Patient participation in quality improvement: managers’ opinions of patients as resources


  • Ann-Christine Andersson,

    1. Authors:Ann-Christine Andersson, RN, Ph.Lic., PhD Candidate, Division of Quality Technology and Management, Linköping University, Linköping, Faculty of Health and Society, Malmö University, Malmö and Development Department, Kalmar County Council, Kalmar; Anna Olheden, RN, Strategic Improvement Officer, Development Department, Kalmar County Council, Kalmar, Sweden
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  • Anna Olheden

    1. Authors:Ann-Christine Andersson, RN, Ph.Lic., PhD Candidate, Division of Quality Technology and Management, Linköping University, Linköping, Faculty of Health and Society, Malmö University, Malmö and Development Department, Kalmar County Council, Kalmar; Anna Olheden, RN, Strategic Improvement Officer, Development Department, Kalmar County Council, Kalmar, Sweden
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Ann-Christine Andersson, Development Department, Kalmar County Council, Box 601, 39126 Kalmar, Sweden. Telephone: +46767762240.;

Aims and objectives

The aim of this study was to investigate managers’ opinions of how to take advantage of patients as resources in quality improvement work in the Swedish healthcare sector.


Quality improvement has lately become a ‘hot’ topic within the Swedish healthcare sector. In the Kalmar county council in south-east Sweden, a large-scale improvement programme was initiated in 2007. The aim is to become the safest county council in Sweden by 2014. Quality in health care is often measured in terms of patient safety. Health care has traditionally seen the patient as an ‘outcome’, but changing this view to begin using the patient as a ‘co-producer’ of healthcare quality improvement may be gaining ground (Lengnick-Hall 1996). Therefore, it is essential to find different ways to derive advantage from patient participation (Groll et al. 2005). The Swedish Association of Local Authorities and Regions (SALAR) has developed a programme to strengthen the role of patients by increasing their participation and influence (SALAR website,; accessed 28 September 2011). The programme is developed from the perspective of practice-based business development and has its focus on the patient and includes the following four steps: (1) capture experiences from both patients and personnel; (2) understand the benefits of those experiences; (3) identify possible improvements; and (4) implement the improvements. Different tools are suggested, such as Breakthrough and the Plan-Do-Study-Act wheel, flow charts and collecting patient stories. The importance of measuring and following up results as well as active, secured management is also emphasised as important to success (SALAR website,; accessed 28 September 2011). Studies on Swedish health care have shown that patients as a factor for improvements appeared far down on a ranking list, in ninth place, far below organisational factors such as optimal daily work and working environment issues (Olsson et al. 2003).

Methods and design

This study is a pilot, part of an ongoing evaluation of the county council improvement programme. Every year, all managers at all levels and representing all professions, from the county council director, heads of administrations and division managers, to unit and first-line managers, are invited to a managers meeting. All participating managers at this meeting in January 2011 were divided into 31 groups, including 300 of the total 330 managers in the county council. The groups were asked to write a short answer to the question, ‘How can I as a manager involve the patient to increase safety in health care by 2014?’ The 31 answers were analysed using a descriptive content analysis by both authors until consensus was reached (Graneheim & Lundman 2004). The result is presented in categories and subcategories.


The result shows the different aspects of how managers in a healthcare organisation (i.e. a county council) consider the options to incorporate patients in the improvement process. Four categories and 10 subcategories were identified (Table 1). The first, overall category was Culture, consisting of the subcategories Attitude and Actions. Attitude involves openness and permission to be involved, moving the perspective from the organisational view to the patient process view. Actions are about demands, requests and making use of patients’ ideas. All personnel are part of the culture in an organisation, and a positive, inviting culture is considered to have greater potential for success. The managers think that the organisation must become more open-minded and the managers themselves must create space for improvement work for both patients and personnel.

Table 1. Categories, subcategories and examples
  1. *The examples are translated into English by the authors.

CultureAttitudeTreating patients open-mindedly and invitingly; shifting perspectives
ActionsDemanding; encouraging; act proactively
ProceduresSecure the systemFeedback on cases that went wrong; secure drug administration and other treatments
Benefit from the patient’s viewsFollow-up talks and calls at discharge, follow-up dissatisfied patients and relatives
Individual nursingEncourage health and wellness training; individually adapted information and feedback/follow-up
MethodsDevelop the organisationUsing methods, such as focus group interviews and surveys; using patient narratives; open up citizen suggestions on website
Strengthen the patientAddress patient education in patient safety issues; specific theme lectures
CollaborationInternal/externalCooperate with patient associations; patients participating in care planning; incident analysis with patients and relatives
Internal/internalCooperation between units; propagate and spread good initiatives in the organisation; emphasise the Patient Safety Committee and use their cases to learn from
External/externalFacilitate patient groups to meet and exchange experiences without interference from health care

The category Procedures is about ways of working at a systematic level. The subcategory Secure the system brings up the importance of systematic handling to avoid errors, for example, drug handling. The next subcategory, Benefit from the patient’s views, is about having or introducing procedures to collect patient input, such as a private talk in connection with discharge. Individual nursing includes procedures about individual nursing care, such as right treatment for the right patient, documentation and individual care plans. This category contains information about suggestions of systematic ways to facilitate managers using patients as a resource.

Methods, the next category, includes the subcategories Develop the organisation and Strengthen the patient. This category differs from Procedures above in its focus on using and developing techniques to improve the structure. Develop the organisation describes how to use methods and techniques to collect the patients’ views, such as surveys and interviews. Strengthen the patient is about information and education to improve patient participation, such as lectures and groups for self-care.

The last category, Collaboration, is about interaction on different levels both inside and outside the organisation. As the subcategories show, these collaborations are to be found at different levels. Internal/external is between the healthcare organisation and patients, and this collaboration can be either passive or active from the patient’s point of view. An example of Internal/internal collaboration is cooperation between different (hospital) units, specialities and staff categories. External/external collaboration will take place without healthcare interference, such as when patient groups meet and exchange experiences. The category contains suggestions about how managers can create arenas for cooperation to improve quality and safety in health care.

Discussion and conclusion

The interest in involving patients in quality improvement has grown considerably in recent years. It was difficult, however, to find written material about the subject. Furthermore, looking at the term ‘patient participation’ there is major confusion. Most of what has been written is about participation in the patient’s own care, with almost nothing about patients taking an active part in improvement work. The confusion about the term ‘patient participation’ does not facilitate healthcare managers making the patient an active part of daily quality improvement work. If health care is to improve, which is necessary, there is great untapped potential in patients. The SALAR programme to strengthen the role of patients suggests a four-step method and emphasises putting the patient in focus (SALAR website,; accessed 28 September 2011). The first step (capturing experiences) is what most managers in our result focus on, suggesting the use of different methods. The other steps suggested were not as obvious in our result, perhaps because the managers have not came that far in their awareness of how to take advantage of patients’ experiences. Whether this can be seen as managers′ lacking competence in improvement knowledge cannot be stated in this study, but would be interesting to investigate further. The aim of the SALAR programme is to improve patient safety, which can be found in our result, in the subcategory Secure the system. However, increasing patient safety was not explicitly mentioned as a benefit of using patient experiences in our result. The conclusions of the present study are that there is a willingness amongst managers to make use of the patient’s point of view, but at the same time a lack of experience in how to make patients active participants.

Relevance to clinical practice

In this study, the managers stated that the healthcare organisation must be more open-minded, inviting and willing to change perspective toward patient processes. Managers can and must create space for improvement work for both patients and personnel and encourage everyone’s active participation. The suggested methods and procedures to make better use of patient ideas in improvement work, such as surveys or interviews, were not revolutionary, but starting to use the methods already known is a first step to increase awareness amongst healthcare personnel of the fact that patients are important resources in healthcare improvement work.

Key words

healthcare settings, managers’ opinions, patient participation, quality improvement


Both authors have contributed equally in analysis and manuscript preparation.

Conflict of interest

Both authors are employed by the county council, and have received no funding. There are no conflicts of interests that we, the authors, are aware of.

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