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Table 3 Main features and examples from the interviews

From: Tending to innovate in Swedish primary health care: a qualitative study

  Quotes from the interviews
1. Managing learning
• The leader strived to provide good conditions for creativity, and readiness to encourage experimentation. If I know that a patient is seeing a physician for varicose veins, I don’t hesitate to knock on the door after the examination, and ask the patient if I could examine her veins. That is how you learn. It is all about practicing. (Nurse assistant E)
• The leaders organized their accessibility, such as allocating consultation time for staff members´ questions during the workday. The manager has great faith in us and says that I am more qualified to handle certain patients than a physician. (Occupational therapist E)
• High demands were made on the staff to take professional responsibility and contribute to quality health care services. I have my own patients 2 days a week […] the doctor refers patients with minor hypertension to me, and I’m responsible for summoning patients for blood pressure checks and consultations about their lifestyle, diet, and physical activity. (Nurse assistant A)
• Time was provided to handle problems and hurdles in ordinary work, and fulfil the county council’s requirements of reporting two improvements per year. By offering proactive health activities, we teach patients more about how they function and contribute to public health. (Manager D)
• The leaders were highly goal-oriented and communicative about their vision. We will not pursuit profit in the welfare sector; we will reduce costs. (Manager B)
• The leaders’ appreciation for staff engagement was reinforced in different activities, such as arranging summer parties for the staff and families, monthly social coffee breaks together with the children, or an annual salary bonus. Our vision is to be the best primary care unit at providing good health care. (Care administrator A)
• A recurrent activity was to use lunch breaks, morning meetings or afternoon coffee breaks as educational settings. This was also a way to deepen the staffs’ awareness of conditions in the reform, such as performances that contribute to increased goal achievement. It (triage) is somewhat of a success […] we save time, suffering, and money […] triage has affected other professional groups, a true professional development for many, which has enhanced their legitimacy. The effect is inspiring, making other professional’s worth visible in the care process by handling tasks that used to belong to the physician. (Manager E)
Although lunch is paid for, having too many lunch meetings in one week becomes stressful. (District nurse B)
2. Monitoring performance
• Many of the tools afforded at the workplace functioned as understandable and valuable feedback mechanisms, but were not always reassuring. The manager involves us in economic issues, which leads both to participation and shared responsibility (Care administrator C)
• Performance measurements were given in different settings (staff meetings, morning gatherings, white board, weekly newsletters), and visually (tables, figures, colours). It is important that we make our goals transparent and can follow progress […] we become more aware and can develop better services. But, there is more focus on finance now, everything has a price […] these kinds of incentives tend to start a surfeit of diagnoses and develop a system that can be manipulated. (Nurse E)
• Some tools for monitoring services were introduced parallel to the introduction of the reform, such as the regional county´s endorsement of a shared electronic medical record system with the hospitals in the region. Other tools gradually developed professional autonomy. People are aware in a completely new way. They can change health care units, and make demands, as consumers. (Care administrator E)
It is stressful to every day see the aggregated sum of dictates that need attention on my computer screen […] but, at the same time, I am triggered when our efforts align with our own goal of transcribing the dictates within 48 hours. (Care administrator C)
patients in a more efficient way. (Physiotherapist D)
3. Adapting to requirements
• The reform created disturbances in practice, and triggered a need to change routines. The increasing administration has forced us to examine our routines to relieve pressure on the doctors. The nurses have taken over some of their work, which in turn has led to new tasks for us. There are many advantages to this rearrangement, more time for patients and professional development for us. (Care administrator C)
• Adaption to compensation rules was necessary for survival, but also needed to realize visions and create patient value. Financial incentives do not destroy professionalism and autonomy, because concerns about monetary resource are included in all sound public finances […] we perform and report as requested, and can use the money creatively. (Manager B)
• Many staff members stressed that health care must be available to all citizens, because taxation is the basis of their existence. I’m not incited by them, but by the management’s desire to provide good care. (Physician B)
• Managers overruled the financial logic of the reform to safeguard patient needs and reinforce professional values. Actually, today we have to perform something to get paid. (Rehabilitation coordinator C)
• Financial incentives were translated to attract professional values We do not talk about financial goals, rather that we have certain areas that need special attention. (Physiotherapist E)
• Not all incentives were appreciated and created frustration when regulations circumscribed possibilities to be innovative. We are here to provide care, to help. If a person seeks help, the first thing we ask is ‘Are you listed here (at this PCU)?’. (Nurse assistant C)
We have decreased our development rate because we are so busy producing. (Occupational Therapist E)
I do not have the authority to relocate the organization for monetary and work environmental benefits. (Manager E)
4. Collaborating with others
• Interaction among various professionals in a team allowed for a more holistic approach and was believed to provide better continuity for the patients. We used to be divided by hierarchy, nurses and nurse assistants, there was no understanding for what we did, but that has changed completely […] today we work together, side by side. (Nurse assistant C)
• The staff experienced that new ways of doing work reduced the administrative workload, supported teamwork and attracted new patients. With the drop-in unit, we quickly respond to the patient in need, not several weeks later […] no scheduling or rebooking is necessary. (Nurse B)
• Crossing of professional boundaries was evident in practice. We solve problems together. You never feel completely alone with something, so if there is a problem, the work climate is so unpretentious that anyone can ask anybody. (Physician A)
Multimodal rehabilitation requires two visits a week for 8 weeks, with at least two professions in addition to the physician […] my role is to monitor the process and inform the physicians of the patients on registered sick leave, but also the care administrator has a role in the goal fulfilment. This is true teamwork. (Rehabilitation coordinator C)
I don’t think there is any physician here who wouldn’t fetch me if they have a patient with an ulcer…they say to the patient that I am an expert. (Nurse assistant E)