Quality and Safety
Week 1
Lecture 1.1 Introducing Quality & Safety
Why is Q&A important: relevant in times of crisis, but just as important in everyday work. How can we
think about this work in general? How can we intervene? Patient care may not be good enough. Effort to
improve Q&S are marginally on the agenda. Existing structures prevent quality improvement (QI).
Instruments for QI are poorly understood.
Institute of Medicine:
Dimensions: effectiveness, efficiency, equity, patient centeredness, safety, timeliness (2001).
Definition Q&A: the degree to which health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent with current professional knowledge
(2013). Relative and dynamic definition of quality.
WHO uses IoM criteria. Wkkgz uses the same criteria, but replaces equity with transparency.
Instruments for Q&A: clinical guidelines, accreditation bodies, performance indicators, (information)
technologies, patient participation tools. However, Q&S are human accomplishments: we need to take
into account the work that people do!
Explanations for lacking Q&S: instruments are badly implemented, evidence of how instruments work is
lacking, interactions between instruments and contexts of use are unclear, interaction between
instruments is unclear
Practical limitations: research is often focused on ‘simple’ interventions in ‘complex’ environments; local
insights rarely universally applicable; there is still a lot we do not know. Different views on what is
important: focus on instruments, tools, structures; ignore practices of Q&A.
Characteristics:
Q&S are multi-layered: interactions between macro, meso and micro levels of care
Q&S are dynamic: changes at each level have consequences for quality instruments; interactions
between instruments, organizations, laws and protocols
Q&S are emergent: Q&S emerge from care practices, they are not inherent properties of care;
consequences of interventions are unpredictable.
What should we do: reflexive and contextual approaches; less top-down focus on implementing
interventions; more focus on making healthcare resilient.
, Lecture 1.2 The Organizing for Quality framework
Organizing for Quality
framework by Bate.
Six challenges in Q&S:
structural, cultural,
educational, political,
technological
&physical, emotional.
Outer = macro level
Inner = meso level
Systemic and
processual focus on
the work of doing
quality improvement
(QI).
Interactions between
challenges is key.
Structural: challenge around structuring, planning and coordinating quality efforts. Good
structures are essential for organizing quality effort (strategies, information sharing,
coordination, dedicated teams). However, too much focus on structure can lead to
bureaucratization, fragmentation and decoupling.
Cultural: 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.
Examples: culture of reflexivity, culture of innovation, culture of openness and sharing.
However, there are dysfunctional cultures (clan-culture, bullying).
Educational: 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 pedantic or lead to navel gazing.
Political: 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. However, politics can become power play, resisting of
change, ‘impossible’ politics
Technological & physical: 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. However, focus on technology can lead to overly mechanistic
approaches and create workarounds and exhaustion.
Week 1
Lecture 1.1 Introducing Quality & Safety
Why is Q&A important: relevant in times of crisis, but just as important in everyday work. How can we
think about this work in general? How can we intervene? Patient care may not be good enough. Effort to
improve Q&S are marginally on the agenda. Existing structures prevent quality improvement (QI).
Instruments for QI are poorly understood.
Institute of Medicine:
Dimensions: effectiveness, efficiency, equity, patient centeredness, safety, timeliness (2001).
Definition Q&A: the degree to which health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent with current professional knowledge
(2013). Relative and dynamic definition of quality.
WHO uses IoM criteria. Wkkgz uses the same criteria, but replaces equity with transparency.
Instruments for Q&A: clinical guidelines, accreditation bodies, performance indicators, (information)
technologies, patient participation tools. However, Q&S are human accomplishments: we need to take
into account the work that people do!
Explanations for lacking Q&S: instruments are badly implemented, evidence of how instruments work is
lacking, interactions between instruments and contexts of use are unclear, interaction between
instruments is unclear
Practical limitations: research is often focused on ‘simple’ interventions in ‘complex’ environments; local
insights rarely universally applicable; there is still a lot we do not know. Different views on what is
important: focus on instruments, tools, structures; ignore practices of Q&A.
Characteristics:
Q&S are multi-layered: interactions between macro, meso and micro levels of care
Q&S are dynamic: changes at each level have consequences for quality instruments; interactions
between instruments, organizations, laws and protocols
Q&S are emergent: Q&S emerge from care practices, they are not inherent properties of care;
consequences of interventions are unpredictable.
What should we do: reflexive and contextual approaches; less top-down focus on implementing
interventions; more focus on making healthcare resilient.
, Lecture 1.2 The Organizing for Quality framework
Organizing for Quality
framework by Bate.
Six challenges in Q&S:
structural, cultural,
educational, political,
technological
&physical, emotional.
Outer = macro level
Inner = meso level
Systemic and
processual focus on
the work of doing
quality improvement
(QI).
Interactions between
challenges is key.
Structural: challenge around structuring, planning and coordinating quality efforts. Good
structures are essential for organizing quality effort (strategies, information sharing,
coordination, dedicated teams). However, too much focus on structure can lead to
bureaucratization, fragmentation and decoupling.
Cultural: 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.
Examples: culture of reflexivity, culture of innovation, culture of openness and sharing.
However, there are dysfunctional cultures (clan-culture, bullying).
Educational: 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 pedantic or lead to navel gazing.
Political: 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. However, politics can become power play, resisting of
change, ‘impossible’ politics
Technological & physical: 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. However, focus on technology can lead to overly mechanistic
approaches and create workarounds and exhaustion.
