Method Usefulness for Quality Improvement in Care
Doktorsavhandling, 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.



care complexity

social care

Quality improvement

health care

Vasa A, Vera Sandbergs Allé 8
Opponent: Prof. Boel Andersson Gäre, Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Sverige


Sara Dahlin

Chalmers, Teknikens ekonomi och organisation, Service Management and Logistics

Dahlin, S. Exploring the usefulness of Lexis diagrams for quality improvement

Process Mining for Quality Improvement: Propositions for Practice and Research

Quality management in health care,; Vol. 28(2019)p. 8-14

Artikel i vetenskaplig tidskrift

Relationship between patient costs and patient pathways

International Journal of Health Care Quality Assurance,; Vol. 32(2019)p. 246-261

Artikel i vetenskaplig tidskrift

Dahlin, S., Camén, C., Eriksson, H. Exploring criteria for quality improvement in care procurement

Dahlin, S., Camén, C. The use of business excellence models to foster quality improvement in public contractual relationships

The improvement of quality has long been an explicit aim for health care, and more recently for social care. Supporting this quest is the research field of quality improvement (QI), through which a vast set of methods are used by practitioners to plan for future care or acquire knowledge about given care and thereby enable relevant action for improvement. Many methods present simple graphics to enable understanding by everyone involved. Although this is effective, limited understanding of the complexity of care has been identified as one reason for care inefficiencies and preventable harm. This is important to address, as the care complexity is not only large but it is also increasing for different reasons, such as the current medical treatment development towards personalised care and an increase of elderly suffering from multi-sickness. In this thesis, I argue that QI needs to expand its method collection to include methods that support practitioners in their understanding of care complexity.

To explore their usefulness for QI, three methods describing care complexity have been studied in this thesis. Lexis diagram and process mining are taken from other research fields but are rather new to QI. They are used to visually describe the complexity of care processes. One method, the use of business excellence models, has already been demonstrated to be useful for describing the complexity of organisations but its usefulness for QI in the specific context of public care procurement is explored in this thesis. To ensure that the conclusions are relevant, the methods were explored in collaboration with practitioners.

The thesis contributes with three main conclusions. First, methods for QI may result in both evaluative and organisational benefits, which highlights the need to correctly match the method and care context. Second, the explored methods bring additional understanding of complexity compared to current methods when used in a similar setting. Third, not only do methods describing complexity support local improvement, but the new perspectives brought to the practitioners seem to develop their understanding of QI as well, which may facilitate future QI efforts.

Operationalisering, utvärdering och styrning av kvalitet vid upphandling av vård och omsorg

Forte (2013-0462), 2014-01-01 -- 2016-12-31.


Hälso- och sjukvårdsorganisation, hälsopolitik och hälsoekonomi


Hållbar utveckling

Innovation och entreprenörskap





Doktorsavhandlingar vid Chalmers tekniska högskola. Ny serie: 4685



Vasa A, Vera Sandbergs Allé 8

Opponent: Prof. Boel Andersson Gäre, Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Sverige

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