THESIS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY Patient involvement in quality improvement

Quality improvements (QI,) based on principles, practices, and tools developed in the manufacturing industry, is becoming a common approach in healthcare, as well as an increasing focus on patient involvement. Healthcare QI is driven by challenges such as future patients’ demand for higher quality of care and their desire to have an amplified impact on their health situation and care. Additional challenges include rapid technical development; decreasing resources, and expansion in the elderly population. Patient involvement in QI is growing as a means to increase the quality of care in healthcare settings; however, the field is still short of practical examples and research. This thesis explores the contributions and challenges of patient involvement in QI. The thesis is based on six appended papers, mainly based on action research (AR) in a specific hospital setting, where the research built on learning in action. Qualitative methods were predominantly used to generate the empirical material, although some quantitative methods were used. The findings demonstrate that patient involvement in QI makes a difference because patients can identify improvement areas that healthcare professionals may not. In addition, patient involvement illuminates the importance of viewing care from a patient perspective, which may help overcome existing gaps in the organizational structure, such as separation into specialist functions like different wards. The improvements reported in the appended papers address both technical (service delivered) and functional (how service was delivered) quality of care. In addition, patient involvement demands new ways of defining quality in healthcare. However, patient involvement in QI also presents challenges. First, patient involvement places patients and healthcare professionals in new roles as co-designers, which calls into question prevailing roles and relationships. Second, patient involvement in QI decreases power asymmetry in the relationship between healthcare professionals and patients. This power shift challenges healthcare professionals to revise their existing relationship to patients from one that creates value for patients to one that creates value with them. The research in this thesis contributes to an emerging science of improvement in healthcare; it makes a methodological contribution to AR and its use in combination with patient involvement in QI; and it provides practical examples of patient involvement in QI that can be of practical value to healthcare professionals.