Table 3 Findings related to the health care contexts based on interviews with managers

Leadership

Financial conditions were found to affect both senior and front-line managers’ ability to work with quality improvement.

“ ..well, you can do things as long as you keep your budget, but it’s very hard…..I find that sometimes the budget is an obstacle.”

“So, the framework we are given is very governing. … to make ends meet in an organization, you need to do this kind of visit or that kind of treatment.”

The decision-making process at the units was described as two-tiered: decisions were made by the senior manager in consultation with the front line manager (at management level) or by the front-line manager in consultation with the staff (at clinical level).

“Yes, like education in this case… often we talk about it at the management board meetings … when there is something new… Should we send someone and what is the situation at the unit…then we have sent both occupational therapist and dietitian. In addition, I have had a few meetings with them, regarding what work material to order, what is reasonable… to go through with.”

The front-line managers were responsible for informing the staff about improvement initiatives determined at management level, and for leading the change of practice in collaboration with the staff.

“It may be X who initiates certain things, our senior manager too… Then it is up to the front line managers to proceed and, well, implement, in the units, I believe.”

Suggestions made by front-line managers and staff regarding changes in administrative and patient-related clinical routines then gained acceptance at management level where the final decisions were made.

“…if anyone has an idea, we have outpatient meetings where we can raise, perhaps, new…, if there are things related to the clinical routines that need to be changed”

“We can decide quite a lot on our own. And I can raise a topic with the members of the management board and ask, ‘do you think we can do this this way, is it a good idea’?”

Culture

While the staffs’ knowledge and support during change of practice were highly valued by the managers in some units, others found it hard to implement change due to a culture where the local staff was less inclined to change.

“Instead, it’s the staff members who sort of, well, see the possibilities and see when things don’t work.”

“…we introduce something …then, it takes time. There … there are old buildings with an old culture, not easy to alter…”

The managers acknowledged their staff for their competence and ability to plan and execute rehabilitation interventions independently.

“And I find that staff members are tremendously good at pointing out and noticing, making suggestions.”

Organizational structure

All units had experienced changes in their assignments concerning the provision of stroke-related rehabilitation interventions in out-patient care. within the last 6 months immediately prior to the start of the data collection

For some units, the change entailed a new assignment while others had been assigned an expanded or reduced assignment.

“And when we formed this new organization now, by adding home based rehabilitation..”

“And now the County Council claimed one full time employment, so it’s a big… well…”

The current assignments included interventions for patients with various diagnoses, including stroke.

“… the toughest change now is that……the stroke team’s assignment was expanded to a neuroteam, including other diagnoses in addition to stroke only.”

Evaluation

In all units, the evaluations at unit level were focused on health care production (e.g. number of patients and types of visits) rather than outcomes in terms of patients’ functioning and disability.

“And the number of visits, the number of follow-ups… so now we are working on reporting once a month. To be able to follow up on how much health care we provide.”

“…nothing standardized exists regarding that we do a good job.

Evaluation of patient outcomes was made on an individual level by the staff, after the rehabilitation intervention.

“We do follow-ups in the sense that… when you treat a patient you set a goal together with the patient. And then, you do an intervention that you agree on, together with the patient. And then, you perform the intervention that you agreed on and then, do the follow-up.”

No standardized procedures were used for evaluation of patient outcome.

“Well,….how we…sort of see that we really have a result. And this is where we sense that we don’t have a good, not yet, set, what we should use, really. So, it is a bit arbitrary.”

Facilitation

The front-line managers described themselves as being responsible for creating conditions that would facilitate change in their units, either through their interaction with staff or by appointing a facilitator from among the staff.

“Well, really, …it’s my job, I would say. Changes, improvements, are what I do at work.”

“…we do everything together with the staff to… I mean, they have the knowledge of how everything works.”

“And try to allocate different areas of responsibility, so that everybody has something. Sometimes I pick a few, when I sense that the others are not able.”

Evidence

The managers described various ways of staying informed about new scientific evidence available at the units. The staff was considered to be responsible for keeping themselves up-to-date.

“It’s the staff … really, you have two missions, you should do the job but you should also stay informed …I believe.”

According to the managers, the staff’s clinical experience and the identified needs of the patient were the primary approach used for guiding the clinical work.

“... patients and significant others, first of all. But really, secondly it’s the improvement propositions from employees, I mean, staff.”

New national guidelines were not always perceived as clinically useful. According to the managers, the staff was already working according to national guidelines, or the guidelines were considered impossible to implement, due to lack of resources.

“..that this administrative process, in itself, regarding implementation of guidelines, works a lot faster in real life practice.”

“evidence and guidelines are basically impossible to follow…there are no resources or personnel.”

Rehabilitation process

Financial conditions directed the outline of rehabilitation interventions. Reimbursement mechanisms in 1 area directed the rehabilitation intervention (by price tagging different rehabilitation interventions), whereas allocation of resources for rehabilitation was guided by budget in the other area.

“How the rehabilitation interventions are outlined is partly a matter of resources, really, for us it’s entirely a question of assignment. What are we assigned to do, what do the administrators and politicians want, in the end.”

“You can do things, as long as you stick to your budget.”

Standardized procedures to be used by staff during rehabilitation interventions were discussed by the front-line manager and staff. The standardization process was at different stages at the various units, and individual differences in the provision of the rehabilitation interventions was known, along with staff habits of using outdated routines.

“So there are large differences, that you need to identify, one may need to limit the interventions he/she provides and others may need to provide a bit more than before.”

“…instead, you end up in…this is how we are used to do it.”

The content of the interventions, provided during the rehabilitation sessions, were directed by staff competence as well as the interaction between staff and patient, focusing on the patient’s needs.

“Partly, it’s up to each professional’s competence and wishes, what you want to do. Honestly, this affects how you treat each patient.”

“…but….really, you need to see to, what needs do the patient have, this is what guides us, all the time.”