Eldercare is facing current demands to develop due to changing demographics with increasing populations of elderly over the age of 85 combined with smaller populations of young people able to provide care and contribute to care via their taxes. The need for development of quality and safety was highlighted during the COVID-19 pandemic. Swedish government subsidies aimed at developing municipalities responsible for publicly managed eldercare have only been evaluated to a limited extent and the realisation of visions of future eldercare is shrouded in mystery. The study aims to explore the development work and strategies in Swedish municipal eldercare organisations, specifically in terms of alignment between democratic visions at political and strategic levels and operationalisation at operational levels. 28 interviews with development leaders were conducted in 14 Swedish municipality organisations between March and October 2021. The interviews focused on supporting roles and functions, responsibilities and collaborations, visions and operationalisations, and the follow-up and evaluation of eldercare development. A thematic analysis resulted in the main theme "top-down handling of unmanageable alignment" and the subthemes "shaping a high road for change;" "sticking to visions, hopes, and respect for practice;" and "self-serving focus on politics." The quality of alignment strategies and putting the strategic vision into practice were related to organisation size and resources. A gap between strategic and operational levels was accentuated in terms of inconsistent responsibilities in following through with development projects and development being characterised by top-down initiatives and resources at the strategic level but strained implementation abilities at operational levels. Peripherally located change agents with legitimacy at multiple organisational levels are suggested to ease top-down as well as bottom-up drive, which could increase a vertical alignment of visions and practice.

The extensive needs for developments of eldercare addressing working conditions, care quality, influence, and safety was highlighted during the pandemic. This mixed-method study contribute with knowledge about capability-strengthening development work and its importance for trustworthy managerial work, before and during the COVID-19 pandemic. Questionnaire data and narratives from first-line managers immediately before (n = 284) and 16 months into the pandemic (n = 189), structured interviews with development leaders (n = 25), and documents were analyzed. The results identify different focuses of development work. Strategic-level development leaders focused the strengthening of old adults' capabilities. While operational-level leaders approached strengthening employees' capability. First-line managers' rating of their trustworthy managerial work decreased during the pandemic and was associated with their workload, development support and capability-strengthening projects focusing employees' resources. The study demonstrates the gap between strategic and the operational levels regarding understanding of capability set and needed resources for strengthening capabilities and trustworthy, integrated managerial work regarding safety, influence, and quality conditions for old adults and employees.

Background: In the last decade, research has highlighted the importance of interprofessional approaches to education and practice. Collaboration between medical practice and engineering has been identified as particularly relevant to developing accountable models for sustainable healthcare and overcoming increased specialization leading to professional barriers. This study aims to analyze insights and understanding expressed by nursing students and biomedical engineering students following a joint learning activity regarding a medical device used in the hospital setting.

Method: A qualitative approach deriving from a phenomenological view examined an interprofessional learning activity where the focus was on active integration and knowledge exchange.

Conclusion: The activity was expressed as a positive opportunity for getting insights into perspectives from other professional groups as well as insights into the importance of a system perspective in patient safety. The learning and insights listed in the evaluations included ideas about how the two professional groups could collaborate in the future.

Aim: The aim of this study was to examine potential benefits provided by dailyvisual management tool use and explore its association with systems performanceand working conditions among hospital nurses.Background: Visual management tools used in everyday work and improvementwork in health care theoretically contribute to shared understanding of complexwork systems and provide certain user benefits. Cognitive load, miscommunicationwithin and between professional groups, and pressure to engage in care processredesign add to nurses’ strained working conditions.Design: Quantitative longitudinal.Methods: Questionnaires were distributed at T0, (N = 948, 66% response rate), T1(N = 900, 70% response rate), and T2 (N = 621, 72% response rate) to nurses atfive hospitals. Three groups of users (daily users, start users, and non‐daily users)were compared by means T1–T2 (significance tested with Wilcoxon signed ranktest) and by mixed model repeated measures T0, T1, T2.Results: Daily use associated to better overview of work, collaboration, social capital,and clinical engagement. Job resources were rated higher by daily users. Mentalstress increased and development opportunities decreased over time among nondailyusers. There were associations between use and perceptions of systems performance,though the differences between groups were small.Conclusion: This study specifically explores visual management tool use in the hospitalsetting, which contributes to research by broadening the understanding of cognitive,social, and emotional benefits provided by visual management tool use. Dailyuse was associated to positive working conditions, small but positive differences insystems performance, and indicated a buffering effect on nurses’ mental stress.

Swedish healthcare has been subject to change efforts to increase efficiency in care processes. In the 2000-2010’s lean production has influenced healthcare with change approaches such as visual management tools to increase patient flows and efficiency. Most previous research on lean healthcare has focused single hospitals or departments as case studies focusing lean production as successful for efficiency, or “mean” production affecting the work environment. Focus in this thesis though is instead on what strategies and approaches hospitals use in their care process redesign and their associations with working conditions and systems performance. This thesis’ overall aim was to assess change strategies and change approaches at strategic and operative levels during care process redesign at hospitals, focusing organization of change agents and use of visual management tools, and its implica-tions for alignment, working conditions and systems performance. Four studies were conducted at five Swedish hospitals, whereof three had lean-inspired change strategies. One qualitative cross-sectional study, one quantitative longitudinal study and two mixed method longitudinal studies are included in the thesis. Data was collected over three years with semi-structured interviews, structured interviews, staff questionnaires, manager questionnaires and photo document-ation. Qualitative data were analyzed by content analysis. Quantitative data were analyzed with Wilcoxon tests, mixed models of repeated measurements, ANOVA, and linear regression models. Results showed strategies involve operative manag-ers as change drivers, supported by change agent functions. Change agents’ contribution to change depends on e.g. closeness to operative managers due to the change agents place in the healthcare hierarchy, and also clarity regarding roles and responsibilities in change. Change agents with a close collaboration with operative managers, have better preconditions to contribute to alignment between change strategies and change approaches. Hospital care units in the 2010’s tend to use lean-inspired operative change approaches also without working with change strategies based on lean. Operative lean approaches show associations with positive working conditions for healthcare professionals. Visual management tools as change strategy has potential to support collaboration and communication within and between organizational levels and is considered to contribute to systems performance and alignment. Visual management tools as a cognitive job resource for operative managers show associations with e.g. lower burnout and more functioning collaboration as well as daily use among nurses show associations with cognitive, social and emotional benefits, perceived systems performance and buffering mental stress. Change agents and use of visual management tools are considered as contributors for operative managers’ and healthcare professionals’ sustainable work during care process redesign.

Svensk sjukvård har länge varit föremål för omorganisationer för att öka effektiv-iteten i vården. Under 2000-2010-talen har sjukvården tagit intryck av lean produktion och prövat olika lean-metoder för att förbättra effektiviteten i patient-flöden. Forskning har studerat fram- eller motgångar vid enskilda vårdverksam-heters införande av lean, och hur införandet påverkat effektivitet och arbetsmiljö. Det kvarstår ett forskningsbehov avseende förändringsstrategier och tillvägagångs-sätt som används i sjukvården, och hur sambanden mellan strategi, tillvägagångs-sätt och arbetsförhållanden ser ut över tid. Syftet med denna avhandling var att undersöka strategier och tillvägagångssätt, som används vid vårdprocessutveckling på sjukhus. Syftet fokuserade organisering av förändringsledare och användningen av visualiseringsverktyg, och undersökte vilken innebörd det har för arbetsförhål-landen och upplevd effektivitet i arbetet för operativa chefer och sjukvårdsprofess-ionella, samt undersökte vilken innebörd det har för samsyn inom sjukhus gällande processutveckling. Fyra delstudier genomfördes vid fem svenska sjukhus, varav tre sjukhus hade lean som huvudinspiration vid vårdprocessutveckling. En kvalitativ tvärsnittsstudie, en kvantitativ longitudinell studie och två blandat kvalitativa och kvantitativa longitudinella studier har gjorts. Datainsamling genomfördes under tre år och bestod av; delvis strukturerade intervjuer, strukturerade intervjuer, med-arbetar- och chefsenkäter och observationer. Kvalitativa data analyserades med innehållsanalys, och kvantitativa data analyserades genom jämförelser inom och mellan grupper med Wilcoxon-tester, mixed models of repeated measurements, ANOVA, och linjär regressionsanalys. Resultaten visade att förändringsstrategier ofta innebär att ansvar för att driva vårdprocessutveckling läggs på operativa chef-er. Dessa kan ha stöd från förändringsledare vars möjligheter att stötta beror bland annat på den organisatoriska närheten till de operativa cheferna och på hur tydlig roll- och ansvarsfördelning man har i processutvecklingen. Förändringsledare i nära samarbete med operativa chefer, har bättre förutsättningar att bidra till sam-verkan mellan strategier och operativa tillvägagångssätt inom och mellan organisa-toriska nivåer på ett sjukhus. Vårdenheter på 2010-talet använder lean-inspirerade tillvägagångssätt i sitt praktiska processutvecklingsarbete, även utan en sjukhus-övergripande strategi att införa lean. Lean-inspirerade tillvägagångssätt visar sig ha samband med positiva arbetsförhållanden för sjukvårdsprofessionella. Visualiser-ing har potential att stötta samverkan mellan strategier och operativa tillväga-gångssätt, och därmed även kunna bidra till systemprestanda inom sjukhus. Vis-ualisering kan tolkas fungera som arbetsresurs för operativa chefer, då de med stöd av visualisering i sitt dagliga arbete generellt har lägre utmattning och bättre fungerande samarbeten. Under- och sjuksköterskors dagliga användning av visual-iseringsverktyg hade samband med upplevda kognitiva, sociala och emotionella fördelar samt något bättre upplevd systemprestanda. Visualisering visade även en tendens till att skydda mot mental stress. Förändringsledare och användning av visualiseringsverktyg tolkas som bidragande till operativa chefers och sjukvårds-professionellas hållbara arbete vid vårdprocessutveckling på sjukhus.

The Swedish health care system is reorienting towards horizontal organization for care processes. A main challenge is to engage health care clinicians in the process. The aim of this study was to assess engagement (i.e. attitudes and beliefs, the cognitive state and clinical engagement behaviour) among health care clinicians, and to investigate how engagement was related to work resources and demands during organizational redesign. A cohort study was conducted, using a questionnaire distributed to clinicians at five hospitals working with care process improvement approaches, two of them having implemented Lean production. The results show that kinds of engagement are interlinked and contribute to clinical engagement behaviour in quality of care and patient safety. Increased work resources have importance for engagements in organizational improvements, especially in top-down implementations. An extended work engagement model during organizational improvements in health care was supported. The model contributes to knowledge about how and when clinicians are mobilized to engage in organizational changes.

Many hospitals have recently implemented the management concept lean production. The aim of this study was to learn how and why three Swedish hospitals selected and developed their hospital-wide lean production strategies. Although previous research shows that the concept is implemented in various ways, there is limited research on how and why different hospitals choose different implementation strategies and if the chosen strategies contribute to sustainable participation in organizational development. A case study of three different Swedish hospitals implementing lean production was thus performed. We studied the content of the hospitals' selected implementation strategies, conditions and rationales behind their strategy selection, and how different organizational actors participated in the implementation. Qualitative interviews with 54 key actors at the studied hospitals were performed. In addition, a self-administered survey questionnaire to employees was answered at T1 (2012, n = 557), T2 (2013, n = 554), and T3 (2014, n = 366). The three studied hospitals chose different strategies for implementing lean production due to different contextual conditions and for different reasons. The hospital-wide implementation strategies were related to employees' interest and participation in lean production. The results show that many different actors at different organizational levels need to participate in lean production in order to sustain and diffuse change processes. Furthermore, broad motives including quality of care seem to be needed for engaging different professional groups.

Background: Swedish health care organizations (HCOs) are changing using management concepts such as Lean, in attempts of improving efficiency, quality of care and work environment. Since there are pre-conditional challenges for operative managers to engage in change, HCOs tend to assign supportive functions such as change agents (CAs) to facilitate change. Research on the use of CAs in HCOs is sparse, thus the aim of this study explores role assignments and conditions of formally appointed CAs contributing to care process redesign.

Methods: A purposive sample of three Swedish hospitals initiating Lean-inspired care process redesign during 2010–2011 was done. In-depth interviews were held with fifty-one key functions during change. Focus group interviews were conducted with thirty-eight health care professionals. Data were analysed by content analysis.

Results: Top managers’ goal was to have operative management responsible for change during care process redesign, with support from assigned CAs. Organizing of CAs varied concerning, e.g. their hierarchical positions, job descriptions and practices, and conditions to act as driving forces towards change. Being granted formal power, having earned legitimacy and credibility, clarity regarding roles and responsibilities in change; a good sense of timing and ability to build relationships and trust, were identified as beneficial for CAs to support change.

Conclusions: Role assignment and organizing of CAs varies. A position closer to the operative levels, formalized and clarified responsibilities, earned legitimacy and timing support adaptation and alignment of planned change, such as Lean-inspired care process redesign.