ON THE SAME PAGE insights book

A project in partnership with:
Sykehjemsetaten
Oslo Kommune
Line T. Bogen, Rickard Jensen, Liz LeBlanc, Simon Søgnen Tveit
Systems Oriented Design Fall 2014
ON THE
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INSIGHT BOOK //08.12.14 2
What we learned 26
Workshop 1 at Solvang 18
Workshop 2 at AHO 20
WORKSHOPS 17
Employee concerns 10
Helsehus 14
Bestillerkontoret & structure 15
Hospital 11
Difference between districts 12
Home care services 13
GENERAL INSIGHTS 9
PROTOTYPING 25
Bestillerkontoret 4
Home care services 5
AHUS 6
Solvang sykehjem 7
Lilleborg sykehjem 8
INTERVIEWS 3
We’ve categorized these insights according to the actor or
organization that is most relevant. We hope this makes them
easier to grasp rather than chronological ordering according
to when we discovered this information.
INSIGHTS
TABLE OF CONTENTS

4INSIGHT BOOK //08.12.14
INTERVIEWS

BESTILLERKONTORET
10 SEPTEMBER BYDEL ALNA
MARIT
1. Always evaluating patients’needs in person
2. Patient has a choice over long term location
3. They don’t care about neighbors staying next to
each other in the long term home.
4. Helse hus is not a spa, it’s an efficient extension of
the hospital
5. Private home care has less bickering. They do only
what is ordered.
6. They now have twice as many gates to check on
people at the hospital and at the helse hus
7. They always use all the rooms
8. They have to prepay for rooms every three months
and estimate what they will need

11 SEPTEMBER BYDEL GRORUD
BENTE
1. Nothing is standard. Each bydel decides who gets
what care by whom
2. Communication is stronger and more open here.
3. Evaluation meeting is not enough time to give
accurate vedtak
4. Opinion of private/public varies by district and
demographic
5. Amount of public housing has huge impact
6. Many have been working 20- 25 years
7. Different employees have different strengths.
Holistic view, or get it done
8. Hospitals, family, and politicians want more room
in the nursing home. Patients and districts want them
to be cared for at home
9. If you haven’t worked in home care, impressions
aren’t great.
10. Miscommunication is an epidemic
11. Want primary person for each patient. But
sometimes that’s not what the patient wants, or it’s
dangerous, or it’s impossible with 24hr care
12. It’s easy to think things are going well but they
only see employees a few times per day
13. Technology is working, they work with device to
control
HJEMMETJENESTE

12 SEPTEMBER
BJØRN & BENTE
1. Patients get better care at home (even
research says so)
2. Still not ideal communication between Ahus
and bestillerkontoret
3. Positive reaction to changes. It gives common
communication.
4. Reform about increasing collaboration so
patients get the best care
5. GP’s are gatekeepers who don’t see the whole
picture
6. 2012 effect- hospital is empty
AHUS

23 SEPTEMBER
TERESA
1. There has been an increase in patients, a
bigger turnover and more work in general for
nursing homes after samhandlingsreformen.
2. Becoming a health house requires a higher
number of full time employees, yet the
number of beds remains the same.
3. About 90 % of the current employees
at Solvang will be moved to other nursing
homes as a direct consequence of
competence following the patients.
4. There will be no unskilled nurses at health
houses.
5. Personal information concerning the
patient, such as eating and sleeping habits are
included in the reports in the Gerica journal.
6. Restructuring Solvang, all long term
patients are given the choice of either moving
internally to a different ward, or to another
nursing home. The majority chooses to stay at
Solvang.
SOLVANG SYKEHJEM

3 OCTOBER
KRYSTYNA
1. Bestillerkontoret visits and evaluates every 2
weeks
2. Normal stay at a short term facility is 2-3
weeks
3. Patients with dementia can seem calm and
balanced in hospital, but act out in nursing
home.
4. First evaluation of patient consists of a cross
disciplinary team.
5. Regular meetings for special case patients
include Bestillerkontor, patient, next of kin and a
representative from the nursing home
6. Some patients have scheduled visits allowing
them stay for instance two weeks in a nursing
home followed by four weeks at home.
HONEY
1. A long term nurse can stay at a health house if
that nurse acquires the necessary competence
2. There is unclarity as to what competence is
needed for short term vs long term patients.
3. The potential possibility of staying at your
facility renders the nurse passive as to whether
or not to apply other places.
4. Practical elements that change when
switching workplace, such as proximity to home
or kindergarten, play a smaller role than losing
colleagues and patient relations.
LILLEBORG SYKEHJEM

GENERAL
INSIGHTS

EMPLOYEE CONCERNS ABOUT THE MOVE
1. Short term staff are more open for change
than long term. The special competence of
the employees will follow the medical needs
of the patients.
2. Employees are concerned about
maintaining the quality of the service they
are providing for the patients, as they start
moving staff and employees around.
3. Some are the“get it done”type, others are
more holistic, short term patients need their
care takers to balance both mind sets.
4. The institution leaders have invested a lot
in putting together people and establishing
internal routines for their place so it´s
emotional to start sending them away and
ripping up all the work they’ve put in.

HOSPITAL
1. Within the first 24 hours from admittance,
the hospital has to notify the municipality
that they have a patient that may need more
care after discharge.
2. At the hospital, they have a lot of
agreements that are used as a tool for
cooperation. Agreements on who is
responsible for what, so there is less
confusion.
3. Teams of nurses that go out in
ambulances. They can follow up on practical
nurse missions and train the home nurses to
care for the patient.
4. Prior to the reform in 2012, patients
stayed longer in hospital, now they are sent
home and need recovery while finished
medication.
5. 24 hours after reforms took place, hospital
was completely empty.
6. If the district is full, they hospital will of
course take care of the patient, but it is
incredibly expensive. First extra night in
hospital can cost 40000 NOK.

1. There are incredible differences in the
patient population from bydel to bydel. Alna
has a mixed population, 200 nationalities,
huge cultural differences.
2. May elderly in Grorud have no social
network, never kept a job, poor living
conditions, average age 67 years old.
3. Frogner has social support structure,
average age 84
4. West side has a lot more complaints, some
times from family members, even though
there are more resources. East side has less
complaints. Take what they can get.
DIFFERENCES ACROSS OSLO
5. Security issues make it harder to get
people to work after dark at Grorud,
stepping over people sleeping in the
hallways.
6. Nothing is standard, each district can
decide for themselves what they want to do.
This creates ownership, but also can mean
patients don’t receive the same quality of
care.
7. Private/public opinion varies from
district to district and which side of the city.
Availability of public housing has an impact
on perception.

HOME HELP SERVICES
1. Working in the home help system
sometimes can be dangerous. Patients
can be aggressive, racist, etc. Can be really
overbearing on the help.
2. The day is broken into 3 shifts: day,
evening, night shift. This drops to 1/3 the
staff on the weekend.
3. Very open to technology, they have GPS
system for employees to make sure they are
not stuck somewhere.
4. Employees can go out in teams. Park the
car somewhere central. And go out together.
5. Great system, morning shift, come back
and eat lunch together, talk about patients.
Give feedback. If there’s a problem, they
always send a second person to make sure
something is really happening (not just that
the patient was having a bad day, etc)
6. Goals: would like to have one primary care
taker, but not always needed. Some patients
like a lot different people to talk to. It’s a
matter of personal preference. They may
also prefer a different employee, or have a
preference on the gender of their care taker.
7. They have an ongoing agreement with
security company to accompany them to
unruly patients.
8. Physical challenges in homes: getting in
and out of shower. High threshold in the
doors, not flat. Is there an elevator? Is the
bed too tall? Wheelchairs getting through
doors. Can the nurse help the patient in that
type of bed? It can take up to two weeks to
order specialized equipment.
9. If you can’t walk up stairs, and there is no
elevator, that is not enough reason to get
into a long term home.
10. 15 hours a week at home care. Anything
more than that, it’s cheaper to go into long
term care. But spaces are not necessarily
available.
11. Many nurses in home health have been
there for 20-25 years. Newer ones leave
quickly. But those who have been in hospital
or other experience tend to do very well.
12. Sometimes hard to get an overview of
what is happening because you don’t see
into the people’s houses. Not like a hospital.
13. A vedtak can just be a call to check in
with the patient, or visits to the home every
3 hours.
14. Friday afternoon: Bestillerkontoret often
calls last minute and has them arrange
something.

HELSEHUS
1. One of the goals for the Helse Hus
patients is no re-admittance to the hospital.
2. The Helsehus should be as an extension
of the hospital. Sterile & efficient, shouldn’t
be too“comfortable”, hindering the flow of
people.
3. Short term patients can stay two in a
room while long term need their own
room. However, there is not always space
to put two beds in one room, which can
complicate the precalculated moving plan.
4. Employees working in the Helsehus have
to know when to“sit on their hands”, so
that the patients do as much as possible by
themselves. This is to prevent the patients
from becoming apathetic and dependent
after a long period in an institution.
5. Beds should be organized according to
medical needs and not according to city
districts.
6. Short term patients in general needs a
higher“care level”. Solvang for example, is
going to have the same number of beds
but they will need a higher number of
FTE´s. Patients are still in treatment when
they leave the hospital. They may have IV’s,
feeding tubes, etc. More care is now typically
needed.
7. Short/long-term isn’t an accurate
description of the patients, only how long
they might need the bed and not about
their needs. An UDI patient and a rehab-
patient are both short-term patients,
but the first can have no hopes of being
independent while the second has a clear
focus on getting better.
8. It has been decided upon that the
name `Helsehus´ can only be used for this
institution. (This hasn´t happened for `Mitt
hjem´ which is still not totally certain that
it´ll be chosen as the name for what will be
the long term nursing home).
9. Employees at the Helsehus needs to be
pragmatic when caring for someone that
just needs to be as comfortable as possible.
They need to focus on motivating the
patients to get better.
10. There´s a greater need for medical
equipment when becoming a Helsehus, but
the costs for that comes out of the pocket of
the individual Helsehus. The need is greater
due to the shortened time at the hospital
and patients with unfinished treatment.
TRADEMARK

BESTILLERKONTORET &
STRUCTURE
1. It’s difficult to get things done because
people have so many interfering obligations.
They want to make improvements, but are
too busy doing their job.
2. Each districts orders a block of the beds
they will need once a year. They have the
opportunity to adjust the order every three
months. They can of course“buy”additional
beds“outside the block”but they are much
more expensive.
3. The patient can often get mixed
messages, especially from doctors and case
workers from BK. The reason for this might
be that the doctor sees the person at his/her
worst and then the case worker comes in a
bit later when the patients condition seems
a bit better. Also the doctor is not always
aware of the different service offerings the
case workers from different city districts has
to offer.
4. There are problems with the logistics
concerning beds. Patients get moved
around because they are not in the bed their
bydel is renting or because there´s a cheaper
bed opening up somewhere.
5. If a patient’s health situation changes
and they need a different kind of care, the
decision is made by the city district they
come from. The bestillerkontoret acts as a
gatekeeper. This means that two patients
with the same needs in the same institution
could get different treatment. This has to
do with what the case workers from BK
have in terms of resources to distribute and
how they evaluate the patients needs. They
might also have different routines when it
comes to evaluation of the patients from
their district.
6. The detailed level of preferences
concerning the patients care (what they
eat, when they eat, what time they like to
go out of bed, etc.) are documented in a
system within each of the nursing homes.
This information is not passed on if a patient
moves from one nursing home to the next.
7. The patient journal is constantly under

BESTILLERKONTORET & STRUCTURE
debate. There is no journal that can follow
the patient, causing big problems for both
them and the different institutions they
meets. It means starting from scratch with
every patient, which costs a lot of time and
money.
9. Samhandlings is really about sliding
between tasks and strengthening the
competence in the municipalities. A lot of
things can be done outside the hospital.
10. Bottleneck at the hospital, it’s the district
that decides what the patient needs. The
doctors in the hospital may tell the patient
something different. It causes a lot of
confusion and distrust for the patient and
their family.

WORKSHOPS

30 OCTOBER SOLVANG SYKEHJEM
WORKSHOP 1

When becoming a health house the institute
will be needing more doctors. In the process
of hiring these, one institute used role
playing in the interview to get a better feel
of the human aspect of the position. This is
something new and the process was quickly
shared with the other institutes.
2. The involved parties are quick to adapt to
new situations and get on top of things such
as more FTEs, new positions and limited
time.
3. There is little or no consensus across the
levels as to what the health house will be,
and the involved parties have a pressing
need to vent any unclarities.
SOLVANG WORKSHOP
We were able to take over a meeting SYE
hade planned in order to discuss progress in
the transition to health houses. The meeting
was originally two and a half hours long
but ended up being split up into a half-
hour meeting followed by our two hour
workshop.
At one point, one of the institute leaders
classified themselves as a“40% health
house”while in reality she meant they are
now at 40% short term patients.
1. Those involved in this transition are not
aware of the fact that a health house is not
the same as a short term facility, nor are they
aware of the length of the transition process
and what it entails. The health house is not
yet defined.

1. Most of the participants pointed out the
issue of moving patients, how that is both
the biggest weakness in the system and the
point where the patient would feel the least
taken care of.
2. Communication is key. The situations
where communication flow is satisfactory
and the patient course is well planned lead
to the employee feeling more in control of
the situation and the patient feels safe.
3. The patient feels safest at home and/or
with the appropriate services, and least safe
if his/her situation is unclear.
4. Inadequate flow of information or
communication robs the employees of
feeling in control.
5. There is an urgent need for better
interaction and collaboration around the
patient, and for getting all partners on board
right away.
6. Economy is insufficient. It’s difficult to
cover all patient’s needs with the resources
available.
7. The best level of care is not necessarily
lowest level.
8. Transparency. Making more information
available could increase patient security in
dire situations.
WORKSHOP 2
5 NOVEMBER AHO

AHO WORKSHOP

PAGE CONTINUED
8. There is an urgent need for better
documentation systems that talk to each
other better, or one single electronic system
that follows the patient. This technology
should be used systematically for follow-ups
and monitoring, ensuring a focused and
targeted stay.
9. Each stopover in the patient journey
demands a lot of resources. Finding the right
level of care the first time around, or as early
as possible, would facilitate making direct
transitions between institutions. This could
speed up the patient journey and reduce
the number of stopovers.
10. Strengthening home services for
patients with dementia would reduce short
term admittances.
11. It is challenging to give the user the
correct services based on needs and wishes
according to the district’s economy and
regulations.
12. Introducing one single contact person
for each patient and all actors around him/
her, could create a more coherent patient
journey, reduce the feeling of insecurity
across multiple levels and give the patients a
greater sense of being included in their own
course of events.
1. Patient journeys need to be standardized
and seen holistically. Focusing on a single
task instead of the end goal results in
confusion and insecurity.
2. There are too many actors involved and
too much individual problem handling.
Not enough familiarity with the roles of
other services and insufficient focus on
collaborating across institutions. Better
interaction and multi disciplinary meetings
would lead to better coordinated services
and higher level of transparency concerning
the course of each patient.
3. Substance abuse patients need better and
more easily accessible housing facilities.
4. The competence in hospitals is too
specialized which could be a problem.
Generalized competence will allow the
hospital to make more qualified decisions
about the patient journey and could help
reduce the number of moves.
5. Improving the system for receiving
physical aids would free up more beds.
6. There are some gaps between the
different services offered, leaving some
patients in between two services either
getting too much or too little help.
The services need to be adjustable and
adaptable to each patient.
7. Invest more resources in preventive work,
enabling the patient to stay at home, and
out of institutions for as long as possible.

PROTOTYPING

FROM INSIGHT TO
DEVELOPMENT
In the brief from SYE they expressed a need for
making their project more visual, in a way that they
could easier explain it to others, such as the leaders
of nursing homes involved and politicians.
While sitting in on a meeting, we started visualizing
their conversation.
We were barely beginning to understand what
caused the most of the confusion and time
consuming discussions in these meetings.
As everybody in the meetings was following their
own notes in their own books they tended to
misunderstand and talk passed each other when
discussing number of patients, employees, FTE’s, etc.
We realized that if we could facilitate their discussion
by illustrating it, we could save time, confusion and
frustration.
Not only did the project leaders at SYE have problems
communicating and explaining the project outside
of the project group, they also had some problems
communicating between themselves in their own
meetings.
So, with a systems oriented design approach, we
made a timeline and the structure of the nursing
homes (in the map we call MAP 6), while Wenche,
leader at Ryen and Bente had the first meeting where
they planned the structuring of departments at Ryen.
Instantly Wenche and Bente lifted their eyes from
their notes and started pointing to the common
sheet, where they both could follow each other’s
trains of thought. The common worksheet eliminated
all confusion around what numbers, floors, which
house or what patients were being discussed.
WHAT WE LEARNED
PROTOTYPING THE TOOL

PROTOTYPING THE TOOL

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