Mid Sweden University

The Swedish public sector in general, and healthcare specifically, is struggling with large deficits: 19 of 21 regions have large negative results in 2019. The demands made by the citizens and their elected politicians that healthcare should offer effective, accessible, good and equal care are difficult to meet. However, when it comes to emergency care, Swedish healthcare scores high on international rankings. The difficulties and challenges today lie in ensuring good and equal care for the large groups of people with multiple illnesses, and patients who need long-term care from different healthcare providers. A complicated system has become even more complex.

Organizational research has shown conflicts between different ways of working to improve and change the organization and the methods that support the daily work of providing healthcare services. Furthermore, quality research shows that there are knowledge gaps to be filled when it comes to understanding how complex problems should be handled and what kind of knowledge could contribute. This also applies to the tensions and conflicts that can arise when knowledge from patients, other professions and fields of knowledge must be integrated with the knowledge that the professions (physicians, nursing) possess. Several public organizations have in recent years also adopted methods, tools and approaches from the design field. Especially user involvement (human-centric), collaboration and visualization. Design research often highlights the methods which are favorable for handling complexity.

The overall purpose of this thesis was therefore to gain a deeper understanding of how the quality development work in healthcare is expressed and how it is affected when different perspectives of knowledge are integrated - with a focus on improvement knowledge, professional knowledge and design thinking. Since the purpose of the licentiate thesis was to gain a deeper understanding of what happens when new knowledge to develop quality in healthcare emerges, the method is based on a qualitative approach. Three research questions were formulated and led to three studies. The first study, a literature review, showed that there is limited research in the area but that there are indications that user involvement in development work affects employees' attitudes and values. In study number two, a case study was set up using design methods and involving users. The results showed tensions between the improvement work and the daily clinical operations. This tension could primarily be attributed to the conflict between faster and slowerxviprocesses (doing and thinking), when moving between different practicing skills (design, improvement and professional). The last study aimed to understand more about the management's view of this, relatively new knowledge (design) in healthcare, in relation to the traditional way to work with improvement and change. The result stresses that there are potential conflicts between the different fields of knowledge. But the interviews were also interpreted as showing the synergy effects that can arise when different practitioners meet, and the results also show that different ways of thinking can challenge the traditional ways of handling improvement and change in the development of healthcare.

The thesis result overall strengthens the research that shows that design can add another dimension to traditional improvement work in healthcare. However, there is also frustration about something which is perceived as more abstract and reflective and which can sometimes be slower than what the solutions-oriented professions, who work under great time pressure and with scarce resources, are used to. Furthermore, the thesis highlights the problem that also has been described in previous research and which signals the (in)ability to both share new knowledge and to absorb it.

A world of increasing uncertainty and global challenges is not in a possible future, it is here and now. The welfare system and healthcare organizations are particularly affected, with demands from citizens and politicians that healthcare should offer effective, accessible, good and equal care – welfare quality. Today, however, this is difficult to meet and/or exceed with the large decrease in resources if they are used as they always have been before.

The difficulties and challenges today lie in ensuring good and equal care for the large groups of people with multiple illnesses, and patients who need long-term care from different healthcare providers. An already complicated system has become even more complex. Quality- and organizational research has shown conflicts among different ways of working to improve, innovate and change the organization and the methods that support the daily work of providing healthcare services. Furthermore, quality research shows that there are knowledge gaps to be filled when it comes to understanding how complex problems should be handled and what kind of knowledge could contribute.

The overall purpose of this thesis was therefore to explore collaborative and participative perspectives and practices for healthcare quality development in times of transformational and complex change.

Since the purpose was exploratory, the methodology was based overall on a qualitative, interpretative and hermeneutical approach. Three research questions were formulated and led to four studies. The first study was a literature review, and this was followed by a second study, which was a case study influenced by experience-based co-design (EBCD). The third study, aimed at understanding the leader perspective, had a deep-interview design, and the final study followed transformational and complex change using scientific social media with an action research approach.

The thesis results overall strengthen the research that shows that participatory and collaborative approaches are needed to connect perspectives and bolster relations – factors that are shown in research as being necessary to navigate in complex change and transformation. Furthermore, the thesis shows how to facilitate navigating in a way that could increase opportunities to participate, be part of change and have agency. However, frustration is also found around methods and perspectives perceived as more abstract and reflective and which can sometimes be slower than what solutions-oriented professionals, who work under great time pressure and with scarce resources, are used to. Furthermore, the thesis highlights a problem that has also been described in previous research and that signals the (in)ability to both share new knowledge and to absorb it.

The thesis conclusion is that there is potential to meet up with a more dynamic way of relating to the concept of quality. Achieved by becoming a listening organization and acknowledging skills to assist in facilitating complex change – through reflection and action.