A proposed model for developing quality and efficiency in transitional care

Purpose – The purpose of this study is to develop a model describing different factors that affect quality and efficiency in transitional care. Design/methodology/approach – A meta-synthesis focusing on the transitions between wards was conducted within a research project. The results from eight studies within that research project have been combined and analysed from a holistic view. Findings – Thefindingsareamodelwithadescriptionofsevendifferentcategoriesconsistingoftheidentified factors affecting quality and efficiency in transitional care. Those categories are (1) learning organisation, (2) standardising and structuring, (3) applying a holistic view, (4) understanding organisational culture in a health care context, (5) management and leadership, (6) for whom value is created and (7) working together. The results from the study have been verified in previous research. Research limitations/implications – The result of the completed meta-synthesis is based on studies conducted at two medium-sized hospitals in Sweden. The developed model can be used in a similar context to improve quality and efficiency in patient transfers by management and employees working based on the various factors. Originality/value – This model describes factors (success factors, prerequisites, conditions and lack thereof) affecting the ability to achieve quality and efficiency in transitional care that can be used in future research as well as for practical improvements.


Introduction
Health care is a sector that is expected to deliver safe and high-quality patient-centred care that must also be both process and cost efficient.Increasing the efficiency of patient treatment as well as improving patient care quality and reducing waiting times are challenges facing health care systems around the world (Fine et al., 2009).There are demonstrations that health care is not as safe as it should be; instead, there are arguments that medical errors are the leading cause of death and injury (Kohn et al., 2000).Registered nurses highlight patient safety and are the major profession within health care; therefore, knowledge of continuous improvement among nurses could positively influence the quality of care (Andersson et al., 2014).Furthermore, there are also challenges in increasing the number of patients treated, cutting wait times, keeping costs under control and becoming a more attractive employer (Van Rossum et al., 2016).To meet the challenges in health care, different quality management (QM) initiatives have been applied (Seidl and Newhouse, 2012) and numerous barriers, such as hierarchy and management roles as well as professional and functional silos, have been identified (de Souza and Pidd, 2011).Due to these challenges and complex health organisations, patients perceive health care as fragmented and witness interruptions in the process (ibid).Based on previous traditions, a chain of diagnoses can involve numerous different assessments by different specialists.Instead, health care has increasingly started to use a QM methodology called "one-stop-shops," where all necessary skills are used to care for the patient (Modig and Ahlstr€ om, 2012).Then, these checks can be conducted simultaneously and with simpler interactions between the different assessment stages (Modig and Ahlstr€ om 2012).
One such process where different specialists are needed is from the intensive care unit (ICU) to the general ward or ICU transitional care.Chaboyer et al. (2005) defined ICU transitional care as "care provided before, during and after the transfer of an ICU patient to another care unit that aims to ensure minimal disruption and optimal continuity of care for the patient."A study of ICU transitional care showed that collaboration, routines and the learning environment need to be improved (H€ aggstr€ om et al., 2009).Organisational learning in practice is a complex process to accomplish (You, 2022).A high level of learning organisation has a positive effect on the satisfaction of the employees, which in turn increases the effectiveness in the organisation (Singh, 2016).Planning for transition from an ICU to a ward is a process with the intention of offering continuity of care for the patient (Whittaker and Ball, 2000).Through person-centred patient education, family conferences before the transfer, and oral and written information about the coming transfer, the patients' and relatives' anxiety can be reduced (Brooke et al., 2012).Yang et al. (2020) agree that an education handbook before the transition can improve health care.
To deliver high-quality patient care, hospitals also need to become collaborative organisations (Praetorius et al., 2018).When investigating several hospitals, Praetorius et al. (2018) found that when daily operations were improved with cross-boundary collaboration, the hospitals used a combination of many different design features and used formal meeting places (war rooms) for planning, discussion, informing, displaying and making decisions.According to Curtis et al. (2006), there is a need for more research to develop the necessary methods and identify the most cost-effective means of improving the quality of health care received by critical ill patients and their relatives.Furthermore, Kauppi et al. (2018) called for more research from an organisational perspective to present a more complete understanding of what is needed to ensure smoother transitional care from the ICU to the general ward.
Overall, there is a need for new knowledge and solutions for how health care can be planned and managed to become sustainable and efficient.To contribute to this endeavour, the results from a research project were compiled and analysed from a holistic view.The purpose of this paper is to develop a model describing different factors that affect quality and efficiency in transitional care.

Method and case study
The research presented in this paper was conducted in a research project called "Increased Quality and Efficiency in Patient Transfers," which was financed by The Kamprad Family Foundation [1].The overall purpose of the research project was to gain new knowledge about how quality and efficiency in patient transfers within ICU transitional care can be improved with a focus on leadership, continuity of care, safety culture and learning.This project is an interdisciplinary cocreation between the research subjects of quality management and nursing science as well as between two health care organisations.Because the project addresses such a complex challenge as improving health care and quality of care, the combination of the two different research subjects is a way to take this challenge on from more than just one aspect.Through their complimentary perspectives, the two research subjects can contribute to a deeper understanding of how to improve the process by taking advantage of the strengths of both research fields.The ethics of the project have been evaluated by the Swedish Ethical Review Authority (Dnr, 2018-159-31 M), a public agency under the Ministry of Education that examines and approves or denies applications for ethics reviews of research involving humans and human biological material.
The results from eight scientific articles and conference papers presenting studies and the results from the research project have been combined and analysed from a holistic view, focusing on the transitions between wards.Using a holistic view when analysing the combined results means that, in this paper, the results from each of the papers are being compiled and analysed as a whole in relation to the overarching challenges of achieving quality and efficiency in transitional care.Using this approach with the results from the entire project, the aim is to gain new interpretations, insights and deepened knowledge about the phenomenon.A summary of the eight articles and papers can be found in Table A1.
The results originate from studies conducted at two mid-sized hospitals located in rural areas in Sweden.The empirical data collected from the hospitals during the project encompassed the following: (1) focus group interviews with co-workers were nine focus group interviews with a total of 47 staff members.
(2) surveys measuring QM values and team collaboration, answered by 113 co-workers.
These studies have been supplemented with one systematic literature review and several scoping reviews and literature searches.The purpose, overall methodology, main results, and conclusions from the papers are summarised and presented in Appendix.This summary was then read through by the four researchers in the research team, and a meta-synthesis was conducted to understand the results from a holistic view and provide overarching results from where a model could be built.
The analyses were conducted as follows (see Figure 1): (1) Individual analysis.Each of the researchers read the summaries individual to see if all important results and conclusions from the articles and conference papers were presented in the table, and then each researcher marked the results pertinent to achieving quality and efficiency in transitional care.
(2) Consensus dialogue.The marked results from each article were discussed, and when a consensus was reached, the results were written on a sticky note formulated as factors affecting the ability to achieve quality and efficiency in transitional care (one sticky note per factor).
(3) Clustering dialogue.All sticky notes were posted on a whiteboard and then clustered by the research team during discussions until everyone agreed on the clusters.
(4) Identifying subcategories.A heading for each cluster was formed and written on new sticky notes.
(5) Identifying categories.A new cluster process started with the new headings, and then a new heading was formed.
A model for developing quality

The analysis process
The clustering process thus far followed the steps in affinity diagrams (Mizuno and Bodek, 2020).
(6) In the step where the relations between the headings are supposed to be determined, the research team realised that all of the results are related and equally important to ensuring quality and efficiency in transitional care; thus, a "circle" was created where this could be illustrated.
This method allowed both perspectives from QM and nursing science to be represented in the results as the researchers from the two scientific disciplines were creating the model together.

Results
The main results and conclusions from eight scientific papers have been summarised (see Table A1).The results were, for example, success factors, prerequisites and conditions for achieving quality and efficiency in transitional care.
When those overarching results were analysed from a holistic view, seven different categories affecting quality and efficiency emerged.Those categories are (1) learning organisation, (2) standardising and structuring, (3) applying a holistic view, (4) understanding organisational culture in a health care context, (5) management and leadership, (6) for whom value is created and ( 7) working together.These categories are described in more detail below and are illustrated in Figure 2.

Learning organisation
The category of learning organisation emerged from the four subcategories of QM culture and core competencies, QM system in ICU care, ability and skills and learning environment, which are described below.
Core competencies in nursing science have similarities with the core values in QM, indicating that core values in QM and the core competencies within nursing science in ICU transitional care are mutually dependent but also exist as a whole.This fact gave rise to the subcategory QM culture and core competencies.A learning environment is coveted A model for developing quality by the staff, and there is a need for increased learning between professions within the health sector.Continuous learning among the hospital staff is needed.There is a need for a greater degree of knowledge exchange between units and professions.The results show a lack of sharing, understanding and using knowledge throughout the entire ICU process.Working in multiprofessional teams within and between hospital units can increase learning between professions.QM is a system that could be applied in ICU transitional care to improve quality of care and patient safety, leading to the subcategory of QM systems in ICU care.The staff must have the ability and skills to ensure safety and quality of care.The nurse must be able to consciously contribute to a good health and work environment and to reflect a good health and working environment.In addition, they must be able to contribute to research, development and education.

Standardising and structuring
From five different subcategories, standardising and structuring emerged.The subcategories were standardised routines, strategies and tools, measurement tools, datadriven development, structured information and communication and a common view of continuous improvement.
There is a need to create standardised routines.Then, the routines and strategies must be implemented.There is also a need for quality improvement tools in the patient transfer process.The analysis then resulted in the category of standardised routines, strategies and tools.One result of the project is a measurement instrument that was developed and designed in collaboration between the two research subjects that can help the organisation detect strengths and opportunities for improvement.The measurement tool can be a basis for developing team collaboration and understanding how team collaboration is performed and how it can be improved.There is a need for follow-up, evaluation and measurement, such as continuous improvement via data-driven evaluation.Structured information and communication are needed to ensure quality and efficiency in ICU transitional care.A standardised and structured process for communication, which facilitates competence exchange, decision-making and leadership, is not only important but also affects the possibility of creating a learning environment.The results show that quality improvements are important and that the staff request shared spaces for continuous improvements between organisational boundaries and professions.Quality initiatives require a shared space for health care personnel from ICUs and wards to discuss improving and implementing new routines and strategies.To summarise, there is a need for a common view of continuous improvement.

Applying a holistic view
The category of applying a holistic view emerged from the three subcategories: holistic view, need for planning and defined and well-designed ICU transitional care processes.
To enhance the quality and efficiency of transitional care, a holistic view is vital, and thereby silos and suboptimality be avoided.A need for a more holistic view across organisational boundaries will help improve processes.Therefore, an increased degree of systematic thinking is important.There is also a need for planning the entire process from a patient view.A requisite identified in the results was defined and well-designed ICU transitional care processes with a holistic view of how to ensure quality of care.Today, the staff perceive the process of ICU transitional care to be undefined.Another result is that ICU transitional care is a complex interpersonal process.

Understanding organisational culture in a health care context
The subcategories QM culture and organisational culture together constitute the category of understanding organisational culture in the health care context.
There is a need to work with the QM culture in health care organisations, and all QM values are needed if such a quality culture is desired.The factor "pride" had the highest mean when measuring the culture within the investigated organisations.The results show high agreement with the QM values in the organisation, indicating the presence of a quality culture in the investigated health care organisations.Simultaneously, different perceptions of quality culture between professions were found.The findings show a common QM culture at the two different ICUs and hospitals.Within the process of ICU transfer care, there are differences in organisational culture and core values between the ICU and the general wards.The category organisational culture emerged from the following: There is a need for a blameless organisational climate when a safety culture is wanted.A safety culture that promotes collaboration and patients' participation is also essential.Welcoming and positive organisational culture within and between teams is needed.

Management and leadership
The category of management and leadership was the result of merging two subcategories: committed leadership and sufficient resources.
The QM value committed leadership is a base for other values but was found the least often in the reviewed articles in the project.ICU transitional care could be safer and more efficient with sufficient resources and with an overall patient focus.Sufficient resources are an essential condition according to the staff.

For whom value is created
The category "for whom value is created" was the result of a merger of the subcategory personcentred care.According to co-workers, ICU transitional care could be safer and more efficient under an overall patient focus.The measured factor "person-centred care between units," which illuminated how much the value for the patient is in focus, had a significantly higher mean for the assistant nurses than for the nurses.This finding can be explained by the fact that the assistant nurses are often responsible for physically transporting the patient from the ICU to the general ward.The results indicated that teams collaborating between hospital units need to focus more on how to increase person-centred care.

Working together
The category of "working together" was the result of merging the two subcategories, multi/ interdisciplinary teamwork and teamwork between and within units.
The ICU transitional care process is characterised by differences in organisational cultures and core values.A process that is interpersonal and involves multidisciplinary teams must collaborate across hospital units.This subcategory was called multi/ interdisciplinary teamwork.Teamwork is a common denominator for both QM and nursing science.Teamwork and collaboration are needed to ensure quality and efficiency in ICU transitional care.The findings from the project show that ICU transitional care could be safer and more efficient by better teamwork between and within the units.A condition is interdisciplinary teamwork within the unit and across the hospital borders.This was also confirmed in the measurement, as the result showed a lower mean for team collaboration between hospital units than within hospital units.

Discussion and conclusions
Providing efficient and high-quality care is the purpose of the health care sector.Due to patient differences, momentary interpersonal relations and the need for collaboration between different professions and departments, this is a complex and difficult task to achieve (Praetorius et al., 2018).The identified general areas for improvement in transferring patients A model for developing quality between wards must have support from top management.There must be a shared picture of the situation within health care, as well as a need for management and leadership with a holistic view, if these changes are to be possible.Management must conduct the changes that are needed in the entire health care system, which is consistent with early research; for example, Curtis et al. (2006), who noted that leadership is crucial to the prosperity of quality improvement projects and that the entire quality improvement program should learn from its successes as well as failures.This is consistent with Andersson et al. (2014), who emphasise that managers must explicitly support continuous improvement work, as this gives legitimacy to the work that the staff are requesting.
We conclude that a learning organisation is important as well as creating a learning environment, as it affects both the employees and the effectiveness in a positive way (Singh, 2016).This is not easy to accomplish in practice according to You (2022).Working together and learning from each other between professions and units are also important.If better teamwork between and within the units can be established, then ICU transitional care could be safer and more efficient.This is consistent with Curtis et al. (2006), who stated that incremental and continuous interdisciplinary teamwork is necessary for successful quality improvement within the health sector.
Person-centred care and standardising routines for structuring information and communication are important (Brooke et al., 2012;Yang et al., 2020).These should be easy things to fix but, simultaneously, this is what the staff, patients and relatives have requested, indicating there is still a need.Why is a big question?Is this also dependent on leadership and management?
All professions in health care want to do the right thing for patients, but the culture, structure and/or identity are hindered and must be overcome.How can these hindrances be conquered?As previously mentioned, management with a holistic view is needed, but what more can be done?According to Ingelsson (2013), leadership is of great importance and managers are key players when cultural transformation is desired.Snyder et al. (2016) maintained that leaders must perform and conduct new methodologies that focus on building an open culture environment if they want to change the culture within an organisation.Ingelsson et al. (2018) established that working with leadership behaviours within the management group affected the culture of the entire organisation.
What we can conclude after analysing the project results from a holistic view is that ensuring high-quality and efficient care is a complex challenge that health care organisations face in providing transitional care.The results described above (see also Figure 2) indicate that the factors, prerequisites and conditions in the model are intertwined and all are needed when quality and efficiency in ICU transitional care are desired.

Future research
The proposed model must be tested, validated and perhaps updated in future research.It would be interesting to do a similar study from other research projects or do the same research in other countries and then compare the results.Another way to further validate the model could be to perform a systematic literature review with the seven identified categories as a base.
(QM and nursing science) through a scoping review The purpose of this paper was to present the state of the art when it comes to QM and nursing science, focusing on patient transfers from Intensive Care Unit (ICU) to general wards, using the TQM values: "customer focus", "leadership commitment", "participation of everybody", "continuous improvement", "process focus" and "base decisions on facts" as an analytical framework The articles that were found emphasised that quality improvements and teamwork are two common denominators for both research areas.
Interdisciplinary care can improve a culture of safety and decrease mortality rates, staff turnover and increase quality of care and patient satisfaction.This means that there is a need for working with the QM culture in the patient transfer from ICU to general wards.When the results were sorted to the TQM values, it was difficult to decide which value, as many descriptions were connected to two or three values.Quantitative, baseline data collection via.
A survey used to assess the quality culture in the two ICUs The purpose of this paper was to present and analyse the results from using a questionnaire measuring the presence of a number of QM values, as well as the use of Appreciative Inquiry (AI) and the feeling of pride in a health care setting focusing on transitional care The results indicated a relatively high agreement with the QM values in the organisation indicating the presence of a quality culture.The results showed no statistically significant differences between the two units, thus indicating the same culture in both ICUs even though they are located in two different hospitals.The use of a questionnaire painted a picture of the exciting culture within an organisation and can help organisations prioritise their work with continuous improvements.The difference in results found between professions could indicate a division and be a sign of professional silos in the units.Pride was the factor with the highest mean.The result regarding the factor system view could be an indication of differences in insight in the whole organisation, where the physicians may have a larger overview since they often work in several units.The assistant nurses are most often the persons responsible for physically transporting the patient from the ICU to the general ward, a fact that may lead to a greater understanding of the whole process.This can be further supported by the statistically significant difference found regarding the factor person-centred care between units where the assistant nurses had statistically significant higher mean then the nurses (continued ) Table A1.The results indicated that there is an internal consistency reliability between the developed factors and statements measuring team collaboration within and between hospital units.The results from the survey also show that the measurement tool can be a basis for improving team collaboration in the studied context.Measuring team collaboration can provide an understanding of how team collaboration is performed and can be improved.The results showed differences between the two main areas.Team collaboration between units had lower mean values than team collaboration within units.This indicates that the co-workers did not perceive a high degree of team collaboration between units.This finding points towards a need for a greater degree of knowledge exchange between units and professions.A need for a more holistic view across organisational boundaries will help improve the process.The results from the questionnaire can be used to identify areas for improvement.The QM perspective can help shift the focus from the individual to team, culture, system, process and continuous improvement.Viewing the process through the lens of QM can give a deeper understanding of cultural and systemic differences and opportunities for continuous improvements in ICU transitional care (continued ) Quantitative development of a questionnaire and measuring team collaboration The purpose of this paper was to describe the development and testing of a questionnaire aiming to measure perceived team collaboration in the patient transfer process from ICU to the general ward.This study also aims to analyse the results to see how the survey could help improve team collaboration within ICU transitional care Team collaboration in ICU transitional care can be measured using a developed and tested questionnaire.
Measuring team collaboration can provide an understanding of how collaboration is perceived and identifying weaknesses and areas for improvement.The results from the survey gave insights that can be useful to improving team collaboration in ICU transitional care.
The results indicated that teams collaborating across hospital units need to focus more on how to increase person-centred care and continuous learning and how to create prerequisites for successful patient transfers between hospital units.The results also showed that there is a need for a more holistic view of team collaboration across organisational boundaries.Team collaboration in this care process requires deeper understanding and mutual learning between professions.
According to the results, there seems to be a lack of sharing, understanding and using knowledge during the entire process.Increased learning between professions requires an increased degree of systematic thinking and less siloed thinking using knowledge from co-workers across organisational boundaries.Collaborating in teams over hospital units along the ICU transitional care process requires a common view of person-centred care, shared objectives, reflection over team performance and knowledge in how the co-workers in teams are interdependent on each other to succeed.The collaboration between two research subjects, nursing science and QM, has given new perspectives on how to develop a measurement tool for measuring team collaboration within ICU transitional care.Measuring perceived team collaboration can give a deeper understanding of how cultural and systemic differences and opportunities can help improve team collaboration in the ICU transitional care process by shifting focus from the individual to team, culture, system, process and continuous improvement (continued ) Qualitative design through focus group discussions The purpose of this paper is to present success factors for increasing the quality and safety of ICU transitional care as described by co-workers at the sharp end using the core values of total quality management (TQM) as a theoretical lens The results indicate that quality of care in ICU transitional care processes can be improved with quality improvement initiatives at the system level including more collaborative actions and with more methodologies and tools.The process could be renewed with conditions that allowed person-centred care, a holistic view avoiding silos.We also conclude that quality initiative requires shared spaces for health care personnel from ICU and the wards to discuss improvements and the implementation of new routines and strategies.Additionally Qualitative content analysis from focus groups discussions The purpose was twofold: first to describe how coworkers within a team perceived team collaboration in patient transfers from an intensive care unit (ICU) to general wards and, second, to describe coworkers' suggestions for an improved future state of team collaboration Results indicated that there is an expressed need to improve team collaboration, define and design ICU transitional care process with a holistic view of how to create quality of care, ensure continuity in care and create a learning environment.Team collaboration could be interpreted as a need for a standardised process for working with continuous improvements, mainly when it came to quality improvements that affect multiple hospital units and that involved coworkers from different professions and hospital units, as well as patients and relatives.A standardised and structured process for communication, competence exchange, decision-making and leadership for teams in ICU transitional care could be important to improve team collaboration and increase quality of care and patient safety.The findings indicated a need for clearer definitions of team membership, roles and responsibilities and deeper insights on how team members depend on each other's work to succeed.Embedded in this is a need for a welcoming and positive organisational culture within and between teams Table A1.

Figure 2 .
Figure 2. A proposed model for improving quality and efficiency in ICU transitional care Sten et al. (2019) The development of a measurement instrument focusing on team collaboration in the patient transfer process from intensive care to the general ward Both qualitative and quantitative.A literature search and development of statements from theory.The Results from questionnaire was analysed with SPSS The purpose of this paper was to describe the development and testing of a questionnaire aiming to measure team collaboration in the patient transfer process from the ICU to the general ward.The purpose is also to analyse the results to see how the survey can help improve team collaboration within ICU transitional care , essential conditions are enough resources and establishing interdisciplinary teamwork within the own unit and across the hospital borders Sten et al. (2021a, b) Improving Team Collaboration in Patient Transfer Processes by Co-Workers' Perceptions and Suggestions