https://www.eur.nl/sites/corporate/files/QUASER-GuideForPayers_0
Bate, Mendel & Robert - Organizing for quality: the improvement
journeys of leading hospitals in Europe and the United States
Chapter 10 - Towards a process model of organizing for quality
Key factors that make a healthcare organization to be one of high quality:
1) Developing the right culture
2) Attracting and retaining the right people
3) Devising and updating the right in-house processes
4) Giving staff the right tools to do their job
Quality improvement models:
● Often describe stages + steps, but tell us little about the process
● The process: not as much a sequence of steps/factors, but what happens between
them; this is what connects everything
○ roads/processes to QI:
■ Most often: structure and culture paths
■ Regular: learning and politics
■ Not often: emotional and technological
Chapter 9 (Not mandatory) - A practitioner’s codebook for the quality
journey
Health care quality improvements QI:
● 6 common challenges, and what to learn (chapter 10):
○ 1) structural challenge: structuring, planning, coordinating quality efforts
■ Focus on getting the basic structure in place
■ Establishment of quality systems, structures and roles, data and
monitoring systems, and training progras, strategic leadership for QI
■ Problem: no effective structural process, result is fragmentation and a
general lack of synergy and joined-upness between the different parts of
the organization doing QI
○ 2) political challenge: addressing the politics and negotiating the buy in, conflict
and relationships of change surrounding any QI effort
■ Deal with conflicts and tensions
■ Clinical engagement, staff and patient empowerment, and partnership
working with external stakeholders
■ Problem: no effective political process, result is disillusionment, because
if a change process will be made difficult because of politics in the
organization, people will give up trying
○ 3) cultural challenge: giving ‘quality’ a shared, collective meaning, value and
significance within the organization
, ■ Take time to build camaraderie and strong teamwork
■ Creating a shared mindset or ethos around quality (culture of an
organization as a social construction)
■ Culture is important in the sustainability aspect: anchoring and fixing the
change in new habits of thinking and patterns of behavior
● Essentially a social accomplishment, incorporated in the binding
commitments that people make to each other in relation to
innovation/change
■ Problem: no effective cultural process, result is evaporation because the
change has not been properly anchored or become a routine, as soon as
the current program or project stops the change will also stop
○ 4) educational challenge: creating and nurturing a learning process that supports
continuous improvement
■ Learn from your mistakes
■ Knowledge harvesting, experimentation and piloting, and leaders who
take a mentorship role to encourage reflective practice and personal
development
■ Problem: no effective educational process, result is amnesia or
frustration, because lessons and knowledge are forgotten
○ 5) emotional challenge: inspiring, energizing, and mobilizing people by linking QI
to inner sentiments and deeper commitments
■ Feel and share the passion for getting to the top
■ Problem: no effective emotional process, result is disinterest and fade-out
because the change effort will run out of energy and forward movement
○ 6) physical and technological challenge: designing physical systems and
technological infrastructure that support improvement and quality of care
■ Avoid being distracted too early by high tech solutions
■ What is needed to regularize quality and deliver it on a routine
■ Problem: when there isnt an effective design process, the result will be
exhaustion, as people run around trying to do it all by hand/word/mouth,
not having the luxury of a system/standardized set of routines to take the
weight of necessary everyday activities
● Overall lesson: don’t look down, manage the context
Bromley & Powell - From smoke and mirrors to walking the talk:
decoupling in the contemporary world
Why do organizations adopt formal policies:
● 1) to secure legitimacy
○ Incorporate elements that are externally legitimated by socially constructed
beliefs in the external environment, regardless of their effects on technical tasks
a hand
● 2) in order to avoid legal sanctions and the glare of public opinions
,Decoupling:
● Definition: disconnecting a link between certain aspects that are seen as important within
organization; aspects that normally used to have a relation/connection, but this relation
isnt clearly visible anymore
● 2 types (which is more important):
○ 1) policy-practice decoupling:
■ Description: formal rules systematically violated and unimplemented +
evaluation/inspection isnt present or is intended as symbolic, it's so vague
that it provides little relevant info
■ Key insight: explains why organizations routinely adopt policies and dont
implement them
■ Key consequences: legitimacy/resources/both → adoption may
be ceremonial; buffering of core activities → may promote
efficiency or protect interests or internal constituents
■ = so gap between policy and practice, because employees make
exceptions to certain rules → this becomes standardized so
policy isnt carries out as expected; studies why/how managers
fail to/avoid implementing formal rules over time
■ More likely if:
● Adoption is motivated by legitimacy rather than technical demands
● It is early in the adoption process
● There is weak capacity to implement policies
● Internal constituents do not reinforce external pressures
■ May decrease because:
● More emphasis on implementing policies
● Policies are selected in part because they can be implemented
and measured
● Pressures in environment that drive creation of policies may
independently be changing practices and outcomes, regardless of
policy implementation
○ 2) means-ends decoupling:
■ Description: rules/policies implemented, but with uncertain relationship to
outcomes; may be multiple unrelated goals
■ Key insight: explains why organizations dedicate resources to practices
that have little known relationship to intended goals
■ Key consequences:
● 1) internal complexity: internal organization structure become
increasingly complex
○ implementation contributes to organizational heterogeneity
and complexity;
● 2) endemic reform: organizations persist in a state of perpetual
reform
, ○ if evaluation/inspection are present this generates
continual periods of reform when inconsistencies are
revealed;
● 3) diverting resources: resources are often diverted away from
core goals
○ arational allocation of resources from purely instrumental
perspective, can direct time/attention away from core goals
● (legitimacy)
■ = so gap between resources and goals → work doesnt reach
intended goal; so policy is implemented but doesn’t relate to the
core tasks of an organization; to understand internal structure of
organization + heterogeneity in process
■ More important because we are becoming an increasingly
managerial world that emphasizes evaluation/standardization
/benchmarking → so policy-practice becomes less common and
means-end more
■ More likely if:
● In contexts where the effects of actions are difficult to measure
● Over time, as raionalizing pressures expand into arenas where
outcomes are hard to measure
● When conflicting pressures are more institutionalized in hard or
soft law, especially when law emphasizes procedure over
outcomes
● When internal constituents champion an external cause
● When the rationalized environment is fragmented, due to:
○ Direct accountability to a greater number of stakeholders
through eg diverse funding streams
○ Greater societal pressure due to visibility because of
size/status/perception of public interest
○ Fragmentation may increase over time with worldwide
adoption of New Public Management and neo-liberal
ideologies
○ Higher fragmentation in contexts where traditional forms of
authority are weak
■ Why does this kind occur in organizations?
● Goals havent been achieved; so organizations use this kind of
decoupling because they want to have more quality and less
bureaucracy
● They want to give more time to patients (= patient centered) +
agreement with staff(management) and local solutions
Bate, Mendel & Robert - Organizing for quality: the improvement
journeys of leading hospitals in Europe and the United States
Chapter 10 - Towards a process model of organizing for quality
Key factors that make a healthcare organization to be one of high quality:
1) Developing the right culture
2) Attracting and retaining the right people
3) Devising and updating the right in-house processes
4) Giving staff the right tools to do their job
Quality improvement models:
● Often describe stages + steps, but tell us little about the process
● The process: not as much a sequence of steps/factors, but what happens between
them; this is what connects everything
○ roads/processes to QI:
■ Most often: structure and culture paths
■ Regular: learning and politics
■ Not often: emotional and technological
Chapter 9 (Not mandatory) - A practitioner’s codebook for the quality
journey
Health care quality improvements QI:
● 6 common challenges, and what to learn (chapter 10):
○ 1) structural challenge: structuring, planning, coordinating quality efforts
■ Focus on getting the basic structure in place
■ Establishment of quality systems, structures and roles, data and
monitoring systems, and training progras, strategic leadership for QI
■ Problem: no effective structural process, result is fragmentation and a
general lack of synergy and joined-upness between the different parts of
the organization doing QI
○ 2) political challenge: addressing the politics and negotiating the buy in, conflict
and relationships of change surrounding any QI effort
■ Deal with conflicts and tensions
■ Clinical engagement, staff and patient empowerment, and partnership
working with external stakeholders
■ Problem: no effective political process, result is disillusionment, because
if a change process will be made difficult because of politics in the
organization, people will give up trying
○ 3) cultural challenge: giving ‘quality’ a shared, collective meaning, value and
significance within the organization
, ■ Take time to build camaraderie and strong teamwork
■ Creating a shared mindset or ethos around quality (culture of an
organization as a social construction)
■ Culture is important in the sustainability aspect: anchoring and fixing the
change in new habits of thinking and patterns of behavior
● Essentially a social accomplishment, incorporated in the binding
commitments that people make to each other in relation to
innovation/change
■ Problem: no effective cultural process, result is evaporation because the
change has not been properly anchored or become a routine, as soon as
the current program or project stops the change will also stop
○ 4) educational challenge: creating and nurturing a learning process that supports
continuous improvement
■ Learn from your mistakes
■ Knowledge harvesting, experimentation and piloting, and leaders who
take a mentorship role to encourage reflective practice and personal
development
■ Problem: no effective educational process, result is amnesia or
frustration, because lessons and knowledge are forgotten
○ 5) emotional challenge: inspiring, energizing, and mobilizing people by linking QI
to inner sentiments and deeper commitments
■ Feel and share the passion for getting to the top
■ Problem: no effective emotional process, result is disinterest and fade-out
because the change effort will run out of energy and forward movement
○ 6) physical and technological challenge: designing physical systems and
technological infrastructure that support improvement and quality of care
■ Avoid being distracted too early by high tech solutions
■ What is needed to regularize quality and deliver it on a routine
■ Problem: when there isnt an effective design process, the result will be
exhaustion, as people run around trying to do it all by hand/word/mouth,
not having the luxury of a system/standardized set of routines to take the
weight of necessary everyday activities
● Overall lesson: don’t look down, manage the context
Bromley & Powell - From smoke and mirrors to walking the talk:
decoupling in the contemporary world
Why do organizations adopt formal policies:
● 1) to secure legitimacy
○ Incorporate elements that are externally legitimated by socially constructed
beliefs in the external environment, regardless of their effects on technical tasks
a hand
● 2) in order to avoid legal sanctions and the glare of public opinions
,Decoupling:
● Definition: disconnecting a link between certain aspects that are seen as important within
organization; aspects that normally used to have a relation/connection, but this relation
isnt clearly visible anymore
● 2 types (which is more important):
○ 1) policy-practice decoupling:
■ Description: formal rules systematically violated and unimplemented +
evaluation/inspection isnt present or is intended as symbolic, it's so vague
that it provides little relevant info
■ Key insight: explains why organizations routinely adopt policies and dont
implement them
■ Key consequences: legitimacy/resources/both → adoption may
be ceremonial; buffering of core activities → may promote
efficiency or protect interests or internal constituents
■ = so gap between policy and practice, because employees make
exceptions to certain rules → this becomes standardized so
policy isnt carries out as expected; studies why/how managers
fail to/avoid implementing formal rules over time
■ More likely if:
● Adoption is motivated by legitimacy rather than technical demands
● It is early in the adoption process
● There is weak capacity to implement policies
● Internal constituents do not reinforce external pressures
■ May decrease because:
● More emphasis on implementing policies
● Policies are selected in part because they can be implemented
and measured
● Pressures in environment that drive creation of policies may
independently be changing practices and outcomes, regardless of
policy implementation
○ 2) means-ends decoupling:
■ Description: rules/policies implemented, but with uncertain relationship to
outcomes; may be multiple unrelated goals
■ Key insight: explains why organizations dedicate resources to practices
that have little known relationship to intended goals
■ Key consequences:
● 1) internal complexity: internal organization structure become
increasingly complex
○ implementation contributes to organizational heterogeneity
and complexity;
● 2) endemic reform: organizations persist in a state of perpetual
reform
, ○ if evaluation/inspection are present this generates
continual periods of reform when inconsistencies are
revealed;
● 3) diverting resources: resources are often diverted away from
core goals
○ arational allocation of resources from purely instrumental
perspective, can direct time/attention away from core goals
● (legitimacy)
■ = so gap between resources and goals → work doesnt reach
intended goal; so policy is implemented but doesn’t relate to the
core tasks of an organization; to understand internal structure of
organization + heterogeneity in process
■ More important because we are becoming an increasingly
managerial world that emphasizes evaluation/standardization
/benchmarking → so policy-practice becomes less common and
means-end more
■ More likely if:
● In contexts where the effects of actions are difficult to measure
● Over time, as raionalizing pressures expand into arenas where
outcomes are hard to measure
● When conflicting pressures are more institutionalized in hard or
soft law, especially when law emphasizes procedure over
outcomes
● When internal constituents champion an external cause
● When the rationalized environment is fragmented, due to:
○ Direct accountability to a greater number of stakeholders
through eg diverse funding streams
○ Greater societal pressure due to visibility because of
size/status/perception of public interest
○ Fragmentation may increase over time with worldwide
adoption of New Public Management and neo-liberal
ideologies
○ Higher fragmentation in contexts where traditional forms of
authority are weak
■ Why does this kind occur in organizations?
● Goals havent been achieved; so organizations use this kind of
decoupling because they want to have more quality and less
bureaucracy
● They want to give more time to patients (= patient centered) +
agreement with staff(management) and local solutions
