title: Context challenges the champion: improving hip fracture care in a Swedish university hospital.
abstract: OBJECTIVE
  The purpose of this paper is to describe and explain a clinician-led improvement of a hip fracture care process in a university hospital, and to assess the results and factors helping and hindering change implementation.
  
  
  METHODS
  The paper has a mixed methods case study design. Data collection was guided by a framework directing attention to the content and process of the change, its context and outcomes.
  
  
  RESULTS
  Using a multiprofessional project team, beneficial changes in the early parts of the care process were achieved, but inability to change surgical staff work practices meant that the original goal of operating patients within 24 hours was not reached. After three years, top management introduced a hospital-wide process improvement programme, which "took over" the responsibility for improving hip fracture care.
  
  
  CONCLUSIONS
  A clear vision why change is needed and what needs to be done, which is well communicated by a respected clinical leader, can motivate personnel, but other influences are also needed to bring about change. Without a plan agreed and supported by top management, changes are likely to be limited to parts of the process and improvements to patient care may be minimal. These and other findings may be applicable to similar situations in other services.
  
  
  CONCLUSIONS
  This case study is an illustration of both the strengths and the weaknesses of a "bottom-up, clinician-champion-led improvement initiative" in a complex university hospital.
authors.affiliation: Medical Management Centre, Karolinska Institutet, Stockholm, Sweden. susanne.lofgren@ki.se
authors.forename: Susanne
authors.initials: S
authors.lastname: Löfgren
authors.forename: Johan
authors.initials: J
authors.lastname: Hansson
authors.forename: John
authors.initials: J
authors.lastname: Øvretveit
authors.forename: Mats
authors.initials: M
authors.lastname: Brommels
mesh_terms: D001291:Attitude of Health Personnel; D019091:Critical Pathways / Q000458:organization & administration* / Q000592:standards; D006620:Hip Fractures / Q000534:rehabilitation* / Q000601:surgery*; D006785:Hospitals, University / Q000458:organization & administration* / Q000592:standards; D006801:Humans; D007407:Interviews as Topic; D019982:Organizational Case Studies; D058996:Quality Improvement / Q000458:organization & administration* / Q000592:standards; D013548:Sweden; D013997:Time Factors