Quality and Safety
Week 1; Introduction
Content of this video
- Introducing quality & safety
➢ Why is it important?
➢ How can we define it?
➢ Q&S in practice
Why is it important?
Very relevant in times of crisis (attention for safety during covid) – but just as important in everyday
work
➢ How we can think about this work in general?
➢ How we can intervene? In the real world of healthcare, this reality is messy and unplanned.
Meanwhile
- Patient care may be substandard, unsafe, fragmented, variable, costly
- Efforts to improve Q&S are marginally on the agenda of healthcare organizations, not always
highest priority.
- Existing power structures and hierarchies prevent quality improvement, heroism among
medical specialist, hard to talk about mistakes
- Instruments for QI are poorly understood
- Demographic changes, aging, population, rise of co-morbidities -> hard to maintain a certain
level of quality.
> Challenges are enormous.
How can we define it?
Institute of Medicine:
> Definition of quality changes over the years.
- Six dimensions: effectiveness, efficiency, equity, patient centeredness, safety, timeliness (IoM,
2001) -> very influential is international policy
> Dimensions can conflict with each other.
- Definition: “the degree to which health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent with current professional
knowledge” (IoM, 2013)
> Relative and dynamic definition of quality (desires and needs of patients and current
professional knowledge changes over time).
- World Health Organization (WHO)
> Same criteria as IoM
- Dutch Quality, Complaints & Disputes Act (Wkkgz):
> Same criteria as IoM, but replaces ‘Equity’ with ‘Transparancy’.
Q&S in practice: what is out there?
Many instruments for Q&S available, think of:
- Clinical guidelines
- Accreditation bodies and external commities
- Performance indicators
- (information) technologies
- Patient participation
- Etc.
However, Q&S are human accomplishments. We need to take into account the work that people do!
,Q&S in practice: what problems do we encounter?
Explanations that are often given for lacking quality and safety
- Instruments are badly implemented: but what is good implementation?
- Evidence of how instruments work is lacking
- Interactions between instruments and contexts of use are unclear
- Interaction between instruments is unclear
Q&S in practice: what makes it hard to research?
Practical limitations:
- Research is often focused on ‘simple’ intervention in ‘complex’ environments
- Local insights rarely universally applicable
- There’s still a lot we don’t know
Different views on what is important:
- Healthcare professionals, managers, policy makers tend to focus on instruments, tools,
structures
- They often ignore practices of quality and safety
Q&S in practice: what characteristics can we discern?
Q&S are multi-layered:
- Interaction between macro, meso, and micro levels of care
Q&S are dynamic
- Changes at each level have consequences for quality instruments (ex: changing use of
guidelines through time)
- Interactions between instruments, organizations, laws and protocols
Q&S are emergent:
- Q&S emerge from care practice, they are not inherent properties of care
- Consequences of interventions are unpredictable
Q&S in practice
What should we do?
➔ Reflexive and contextual approaches to Q&S, looking at processes, not the static view of
healthcare. We need to move along with healthcare.
➔ Less top-down focus on implementing interventions, interventions can be done bottom-up.
➔ More focus on making healthcare resilient, think more about prevention.
In short;
- Huge and complex challenge!
- Dynamic definitions of Q&S
- Many different instruments
- Effects are poorly understood
- Multi-layered, dynamic, emergent
Organizing for Quality framework
Content of this video
- Introducing the ‘Organizing for Quality’ framework by Bate et al. (2008)
Six challenges in quality and safety work explained
➢ Structural
➢ Cultural
➢ Educational
➢ Political
, ➢ Technological & physical
➢ Emotional
Six challenges in Quality & Safety
> Framework that we use in this course. Made successful quality improvements. They made this by
asking how questions in healthcare organizations.
Outer context: macro level, like markets, regulations, cultural environment
Inner context: meso level, like internal structure of an organization
Structural challenge
Challenge around structuring, planning and coordination quality efforts
- Good structures are essential for organizing quality effort: e.g. strategies, information
sharing, coordination, dedicated teams
- However, too much focus on structure can lead to bureaucratization, fragmentation and
decoupling.
By using verbs, the emphasize the work that must be done to structure an organization.
Cultural challenge
Challenge of giving quality a shared, collective meaning, value and significance within the
organization
- Culture is crucial for sustaining change and for processes of sense-making.
Example: culture of reflexivity, culture of innovation, culture of openness and sharing.
- However, there are also dysfunctional cultures (think of clan-culture, a toxic culture on the
work floor etc. )
Educational challenge
Challenge of creating and nurturing a learning process to support continuous improvement
- Accumulating and disseminating knowledge, reflecting on emergent effects and
organizational barriers, and other forms of learning are of vital importance.
- However, emphasis on learning can become pendantic, or lead to navel gazing
, Political challenge
Challenge of addressing the politics and negotiating the buy-in, conflict, and relationships of change
- Politics needed to engage clinical staff and senior leaders, empower patients and staff, link
with stakeholders etc.
- However, politics can become power play, resistance to change
Technological and physical challenge
Challenge of designing physical infrastructure and technological systems supportive of quality efforts
- Importance of physical infrastructure to support and govern quality work, such as ICT
systems, patient-friendly designs of physical infrastructure and user-friendly design of
equipment etc.
- However, focus on technology can lead to overly mechanistic approaches, and create
workarounds & exhaustion.
Emotional challenge
Challenge of inspiring, energizing and mobilizing people by linking QI to inner sentiments and deeper
commitments
- Creating a ‘movement for improvement’, making quality something that ‘has to be done’, for
example by engaging with patient, stories, through inspirational leadership, or with the help
of motivational speakers, champions, or activist.
- However, focus on emotions can lead to uncertainty, or laissez-faire policies
In short;
- Systemic and processual focus on the work of doing quality improvement (QI)
- One specific challenge will be addresses for each problem – but interaction between
challenges is key
- Less emphasis on specific instruments, more focus on how to critically and conceptually
reflect on the work of doing QI
Structural challenge
Content of this video
The structural challenge
➢ Structural challenge according to Bate et al.
➢ Policy-practice decoupling
➢ Workarounds
➢ Mean-ends decoupling
➢ Ex-post theory
Structural challenge: main focus of this first week
Good structures are essential for organizing quality effort; e.g. strategies, information sharing,
coordination, dedicated teams.
> You can’t really do without structures, otherwise the chaos will fall apart
However, too much focus on structure can lead to bureaucratization, fragmentation and decoupling
Decoupling (Bromley & Powell, 2012)
Decoupling = gap between policies and implementation, not directly a bad things, gives flexibility of
intern processes. Can make organizations more efficient or effective.
Two forms of decoupling
1. Policy-practice decoupling: classic form of decoupling
2. Mean-ends decoupling
Week 1; Introduction
Content of this video
- Introducing quality & safety
➢ Why is it important?
➢ How can we define it?
➢ Q&S in practice
Why is it important?
Very relevant in times of crisis (attention for safety during covid) – but just as important in everyday
work
➢ How we can think about this work in general?
➢ How we can intervene? In the real world of healthcare, this reality is messy and unplanned.
Meanwhile
- Patient care may be substandard, unsafe, fragmented, variable, costly
- Efforts to improve Q&S are marginally on the agenda of healthcare organizations, not always
highest priority.
- Existing power structures and hierarchies prevent quality improvement, heroism among
medical specialist, hard to talk about mistakes
- Instruments for QI are poorly understood
- Demographic changes, aging, population, rise of co-morbidities -> hard to maintain a certain
level of quality.
> Challenges are enormous.
How can we define it?
Institute of Medicine:
> Definition of quality changes over the years.
- Six dimensions: effectiveness, efficiency, equity, patient centeredness, safety, timeliness (IoM,
2001) -> very influential is international policy
> Dimensions can conflict with each other.
- Definition: “the degree to which health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent with current professional
knowledge” (IoM, 2013)
> Relative and dynamic definition of quality (desires and needs of patients and current
professional knowledge changes over time).
- World Health Organization (WHO)
> Same criteria as IoM
- Dutch Quality, Complaints & Disputes Act (Wkkgz):
> Same criteria as IoM, but replaces ‘Equity’ with ‘Transparancy’.
Q&S in practice: what is out there?
Many instruments for Q&S available, think of:
- Clinical guidelines
- Accreditation bodies and external commities
- Performance indicators
- (information) technologies
- Patient participation
- Etc.
However, Q&S are human accomplishments. We need to take into account the work that people do!
,Q&S in practice: what problems do we encounter?
Explanations that are often given for lacking quality and safety
- Instruments are badly implemented: but what is good implementation?
- Evidence of how instruments work is lacking
- Interactions between instruments and contexts of use are unclear
- Interaction between instruments is unclear
Q&S in practice: what makes it hard to research?
Practical limitations:
- Research is often focused on ‘simple’ intervention in ‘complex’ environments
- Local insights rarely universally applicable
- There’s still a lot we don’t know
Different views on what is important:
- Healthcare professionals, managers, policy makers tend to focus on instruments, tools,
structures
- They often ignore practices of quality and safety
Q&S in practice: what characteristics can we discern?
Q&S are multi-layered:
- Interaction between macro, meso, and micro levels of care
Q&S are dynamic
- Changes at each level have consequences for quality instruments (ex: changing use of
guidelines through time)
- Interactions between instruments, organizations, laws and protocols
Q&S are emergent:
- Q&S emerge from care practice, they are not inherent properties of care
- Consequences of interventions are unpredictable
Q&S in practice
What should we do?
➔ Reflexive and contextual approaches to Q&S, looking at processes, not the static view of
healthcare. We need to move along with healthcare.
➔ Less top-down focus on implementing interventions, interventions can be done bottom-up.
➔ More focus on making healthcare resilient, think more about prevention.
In short;
- Huge and complex challenge!
- Dynamic definitions of Q&S
- Many different instruments
- Effects are poorly understood
- Multi-layered, dynamic, emergent
Organizing for Quality framework
Content of this video
- Introducing the ‘Organizing for Quality’ framework by Bate et al. (2008)
Six challenges in quality and safety work explained
➢ Structural
➢ Cultural
➢ Educational
➢ Political
, ➢ Technological & physical
➢ Emotional
Six challenges in Quality & Safety
> Framework that we use in this course. Made successful quality improvements. They made this by
asking how questions in healthcare organizations.
Outer context: macro level, like markets, regulations, cultural environment
Inner context: meso level, like internal structure of an organization
Structural challenge
Challenge around structuring, planning and coordination quality efforts
- Good structures are essential for organizing quality effort: e.g. strategies, information
sharing, coordination, dedicated teams
- However, too much focus on structure can lead to bureaucratization, fragmentation and
decoupling.
By using verbs, the emphasize the work that must be done to structure an organization.
Cultural challenge
Challenge of giving quality a shared, collective meaning, value and significance within the
organization
- Culture is crucial for sustaining change and for processes of sense-making.
Example: culture of reflexivity, culture of innovation, culture of openness and sharing.
- However, there are also dysfunctional cultures (think of clan-culture, a toxic culture on the
work floor etc. )
Educational challenge
Challenge of creating and nurturing a learning process to support continuous improvement
- Accumulating and disseminating knowledge, reflecting on emergent effects and
organizational barriers, and other forms of learning are of vital importance.
- However, emphasis on learning can become pendantic, or lead to navel gazing
, Political challenge
Challenge of addressing the politics and negotiating the buy-in, conflict, and relationships of change
- Politics needed to engage clinical staff and senior leaders, empower patients and staff, link
with stakeholders etc.
- However, politics can become power play, resistance to change
Technological and physical challenge
Challenge of designing physical infrastructure and technological systems supportive of quality efforts
- Importance of physical infrastructure to support and govern quality work, such as ICT
systems, patient-friendly designs of physical infrastructure and user-friendly design of
equipment etc.
- However, focus on technology can lead to overly mechanistic approaches, and create
workarounds & exhaustion.
Emotional challenge
Challenge of inspiring, energizing and mobilizing people by linking QI to inner sentiments and deeper
commitments
- Creating a ‘movement for improvement’, making quality something that ‘has to be done’, for
example by engaging with patient, stories, through inspirational leadership, or with the help
of motivational speakers, champions, or activist.
- However, focus on emotions can lead to uncertainty, or laissez-faire policies
In short;
- Systemic and processual focus on the work of doing quality improvement (QI)
- One specific challenge will be addresses for each problem – but interaction between
challenges is key
- Less emphasis on specific instruments, more focus on how to critically and conceptually
reflect on the work of doing QI
Structural challenge
Content of this video
The structural challenge
➢ Structural challenge according to Bate et al.
➢ Policy-practice decoupling
➢ Workarounds
➢ Mean-ends decoupling
➢ Ex-post theory
Structural challenge: main focus of this first week
Good structures are essential for organizing quality effort; e.g. strategies, information sharing,
coordination, dedicated teams.
> You can’t really do without structures, otherwise the chaos will fall apart
However, too much focus on structure can lead to bureaucratization, fragmentation and decoupling
Decoupling (Bromley & Powell, 2012)
Decoupling = gap between policies and implementation, not directly a bad things, gives flexibility of
intern processes. Can make organizations more efficient or effective.
Two forms of decoupling
1. Policy-practice decoupling: classic form of decoupling
2. Mean-ends decoupling
