Summary Quality and Safety - Complete Readings| EUR | Grade 9.2/10| 2025/26

Lecture 1

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Introducing Quality and Safety

Institute of Medicine on quality and safety in healthcare (crossing the quality chasm):
- Six dimensions: effectiveness, efficiency, equity, person centeredness, safety, timeliness.
o These can contradict 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 (2013).
- WHO: same criteria as IoM.
- Dutch Quality, Complaints, and Disputes Act (Wkkgz):
o Same criteria as IoM, but replaces “equity” with “transparency”.

Many instruments for Q&S available:
- Clinical guidelines, accreditation bodies, performance indicators etc.
- However, Q&S are human accomplishments; we need to take into account the work that
people do!

What problems do we encounter? Often about lacking quality and safety.
- 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.

What makes it hard to research Q&S?
- Practical limitations:
o Research is often focused on “simple” interventions in “complex” environments.
o Local insights rarely universally applicable.
o There is still a lot we don’t know.
- Different views on what is important.
o Healthcare professionals, managers, policy makers tend to focus on instruments,
tools, structures.
o They often ignore practices of quality and safety.

What characteristics can we discern?
- Q&S are multi-layered.
o Interactions between macro, meso, and micro levels of care.
- Q&S are dynamic.
o Changes at each level have consequences for quality instruments (e.g. changing use
of guidelines through time).
o Interactions between instruments, organizations, laws and protocols etc.
- Q&S are emergent.
o Q&S emerge from care practices; they are not inherent properties of care.
o 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.

,The “Organizing for Quality” Framework.

By Bate et al. (2008).
- Six challenges in quality and safety work:
o Structural.
 Challenge around structuring, planning, and coordinating quality efforts.
 But too much focus on structure can lead to bureaucratization,
fragmentation, and decoupling.
o Cultural.
 Challenge of giving quality a shared, collective meaning, value and
significance within the organization.
 But also dysfunctional cultures (toxic culture on work floor etc.)
o Educational.
 Challenge of creating and nurturing a learning process to support continuous
improvement.
 But emphasis on learning can become pedantic, or lead to navel gazing.
o Political.
 Challenge of addressing the politics and negotiating the buy-in, conflict, and
relationships of change.
 But politics can become power play, resistance to change.
o Technological & physical.
 Challenge of designing physical infrastructures and technological systems
supportive of quality efforts.
 But focus on technology can lead to overly mechanistic approaches and
create workarounds and exhaustion.
o Emotional.
 Challenge of inspiring, energizing, and mobilizing people by linking quality
improvement to inner sentiments and deeper commitments.
 But too much focus on emotions can lead to uncertainty, or laissez-faire
policies.
- Analytical framework; new way of looking at quality and safety.
- Things we need to think about when improving quality and safety in healthcare.


The Structural Challenge.

Decoupling = gap between policies and implementation.
- Two forms:
o Policy-practice decoupling; classic form.
 Institutional adoption of rules and policies is largely symbolic and
inconsequential.
 “ceremonial window dressing”.
 Rules are systematically violated and unimplemented.
 Formal policies are disconnected from daily practices.
 Daily practices may or may not be linked to intended outcomes.
 Example: workarounds (dealing with a problem/making something work
despite the problem, without completely solving it; skipping certain steps to
get the job done).
 We need feedback.
o Means-ends decoupling.

,  Rules and policies are implemented I practice, work activities are altered,
policies are evaluated, however;
 Little evidence that formal policies are linked to intended outcomes.
 Daily practices are disconnected from intended outcomes.
 Rather, they are connected to accounting, personnel management,
evaluation, or monitoring systems.
 This is an increasingly prevalent form of decoupling.
 Example: indicators and rankings (goal is to core higher (focus on
measurable outcomes), not to achieve good outcomes).
Ex-post theory.
- Dixon-Woods et al. reflect on how to learn from quality improvement work.
- Quality improvement as a complex social intervention.
- Cargo-cult: simply transferring a “best practice” in a new environment does not suffice.
- Ex-post theory: retrospectively applying social theory to empirical findings: what actually
happened? What social processes have contributed to the success of an intervention?


Leading patient safety improvements in practice

Why is patient safety so hard to improve?
- Visibility.
o Safety not very visible in healthcare.
- Ambiguity.
o Something has gone wrong, but uncertain about relationship between unsafety and
outcome. Not sure what has gone wrong.
o System error, or personal error?
- Complexity.
o Everything can have an impact on safety; many different factors in a hospital.
- Autonomy.
o Side effects of professionalism.
o Non-intervention principle: if you leave me alone, I will leave you alone.
o Highly trained healthcare professionals do not want people to meddle.

Theory – leading professionals/improvements.
- Command and control.
o Very regulating.
o But only when you are very certain that you are right.
- Project management.
o Give bandwidth of autonomy.
o But can lead to discussions.
- Deference to professionals.
o You decide.
o But make sure professionals help each other when something does not go as
planned
- Process management.
o Right people in right circumstances.
o More in charge of what is happening in terms of process compared to project
management.
o The social process does the work.
o Needed:
 Openness.