Purpose Primary healthcare service delivery prioritizes person-centricity and relational values such as equality and continuity. The emergence of technology has enabled digital face-to-face (D-F2F) service encounters between patients as end-users and physicians as professional care providers, which calls for a renewed understanding of relational approaches. To that end, the study investigated the perceptions of three groups of actors-patients, physicians, and first-line managers-of D-F2F service encounters in order to capture key aspects that can enhance relational primary healthcare in the era of digitalization. Design/methodology/approach We adopted an interactive research design following a multi-actor approach and conducted conceptually and empirically informed concept mapping of the key actors in the primary healthcare service triad: patients with chronic, long-term needs, physicians, and first-line managers. Findings From seven clusters capturing what D-F2F service encounters between patients and physicians mean, we derived four triadic perspectives that capture how relational primary healthcare can be advanced: "continuity," "person-centered," "interaction quality," and "developability." Research limitations/implications Despite high volumes and heterogeneity of end-users, primary healthcare requires a relational, person-centered perspective when it comes to healthcare delivery. Other sectors such as energy and automotive that are undergoing digital transformation and pursue an end-user's perspective can draw on the relational principles developed in our study. Our findings also raise questions about potential conflicts between end-users' service co-creation and providers' professional boundaries. Originality This paper presents a relational, multi-actor approach to the digitalization of a professional service encounter in primary healthcare. We propose a set of conditions conducive to taking a relational approach to D-F2F relationships.

Background Co-design is a collaborative approach involving end users, stakeholders, and designers in creating digital tools for health care. This study focuses on the co-design and evaluation of Behavior, Emotion, Therapy System, and You (BETSY), a mental health chatbot and digital human for mild to moderate anxiety. Objective This study aims to develop and evaluate BETSY through a co-design process involving potential users. Methods The study used a mixed-methods approach across 3 phases. Phase 1 involved recruiting 87 volunteer participants through social media for initial end-user requirements. Phase 2 focused on the design process based on end-user requirements using the expertise of 10 stakeholders in health care and health service user. Phase 3 evaluated the 2 prototyped interfaces (a text-only chatbot and a voice-activated digital human chatbot) with 45 healthy volunteers. Results For phase 1, 61% (n=51) of participants had previous experience with chatbots and 86% expressed a willingness or potential willingness to use a chatbot for mental health support. Thematic analysis in phase 2 revealed key user preferences for a personalized, nonjudgmental chatbot with a clear identity and a focus on empathy. Privacy concerns and the need for clear interaction guidelines were highlighted. In phase 3, the users showed a strong preference for discussing anxiety related to work, relationships, and health. Both text-only and voice-activated digital human users considered BETSY valuable for managing mild to moderate anxiety and providing self-help exercises. Conclusions The co-design process yielded valuable insights for developing BETSY. While users recognized its potential as an accessible first step before seeking professional help, they also identified areas for improvement, including more nuanced conversation capabilities and a broader range of exercises. BETSY’s potential as a screening tool for health care was consistently acknowledged, suggesting its capability for alleviation of health care system burdens.

BackgroundThe use of chatbots in mental health support has increased exponentially in recent years, with studies showing that they may be effective in treating mental health problems. More recently, the use of visual avatars called digital humans has been introduced. Digital humans have the capability to use facial expressions as another dimension in human-computer interactions. It is important to study the difference in emotional response and usability preferences between text-based chatbots and digital humans for interacting with mental health services. ObjectiveThis study aims to explore to what extent a digital human interface and a text-only chatbot interface differed in usability when tested by healthy participants, using BETSY (Behavior, Emotion, Therapy System, and You) which uses 2 distinct interfaces: a digital human with anthropomorphic features and a text-only user interface. We also set out to explore how chatbot-generated conversations on mental health (specific to each interface) affected self-reported feelings and biometrics. MethodsWe explored to what extent a digital human with anthropomorphic features differed from a traditional text-only chatbot regarding perception of usability through the System Usability Scale, emotional reactions through electroencephalography, and feelings of closeness. Healthy participants (n=45) were randomized to 2 groups that used a digital human with anthropomorphic features (n=25) or a text-only chatbot with no such features (n=20). The groups were compared by linear regression analysis and t tests. ResultsNo differences were observed between the text-only and digital human groups regarding demographic features. The mean System Usability Scale score was 75.34 (SD 10.01; range 57-90) for the text-only chatbot versus 64.80 (SD 14.14; range 40-90) for the digital human interface. Both groups scored their respective chatbot interfaces as average or above average in usability. Women were more likely to report feeling annoyed by BETSY. ConclusionsThe text-only chatbot was perceived as significantly more user-friendly than the digital human, although there were no significant differences in electroencephalography measurements. Male participants exhibited lower levels of annoyance with both interfaces, contrary to previously reported findings.

BACKGROUND:With the increasing complexity of health care services, more comprehensive and integrated services need to be designed. Action researchers are encouraged to facilitate multiactor participation and user-centered approaches to initiate service development. However, "orchestrating" co-innovation, in which actors have diverse attitudes, agendas, positions of power, and horizons of understanding, is challenging, and a framework that supports action researchers in co-innovation studies lack. The purpose of this article was to explore how action researchers can facilitate multiactor engagement and handle possible challenges and stimulate creativity among diverse stakeholders.METHODS:We have studied and discussed two Scandinavian cases of rehabilitation innovation (for cancer patients and persons with acquired brain injury) where two research teams with action research approaches have acted in an orchestrating role to create co-innovation.RESULTS:We identified four themes that are essential for action researchers to facilitate collaborative and creative co-innovation processes: (1) relational power reflexibility, (2) resource integration, (3) joint understanding, and (4) the facilitation of creativity. These mutually dependent themes constitute a theoretical and methodological framework for of co-innovation.CONCLUSIONS:This paper offers a contribution that supports action researchers in orchestrating diverse actors and their contributions in co-innovation processes.

PURPOSE:Network configurations have been proposed as an efficient form of organisation and a promising area of research; however, a lack of conceptual clarity can be noted. The purpose of this review is to allow for a broad appreciation of network configurations and provide guidance for future studies of the concept. DESIGN/METHODOLOGY/APPROACH:A systematic literature review was conducted based on the PRISMA method; Scopus, Web of Science, PubMed and the Cochrane Library were searched for conference proceedings and journal articles describing organisational networks to integrate resources aimed at care delivery. Around 80 articles were included in the final review and analysed thematically and by use of bibliographic coupling. FINDINGS:The last decades have seen an increase in the frequency of articles describing networks for healthcare delivery. The most common contexts are care for multiple and/or long-term conditions. Three clusters of articles were found, corresponding to different conceptualisations of networks in healthcare: efficiency-enhancing cooperation, efficiency-enhancing integration and involvement for cocreation. RESEARCH LIMITATIONS/IMPLICATIONS:To increase conceptual clarity and allow the research on network configurations in healthcare to produce meta-learnings and guidance to practice, scholars are advised to provide ample descriptions of studied networks and relate them to established network classifications. ORIGINALITY/VALUE:The current review has only included articles including networks as a key concept, which provides a focused overview of the use of network configurations but limits the insights into similar approaches not described explicitly as networks.

PurposeThis article aims to examine how users' involvement in value co-creation influences the development and orchestration of well-being ecosystems to help tackle complex societal challenges. This research contributes to the public management literature and answers recent calls to investigate novel public service governances by discussing users' involvement and value co-creation for novel well-being solutions.Design/methodology/approachThe authors empirically explore this phenomenon through a case study of a complex ecosystem addressing increased well-being, focussing on the formative evaluation stage of a longitudinal evaluation of Sweden's first support centre for people affected by cancer. Following an abductive reasoning and action research approach, the authors critically discuss the potential of user involvement for the development of well-being ecosystems and outline preconditions for the success of such approaches.FindingsThe empirical results indicate that resource reconfiguration of multi-actor collaborations provides a platform for value co-creation, innovative health services and availability of resources. Common themes include the need for multi-actor collaborations to reconfigure heterogeneous resources; actors' adaptive change capabilities; the role of governance mechanisms to align the diverse well-being ecosystem components, and the engagement of essential actors.Research limitations/implicationsAlthough using a longitudinal case study approach has revealed stimulating insights, additional data collection, multiple cases and quantitative studies are prompted. Also, the authors focus on one country but the characteristics of users' involvement for value co-creation in innovative well-being ecosystems might vary between countries.Practical implicationsThe findings of this study demonstrate the value of cancer-affected individuals, with "lived experiences", acting as sources for social innovation, and drivers of well-being ecosystem development. The findings also suggest that participating actors in the ecosystem should utilise wider knowledge and experience to tackle complex societal challenges associated with well-being.Social implicationsPolicymakers should encourage the formation of well-being ecosystems with diverse actors and resources that can help patients navigate health challenges. The findings especially show the potential of starting from the user's needs and life situation when the ambition is to integrate and innovate in fragmented systems.Originality/valueThe proposed model proposes that having a user-led focus on innovating new solutions can play an important role in the development of well-being ecosystems.

IMPACT The traditional public service ethos needs to be challenged by including citizens/users in developing and improving public services. However, the often one-sided positive accounts of co-production, co-design and co-innovation risk public managers and policy-makers involving citizens/users when it may be inappropriate and/or cause more harm than good. This article explains these ‘co-concepts’ and suggests how managers and policy-makers should balance the positive with potential negative (disvalue) aspects to enable a more useful practice of citizen/user involvement.

There is consensus that complex problems of contemporary society call for public service collaborations. So-called public service logic (PSL) focuses on joint value creation among a multiplicity of actors in service ecosystems. Despite recognizing various actors, this logic is essentially user-centric, with the service user being the one realizing the value. Consequently, single and collaborating organizations cannot deliver value, only potential value, or so-called value propositions. The elusive public service logic takes a network value configuration for granted and as a starting point. Drawing from two cases in Swedish healthcare, this paper argues that two other value configurations (chain and shop) are also relevant for understanding the development of value propositions - and that these may be related to both intra- and inter-organizational processes. Theoretically, we conclude that just like public service logic, other collaborative public management theories need to recognize the importance of a multiplicity of value configurations and that these are often related to both intra- and inter-organizational processes. We conclude that managers should not adopt the latest network trends without first reflecting on the relevance of existing internal processes.

Introduction:Departing from a practical problem of how to use digitalization to improve care quality and efficiency, this paper investigates how the concept of Learning Health Systems (LHSs) can be applied to an existing organization. LHSs offer a vision for how healthcare can accelerate both scale-up of innovations and quality improvements at all levels. However, aligning stakeholders at different levels to convergent development is challenging and translation and adaptation of the LHS concept to fit with the existing organization is essential. Methods:A one-year longitudinal action research (AR) study was conducted within five psychiatric departments at the Sahlgrenska University Hospital in Gothenburg, Sweden. Translation of the LHS concept to the local circumstances within the organization was set as the aim, to both improve practice and further scientific understanding. An AR group led the practical and scholarly work and holistic data were collected, including field notes, documents, recordings, and workshops. Data were analyzed by an insider-outsider approach. Results:The one-year study is described to provide insights into the process of designing a locally adapted LHS using an AR approach. Practical needs were identified and iteratively matched with theory to form a local LHS model. A conflict between top-down and bottom-up views on development emerged, where higher-level management tended to prioritize uniform solutions and developers local learning. An adapted solution to balance these approaches was negotiated, consisting of a technical and an organizational part. Conclusions:The conflict between top-down and bottom-up approaches for how to implement LHSs needs to be considered both in practical work to transform care organizations and in scientific studies of LHSs. The approach to translate, rather than instrumentally implement, LHSs to real-world settings is suggested as advantageous. Furthermore, designing such endeavors as AR projects can provide excellent conditions to create LHSs that work in practice.

This paper addresses a service approach in public management by highlighting the insufficiently explored concept of resource integration. Specifically, we identify the actors who contribute to such integration, as well as the kind of resources they bring. The empirical material draws from two action research cases in cancer care, suggesting that, for complex challenges, resource-integrating actors may represent public, private and third-sector organizations, citizens/service users, as well as their private spheres. Moreover, resources may be both tangible and, more importantly, intangible. Because all actors in the sys- tem are doing the same thing – integrating resources – multi-actor resource integration frames interorganizational collaboration and citizen/user co-production. In contrast to the private sector’s foci on profit and customer satisfaction, the gain herein concerns better usage of common resources and addressing public interests – such as access to services that meet the needs of disregarded groups. In the complex realities of contemporary societies, actors from all sectors should help meet such needs through collaborative resource integration rather than competition.

Background Demands for both customization and standardization are increasing in healthcare. At the same time, resources are scarce, and healthcare managers are urged to improve efficiency. A framework of three value configurations – shop, chain, and network – has been proposed for how healthcare operations can be designed and organized for efficient value creation. In this paper, use of value configurations for balancing of standardization and customization is explored in the context of care for chronic mental conditions. Methods A typical case is presented to illustrate the manifestations of conflicting demands between customization and standardization, and the potential usefulness of the value configurations framework. Qualitative data were collected from managers and care developers in two focus groups and six semi-structured interviews, completed by a national document describing a care pathway. Data were coded and analysed using an insider-outsider approach. Results Operationalization of the balance between standardization and customization were found to be highly delegated and ad hoc. Also, the conflict between the two demands was often seen as aggravated by scarce resources. Value configurations can be fruitful as a means of discussing and redesigning care operations if applied at a suitable level of abstraction. Applied adequately, all three value configurations were recognized in the care operations for the patient group, with shop as the overarching configuration. Some opportunities for improved efficiency were identified, yet all configurations were seen as vital in the chronic care process. Conclusions The study challenges the earlier proposed organizational separation of care corresponding to different value configurations. Instead, as dual demand for customization and standardization permeates healthcare, parallel but explicated value configurations may be a path to improved quality and efficiency. Combined and intermediate configurations should also be further investigated.

OBJECTIVE:Kraftens Hus is the first support centre in Sweden designed by and for people affected by cancer, including patients, family, friends, staff members and local community representatives (collectively 'stakeholders'). The purpose of this study was to explore the meaning, role and experiences of Kraftens Hus stakeholders using a patient and public involved methodology.METHODS:To understand and map the experiences of visitors to Kraftens Hus, we applied concept mapping (CM), a mixed methods approach where data are collected and analysed in four structured steps designed to capture the diverse perspectives of multiple stakeholders. Qualitative interviews with relevant stakeholders supplemented the CM findings.RESULTS:The final concept map contained six clusters of ideas. Within the clusters, there was a recurring theme that cancer-affected people value accessible and long-term psychosocial support (PSS). The intended emotional, social and practical needs identified in a previous design process seem to have been addressed and appreciated by Kraftens Hus visitors.CONCLUSION:Kraftens Hus is an example of a new patient-led social innovation based on a life-event perspective and integration of resources from different sectors in society. By focusing on life, not the disease, the care continuum expands, and long-term PSS is provided alongside cancer treatment. The evaluation confirms that PSS should focus on health and well-being in the broadest sense.

PurposeThe purpose of this paper is to empirically explore and demonstrate the ability of healthcare professionals to attain professional fulfilment when providing healthcare inspired by “value shops”.Design/methodology/approachA qualitative case study incorporating interviews and observations was conducted.FindingsThe empirical data suggest that the professional fulfilment of both physicians and nurses is facilitated when care is organized through “value shops”. Both groups of professionals state that they are able to return to their “professional core”.Originality/valueThe beneficial outcomes of organizing healthcare inspired by the “value shop” have previously been explored in terms of efficiency and quality. However, the professional fulfilment of healthcare professionals when providing such care has not been explicitly addressed. Professional fulfilment is vital in order to safeguard high-quality care, as well as healthcare professionals' involvement and engagement in implementing quality improvements. This paper highlights the fact that care provision inspired by the “value shop” may facilitate professional fulfilment, which further strengthens the potential positive outcomes of the “value shop” when utilized in a healthcare setting.

Background The need for training in quality improvement for healthcare staff is well acknowledged, but long-term outcomes of such training are hard to evaluate. Behaviour change, improved organisational performance and results are sought for, but these variables are complex, multifactorial and difficult to assess. Aim The purpose of this article is to explore the personal and organisational outcomes identified by participants over 14 years of university-led QI courses for healthcare professionals. Method Inspired by the Kirkpatrick model for evaluation, we used concept mapping, a structured mixed method that allows for richness of data to be captured and visualised by inviting stakeholders throughout the process. In total, 331 previous course participants were included in the study by responding to two prompts, and 19 stakeholders taking part in the analysis process by doing the sorting. Result Two maps, one for personal outcomes and one for organisational outcomes, show clusters of the responses from previous course participants and how the outcomes relate to each other in meta-clusters. Both maps show possible long-term outcomes described by the previous course participants. Conclusion The results of this study indicate that it is possible that training in quality improvement with a strong experiential pedagogical approach fosters a long-term improvement capability for the course participants and, even more important, a long-term improvement capability (and increased improvement skill) in their respective organisations.

This study explores the various roles of quality departments and investigates whether their roles have different influence on business results. Based on a survey of quality managers in 211 Swedish organisations, the analysis identifies four roles of quality departments: firefighters, auditors, process improvers, and orchestrators. The roles vary in their predominant adoption of Quality Management practices ranging from a narrow scope focusing on quality management systems to a broader scope, based on multiple practices. An analysis was performed to identify how each of the identified roles influences business results. The results show that quality departments with a broad focus, combining both explorative and exploitative quality practices, contribute the most to business results.

Drawing from collaborative public management, this article seeks to contribute to public service logic by focusing on what precedes the public service user's realization of value: the value proposition. A new care model for elderly people with multiple chronic diseases shows that coordinators with an inter-organizational mission, vertical and horizontal supporting structures, trust established through relationships, and recognition of service systems' embeddedness in social systems are pivotal for the ability of public service organizations to develop coordinated value propositions. The contribution to policy and practice is an increased understanding of a coherent, rather than fragmented, welfare system for users/citizens.

Background: Interest in the implementation of various innovations (e.g. medical interventions and organizational approaches) has increased rapidly, and management innovations (MIs) are considered particularly complex to implement. In contrast to a traditional view that innovations are implemented, some scholars have promoted the view that innovations are translated into contexts, a view referred to as translation theory. The aim of this paper is to investigate how a translation theory perspective can inform the Consolidated Framework of Implementation Research (CFIR) to increase understanding of the complex process of putting MIs into practice. The empirical base is a two-year implementation of the MI Value-Based Health Care (VBHC) to a psychiatric department in a large Swedish hospital. Methods: In this longitudinal case study, a qualitative approach was applied using an insider researcher with unique access to data, who followed the implementation starting in 2015. Data sources includes field notes, documents, and audio recordings of meetings and group reflections which were abridged into an event data file structured by CFIR domains. In a joint analysis, an outsider researcher was added to strengthen the analysis and mitigate potential bias. Results: Two themes were identified, for which CFIR did not satisfactorily explain the findings. First, the intervention characteristics (i.e. the content of the MI) were modified along the process and, second, the process did not follow predefined plans. However, the project was still perceived to be successful by internal and external stakeholders. Conclusions: The paper proposes three ways in which translation theory can inform CFIR when applied to MIs: 1) strength of evidence is not as important for MIs as for medical and technical innovations; 2) adaptability of the MI can be emphasized more strongly, and 3) it can be more fruitful to view implementation as a dynamic process rather than seeing it as a matter of planning and execution. For managers, this implies encouragement to seize the opportunity to translate MIs to fit their organization, rather than to aim to be true to an original concept.

In the last years, a variety of theoretical frameworks have been proposed to support decision-makers while assessing eHealth initiatives. These frameworks aim at guaranteeing a rational, efficient and fair assessment to select those initiatives that are value-for-money. This study, by means of a systematic literature review, investigates the actual application of the theoretical frameworks when assessing eHealth initiatives. Results show that empirical studies do not rely on theoretical frameworks and prefer tailor-made approaches, thus reducing the comparability of current assessments.

Purpose The concept of value is becoming increasingly fashionable in healthcare and various improvement approaches (IAs) have been introduced with the aim of increasing value. The purpose of this paper is to construct a taxonomy that supports the management of parallel IAs in healthcare. Design/methodology/approach Based on previous research, this paper proposes a taxonomy that includes the dimensions of view on value and organizational focus; three contemporary IAs - lean, value-based healthcare, and patient-centered care - are related to the taxonomy. An illustrative qualitative case study in the context of psychiatric (psychosis) care is then presented that contains data from 23 interviews and focuses on the value concept, IAs, and the proposed taxonomy. Findings Respondents recognized the dimensions of the proposed taxonomy and indicated its usefulness as support for choosing and combining different IAs into a coherent management model, and for facilitating dialog about IAs. The findings also suggested that the view of value as "health outcomes" is widespread, but healthcare professionals are less likely than managers to also view value as a process. Originality/value The conceptual contribution of this paper is to delineate some important characteristics of IAs in relation to the emerging "value era". It also highlights the coexistence of different IAs in healthcare management practice. A taxonomy is proposed that can help managers choose, adapt, and combine IAs in local management models.