with perceptions about quality of care and identify areas for improvement.

The paper is based on a cross‐sectional survey in a large clinical department that used two validated questionnaires. The first contained 20 items addressing perceptions of cultural typology (64 respondents). The second one assessed staff views on quality improvement implementation (48 faculty) in three domains: leadership, information and analysis and human resource utilization (employee satisfaction).

All four cultural types received scoring, from a mean of 17.5 (group), 13.7 (developmental), 31.2 (rational) to 37.2 (hierarchical). The latter was the dominant cultural type. Group (participatory) and developmental (open) culture types had significant positive correlation with optimistic perceptions about leadership (r=0.48 and 0.55 respectively, p<0.00). Hierarchical (bureaucratic) culture was significantly negatively correlated with domains; leadership (r=−0.61, p<0.00), information and analysis (−0.50, p<0.00) and employee satisfaction (r=−0.55, p<0.00). Responses reveal a need for leadership to better utilize suggestions for improving quality of care, strengthening the process of information analysis and encouraging reward and recognition for employees.

It is likely that, by adopting a participatory and open culture, staff views about organizational leadership will improve and employee satisfaction will be enhanced. This finding has implications for quality care implementation in other hospital settings.

The paper bridges an important gap in the literature by addressing the relationship between culture and quality care perceptions in a Pakistani hospital. As such a new and informative perspective is added.

The purpose of this paper is to explain how different emergency services adopt and adapt the same hospital-wide lean-inspired intervention and how this is reflected in hospital process performance data.

A multiple case study based on a realistic evaluation approach to identify mechanisms for how lean impacts process performance and services’ capability to learn and continually improve. Four years of process performance data were collected from seven emergency services at a Swedish University Hospital: ear, nose and throat (ENT) (two), pediatrics (two), gynecology, internal medicine, and surgery. Performance patterns were linked with qualitative data collected through realist interviews.

The complexity of the care process influenced how improvement in access to care was achieved. For less complex care processes (ENT and gynecology), large and sustained improvement was mainly the result of a better match between capacity and demand. For medicine, surgery, and pediatrics, which exhibit greater care process complexity, sustainable, or continual improvement were constrained because the changes implemented were insufficient in addressing the higher degree of complexity.

The variation in process performance and sustainability of results indicate that lean efforts should be carefully adapted to the complexity of the care process and to the educational commitment of healthcare organizations. Ultimately, the ability to adapt lean to a particular context of application depends on the development of routines that effectively support learning from daily practices.

The purpose of this paper is to compare the implementation of 12 different organisation and management innovations (OMIs) in Swedish healthcare, to discover the generic and specific factors important for successful healthcare improvement change in a public health system.

Longitudinal cross‐case comparison of 12 case studies was employed, where each case study used a common framework for collecting data about the process of change, the content of the change, the context, and the intermediate and final outcomes.

Clinical leaders played a more important part in the development of these successful service innovations than managers. Strategies for and patterns of change implementation were found to differ according to the type of innovation. Internal organisational context factors played a significant role in the development of nearly all, but external factors did not. “Developmental evolution” better described the change process than “implementation”.

The 12 cases were all of relatively successful change processes: some unsuccessful examples would have provided additional testing of the hypotheses about what would predict successful innovation which were used in the case comparison. The cross‐case comparative hypothesis testing method allows systematic comparison if the case data are collected using similar frameworks, but this approach to management research requires considerable resources and coordination.

Management innovations that improve patient care can be carried out successfully by senior clinicians, under certain circumstances. A systematic approach is important both for developing and adapting an innovation to a changing situation. A significant amount of time was required for all involved, which could be reduced by “fast‐tracking” approval for some types of change.

This is the first empirical report comparing longitudinal and contextualised findings from a number of case studies of different organisational and management healthcare innovations. The findings made possible explanations for success factors and useful practical recommendations for conditions needed to nurture such innovation in public healthcare.

This study aims to describe implementation of simulator‐based medical team training and the effect of this programme on inter‐professional working in an intensive care unit (ICU).

Over a period of two years, 90 percent (n=152) of the staff of the general ICU at Karolinska University Hospital, Huddinge, Sweden, received inter‐professional team training in a fully equipped patient room in their own workplace. A case study method was used to describe and explain the planning, formation, and results of the training programme.

In interviews, the participants reported that the training had increased their awareness of the importance of effective communication for patient safety. The intervention had even had an indirect impact by creating a need to talk, not only about how to communicate efficaciously, but also concerning difficult care situations in general. This, in turn, had led to regular reflection meetings for nurses held three times a week. Examples of better communication in acute situations were also reported. However, the findings indicate that the observed improvements will not last, unless organisational features such as staffing rotas and scheduling of rounds and meetings can be changed to enable use of the learned behaviours in everyday work. Other threats to sustainability include shortage of staff, overtime for staff, demands for hospital beds, budget cuts, and poor staff communication due to separate meetings for nurses and physicians.

The present results broaden our understanding of how to create and sustain an organizational system that supports medical team training.

The purpose of this paper is to examine how and why a decision to merge two university hospitals in a public context might occur by using an in‐depth case study of the pre‐merger process of Karolinska University Hospital.

Based on extensive document analysis and 35 key informant interviews the paper reconstructed the pre‐merger process, searched for empirical patterns, and interpreted those by applying neo‐institutional theory.

Spanning nearly a decade, the pre‐merger process goes from idea generation through transition to decision, and took place on two arenas, political, and scientific. Both research excellence and economic efficiency are stated merger motives. By applying a neo‐institutional perspective, the paper finds that the two initial phases are driven by decision rationality, which is typical for political organizations and that the final phase demonstrated action rationality, which is typical for private firms. Critical factors behind this radical change of decision logic are means convergence, uniting key stakeholder groups, and an economic and political crisis, triggering critical incidents, which ultimately legitimized the formal decision. It is evident from the paper that merger decisions in the public sector might not necessarily result from stated and/or economic drivers only.

This paper suggests that a change of decision logic from decision to action rationality might promote effective decision making on large and complex issues in a public context.

This is the first systematic in‐depth study of a university hospital merger employing a decision‐making perspective.