Background To reduce patient harm, healthcare has focused on improvement based on learning from e... more Background To reduce patient harm, healthcare has focused on improvement based on learning from errors and adverse events (Safety-I). Daily huddles with staff are used to support incident reporting and learning in healthcare. It is proposed that learning for improvement should also be based on situations where work goes well (Safety-II); daily safety huddles should also reflect this approach. A Safety-II-inspired model for safety huddles was developed and implemented at the Neonatal Care Unit at a regional hospital in Sweden. This study followed the implementation with the research questions: Do patient safety huddles with a focus on Safety-II affect the results of measurements of the patient safety culture? What are the experiences of these huddles amongst staff? What experiences of everyday work arise in the patient safety huddles? Methods A multi-method approach was used. The quantitative part consisted of a questionnaire (151 items), submitted on four different occasions, and an...
Knowledge about safety in complex systems are growing and health care is a complex system that is... more Knowledge about safety in complex systems are growing and health care is a complex system that is both developing and under pressure. Therefore, patient safety work also has to develop. Basic conditions for safe performance are important: management that values safety, good working conditions, safety culture, adequate staffing and competence, and equipment that facilitates safe practice. Patients and relatives can play a more active role in patient safety work. Safety-II is a valuable new approach to patient safety. The Swedish National Board of Health and Welfare now launches a national action plan for patient safety that addresses these challenges and opportunities.
The adaptation of the healthcare needed in the covid-19 pandemic poses challenges to patient safe... more The adaptation of the healthcare needed in the covid-19 pandemic poses challenges to patient safety. Proactive patient safety work must continue even under conditions such as a pandemic. Methods are needed that assess and support patient safety as the work is carried out. Patient safety in real time appears to be such a useful method in which patient record review to identify patient harm is combined with interviews with patients and healthcare staff. The method was used in wards and intensive care units (ICU) for covid-19 patients in Region Jönköping County. Patient harm was found in ICU care. Patients were overall satisfied with the care, and in the interviews with healthcare staff areas for improvement were identified. Valid indicators for patient record review to evaluate patient harm in covid-19 need to be developed. To judge if patient harm in care of a Covid-19 is avoidable or not is difficult since the level of knowledge and treatment principles in the disease develops very ...
"I trust my physician but want to be involved" - Older persons' Experiences of reg... more "I trust my physician but want to be involved" - Older persons' Experiences of regarding evaluation of their medication treatment
Modern health-care is a complex socio-technical system, and as such variability is normal and nec... more Modern health-care is a complex socio-technical system, and as such variability is normal and necessary. The ability of a complex system such as health-care to quickly and correctly adapt to varying circumstances is crucial to how well the system works. Both increased compliance to guidelines, and a concurrent ability in individuals to deviate from these guidelines in certain situations, can be expected to increase safety. Today, we know too little about these adaptations, and how they affect safety. New knowledge is needed to describe and understand complexity and variability in health-care. FRAM (Functional Resonance Analysis Method) is one such method.
Objective In 2014, an escalation plan and morning handover meetings were implemented in an intens... more Objective In 2014, an escalation plan and morning handover meetings were implemented in an intensive care unit (ICU) to reduce access block for post-operative care. In this study, the improvement intervention is revisited 5 years on with the objective to see if the changes are sustained and to understand factors contributing to sustainability. Design A mixed-method approach was used, with quantitative analysis of ICU administrative data and qualitative analysis of interviews with hospital management and ICU staff. Setting ICU with mixed surgical and non-surgical cases in a regional hospital in Australia. Participants Interview participants: ICU nurses (four), ICU doctors (four) and hospital management (four). Main outcome measures Monthly number of elective surgeries were cancelled due to unavailability of ICU beds. Staff perceptions of the interventions and factors contributed to sustainability. Results After a decline in elective surgeries being cancelled in the first year after t...
Background Older persons with polypharmacy are at increased risk of harm from medications. Theref... more Background Older persons with polypharmacy are at increased risk of harm from medications. Therefore, it is important that physicians and nurses, together with the persons, evaluate medications to avoid hazardous polypharmacy. It remains unclear how healthcare professionals experience such evaluations. This study aimed to explore physicians’ and nurses’ experiences from evaluations of older persons’ medications, and their related actions to manage concerns related to the evaluations. Method Individual interview data from 29 physicians and nurses were collected and analysed according to the critical incident technique. Results The medication evaluation for older persons was influenced by the working conditions (e.g. healthcare professionals’ clinical knowledge, experiences, and situational conditions) and working in partnership (e.g. cooperating around and with the older person). Actions taken to manage these evaluations were related to working with a plan (e.g. performing day-to-day...
Modern health-care is a complex socio-technical system, and as such variability is normal and nec... more Modern health-care is a complex socio-technical system, and as such variability is normal and necessary. The ability of a complex system such as health-care to quickly and correctly adapt to varying circumstances is crucial to how well the system works. Both increased compliance to guidelines, and a concurrent ability in individuals to deviate from these guidelines in certain situations, can be expected to increase safety. Today, we know too little about these adaptations, and how they affect safety. New knowledge is needed to describe and understand complexity and variability in health-care. FRAM (Functional Resonance Analysis Method) is one such method.
BACKGROUND The work environment is a complex phenomenon in which many factors interact. Scientifi... more BACKGROUND The work environment is a complex phenomenon in which many factors interact. Scientific research indicates a relation between the work environment and employee health, staff turnover, patient satisfaction and patient safety. There is a great need for knowledge on how to conduct work environment interventions and practical work environment management to maximize benefits to the employees. OBJECTIVE The aim of this study is to explore how occupational health service support will affect the work environment, sick leave, staff turnover, patient satisfaction and patient safety during and following the Covid-19 pandemic in a medical ward setting. METHODS Mixed methods evaluation of a concurrent work environment quality improvement project at the Department of Internal Medicine and Geriatrics in a local hospital in the south of Sweden. RESULTS The mixed methods evaluation of the quality improvement project received funding from FUTURUM – Academy for Health and Care Jönköping Cou...
Journal of Health Organization and Management, 2021
PurposeThe purpose of this paper is to inductively explore the context-specific preconditions for... more PurposeThe purpose of this paper is to inductively explore the context-specific preconditions for nurses' perceived organizational support (POS) in healthcare organizations.Design/methodology/approachA qualitative interview study was performed, based on the critical incident technique (CIT), with 24 registered nurses in different specialities of hospital care.FindingsThe nurses perceived three actors as essential for their POS: the first-line manager, the overarching organization and their college. The preconditions affecting the nurses’ perceptions of organizational support were supportive structuring and structures at work, as well as individual recognition and professional acknowledgement.Originality/valuePrevious studies of POS have mostly had a quantitative outset. In this paper, context-specific preconditions for nurses' POS are described in depth, enabled by the qualitative approach of the study. The findings may be used to guide healthcare organizations and managers ...
ObjectivesTo explore how mandatory reporting to the supervisory authority of suicides among recip... more ObjectivesTo explore how mandatory reporting to the supervisory authority of suicides among recipients of healthcare services has influenced associated investigations conducted by the healthcare services, the lessons obtained and whether any suicide-prevention-related improvements in terms of patient safety had followed.Design and settingsRetrospective study of reports from Swedish primary and secondary healthcare to the supervisory authority after suicide.ParticipantsCohort 1: the cases reported to the supervisory authority in 2006, from the time the reporting of suicides became mandatory, to 2007 (n=279). Cohort 2: the cases reported in 2015, a period of well-established reporting (n=436). Cohort 3: the cases reported from September 2017, which was the time the law regarding reporting was removed, to November 2019 (n=316).Primary and secondary outcome measuresDemographic data and received treatment in the months preceding suicide were registered. Reported deficiencies in healthcar...
Background Health care workers (HCWs) are at high risk of occupational injuries and approximately... more Background Health care workers (HCWs) are at high risk of occupational injuries and approximately 10-15% of patients are affected by an adverse event during their hospital stay. There is scarce scientific literature about how HCWs manage these risks in practice and what support they need. This knowledge is needed to improve safety for patients and HCWs. This study explores HCWs’ experiences of workplace incidents that led to injury or posed a risk of patient and worker injury, with focus on HCWs’ actions and emotions.Methods This study employed a qualitative design using the critical incident technique. Semi-structured individual interviews were held with 34 HCWs from three regions in Sweden. Data were analysed using inductive category development. Results Altogether 71 workplace incidents were reported. The analysis of two dimensions – actions HCWs take and emotions they feel when a workplace incident occurs – yielded two main areas each: HCWs’ actions, actions by the team and mana...
Region Jönköping County (RJC) in Sweden is a healthcare system that is characterised by sustainab... more Region Jönköping County (RJC) in Sweden is a healthcare system that is characterised by sustainable work with quality in healthcare and long-term system-wide improvement. This article describes important factors behind the improvement work in RJC, and how the improvement methods and initiatives have been adopted also in mental healthcare. For example, patients otherwise eligible for admission to a psychiatric department were treated at home after introduction of home treatment teams. Patient satisfaction was high and the number of visits to the emergency department, hospital admissions and hospital stay decreased.
ObjectivesThe overall aim of this study was to aggregate the conclusions of all investigations co... more ObjectivesThe overall aim of this study was to aggregate the conclusions of all investigations conducted after suicides reported to the supervisory authority in Sweden in 2015, and to identify deficiencies in healthcare found in these investigations; the actions proposed to deal with the deficiencies; the level of the organisational hierarchy (micro–meso–macro) in which the deficiencies and actions were situated; and outcomes of the supervisory authority’s decisions.Design and settingThis is a retrospective study of all reports from Swedish primary and secondary healthcare after suicide to the regulatory authority in Sweden in 2015.ResultsIn 55% (n=240) of cases, healthcare providers reported healthcare deficiencies that contributed to suicide; these deficiencies were primarily in ‘suicide risk assessment’ and ‘treatment’. Actions aimed at preventing new suicides were proposed in 80% of cases (n=347). By far, the most frequent actions were ‘education and competence’, present in 52% ...
Background Incidental gallbladder cancer is a rare event, and its prognosis is largely affected b... more Background Incidental gallbladder cancer is a rare event, and its prognosis is largely affected by the tumour stage and treatment. The aim of this study was to analyse the management, treatment and survival of patients with incidental gallbladder cancer in a national cohort over a decade. Methods Patients were identified through the Swedish Registry of Gallstone Surgery (GallRiks). Data were cross-linked to the national registry for liver surgery (SweLiv) and the Cancer Registry. Medical records were collected if registry data were missing. Survival was measured as disease-specific survival. The study was divided into two intervals (2007–2011 and 2012–2016) to evaluate changes over time. Results In total, 249 patients were identified with incidental gallbladder cancer, of whom 92 (36·9 per cent) underwent re-resection with curative intent. For patients with pT2 and pT3 disease, median disease-specific survival improved after re-resection (12·4 versus 44·1 months for pT2, and 9·7 ver...
Background To reduce patient harm, healthcare has focused on improvement based on learning from e... more Background To reduce patient harm, healthcare has focused on improvement based on learning from errors and adverse events (Safety-I). Daily huddles with staff are used to support incident reporting and learning in healthcare. It is proposed that learning for improvement should also be based on situations where work goes well (Safety-II); daily safety huddles should also reflect this approach. A Safety-II-inspired model for safety huddles was developed and implemented at the Neonatal Care Unit at a regional hospital in Sweden. This study followed the implementation with the research questions: Do patient safety huddles with a focus on Safety-II affect the results of measurements of the patient safety culture? What are the experiences of these huddles amongst staff? What experiences of everyday work arise in the patient safety huddles? Methods A multi-method approach was used. The quantitative part consisted of a questionnaire (151 items), submitted on four different occasions, and an...
Knowledge about safety in complex systems are growing and health care is a complex system that is... more Knowledge about safety in complex systems are growing and health care is a complex system that is both developing and under pressure. Therefore, patient safety work also has to develop. Basic conditions for safe performance are important: management that values safety, good working conditions, safety culture, adequate staffing and competence, and equipment that facilitates safe practice. Patients and relatives can play a more active role in patient safety work. Safety-II is a valuable new approach to patient safety. The Swedish National Board of Health and Welfare now launches a national action plan for patient safety that addresses these challenges and opportunities.
The adaptation of the healthcare needed in the covid-19 pandemic poses challenges to patient safe... more The adaptation of the healthcare needed in the covid-19 pandemic poses challenges to patient safety. Proactive patient safety work must continue even under conditions such as a pandemic. Methods are needed that assess and support patient safety as the work is carried out. Patient safety in real time appears to be such a useful method in which patient record review to identify patient harm is combined with interviews with patients and healthcare staff. The method was used in wards and intensive care units (ICU) for covid-19 patients in Region Jönköping County. Patient harm was found in ICU care. Patients were overall satisfied with the care, and in the interviews with healthcare staff areas for improvement were identified. Valid indicators for patient record review to evaluate patient harm in covid-19 need to be developed. To judge if patient harm in care of a Covid-19 is avoidable or not is difficult since the level of knowledge and treatment principles in the disease develops very ...
"I trust my physician but want to be involved" - Older persons' Experiences of reg... more "I trust my physician but want to be involved" - Older persons' Experiences of regarding evaluation of their medication treatment
Modern health-care is a complex socio-technical system, and as such variability is normal and nec... more Modern health-care is a complex socio-technical system, and as such variability is normal and necessary. The ability of a complex system such as health-care to quickly and correctly adapt to varying circumstances is crucial to how well the system works. Both increased compliance to guidelines, and a concurrent ability in individuals to deviate from these guidelines in certain situations, can be expected to increase safety. Today, we know too little about these adaptations, and how they affect safety. New knowledge is needed to describe and understand complexity and variability in health-care. FRAM (Functional Resonance Analysis Method) is one such method.
Objective In 2014, an escalation plan and morning handover meetings were implemented in an intens... more Objective In 2014, an escalation plan and morning handover meetings were implemented in an intensive care unit (ICU) to reduce access block for post-operative care. In this study, the improvement intervention is revisited 5 years on with the objective to see if the changes are sustained and to understand factors contributing to sustainability. Design A mixed-method approach was used, with quantitative analysis of ICU administrative data and qualitative analysis of interviews with hospital management and ICU staff. Setting ICU with mixed surgical and non-surgical cases in a regional hospital in Australia. Participants Interview participants: ICU nurses (four), ICU doctors (four) and hospital management (four). Main outcome measures Monthly number of elective surgeries were cancelled due to unavailability of ICU beds. Staff perceptions of the interventions and factors contributed to sustainability. Results After a decline in elective surgeries being cancelled in the first year after t...
Background Older persons with polypharmacy are at increased risk of harm from medications. Theref... more Background Older persons with polypharmacy are at increased risk of harm from medications. Therefore, it is important that physicians and nurses, together with the persons, evaluate medications to avoid hazardous polypharmacy. It remains unclear how healthcare professionals experience such evaluations. This study aimed to explore physicians’ and nurses’ experiences from evaluations of older persons’ medications, and their related actions to manage concerns related to the evaluations. Method Individual interview data from 29 physicians and nurses were collected and analysed according to the critical incident technique. Results The medication evaluation for older persons was influenced by the working conditions (e.g. healthcare professionals’ clinical knowledge, experiences, and situational conditions) and working in partnership (e.g. cooperating around and with the older person). Actions taken to manage these evaluations were related to working with a plan (e.g. performing day-to-day...
Modern health-care is a complex socio-technical system, and as such variability is normal and nec... more Modern health-care is a complex socio-technical system, and as such variability is normal and necessary. The ability of a complex system such as health-care to quickly and correctly adapt to varying circumstances is crucial to how well the system works. Both increased compliance to guidelines, and a concurrent ability in individuals to deviate from these guidelines in certain situations, can be expected to increase safety. Today, we know too little about these adaptations, and how they affect safety. New knowledge is needed to describe and understand complexity and variability in health-care. FRAM (Functional Resonance Analysis Method) is one such method.
BACKGROUND The work environment is a complex phenomenon in which many factors interact. Scientifi... more BACKGROUND The work environment is a complex phenomenon in which many factors interact. Scientific research indicates a relation between the work environment and employee health, staff turnover, patient satisfaction and patient safety. There is a great need for knowledge on how to conduct work environment interventions and practical work environment management to maximize benefits to the employees. OBJECTIVE The aim of this study is to explore how occupational health service support will affect the work environment, sick leave, staff turnover, patient satisfaction and patient safety during and following the Covid-19 pandemic in a medical ward setting. METHODS Mixed methods evaluation of a concurrent work environment quality improvement project at the Department of Internal Medicine and Geriatrics in a local hospital in the south of Sweden. RESULTS The mixed methods evaluation of the quality improvement project received funding from FUTURUM – Academy for Health and Care Jönköping Cou...
Journal of Health Organization and Management, 2021
PurposeThe purpose of this paper is to inductively explore the context-specific preconditions for... more PurposeThe purpose of this paper is to inductively explore the context-specific preconditions for nurses' perceived organizational support (POS) in healthcare organizations.Design/methodology/approachA qualitative interview study was performed, based on the critical incident technique (CIT), with 24 registered nurses in different specialities of hospital care.FindingsThe nurses perceived three actors as essential for their POS: the first-line manager, the overarching organization and their college. The preconditions affecting the nurses’ perceptions of organizational support were supportive structuring and structures at work, as well as individual recognition and professional acknowledgement.Originality/valuePrevious studies of POS have mostly had a quantitative outset. In this paper, context-specific preconditions for nurses' POS are described in depth, enabled by the qualitative approach of the study. The findings may be used to guide healthcare organizations and managers ...
ObjectivesTo explore how mandatory reporting to the supervisory authority of suicides among recip... more ObjectivesTo explore how mandatory reporting to the supervisory authority of suicides among recipients of healthcare services has influenced associated investigations conducted by the healthcare services, the lessons obtained and whether any suicide-prevention-related improvements in terms of patient safety had followed.Design and settingsRetrospective study of reports from Swedish primary and secondary healthcare to the supervisory authority after suicide.ParticipantsCohort 1: the cases reported to the supervisory authority in 2006, from the time the reporting of suicides became mandatory, to 2007 (n=279). Cohort 2: the cases reported in 2015, a period of well-established reporting (n=436). Cohort 3: the cases reported from September 2017, which was the time the law regarding reporting was removed, to November 2019 (n=316).Primary and secondary outcome measuresDemographic data and received treatment in the months preceding suicide were registered. Reported deficiencies in healthcar...
Background Health care workers (HCWs) are at high risk of occupational injuries and approximately... more Background Health care workers (HCWs) are at high risk of occupational injuries and approximately 10-15% of patients are affected by an adverse event during their hospital stay. There is scarce scientific literature about how HCWs manage these risks in practice and what support they need. This knowledge is needed to improve safety for patients and HCWs. This study explores HCWs’ experiences of workplace incidents that led to injury or posed a risk of patient and worker injury, with focus on HCWs’ actions and emotions.Methods This study employed a qualitative design using the critical incident technique. Semi-structured individual interviews were held with 34 HCWs from three regions in Sweden. Data were analysed using inductive category development. Results Altogether 71 workplace incidents were reported. The analysis of two dimensions – actions HCWs take and emotions they feel when a workplace incident occurs – yielded two main areas each: HCWs’ actions, actions by the team and mana...
Region Jönköping County (RJC) in Sweden is a healthcare system that is characterised by sustainab... more Region Jönköping County (RJC) in Sweden is a healthcare system that is characterised by sustainable work with quality in healthcare and long-term system-wide improvement. This article describes important factors behind the improvement work in RJC, and how the improvement methods and initiatives have been adopted also in mental healthcare. For example, patients otherwise eligible for admission to a psychiatric department were treated at home after introduction of home treatment teams. Patient satisfaction was high and the number of visits to the emergency department, hospital admissions and hospital stay decreased.
ObjectivesThe overall aim of this study was to aggregate the conclusions of all investigations co... more ObjectivesThe overall aim of this study was to aggregate the conclusions of all investigations conducted after suicides reported to the supervisory authority in Sweden in 2015, and to identify deficiencies in healthcare found in these investigations; the actions proposed to deal with the deficiencies; the level of the organisational hierarchy (micro–meso–macro) in which the deficiencies and actions were situated; and outcomes of the supervisory authority’s decisions.Design and settingThis is a retrospective study of all reports from Swedish primary and secondary healthcare after suicide to the regulatory authority in Sweden in 2015.ResultsIn 55% (n=240) of cases, healthcare providers reported healthcare deficiencies that contributed to suicide; these deficiencies were primarily in ‘suicide risk assessment’ and ‘treatment’. Actions aimed at preventing new suicides were proposed in 80% of cases (n=347). By far, the most frequent actions were ‘education and competence’, present in 52% ...
Background Incidental gallbladder cancer is a rare event, and its prognosis is largely affected b... more Background Incidental gallbladder cancer is a rare event, and its prognosis is largely affected by the tumour stage and treatment. The aim of this study was to analyse the management, treatment and survival of patients with incidental gallbladder cancer in a national cohort over a decade. Methods Patients were identified through the Swedish Registry of Gallstone Surgery (GallRiks). Data were cross-linked to the national registry for liver surgery (SweLiv) and the Cancer Registry. Medical records were collected if registry data were missing. Survival was measured as disease-specific survival. The study was divided into two intervals (2007–2011 and 2012–2016) to evaluate changes over time. Results In total, 249 patients were identified with incidental gallbladder cancer, of whom 92 (36·9 per cent) underwent re-resection with curative intent. For patients with pT2 and pT3 disease, median disease-specific survival improved after re-resection (12·4 versus 44·1 months for pT2, and 9·7 ver...
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Papers by Axel Ros