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"This chapter focus on Norwegian healthcare policies and regulations for
care coordination and patient safety. The Norwegian Coordination Reform implemented
in 2012 emphasizes patient engagement, care pathways, and competence
development in municipal healthcare services. Moreover, protocols for division of
work tasks and collaboration between specialist and municipal healthcare services
are key aspects. The reform identifies fragmented health services and the lack of
coordinated care as main challenges. The authors introduce the concepts of care
coordination, continuity of care and patient handovers, and relate these to patient
safety. Results from a Norwegian observational study, identifying factors affecting
care coordination and patient safety in care transitions between hospital and municipal
care, are presented. Finally, the authors introduce relevant measures to improve
care coordination and patient safety, including the regulatory work and follow-up
of health services through nationwide audits performed by the Norwegian Board of
Health Supervision."

Resilience has become an important topic on the safety research agenda and in organizational practice. Most empirical work on resilience has been descriptive, identifying characteristics of work and organizing activity which allow organizations to cope with unexpected situations. Fewer studies have developed testable models and theories that can be used to support interventions aiming to increase resilience and improve safety. In addition, the absent integration of different system levels from individuals, teams, organizations, regulatory bodies, and policy level in theory and practice imply that mechanisms through which resilience is linked across complex systems are not yet well understood. Scientific efforts have been made to develop constructs and models that present relationships; however, these cannot be characterized as sufficient for theory building. There is a need for taking a broader look at resilience practices as a foundation for developing a theoretical framework that can help improve safety in complex systems. This book does not advocate for one definition or one field of research when talking about resilience; it does not assume that the use of resilience concepts is necessarily positive for safety. We encourage a broad approach, seeking inspiration across different scientific and practical domains for the purpose of further developing resilience at a theoretical and an operational level of relevance for different high-risk industries. The aim of the book is twofold: 1. To explore different approaches for operationalization of resilience across scientific disciplines and system levels. 2. To create a theoretical foundation for a resilience framework across scientific disciplines and system levels. By presenting chapters from leading international authors representing different research disciplines and practical fields we develop suggestions and inspiration for the research community and practitioners in high-risk industries. This book is Open Access under a CC-BY licence. ; Explores different approaches for operationalization of resilience across scientific disciplines and system levels Creates a theoretical foundation for a resilience framework across scientific disciplines and system levels Develops suggestions and inspiration for the research community and practitioners in high-risk industries Presents chapters from leading international authors representing different research disciplines and practical fields

Background The Quality Improvement Regulation was introduced to the Norwegian healthcare system in 2017 as a new national regulatory framework to support local quality and safety efforts in hospitals. A research-based response to this, was to develop a study with the overall research question: How does a new healthcare regulation implemented across three system levels contribute to adaptive capacity in hospital management of quality and safety? Based on development and implementation of the Quality Improvement Regulation, this study aims to synthesize findings across macro, meso, and micro-levels in the Norwegian healthcare system. Methods The multilevel embedded case study collected data by documents and interviews. A synthesizing approach to findings across subunits was applied in legal dogmatic and qualitative content analysis. Setting: three governmental macro-level bodies, three meso-level County Governors and three micro-level hospitals. Participants: seven macro-level regulators, 12 meso-level chief county medical officers/inspectors and 20 micro-level hospital managers/quality advisers. Results Based on a multilevel investigation, three themes were discovered. All system levels considered the Quality Improvement Regulation to facilitate adaptive capacity and recognized contextual flexibility as an important regulatory feature. Participants agreed on uncertainty and variation to hamper the ability to plan and anticipate risk. However, findings identified conflicting views amongst inspectors and hospital managers about their collaboration, with different perceptions of the impact of external inspection. The study found no changes in management- or clinical practices, nor substantial change in the external inspection approach due to the new regulatory framework. Conclusions The Quality Improvement Regulation facilitates adaptive capacity, contradicting the assumption that regulation and resilience are "hopeless opposites". However, governmental expectations to implementation and external inspection were not ...

BACKGROUND: The Quality Improvement Regulation was introduced to the Norwegian healthcare system in 2017 as a new national regulatory framework to support local quality and safety efforts in hospitals. A research-based response to this, was to develop a study with the overall research question: How does a new healthcare regulation implemented across three system levels contribute to adaptive capacity in hospital management of quality and safety? Based on development and implementation of the Quality Improvement Regulation, this study aims to synthesize findings across macro, meso, and micro-levels in the Norwegian healthcare system. METHODS: The multilevel embedded case study collected data by documents and interviews. A synthesizing approach to findings across subunits was applied in legal dogmatic and qualitative content analysis. Setting: three governmental macro-level bodies, three meso-level County Governors and three micro-level hospitals. Participants: seven macro-level regulators, 12 meso-level chief county medical officers/inspectors and 20 micro-level hospital managers/quality advisers. RESULTS: Based on a multilevel investigation, three themes were discovered. All system levels considered the Quality Improvement Regulation to facilitate adaptive capacity and recognized contextual flexibility as an important regulatory feature. Participants agreed on uncertainty and variation to hamper the ability to plan and anticipate risk. However, findings identified conflicting views amongst inspectors and hospital managers about their collaboration, with different perceptions of the impact of external inspection. The study found no changes in management- or clinical practices, nor substantial change in the external inspection approach due to the new regulatory framework. CONCLUSIONS: The Quality Improvement Regulation facilitates adaptive capacity, contradicting the assumption that regulation and resilience are "hopeless opposites". However, governmental expectations to implementation and external inspection were ...

OBJECTIVES: To explore hospital physicians' views on readmission and discharge processes in the interface between hospitals and municipalities. DESIGN: Qualitative case study. SETTING: The Norwegian healthcare system. PARTICIPANTS: Fifteen hospital physicians (residents and consultants) from one hospital, involved in the treatment and discharge of patients. RESULTS: The results of this study showed that patients were being discharged earlier, with more complex medical conditions, than they had been previously, and that discharges sometimes were perceived as premature. Insufficient capacity at the hospital resulted in pressure to discharge patients, but the primary healthcare service of the area was not always able to assume care of these patients. Communication between levels of the healthcare service was limited. The hospital stay summary was the most important, and sometimes only, form of communication between levels. The discharge process was described as complicated and was affected by healthcare personnel, by patients themselves and by aspects of the primary healthcare service. Early hospital discharges, poor communication between healthcare services and inadequacies in the discharge process were perceived to affect hospital readmissions. CONCLUSION: The results of this study provide a better understanding of hospital physicians' views on the discharge and hospital readmission processes in the interface between the hospital and the primary healthcare service. The study also identifies discrepancies in governmental requirements, reform regulations and current practices in municipalities and hospitals.

Objectives: The aim of this study was to explore if, and in what ways, there has been changes in the supervisory approach towards Norwegian hospitals, due to implementation of a new management and quality improvement Regulation. Moreover, we aimed to understand how inspectors' work promote or hamper resilience potentials of adaptive capacity and learning in hospitals. Methods: The study design is a case study of implementation and impact of the Regulation. We conducted- and analyzed three focus groups and two individual interviews with regulatory inspectors, recruited from three County Governor-offices who are responsible for implementation and supervision of the Regulation in Norwegian regions. Results: Data analysis resulted in five themes. Informants described no substantial change in their approach due to the Regulation. Regardless, data pointed to a development in their practices and expectations. Although the Norwegian Board of Health Supervision, at the national level, occasionally provides guidance, supervision is adapted to specific contexts and inspectors balance trade-offs. Informants expressed concern about the impact of supervision on hospital performance. Benefits and disadvantage with positive feedback from inspectors were debated. Inspectors could nurture learning by improving their follow-up and add more hospital self-assessment.Conclusions: A non-detailed regulatory framework such as the Regulation provides hospitals with room to maneuver, and self-assessment might reduce resource demands. The impact of supervision is scarce with an unfulfilled potential to learn from supervision. The Government could contribute to a shift in focus by instructing the County Governors to actively reflect on and communicate positive experiences from- and smart adaptations in hospital practice

The aim of this study was to explore if, and in what ways, there has been changes in the supervisory approach toward Norwegian hospitals due to the implementation of a new management and quality improvement regulation (Regulation on Management and Quality Improvement in the Healthcare Services, hereinafter referred to as "Quality Improvement Regulation"). Moreover, we aimed to understand how inspectors' work promotes or hampers resilience potentials of adaptive capacity and learning in hospitals. METHODS: The study design is a case study of implementation and impact of the Quality Improvement Regulation. We performed a document analysis, and conducted and analyzed 3 focus groups and 2 individual interviews with regulatory inspectors, recruited from 3 county governor offices who are responsible for implementation and supervision of the Quality Improvement Regulation in Norwegian regions. RESULTS: Data analysis resulted in 5 themes. Informants described no substantial change in their approach owing to the Quality Improvement Regulation. Regardless, data pointed to a development in their practices and expectations. Although the Norwegian Board of Health Supervision, at the national level, occasionally provides guidance, supervision is adapted to specific contexts and inspectors balance trade-offs. Informants expressed concern about the impact of supervision on hospital performance. Benefits and disadvantage with positive feedback from inspectors were debated. Inspectors could nurture learning by improving their follow-up and add more hospital self-assessment. CONCLUSIONS: A nondetailed regulatory framework such as the Quality Improvement Regulation provides hospitals with room to maneuver, and self-assessment might reduce resource demands. The impact of supervision is scarce with an unfulfilled potential to learn from supervision. The Government could contribute to a shift in focus by instructing the county governors to actively reflect on and communicate positive experiences from, and smart adaptations in, ...

BACKGROUND: The relationship between quality and safety regulation and resilience in healthcare has received little systematic scrutiny. Accordingly, this study examines the introduction of a new regulatory framework (the Quality Improvement Regulation) in Norway that aimed to focus on developing the capacity of hospitals to continually improve quality and safety. The overall aim of the study was to explore the governmental rationale and expectations in relation to the Quality Improvement Regulation, and how it could potentially influence the management of resilience in hospitals. The study applies resilience in healthcare and risk regulation as theoretical perspectives. METHODS: The design is a single embedded case study, investigating the Norwegian regulatory healthcare regime. Data was collected by approaching three regulatory bodies through formal letters, asking them to provide internal and public documents, and by searching through open Internet-sources. Based on this, we conducted a document analysis, supplemented by interviews with seven strategic informants in the regulatory bodies. RESULTS: The rationale for introducing the Quality Improvement Regulation focused on challenges associated with implementation, lack of management competencies; need to promote quality improvement as a managerial responsibility. Some informants worried that the generic regulatory design made it less helpful for managers and clinicians, others claimed a non-detailed regulation was key to make it fit all hospital-contexts. The Government expected hospital managers to obtain an overview of risks and to adapt risk management and quality improvement measures to their specific context and activities. CONCLUSIONS: Based on the rationale of making the Quality Improvement Regulation flexible to hospital context, encouraging the ability to anticipate local risks, along with expectations about the generic design as challenging for managers and clinicians, we found that the regulators did consider work as done as important when ...