Lecture 1
Q&S
Introduction
Why quality and safety?
- Patients are receiving care that is:
o Poorly integrated / Substandard / Unsafe / Variable / Too costly
- Too marginal on the agenda of healthcare organizations
- Existing power and hierarchical structures prevent improvement
- Culture of ‘heroism’
- Instruments for quality & safety improvement are poorly understood
- Demographic changes: huge challenge!
Defining Q&S: IoM
- Institute of Medicine: “Quality care is care that lives up to our expectations”.
- Relative, dynamic and situational definition of quality
- Six dimensions: Effectiveness / Efficiency / Accessibility / Safe / Patient-centered /
Equitable
- Dutch Quality, Complaints & Disputes Act (WKKGZ): Same criteria as IoM, without
‘Accessibility’ + Transparent / Based on professional guidelines / Respect rights of
clients, treat them with respect
How to do Q&S
- A plethora of instruments for Q&S is available:
o clinical guidelines / accreditation / performance indicators / information
technologies / patient participation tools / etc. etc.
o Despite all these instruments, however, quality and safety are lacking…
- Explanations that are often given:
o Instruments are badly implemented
o Evidence of how instruments work is lacking
o Interactions between instruments and contexts of use is unknown
o Interaction between instruments is unknown
- Research focused on ‘simple’ interventions in ‘complex’ environments creates
‘evidence bias’.
Q&S are multi-layered and systemic
- Interactions between macro, meso and micro levels seem key:
o Example: pressure ulcers in Dutch hospitals
- Changes at one level have consequences for significance and nature of quality
instruments.
o Example: changing nature of guidelines
- Interactions between components are key
- Quality and safety are emergent properties
- Consequences of interventions are unpredictable
- Therefore: reflexive and contextual approaches are needed!
, Organising for Quality framework
Structural challenge
- Challenge around organizing, planning and coordinating quality efforts
- Good structures are essential for organizing quality effort
o E.g. strategies, information sharing, coordination, dedicated teams
- Too much focus on structure can lead to bureaucratization, fragmentation and
decoupling
- Decoupling: gap between policies and implementation. Two forms:
o Classical: policy – practice gap (symbolic adoption)
o Means – ends (symbolic implementation)
Educational challenge
- Challenge of creating and nurturing a learning process that supports continuous
improvement
- Accumulating and disseminating knowledge of vital importance, as is reflecting on
emergent effects and organizational barriers, a culture of sharing and open
discussion, etc
- But emphasis on learning can become pedantic, or lead to navel gazing
Cultural challenge
- Challenge of giving quality a shared, collective meaning, value and significance in
the organization
- Culture crucial for sustaining change, and for processes of sense-making
o E.g. strong costumer/care ethic, culture of mindfulness, culture of reflexivity
and innovation
Q&S
Introduction
Why quality and safety?
- Patients are receiving care that is:
o Poorly integrated / Substandard / Unsafe / Variable / Too costly
- Too marginal on the agenda of healthcare organizations
- Existing power and hierarchical structures prevent improvement
- Culture of ‘heroism’
- Instruments for quality & safety improvement are poorly understood
- Demographic changes: huge challenge!
Defining Q&S: IoM
- Institute of Medicine: “Quality care is care that lives up to our expectations”.
- Relative, dynamic and situational definition of quality
- Six dimensions: Effectiveness / Efficiency / Accessibility / Safe / Patient-centered /
Equitable
- Dutch Quality, Complaints & Disputes Act (WKKGZ): Same criteria as IoM, without
‘Accessibility’ + Transparent / Based on professional guidelines / Respect rights of
clients, treat them with respect
How to do Q&S
- A plethora of instruments for Q&S is available:
o clinical guidelines / accreditation / performance indicators / information
technologies / patient participation tools / etc. etc.
o Despite all these instruments, however, quality and safety are lacking…
- Explanations that are often given:
o Instruments are badly implemented
o Evidence of how instruments work is lacking
o Interactions between instruments and contexts of use is unknown
o Interaction between instruments is unknown
- Research focused on ‘simple’ interventions in ‘complex’ environments creates
‘evidence bias’.
Q&S are multi-layered and systemic
- Interactions between macro, meso and micro levels seem key:
o Example: pressure ulcers in Dutch hospitals
- Changes at one level have consequences for significance and nature of quality
instruments.
o Example: changing nature of guidelines
- Interactions between components are key
- Quality and safety are emergent properties
- Consequences of interventions are unpredictable
- Therefore: reflexive and contextual approaches are needed!
, Organising for Quality framework
Structural challenge
- Challenge around organizing, planning and coordinating quality efforts
- Good structures are essential for organizing quality effort
o E.g. strategies, information sharing, coordination, dedicated teams
- Too much focus on structure can lead to bureaucratization, fragmentation and
decoupling
- Decoupling: gap between policies and implementation. Two forms:
o Classical: policy – practice gap (symbolic adoption)
o Means – ends (symbolic implementation)
Educational challenge
- Challenge of creating and nurturing a learning process that supports continuous
improvement
- Accumulating and disseminating knowledge of vital importance, as is reflecting on
emergent effects and organizational barriers, a culture of sharing and open
discussion, etc
- But emphasis on learning can become pedantic, or lead to navel gazing
Cultural challenge
- Challenge of giving quality a shared, collective meaning, value and significance in
the organization
- Culture crucial for sustaining change, and for processes of sense-making
o E.g. strong costumer/care ethic, culture of mindfulness, culture of reflexivity
and innovation
