From MEDICAL MANAGEMENT CENTRE DEPARTMENT OF LEARNING, INFORMATICS, MANAGEMENT AND ETHICS Karolinska Institutet, Stockholm, Sweden

This thesis analyses a research and development pro ject on hip fracture care that was conducted between 2006 and 2010 at the Karolins ka University Hospital, Stockholm, Sweden. The thesis is a case study of th is change project that was intended to decrease the time to operation for hip fracture patients, to discharge these patients within 5 days of admission and to em power these patients in their post-operative care. Two sites of the hospital were us d: at Huddinge, the patients formed the study group; at Solna, the pati ents formed the control group. The general aim of the thesis is to advance our kno wledge of the facilitators and hindrances in organisational change by studying the hip fracture project. The thesis presents four studies that arose from the pr oj ct. Study I is a patient register study that describes the dem ographic characteristics of hip fracture patients and characteristics of the ir ospital care in Stockholm County in the years 1998-2007. Pettigrew and Whipp’s framework for managing change , d scribing context, process and content, was used as the basis of the a nalysis in Study II and Study III. Study II is a case study that analyses the change project a imed at improving hip fracture care in terms of the factors that facilita ted or hindered its outcomes. This study examines the dimensions of process and contex t. Study III evaluates the outcome of a novel intervention appr oach that used a new post-operative rehabilitation programme aimed at pa tient empowerment. This study examines the dimension of content in strategi c change. Study IV compares the costs and outcomes of the study group with those of the control group resulting from the two ways of organi si g hip fracture care. This study compares lengths of hospital stay and, using three costing measures, compares direct medical costs of such care. The thesis reaches the following conclusions: Between 1998 and 2007, in Stockholm County, the num ber of hip fracture patients and the length of their post-operative hos pital stays were constant even as the numbers of elderly persons increased considerab ly. Overall, the ratio of hip fracture patients to the general population decreas ed by 16% in these years. The attempt to redesign the care process at admissi on decreased the time to diagnosis and the waiting time because the nurses w rote the referrals to radiological examination. However, there was no inc rease in the rate of patients operated on within 24 hours of admission. A coordinated care model based on an individually d esigned, post-operative rehabilitation programme that included patient empo werment reduced the length of hospital stay, led to earlier returns to pre-acc ident housing, and was less costly than fragmented care. On the fifth day for discharge was an overly optimistic goal. Hip fracture patients cannot easily be compar ed to hip replacement patients even though the surgical methods in many cases are imilar. The findings may have implications for initiatives that are intended to optimise the organisation of care. It requires evaluation of improvement initiat ives, including the extent of top management commitment and the use of champions or c hange agents. The participation of all involved in such initiatives i essential. LIST OF PUBLICATIONS I. Löfgren, S., Ljunggren, G., Brommels, M. No ticking time bomb: Hospital utilisation of 28,528 hip fracture patients in Stoc kholm during 1998-2007. Scandinavian Journal of Public Health. 2010;38:41825 II. Löfgren S, Hansson J, Øvretveit J, Brommels M. Cont ext challenges the champion: Improving hip fracture care in a Swedish university hospital. International Journal of Health Care Quality Assura nce. Accepted for publication in Vol 25 Issue 2 III. Löfgren S, Flodin L, Ekström W, Hedström M, Lindber g L, Ryd L. Empowerment A way to improve post-operative rehab ilit tion for hip fracture patients? In manuscript IV. Löfgren S, Rehnberg C, Ljunggren G, Brommels M. A comparison of costs and outcomes of two models fo r organising hip fracture care. In manuscript