title: Depicting the interplay between organisational tiers in the use of a national quality registry to develop quality of care in Sweden.
abstract: BACKGROUND
  With a pending need to identify potential means to improved quality of care, national quality registries (NQRs) are identified as a promising route. Yet, there is limited evidence with regards to what hinders and facilitates the NQR innovation, what signifies the contexts in which NQRs are applied and drive quality improvement. Supposedly, barriers and facilitators to NQR-driven quality improvement may be found in the healthcare context, in the politico-administrative context, as well as with an NQR itself. In this study, we investigated the potential variation with regards to if and how an NQR was applied by decision-makers and users in regions and clinical settings. The aim was to depict the interplay between the clinical and the politico-administrative tiers in the use of NQRs to develop quality of care, examining an established registry on stroke care as a case study.
  
  
  METHODS
  We interviewed 44 individuals representing the clinical and the politico-administrative settings of 4 out of 21 regions strategically chosen for including stroke units representing a variety of outcomes in the NQR on stroke (Riksstroke) and a variety of settings. The transcribed interviews were analysed by applying The Consolidated Framework for Implementation Research (CFIR).
  
  
  RESULTS
  In two regions, decision-makers and/or administrators had initiated healthcare process projects for stroke, engaging the health professionals in the local stroke units who contributed with, for example, local data from Riksstroke. The Riksstroke data was used for identifying improvement issues, for setting goals, and asserting that the stroke units achieved an equivalent standard of care and a certain level of quality of stroke care. Meanwhile, one region had more recently initiated such a project and the fourth region had no similar collaboration across tiers. Apart from these projects, there was limited joint communication across tiers and none that included all individuals and functions engaged in quality improvement with regards to stroke care.
  
  
  CONCLUSIONS
  If NQRs are to provide for quality improvement and learning opportunities, advances must be made in the links between the structures and processes across all organisational tiers, including decision-makers, administrators and health professionals engaged in a particular healthcare process.
authors.affiliation: Department of Public Health and Caring Sciences, Uppsala University, Box 564, SE751 22, Uppsala, Sweden. ace@du.se.|School of Health and Social Science, Dalarna University, SE791 88, Falun, Sweden. ace@du.se.
authors.forename: Ann Catrine
authors.initials: AC
authors.lastname: Eldh
authors.affiliation: Department of Public Health and Caring Sciences, Uppsala University, Box 564, SE751 22, Uppsala, Sweden. mio.fredriksson@pubcare.uu.se.
authors.forename: Mio
authors.initials: M
authors.lastname: Fredriksson
authors.affiliation: Department of Public Health and Caring Sciences, Uppsala University, Box 564, SE751 22, Uppsala, Sweden. sofie.vengberg@pubcare.uu.se.
authors.forename: Sofie
authors.initials: S
authors.lastname: Vengberg
authors.affiliation: Department of Public Health and Caring Sciences, Uppsala University, Box 564, SE751 22, Uppsala, Sweden. christina.halford@akademiska.se.
authors.forename: Christina
authors.initials: C
authors.lastname: Halford
authors.affiliation: School of Health and Social Science, Dalarna University, SE791 88, Falun, Sweden. lars.wallin@du.se.|Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, SE171 77, Stockholm, Sweden. lars.wallin@du.se.
authors.forename: Lars
authors.initials: L
authors.lastname: Wallin
authors.affiliation: Department of Public Health and Caring Sciences, Uppsala University, Box 564, SE751 22, Uppsala, Sweden. tobias.dahlstrom@ltdalarna.se.
authors.forename: Tobias
authors.initials: T
authors.lastname: Dahlström
authors.affiliation: Department of Public Health and Caring Sciences, Uppsala University, Box 564, SE751 22, Uppsala, Sweden. ulrika.winblad@pubcare.uu.se.
authors.forename: Ulrika
authors.initials: U
authors.lastname: Winblad
mesh_terms: D000288:Administrative Personnel / Q000523:psychology*; D003299:Cooperative Behavior; D003657:Decision Making; D003695:Delivery of Health Care; D006282:Health Personnel; D006801:Humans; D007400:Interprofessional Relations; D007407:Interviews as Topic; D011057:Politics; D036301:Qualitative Research; D058996:Quality Improvement / Q000458:organization & administration; D011787:Quality of Health Care / Q000592:standards*; D012042:Registries; D020521:Stroke; D013548:Sweden