The data showed how alignment work was done in the here and now, but also in the short and long term, with both the past and future being present in the minds of top management team participants during discussions. It was noted during interviews, conversations, and meetings that a general approach permeated the organization, which enabled connecting actions, i.e., different forms of alignment work, occurring at different points in time, and connecting different types of knowledge across organizational borders and stakeholders. As putting this approach into practice requires work in practice, we present the categories of work and the general approach separately in the result’s section, since the general approach underpins the four categories of work. We suggest that the general approach can be seen as the soil through and/or upon which collaborative work, preventive work, supportive work, and contextualizing work grow into alignment.
In the following, categories of work will be presented with types of work as subcategories. Thereafter, the themes that constitute the general approach will be presented.
Categories of alignment work
Collaborative work
To align demand and capacity, top management was engaged in efforts to shift perspectives, seeing all the different parts of the system, as well as the bigger picture. Two types of collaborative work were identified, i.e., taking a systems view and working to enable collaboration.
Taking a systems view
To align demand and capacity, top management adopted a systems view, shifting their focus from details to “the bigger picture” and trying to look beyond organizational borders and focus on “the whole.” This was done in various ways in relation to different external and internal parts of the system, employees, and patients. For example, there were times when the top management teams deemed that some issues were better handled in another part of the system. In such cases, they would discuss which people were best suited to deal with these issues and how the management team could help and support this.
In discussing a new governmental initiative, “good quality local healthcare” it was mentioned that this was an issue for the whole system, not only a particular part of it:
It is not possible to strengthen primary care without sacrificing something else. Everyone needs to be able to raise their gaze and see the bigger picture in order for it to be possible to bring care closer to the patients. (Conv01)
Another way of taking a systems view was in relation to the employees. When discussing a new governmental initiative, it was thoroughly discussed how it would affect the work of the employees in practice:
“From the employees’ point of view … [will there be] too many changes and groups?” (RHCMT02)
This systems view also encompassed adaptability to patient needs. When discussing new ways of providing care, the different needs of patients were highlighted:
We have had very old people who have attended therapy online. But at the same time, we have those who want to meet their therapist in person. These choices differ and look different for different individuals … we need to take the perspectives of the patients into account. (RHCMT03)
Enabling collaboration
To align demand and capacity, the management teams needed knowledge and input from different parts of the healthcare system and for these parts to “work together.” This was achieved through active work in creating good relationships between stakeholders within and outside the healthcare system. In practice, creating and maintaining such relationships entailed not being afraid of “picking up the phone” and call another stakeholder, both to manage difficulties and to praise each other. Revealing how the different actors in the healthcare system worked “together,” one of the interviewees said:
I mean when hospital X received an award /…/ then [the manager of the hospital] called the surrounding municipalities. And told them: “Well, you helped us [to get this award] because you made sure we have the right patients at our hospital …” (Int01)
Another way to enable collaboration was trying to identify and align demand and capacity in the entire region, regardless of organizational borders. One example of this was identifying critical gaps between different organizations. Many different types of care providers and stakeholders operated in the studied healthcare region. Sometimes, it was not always clear which unit or organization could help a specific patient in the best way and how different stakeholders could collaborate. To help stakeholders overcome collaborative difficulties, meetings were organized and facilitated by top management, at which specific cases were brought up and discussed. One of the interviewees described this as follows:
So we looked at specific cases. The school services identified cases and psychiatric services identified cases, healthcare, like hospital care and social services identified cases, patient cases or student cases where the collaboration had failed, or cases where it had worked well. And then we anonymized them and then we discussed them in groups together. (Int02)
In this way, top management took responsibility for enabling collaboration – not leaving this entirely up to the managers at lower levels of the healthcare system. By studying and analyzing the capacities and demands of different stakeholders, they aimed to increase the region’s capacity to provide good care.
Preventive work
This category of work included ways of working preventively; to make sure patients end up in the right care facility and/or working with public health to prevent inhabitants from being patients in the future.
Working for public health
One way to align demand and capacity was related to the management of potential demands. Here top management conducted work activities aimed at preventing inhabitants future need of healthcare. One such effort involved investigating how various local stakeholders could contribute to health; for example, local libraries were asked how they could contribute to public health. In line with this, a general citizens perspective permeated the organization. Another example of this was a discussion at one of the management team meetings (RMT02) on how to promote public health among the inhabitants in the region. Here the focus of the discussion was the region’s own employees, since the region itself is a big employer. Supporting good health and good working environments for the employees in the Region was also seen as a tool to work preventively with public health as these employees were also seen as citizens. The discussion resulted in suggestions on how to work preventively through attracting and retaining personnel through supporting a good working environment.
Making it easy for citizens to access the appropriate care facility
In order to make the best use of the capacity available, given current demands, it was mentioned how the region needed to organize its services in a way that the inhabitants in the geographical area would find easy to navigate. In one of the regional health care managements meetings it was formulated like this:
… we have been too focused on our own ways of organizing things … it’s not the patients’ fault if they can’t find the way! (RHCMT01)
This was also mentioned at another RHCMT meeting:
We really need to drop the idea that it’s the patient who goes to the wrong place. It’s not the patient who gets it wrong, we’re the ones who create the system. (RHCMT04)
One of the interviewees expressed a similar view:
A department store would never blame the customers for going in the wrong direction. Obviously, we haven’t designed the healthcare system in an appropriate way that is adapted to suit patients’ care needs. (Int01)
Supportive work
This category of work represents work to support managers, on different levels of the health care system, so that they in turn can support their coworkers. This involved for example providing good working conditions and support for the managers on all levels in the Region.
Creating support for managers
Top management highlighted that the managers needed support and the right prerequisites, including administrative support, to be able to support their employees in their clinical work. The below quotes illustrate how top management aimed to support managers throughout the organization and help them identify the capacities needed to meet organizational demands.
During meetings and discussions, it was a strong focus on creating good work environment in the Region and that creating support structures for this was an organizational responsibility. For example, a survey on staff wellbeing and the work environment was distributed to all employees on a regular basis. At an RMT meeting, the managers discussed how the results from these surveys should be used as indicators of how the organization was functioning, rather than focusing on individuals’ performance:
We should try to drop the idea that the survey is an evaluation of the manager, it’s about the organizational level …It shouldn’t be a beauty pageant for the managers… (RMT01)
The same went for the employees:
We should never see an issue as connected only to any one individual … (RMT01)
During interviews and meetings, it was articulated that it should be “easy” to be a manager within the region, at all levels; to make it easy one interviewee explains how:
… we have /… / created checklists and agendas and made suggestions to avoid losing track of [important] aspects /… /. The work environment should be a top priority in all contexts and so on. We have worked a lot with these things. (Int03)
Contextualizing work
Here, work centered around managing the risk of just accepting indicators, initiatives, and trends, rather than putting them into their contexts. This work was seen as a way to align demand and capacity.
Making sense of data and other types of information
To manage future demands, gain insight into current capacities, and align the two, various types of measurements were used within the region. These were discussed at some length, as the ambition was to use the data generated in an appropriate way. The potential difficulties of using data to manage future demands were also discussed:
“Isn’t there a risk that we measure what we already do? What we want to do is make a real shift, right?” (RHCMT01)
Another discussion focused on the differences between “soft” and “hard” data, and how to manage these two to increase knowledge on current capacities and thereby better align demands and capacities. More specifically, the issue of care accessibility was discussed during a meeting:
“How should we move forward with the issue of accessibility … to avoid focusing only on what we measure … we need to have another discussion … we need to understand how care accessibility is experienced.” (RHCMT01)
One aspect that tied into how the Region reasoned about and managed data, was that they also created their own demands, which went beyond what was actually required of the region. One example of this concerned the patient experience of coordination: it was stated that this was an important indicator of good care that should be followed and measured and included in the regional plan on healthcare provision, which it was not at the time.
In other words, data alone were not seen as enough to manage future demands. Rather, what types of data were gathered and how they were used were important aspects for facilitating learning and adaption in the organization.
Translating concepts and management incentives
To find a resilient way of aligning demand and capacity, there was a clear ambition to discuss how new demands, government initiatives, and management trends in healthcare would impact the region and to contextualize them before deciding how to implement them (if at all). One common stance in the studied region was:
“We don’t buy into new concepts straight away.” (Conv01)
This was also mentioned during a meeting with the RHCMT:
… Maybe we need to start talking about what they [the concepts] mean … we need to take it one clinic at a time /…/ “what does this mean for you” … go to every clinic: “what could work for you? What does this look like at your place?” (RHCMT03)
Learning from experiences
During meetings, participants considered and discussed how past experiences from their region could be used for future learnings, and also how to learn from other healthcare regions. One example could be using best practices and models developed elsewhere (RMT01). During one meeting, the following questions were posed by a member of the RHCMT, illustrating how top management aimed to relate their own past experiences to current research, to enhance learning:
What did we learn from the “cancer implementation”? What does research tell us? Should a pilot be used or not? (RHCMT01)
The general approach in the Region
Three aspects were identified that together made up a general approach that permeated the entire region.
Focus on opportunities
Overall, a tendency to focus on the future and opportunities rather than on obstacles was seen in the data. Obviously, some obstacles existed and were mentioned, but these were put on a back burner, in favor of focusing on possibilities. For example, rather than dwelling on all the things that complicated collaboration, the focus was on what could be done despite the obstacles:
… all these organizational constraints that actually say you can't do this and you can't do that. You have different electronic medical record systems, and you have different laws that … Take for instance the social services – those laws versus the healthcare laws are not always compatible. But if you ignore what doesn't work and try to find what does, it's much easier. (Int02)
Building a stable foundation for the future
There was also a focus on “building on the past” – to learn from experiences and gain cohesion throughout the healthcare system:
… I mean, we're a big organization /…/ we have retained our ways of working /…/ always keeping an open dialogue /…/ There is a clear connection from the overall document describing our budget and plan, which is also a political document describing what, what we should do … /…/ And based on that, we operationalize it in all our central organizations /…/ … that creates cohesion. (Int01)
This way of building on previous experience was evident in the way the region was “working together.” This setup had been used within the region for a long time, and having an established way for stakeholders to collaborate within the healthcare system enabled smoother adaptation to new laws and regulations. For example, one interviewee said:
And now, when we are trying to change the way we work with regards to the new law on collaboration in discharge, which was introduced in January 2018 /…/ you clearly see the benefits of having an established platform for collaboration. We have had this collaboration [for several years]. It’s made it much easier to agree on how we [different types of actors] can do this together. (Int02)
Taking a reflective stance
During both RHCMT and RMT meetings, considerable time was regularly set aside for free reflection, during which participants were encouraged to freely discuss. These discussions showed how the possibility to be reflective was founded on trust between the meeting participants and the idea that everyone’s opinion was equally important. The reflections usually focused on a certain issue on the agenda, but themes varied from time to time. Multiple aspects contributed to the reflections, with participants helping each other to shift perspective from details to seeing the bigger picture. Together, they kept a focus on the overall purpose of providing good care to the region’s citizens.
It was noted how the perspectives of both employees, patients, and other stakeholders were raised during these reflections.
This reflective stance was also reflected in how the organization was described in a conversation with a management team member. According to that person, the region should be able to adapt to trends that “we do not even know about yet.” The management team member likened the region to a creature that could adapt in different ways: “walking around, lying flat, and climbing over things if needed”. The main point was that not all new trends should be implemented in the region, according to this participant.
“The region needs to have the capacity for learning and for reflection, to know when to adopt new trends and when to say no.” (Conv12)