Method Usefulness for Quality Improvement in Care
Doctoral thesis, 2019
Complexity in care arises from several concurrent sources, such as siloed care organisations and complex care processes handled by several medical specialities. Due to factors including the ongoing development of personalised care and increasingly older populations suffering from multi-sickness, care complexity can only be expected to increase. Simultaneously, organisational efficiency needs to be increased alongside this growing complexity. To address these challenges, there is a need to understand care complexity in order to drive care improvement.
Quality improvement (QI) aims to develop health and social care. Methods are central for QI by describing the care and thereby support i) planning for future care, ii) acquisition of knowledge and understanding of the current practice, and iii) prediction of the future of care from historical data. Methods for QI generally display data in a simple, graphic way, so that they are easy for practitioners to understand; however, this strong focus on simplicity may limit the understanding of care complexity and thereby reduce the support provided for QI. As QI research with a focus on methods describing care complexity is scarce, the purpose of this thesis is to explore the usefulness of methods describing care complexity for QI in care.
To fulfil this purpose, two research questions guided the analysis of the five appended papers. The first research question (What usefulness can visual methods describing care process complexity have for QI?) addresses the need to identify new methods describing care complexity where current methods are lacking. Two methods are chosen, guided by visual analytics theory: Lexis diagram and process mining. Two case studies and a literature review explore the usefulness of Lexis diagrams and process mining through visualisation of process variations at a patient and a population level, across groups and over time. The second research question (What usefulness can methods describing care organisation complexity have for QI in public procurement?) expands and explores the use of current methods describing complexity into the public care procurement context. First, the current state of QI in public care procurement is explored through an archival study, and next, a case study is conducted to explore the use of business excellence models to support QI in public care procurement. The thesis is guided by a pragmatic approach, leading to a mixed-methods approach and domain expert collaboration.
This thesis makes three main contributions. First, each method’s properties are connected to a set of evaluative and organisational benefits, revealing the possibility of and need for matching methods to the local contextual conditions and needs for QI. Subsequently, a framework for this task is presented. Second, the results on the explored methods describing care complexity yield additional understanding of variations and care systems across stakeholders compared to traditional methods used for QI in each context. Methods describing care complexity may, therefore, be useful to support QI efforts. Third, when methods describe care complexity, stakeholders might be supported in driving local QI efforts, and as the new perspectives seem to challenge their mental models, they also seem to develop their understanding of QI.
The findings and conclusions of this thesis primarily contribute to the QI research field but can also inform other research on Lexis diagrams, process mining, and public care procurement.