Two different strategies to facilitate involvement in healthcare improvements: a Swedish county council initiative.

BACKGROUND: From a management point of view, there are many different approaches from which to choose to engage staff members in initiatives to improve performance.
OBJECTIVE: The present study evaluated how two different types of improvement strategies facilitate and encourage involvement of different professional groups in health-care organizations. METHODS/
DESIGN: Empirical data of two different types of strategies were collected within an improvement project in a County Council in Sweden. The data analysis was carried out through classifying the participants' profession, position, gender, and the organizational administration of which they were a part, in relation to their participation.
SETTING: An improvement project in a County Council in Sweden. PARTICIPANTS: Designed Improvement Processes consisted of n=105 teams and Intrapreneurship Projects of n=202 projects. INTERVENTION: Two different types of improvement strategies, Designed Improvement Processes and Intrapreneurship Projects. MAIN OUTCOME MEASURES: How two different types of improvement strategies facilitate and encourage involvement of different professional groups in healthcare organizations.
RESULTS: Nurses were the largest group participating in both improvement initiatives. Physicians were also well represented, although they seemed to prefer the less structured Intrapreneurship Projects approach. Assistant nurses, being the second largest staff group, were poorly represented in both initiatives. This indicates that the benefits and support for one group may push another group aside.
CONCLUSIONS: Managers need to give prerequisites and incentives for staff who do not participate in improvements to do so. Comparisons of different types of improvement initiatives are an underused research strategy that yields interesting and thoughtful results.

INTRODUCTION

Today's fast-paced world is increasingly characterized by continuous changes and efforts to leverage quality and efficiency of operations. From a management point of view, there are many degrees of freedom in how to engage in initiatives to improve performance. For instance, top-down approaches mostly involve actors at the center of the organization and tend to dismiss ideas and initiatives from local units with less influence and legitimacy.[1] In many situations, it is of importance to select an improvement strategy that engages certain groups. Strong professions and important stakeholders can either thwart or facilitate an incentive.[2,3] An important factor to understand, therefore, is that the way improvement initiatives are organized can both enable and constrain involvement. The present study aims to describe and evaluate how two different types of improvement strategies facilitate and encourage involvement of different professional groups in health-care organizations, while others could be locked out. An analysis of evaluation reports from the Health Foundation Improvement Program highlights two of ten challenges: the importance of stimulating participation and the risk of a lack of staff participation.[4] Berwick et al argue that healthcare systems face great challenges to motivate the staff to work with improvements.[5] One way to increase the engagement in improvement work is to dedicate specific professions (ie, physicians) as project leaders.[2] Other initiatives use different incentives to encourage healthcare staff improvements, like pay for performance (P4P)[6] or naming-and-shaming.[7] Another way to use incentives is to attract participation in improvement projects, not rewards for results or outcomes.[8] To our knowledge, little has been written about staff member involvement in improvement work, except for the importance of engaging physicians and other important stakeholders.[2,3]

TWO IMPROVEMENT STRATEGIES FROM A THEORETICAL PERSPECTIVE

In this study, two types of improvement initiatives are conceptualized and evaluated empirically. The first type is called Designed Improvement Processes and consists of a methodologically guided collaborative program, following the Breakthrough Series Collaborative.[9] The second type is called Intrapreneurship Projects and is characterized by a project methodology that is set by an intrapreneur in a rather free manner. These two models differ significantly in their assumptions of how to organize for improvements. To deepen the understanding of how Designed Improvement Processes and Intrapreneurship Projects have effects on who is engaging in improvement initiatives, the following assumptions are used. First, Designed Improvement Processes are defined as predefined structures that move improvement projects from start to finalization.[10] Second, the Intrapreneurship Projects are defined as activities in which individuals inside organizations pursue opportunities.[11]

Designed Improvement Processes

The Designed Improvement Process is a common way of organizing for improvement in organizations. It is used as an umbrella term for a wide range of arrangements that organizations adopt. For instance, the systematic use of quality improvement teams is one such process.[12] Their aim is to identify and analyze important “vital fews”[13] by using cross-functional problem-solving teams. Another similar type is DMAIC (Define, Measure, Analyze, Improve, and Control) projects in the context of Six Sigma. It offers a structured method for process improvements patterned after the Plan-Do-Check-Act (PDCA) cycle, which in turn was proposed by Shewhart.[14] In the healthcare sector, Breakthrough Series Collaborative methodology is used as a way to organize such improvement initiatives.[9] This approach is based on a structure in which healthcare teams from various organizations create a joint learning experience. Several members of the organization join collaborative efforts to solve a specific problem. Although such teams may consist of experts in quality methods, the emphasis is to organize people who have first-hand experience of the problem that the team effort is supposed to solve.[12]

Participants who implement Designed Improvement Processes are expected to follow a specific route that others have developed.[10] An important element is that the Designed Improvement Process is a strategic priority for management. By having a route by which participants may enter, the organization creates an infrastructure that is conducive to improvements, such as the Breakthrough Series Collaborative. As a strategic priority, management assigns legitimacy for participation in the Designed Improvement Processes.[15]

Intrapreneurship Projects

The Intrapreneurship Project is built on the idea that a champion with appropriate resources engages in constructive, goal-oriented activities that lead to change.[16] The Intrapreneurship Project is based on the premise that an intrapreneur has a solution to a specific problem within her organization, there is a space for play for the intrapreneur, and that the intrapreneur gains legitimacy through achievements recognized by the organization.[17]

An intrapreneur is a participant that brings about change within specific organizational contexts. An identified problem in organizational performance is thus the foundation for Intrapreneurship Projects. Such problems can be anything from technical solutions that don't seem to work properly[18] to organizational coordination[19] or clinical innovations.[20] The requirement for an intrapreneur to engage in problem solving is that there is freedom to act.[13] This implies that the intrapreneur has both the ability and necessary resources in the organizational environment to act. A problem can be anything that is generally conceived of by the members of the organization and does not necessarily need to be associated with the intrapreneur. The role of the intrapreneur is that of a participant that identifies designs and realizes a solution for this problem in specific projects.

The innovative actions depend on the intrapreneur's interests, competence, and acceptance by other members of the organization. Legitimacy for engaging in new activities is dependent on the informal social position the intrapreneur has created in the organization. Rövik suggests that social authority is of central importance for successful translation of new ideas into an organization.[21] The intrapreneur does not, however, operate in isolation. Bartlett and Dibben argue that the intrapreneur establishes authorization and political support from sponsors.[22] It is also assumed that the intrapreneur needs other people to design and realize ideas. An Intrapreneurship Project is therefore a collective achievement.

THE COUNTY COUNCIL IMPROVEMENT PROGRAM— THE EMPIRICAL CONTEXT

The study took place in a county council southeast of Sweden. In this healthcare organization, more than 6600 employees are divided into eight different organizational administrations: Primary Care, Somatic Specialist Care, Psychiatric Special Care, Facilities and Service, Information Technology (IT), Dental Care, Folk High Schools, and Support Organization. A large number of professions and staff categories are represented. Those could be classified into four different groups: healthcare staff (74%), dental care staff (6%), administrative staff (12%), and “other,” such as school personnel and support staff (8%).

An improvement program was initiated to encourage improvement initiatives and to spread the skills and knowledge in quality improvement in the organization. This program is financed by special grants that have been awarded by the County Council Delegate and coordinated by the top management team. All healthcare departments, primary healthcare centers, dental care centers and other units in the county council are invited to accomplish improvement projects in two different tracks: (1) applying for financial support for one's own improvement project (Intrapreneurship Projects) and (2) participating in the Breakthrough Series collaborative programs (Designed Improvement Processes).

METHODS

Sample and Data Collection

Data were drawn from (1) the applications in the Intrapreneurship Projects track and (2) a database connected to the Designed Improvement Processes track. The Intrapreneurship Projects data emerged from a total of 202 applications submitted from 2007 to 2009. The number of people involved was 230. The Designed Improvement Processes listed a total of 477 people participating from 2007 to 2010. The first author collected all data. The study was approved by the county council director and followed the ethical principles and general rules of good research. All data were treated confidentially and analyzed anonymously.

Data Analysis

The data analysis was carried out through classifying the participants' profession, position, gender, and the organizational administration of which they were a part. A categorization of the staff disciplines was made as follows: registered nurses including midwives; assistant nurses and caretakers; physicians; managers—healthcare staff; managers—support staff (eg, headmaster, library manager, communication manager, IT manager); other healthcare staff (eg, psychologists, physiotherapists, dieticians, medical secretaries); and other support staff (eg, business developers, educationalists, messengers, economists, IT personnel).

After categorization, descriptive (actual and relative frequencies) and inferential statistics (chi-square test) were used in the analysis. To evaluate participation, the staff groups were compared to the overall employees in that group to the degree to which they were statistically expected to participate. Expected values were statistically calculated using contingency tables.[23] The total number of people participating in the two tracks was 707, but some analysis was focused on healthcare staff only (n=609) due to the small sample sizes of other staff groups.

RESULTS

The largest group, Somatic Specialist Care, had the most people engaged in both types of improvement strategies. Of the n=202 Intrapreneurship Projects, 131 (65%) came from the Somatic Specialist Care administration. In the Designed Improvement Processes, the majority also came from Somatic Specialist Care, in total 59 of 105 (56%). In the Primary Care administration, 23 of the 29 primary care centers were engaged in Intrapreneurship Projects. In the Designed Improvement Processes, 22 teams from 12 of the primary care centers took part. Six primary care centers were not represented at all. The Psychiatric Specialist Care administration was represented with eight Intrapreneurship Project applications and 15 teams in the Designed Improvement Processes. All administrations were represented in Intrapreneurship Projects, even if IT and Folk High Schools accounted for only one project application each. Two administrations, IT and Dental Care, had no teams represented in the Designed Improvement Processes.

Most participants in both types of improvement strategies were healthcare staff, which is the largest staff group in the county council. Included in this group are physicians, registered nurses, assistant nurses, and caretakers. Table 1 provides an overview of the actual frequencies of the participants in both the Intrapreneurship Projects and Designed Improvement Processes strategies compared to the general number of employees in the county council. The table shows that of the total nurses and midwives employed in the county council (n=1931), 155 had participated in the Designed Improvement Processes and 64 in the Intrapreneurship Projects. Those comparisons were made between the most represented professions (nurses, assistant nurses, and physicians), healthcare managers, support staff managers, and other participants as one healthcare staff group and one group of support staff. The distribution between men and women is also shown in Table 1. A total of 230 people stood behind the 202 Intrapreneurship Projects, 70% (n=160) of them women, which corresponds to the overall gender distribution in the county council. The 75 granted Intrapreneurship Projects were produced by 81 people, mostly managers and physicians, 57 women and 24 men.

Table 1

Participants and Their Staff Categories Compared to the Overall Number of County Council Employees in That Category (Actual Frequencies, f)

	Intrapreneurship Project f (Women/Men)	Designed Improvement Processes f (Women/Men)	Overall in the County Councila f (Women/Men)
Nurses/midwives	64 (61/3)	155 (145/10)	1931 (1720/211)
Assistant nurses/caretakers	6b (6/0)	55 (47/8)	1451 (1226/225)
Physicians	44 (15/29)	53 (20/33)	683 (275/408)
Managers, healthcare staff	71c(45/26)	68 (55/13)	242 (175/68)
Managers, support staffd	9 (4/5)	11 (6/5)	51 (19/31)
Other healthcare staffe	10c (8/2)	83 (77/6)	1527 (1362/165)
Other support stafff	26 (22/4)	52 (38/14)	798 (495/303)
Total	230 (160/70)	477 (387/90)	6683 (5305/1378)

County council data from December 31, 2008.

P < .05,

P < .01, Chi2, df 4.

eg headmaster, library manager, communication manager, information technology (IT) manager.

eg, psychologists, physiotherapists, dieticians, medical secretaries.

eg, business developers, educationalists, messengers, economists, information technology personnel.

Except for assistant nurses, managers, and other healthcare staff, all profession groups participated to a degree statistically expected in the Intrapreneurship Projects track. Assistant nurses and other healthcare staff participated significantly less in Intrapreneurship Projects than would be statistically expected; only six of 202 Intrapreneurship Projects had an assistant nurse responsible for the application. Managers participated significantly more than expected in the Intrapreneurship Projects. The descriptive statistics indicated that nurses and assistant nurses were more likely to participate in the Designed Improvement Processes. Those trends are not statistically significant, however.

Female nurses are the largest staff group in the county council (25.7%) and are also the largest group of participants (29.1%). Overall, there are relatively more female nurses and female assistant nurses participating, but there are relatively more males from the physician group participating. The physicians in total are participating above their representation; 13.7% of the participants are physicians compared to 10.2% of the county council employees. Participation of health-care staff by percentages is shown in Table 2.

Table 2

Participants and Their Inclination to Participate in Quality Improvement (QI) Projects Categorized by Staff Categories and Gender, Healthcare Staff Only

	Intrapreneurship Project % (Women/Men)	Designed Improvement Processes % (Women/Men)	Total QI Participationa % (Women/Men)
Nurses/ midwives	3.3 (3.5/1.4)	8.0 (8.4/4.7)	11.3 (11.9/6.2)
Assistant nurses/ caretakers	0.4 (0.5/0)	3.8 (3.8/3.5)	4.2 (4.3/3.5)
Physicians	6.4 (5.4/7.1)	7.8 (7.2/8.0)	14.2 (12.7/15.1)
Managers healthcare staff	29.3 (25.7/38.2)	28.1 (31.4/19.1)	57.4 (57.1/57.4)
Other healthcare staffb	0.7 (0.6/1.2)	5.4 (5.7/3.6)	6.1 (6.2/4.8)

Percentages of the participation of the number of county council employees.

eg, psychologists, physiotherapists, dieticians, medical secretaries.

In Intrapreneurship Projects, healthcare managers were significantly more inclined to participate than expected (Table 1). Calculated as percentages, managers' participation in both improvement strategies was high (Table 2). A majority of the participating managers were registered nurses, followed by other staff members, such as physiotherapists, psychologists, and laboratory technologists (Table 3). There were no significant differences within the healthcare manager group in relation to profession; they were all participating as was statistically expected.

Table 3

Managers Participating in Quality Improvement Projects Divided Into the Largest Staff Categories (Actual Frequencies, f), Healthcare Staff Only

	Intrapreneurship Project f (Women/Men)	Designed Improvement Processes f (Women/Men)	Total f(Women/Men)
Nurses/midwives	43 (39/4)	49 (40/9)	92 (79/13)
Physicians	18 (1/17)	3 (1/2)	21 (2/19)
Other healthcare staffa	10 (5/5)	16 (14/2)	45 (28/17)
Total	71 (44/26)	68 (55/13)	158 (109/49)

eg, psychologists, physiotherapists, dieticians, medical secretaries.

The county council has a large number of women managers, but the higher up in the organization, the fewer women there are. Most women are first-level managers or the equivalent, and most nurse managers are found at this level. In the largest administration, Somatic Specialist Care, 75% of the managers are women and 58% are registered nurses.

DISCUSSION

The data analyzed in this study emanate from two different improvement models, Designed Improvement Processesand Intrapreneurship Projects, the methodology of the former following the Breakthrough Series Collaborative (BC) program, and the latter following Free Application projects (FA) based on local problems addressed with the applicant's own choice of methodology. Skytt et al states that offering programs that are structured differently gives participants the opportunity to choose what they think suits them best.[24] At the same time, there is a risk of excluding other professions, as we saw with the assistant nurses participating to a small extent in both initiatives but especially in the Intrapreneurship Projectsapproach.

Registered nurses are the largest staff group in the county council and are highly represented in both Intrapreneurship Projects and Designed Improvement Processes. They seem very willing to participate, which might indicate that registered nurses as a group are a good base for quality improvement work. Further, the results indicate that (male) physicians, especially in a management position, are more attracted to the Intrapreneurship Projects. This in turn might mean that one way to attract physicians into improvement work is by offering the possibility to figure out both objectives and methodology in a more “free” process. Another way, suggested by Thor, is to make physicians team leaders in improvement work.[2] Gunningberg et al found that low involvement from physicians was an unfavorable factor in improvement work.[25] Our study shows that the approach of offering different ways to participate might be an effective strategy to attract different staff categories, not least the physician group, which often is seen as an authority and therefore important to involve in the process.[2,3,21] Different approaches can also be a way to let the participants— the staff members who should accomplish change and improvement—have some influence on what to do and how to do it.

Dixon-Woods et al concluded that there is no miraculous way to improve healthcare.[4] On the contrary, multiple approaches are more likely to succeed. A study by Parker et al found that if participants felt they had some control, their work and efforts were positively affected.[26] They also conclude that physicians prefer autonomy. Mountford and Shojania stress that if physicians want to have control of and influence on improvements, they need to actively participate.[27] Nurses have already realized this, and as shown in both our study and in recent improvement literature, nurses are most likely to participate and easiest to motivate. The report “The Future of Nursing: Leading Change, Advancing Health”[28] points out that nurses have important and particular roles in the improvement of healthcare. As the largest staff group and having close contact with patients, nurses can easily and effectively improve quality, safety, and efficiency.

The results of our study do not show any clearly pronounced differences from a gender perspective when it comes to participation; representation is concordant with the overall county council gender distribution. However, the data so far point to the fact that teams led by female registered nurses and nurse managers were more successful in completing the projects (ie, producing a final report), as women are behind a vast majority of the finalization projects. Thor also found that women (in that case physicians) as team leaders were more successful than their male colleagues.[2] But results in this area seem divergent. Another study found no differences between male and female team leaders in performing successful improvement work.[29] Whether the difference in our study on this matter endures when more projects are finalized remains to be seen.

To change climate and culture, it is essential to erase the hierarchical organization, especially as it has been found to be an obstacle in improvement work.[30] Another important factor influencing participation and change is motivation; however, that was not investigated in this study. But the two different approaches can be seen as ways to try to motivate different professional groups. This is also shown, as physicians preferred the Intrapreneurship Projects, while assistant nurses seem to prefer a more guided approach and teamwork as the collaborative element in the Designated Improvement Processes. Incentives can be offered to motivate participation,[6,7] but it is difficult to incorporate improvement work in one's daily work, keeping professionals engaged beyond the project phase, as expressed by Batalden and Davidoff: “Everyone in healthcare really has two jobs when they come to work every day: to do their work and to improve it.”[31]

Management needs to be aware of risks when appealing to different professions; the benefits and support for one group may push another group aside.[4] Therefore, the approach of the county council improvement program examined in this study, involving different models, could offer a way to simultaneously appeal to different staff professions. Skytt et al found that programs with different approaches can reach almost equal results but have the benefit of offering different methods that appeal to different participants—in their case, first-line nurse managers.[24]

Our results indicate that the county council seems to be successful in encouraging managers, as 54.3% of the managers have participated in some way. One factor in the county council program's success when it comes to engaging staff and managers in improvement work might be the two different approaches offered. But at the same time, our results indicate that assistant nurses as a group might need extra motivational coaching to become active in structured improvement work and that they seem to prefer a collective, clearly guided approach. A challenge for the managers would be to give prerequisites and incentives for staff who do not participate to do so. The approach of comparing different types of improvement strategies is an interesting and valuable research strategy. Classifying the different improvement strategies into more general classes (such as Designed Improvement Processes and Intrapreneurship Projects) will also improve the ability to generalize the improvements into something that has validity outside the studied cases.