Purpose The Swedish health-care system currently implements cancer care pathways (CCPs) for better and more timely cancer diagnostics. The purpose of this paper is to elucidate and define “crowding out” effects associated with the CCP implementation. Design/methodology/approach A document study based on implementation reports and action plans from Swedish county councils (n = 21) and a case study in one county council were conducted. Qualitative data collection and analysis were used to acquire more knowledge about the “crowding out” effects associated with the CCP implementation. Findings Three effects discussed under “crowding out” were defined. The first effect, called the push-out effect, occurs when other patients have to wait for care longer in favour of CCP patients. Another effect is the inclusion effect, whereby “crowding out” is reduced for vulnerable patients due to the standardised procedures and criteria in the referral process. The final effect is the exclusion effect, where patients in need of cancer diagnostics are, for some reason, not referred to CCP. These patients are either not diagnosed at all or diagnosed outside CCP by a non-standard process, with the risk of longer waiting times. Originality/value “Crowding out” effects are an urgent topic related to CCP implementation. While these effects have been reported in international research studies, no shared definition has been established to describe them. The present paper creates a common base to measure the “crowding out” effects and support further development of CCPs to avoid the negative effects on waiting times.

Purpose How do organisations know which problems are worthy of their attention? Despite good intentions, many attempts to solve problems fail. One reason for this failure might be because of attempts to solve non-problems or to solve problems with insufficient means, a concept proposed by Deming as tampering. The purpose of this paper is to suggest a definition of tampering, outline what is currently known about possible practical implications of tampering and to suggest how to extend this knowledge by proposing an agenda for future research. Design/methodology/approach To fulfil the purpose, a narrative literature review was conducted. Findings Through this review, common aspects of what constitutes tampering are identified and the following definition is proposed: Tampering is a response to a perceived problem in the form of an action that is not directed at the fundamental cause of the problem, which leads to a deterioration of the process or the process output. In addition, recommendations are generated regarding how tampering manifests itself in practice and why tampering occurs. These recommendations could be studied in future research. Originality/value To the best of the authors’ knowledge, this is the first paper that suggests a revitalisation of tampering. The results presented in this paper form the basis for continued studies on how tampering in organisations can be understood, managed and prevented.

One of the central challenges for the healthcare system today is how to manage care for patients with complex needs. This patient group is not well-defined but covers patients with serious diseases and comorbidities, or with a limited ability to perform basic daily functions due to physical, mental or psychosocial challenges. This group has a high service and resource utilisation resulting in high costs for the healthcare system and, typically, poor health outcomes. To improve care for these patients, it is necessary to implement strategies to manage the differentiated care needs, the additional support needs, the uncertainty in care delivery, and the coordination needs of the involved providers and the patient. Care pathways are increasingly used internationally to make care more patient-centred and to structure and design care processes for individual patient groups. Important elements in care pathways include structuring care activities, by defining their content and sequence; coordinating between providers and professionals; and involving patients in their care process. In this thesis, care pathways are proposed as the overall strategy for managing care for patients with complex care needs. The purpose of this thesis is thus to contribute with knowledge on how care pathways can be managed for patients with complex care needs. This is achieved by analysing how the practices coordination, standardisation, customisation and personalisation can support management of care pathways and by discussing how these practices influence quality of care. The quality of care dimensions discussed are accessible, timely, equitable, and patient-centred care. The empirical context in this thesis is the Standardised Cancer Care Pathways (CCPs) which were implemented in Sweden from 2015 to 2018. CCPs is the umbrella term for the national initiative to shorten waiting times, decrease regional differences and reduce fragmentation in care processes. CCPs include elements such as diagnosis-specific pathways and guidelines, introduction of CPP coordinators, and mandatory reporting of waiting times. Focus has been on implementing care pathways for 31 cancer diagnoses in all Swedish healthcare regions. Both qualitative and quantitative research methods have been used. A case study was conducted to examine standardised and customised care pathways, and coordination and multidisciplinary work in care pathways. A document study of regional reports on CCPs was analysed to study effects of care pathways on accessibility, timeliness and equitability. Finally, a national survey was conducted to deepen the understanding of the role of coordination, as performed by coordinators, in care pathways. This thesis argues that standardised and customised care pathways should be combined to manage care for patients with complex care needs. The customised pathway in particular benefits patients with serious unspecific symptoms, unknown primary tumour or more complex care needs, while patients with care needs that can be treated independently of the main d...

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Some people's biggest dream is to climb the world's highest mountain, others to travel around the world. My dream was to become a PhD. A dream that I have a hard time believing that I have completed! It has been quite the adventure; an adventure I never could have completed alone. 'It takes a village to raise a child' and I have so many people to thank for contributing to this adventure. I might as well begin by thanking you for reading this dissertation! If we rewind to 2016, I would like to thank Jostein for asking me what I wanted to do after my engineering studies and for telling Bonnie about my dream. I am eternally grateful to you Bonnie, for believing in me and for everything you have taught me. Even though we did not complete this adventure together, you and our work mean a lot to me.Mattias, Jason and Idamy super-supervisor team! I will miss our meetings and how they were always filled with equal amount of laughter and fun as well as work. Well, sometimes it may have been more fun than work ☺ Mattias, I will never be able to express how grateful I am to you and HELIX for enabling me to continue to pursue my dream. You have taught me so much and I know that I would not have been the researcher or teacher I am today if it were not for you! Jason, it has been incredibly fun to share this whole adventure with you, going from taking doctoral courses together to you being my supervisor. Thank you for the professor's card joke, attending Academic Ceremonies and the horror movie tips. Ida, since the first time I met you in Elsinore, you have been a huge inspiration to me. I am so grateful that you wanted to be one of my supervisors. When you joined, my supervising team became complete! Thank you, Erik Eriksson, for reading an early draft of this dissertation and providing me with feedback that helped me improve it! Thank you, my work-Peter, for always being curious about my work, taking the time to discuss tampering and making me feel like a ★! Henrik, I am so happy to have you as my work-BFF! Thank you for always allowing me to come rushing into your room to pour my heart out. Your friendship means a lot! Maria H-B, I am so happy that we ended up working together, even though I did not follow your advice to pursue logistics. I look forward to many more long lunches and coffee breaks! I would also like to thank my fantastic colleagues at the Department of Logistics and Quality Management. When this adventure has been stressful and frustrating, you have always been there to cheer me on or provide support. I feel so lucky to work with such awesome people! To my dear family and friends. Thank you for your patience and for always being there for me. It has been some turbulent years professionally and privately, but you have stood by my side through it all. I will never be able to repay you for all the love and support, but I will spend my life trying. A special thanks to my home-Peter for your love and reminders that there is more to life than work. Lots of love to Frans and Albus for being the best distance-mode co...