title: Unpacking the key components of a programme to improve the timeliness of hip-fracture care: a mixed-methods case study.
abstract: BACKGROUND
  Delay to surgery for patients with hip fracture is associated with higher incidence of post-operative complications, prolonged recovery and length of stay, and increased mortality. Therefore, many health care organisations launch improvement programmes to reduce the wait for surgery. The heterogeneous application of similar methods, and the multifaceted nature of the interventions, constrain the understanding of which method works, when, and how. In complex acute care settings, another concern is how changes for one patient group influence the care for other groups. We therefore set out to analyse how multiple components of hip-fracture improvement efforts aimed to reduce the time to surgery influenced that time both for hip-fracture patients and for other acute surgical orthopaedic inpatients.
  
  
  METHODS
  This study is an observational mixed-methods single case study of improvement efforts at a Swedish acute care hospital, which triangulates control chart analysis of process performance data over a five year period with interview, document, and non-participant observation data.
  
  
  RESULTS
  The improvement efforts led to an increase in the monthly percentage of hip-fracture patients operated within 24 h of admission from an average of 47% to 83%, with performance predictably ranging between 67% and 98% if the process continues unchanged. Meanwhile, no significant changes in lead time to surgery for other acute surgical orthopaedic inpatients were observed. Interview data indicated that multiple intervention components contributed to making the process more reliable. The triangulation of qualitative and quantitative data, however, indicated that key changes that improved performance were the creation of a process improvement team and having an experienced clinician coordinate demand and supply of surgical services daily and enhance pre-operative patient preparation.
  
  
  CONCLUSIONS
  Timeliness of surgery for patients with hip fracture in a complex hospital setting can be substantially improved without displacing other patient groups, by involving staff in improvement efforts and actively managing acute surgical procedures.
authors.affiliation: Medical Management Centre, the Department for Learning, Informatics, Ethics and Management, Tomtebodavägen 18A, Karolinska Institutet, SE-17177, Stockholm, Sweden. pamela.mazzocato@ki.se.
authors.forename: Pamela
authors.initials: P
authors.lastname: Mazzocato
authors.affiliation: Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Division of Orthopaedics, SE-18288, Stockholm, Sweden. maria.unbeck@ki.se.
authors.forename: Maria
authors.initials: M
authors.lastname: Unbeck
authors.affiliation: Department of Management and Engineering, Linköping University, SE-581 83, Linköping, Sweden. mattias.elg@liu.se.
authors.forename: Mattias
authors.initials: M
authors.lastname: Elg
authors.affiliation: Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Division of Orthopaedics, SE-18288, Stockholm, Sweden. olof.skoldenberg@ds.se.
authors.forename: Olof Gustaf
authors.initials: OG
authors.lastname: Sköldenberg
authors.affiliation: Medical Management Centre, the Department for Learning, Informatics, Ethics and Management, Tomtebodavägen 18A, Karolinska Institutet, SE-17177, Stockholm, Sweden. Johan.Thor@ju.se.|Vinnvård Fellow of Improvement Science, The Jönköping Academy for Improvement of Health and Welfare, Jönköping University, P O Box 1026, SE-551 11, Jönköping, Sweden. Johan.Thor@ju.se.
authors.forename: Johan
authors.initials: J
authors.lastname: Thor
mesh_terms: D000367:Age Factors; D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects / Q000379:methods; D016009:Chi-Square Distribution; D005069:Evaluation Studies as Topic; D005260:Female; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000009:adverse effects / Q000379:methods; D006620:Hip Fractures / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D015601:Injury Severity Score; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D020380:Needs Assessment; D010348:Patient Care Team / Q000458:organization & administration*; D018570:Risk Assessment; D012737:Sex Factors; D013548:Sweden; D061665:Time-to-Treatment; D016896:Treatment Outcome; D014850:Waiting Lists