Strategies to facilitate implementation and sustainability of large system transformations: a case study of a national program for improving quality of care for elderly people

Abstract

BackgroundLarge-scale change initiatives stimulating change in several organizational systems in the health and social care sector are challenging both to lead and evaluate. There is a lack of systematic research that can enrich our understanding of strategies to facilitate large system transformations in this sector. The purpose of this study was to examine the characteristics of core activities and strategies to facilitate implementation and change of a national program aimed at improving life for the most ill elderly people in Sweden. The program outcomes were also addressed to assess the impact of these strategies.MethodsA longitudinal case study design with multiple data collection methods was applied. Archival data (n = 795), interviews with key stakeholders (n = 11) and non-participant observations (n = 23) were analysed using content analysis. Outcome data was obtained from national quality registries.ResultsThis study presents an approach for implementing a large national change program that is characterized by initial flexibility and dynamism regarding content and facilitation strategies and a growing complexity over time requiring more structure and coordination. The description of activities and strategies show that the program management team engaged a variety of stakeholders and actor groups and accordingly used a palate of different strategies. The main strategies used to influence change in the target organisations were to use regional improvement coaches, regional strategic management teams, national quality registries, financial incentives and annually revised agreements. Interactive learning sessions, intense communication, monitor and measurements, and active involvement of different experts and stakeholders, including elderly people, complemented these strategies. Program outcomes showed steady progress in most of the five target areas, less so for the target of achieving coordinated care.ConclusionsThere is no blue-print on how to approach the challenging task of leading large scale change programs in complex contexts, but our conclusion is that more attention has to be given to the multidimensional strategies that program management need to consider. This multidimensionality comprises different strategies depending on types of actors, system levels, contextual factors, program progress over time, program content, types of learning and change processes, and the conditions for sustainability.

Enhancing policy implementation to improve healthcare practices: The role and strategies of hybrid national‐local support structures

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“…National quality registries have been proven to be useful in research and also identified as promising for improving healthcare practices . Whether or not the use of the NQRs, or other clinical databases, leads to actual improvement in clinical practice, or to what extent, is less known, but indications can be found . Data from NQRs are openly displayed online and form the basis for benchmarking for all regional and local care providers.…”

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“…), the United States (LaVela and Hill , Scott and Steinbinder , Tatman and Zauner ), Sweden (Nyström et al . ) and South Africa (Schneider et al . ).…”

“…Some studies employ theory to guide their analysis, particularly complexity theory (e.g. Datt ee and Barlow 2010, Nystr€ om et al 2014, Schneider et al 2014, diffusion of innovation theory (e.g. Macfarlane et al 2011), and realist evaluation (e.g.…”

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