Quality & Safety
Week 1
Knowledge clips
Introduction quality & safety
Very relevant in times of crisis – but just as important in everyday work
How we can think about this work in general?
How we can intervene?
Meanwhile…
• Patient care may be substandard, unsafe, fragmented, variable, costly
• Efforts to improve Q&S are marginally on the agenda of healthcare organizations
• Existing power structures and hierarchies prevent quality improvement (in heroism f.e.)
• Instruments for QI are poorly understood
• Demographic changes, aging population, rise of co-morbidities…
Defining it - Institute of Medicine:
Six dimensions: Effectiveness / Efficiency / Equity / Patient-centeredness / Safety / Timeliness
(IoM, 2001)
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
World Health Organization (WHO)
Same criteria as IoM
Dutch Quality, Complaints & Disputes Act (Wkkgz):
Same criteria as IoM, but replaces ‘Equity’ with ‘Transparency’
In practice
Many instruments for Q&S available, think of:
• clinical guidelines
• accreditation bodies
• performance indicators
• (information) technologies
• patient participation tools
• etc.
However, Q&S are human accomplishments:
We need to take into account the work that people do! Crucial inside in this course…
Problems 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
What makes it hard to research?
Practical limitations:
• Research is often focused on ‘simple’ interventions 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
Characteristics:
Q&S are multi-layered:
• Interactions between macro, meso and micro levels of care (looking at organizational
theories and interactional theories so from different scopes)
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, etc.
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?
à Reflexive and contextual approaches (looking
at processes)
à Less top-down focus on implementing
interventions (but focus on bottom-up)
à More focus on making healthcare resilient
(think more about prevention)
‘Organizing for quality’ framework by Bate et al. (2008)
– analytical framework
Six challenges in quality and safety work explained:
Structural
Cultural
Educational
Political
Technological & Physical
Emotional
Structural challenge:
Challenge around structuring, planning and
coordinating quality efforts (Bate et al.)
• 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.
Cultural challenge:
Challenge of giving quality a shared, collective meaning, value and significance within the
organization (Bate et al.)
• 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 also dysfunctional cultures (think of clan-culture, a toxic culture on the
work floor, etc.). Als je niet goed genoeg meeneemt wat de cultuur inhoudt, sluit het niet
goed aan bij de dagelijkse gewoontes en processen.
,Educational challenge:
Challenge of creating and nurturing a learning process to support continuous improvement (Bate
et al.). You do not stop learning when education stops!
• 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. Wat gebeurt
er als je helemaal niet leert (van het verleden)? Je vergeet dingen die je al weet of nuttig zijn
om te weten.
Political challenge:
Challenge of addressing the politics and negotiating the buy-in, conflict, and relationships of
change (Bate et al.). Power!
• Politics needed to engage clinical staff and senior leaders, empower patients and staff, link
with stakeholders, etc. (create coalition)
• However, politics can become power play, resistance to change
Technological and physical challenge:
Challenge of designing physical infrastructures and technological systems supportive of quality
efforts (Bate et al.)
• 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, or doing something about slippery hallways or empty soap-dispensers.
• However, focus on technology can lead to overly mechanistic approaches, and create
workarounds & exhaustion (te groot aspect van je werk). Geen technologie is ook
vermoeiend en kan minder efficiëntie betekenen (related to structural challenge).
Emotional challenge
Challenge of inspiring, energizing, and mobilizing people by linking QI (quality improvement) to
inner sentiments and deeper commitments (Bate et al.). Often overlooked but important!
• 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 activists
• However, focus on emotions can lead to uncertainty, or laissez-faire policies (dat je als leider
het laat gaan en niet aan het leiden bent). Helemaal geen focus op emoties leidt tot
desintresse (sluit aan bij cultural challenge).
In short
• Systemic and processual focus on the work of doing quality improvement (QI)
• One specific challenge will be addressed 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
Further elaboration of the structural challenge:
Decoupling = gap between policies and implementation
Not a bad thing, can serve as a buffer between external demands (f.e. from governments), where
the expectations do not match with situations in daily lives.
Also, leads to flexibility in organizations, to safeguard their internal processes from external
pressure like national policies/guidelines.
Can make organizations more effective/efficient in terms of QoC.
Two forms of decoupling:
, 1. Policy-practice decoupling: policy sluit niet aan bij daily practice
2. Means-ends decoupling: policy wordt uitgevoerd maar leidt niet tot intended outcomes,
omdat het bv. veel extra papierwerk oplevert
See: Bromley & Powell (2012)
*Structuring is a way of ordering in chaos; it is needed in case of quality improvement. But too much
focus on structuring is not good, leads to f.e. bureaucratization.
Policy-practice decoupling:
• Institutional adoption of rules and policies is largely symbolic and inconsequential
• ‘Ceremonial window dressing’ – it is done for the stage (organization saying they have
implemented policy while they did not)
• Rules are systematically violated and unimplemented
• Formal policies are disconnected from daily practices
• Daily practices may or may not be linked to intended outcomes
This is the classical explanation of decoupling
See: Bromley & Powell (2012)
Example: workarounds
“A way of dealing with a problem or making something work despite the problem, without
completely solving it” (Cambridge Dictionary)
“In computing, a method for overcoming a problem or limitation in a program or system (Concise
Oxford English Dictionary)
• Workarounds are inherent to organizing; necessary to ‘get the job done’ (this is done very
often)
• Workarounds often build on each other and create organizational ‘drift’
à This calls for reflection on actual practices:
o Workarounds as feedback on structure (think of decoupling!)
o Feedback can lead to organizational learning
Means-ends decoupling:
• Rules and policies are implemented in 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
See: Bromley & Powell (2012)
Example: indicators and rankings
Using performance indicators and rankings to improve hospital care
However, in practice we often see:
• Excessive focus on measurable outcomes & parameters (≠ intended outcomes!)
• Increasing pressure on registration
• Registration comes to define quality, strengthens top-down management approach
This calls for reflection on (qualitative interpretation of) numerical data
Indicators can be useful as ‘entrance to reflection process’
Week 1
Knowledge clips
Introduction quality & safety
Very relevant in times of crisis – but just as important in everyday work
How we can think about this work in general?
How we can intervene?
Meanwhile…
• Patient care may be substandard, unsafe, fragmented, variable, costly
• Efforts to improve Q&S are marginally on the agenda of healthcare organizations
• Existing power structures and hierarchies prevent quality improvement (in heroism f.e.)
• Instruments for QI are poorly understood
• Demographic changes, aging population, rise of co-morbidities…
Defining it - Institute of Medicine:
Six dimensions: Effectiveness / Efficiency / Equity / Patient-centeredness / Safety / Timeliness
(IoM, 2001)
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
World Health Organization (WHO)
Same criteria as IoM
Dutch Quality, Complaints & Disputes Act (Wkkgz):
Same criteria as IoM, but replaces ‘Equity’ with ‘Transparency’
In practice
Many instruments for Q&S available, think of:
• clinical guidelines
• accreditation bodies
• performance indicators
• (information) technologies
• patient participation tools
• etc.
However, Q&S are human accomplishments:
We need to take into account the work that people do! Crucial inside in this course…
Problems 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
What makes it hard to research?
Practical limitations:
• Research is often focused on ‘simple’ interventions 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
Characteristics:
Q&S are multi-layered:
• Interactions between macro, meso and micro levels of care (looking at organizational
theories and interactional theories so from different scopes)
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, etc.
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?
à Reflexive and contextual approaches (looking
at processes)
à Less top-down focus on implementing
interventions (but focus on bottom-up)
à More focus on making healthcare resilient
(think more about prevention)
‘Organizing for quality’ framework by Bate et al. (2008)
– analytical framework
Six challenges in quality and safety work explained:
Structural
Cultural
Educational
Political
Technological & Physical
Emotional
Structural challenge:
Challenge around structuring, planning and
coordinating quality efforts (Bate et al.)
• 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.
Cultural challenge:
Challenge of giving quality a shared, collective meaning, value and significance within the
organization (Bate et al.)
• 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 also dysfunctional cultures (think of clan-culture, a toxic culture on the
work floor, etc.). Als je niet goed genoeg meeneemt wat de cultuur inhoudt, sluit het niet
goed aan bij de dagelijkse gewoontes en processen.
,Educational challenge:
Challenge of creating and nurturing a learning process to support continuous improvement (Bate
et al.). You do not stop learning when education stops!
• 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. Wat gebeurt
er als je helemaal niet leert (van het verleden)? Je vergeet dingen die je al weet of nuttig zijn
om te weten.
Political challenge:
Challenge of addressing the politics and negotiating the buy-in, conflict, and relationships of
change (Bate et al.). Power!
• Politics needed to engage clinical staff and senior leaders, empower patients and staff, link
with stakeholders, etc. (create coalition)
• However, politics can become power play, resistance to change
Technological and physical challenge:
Challenge of designing physical infrastructures and technological systems supportive of quality
efforts (Bate et al.)
• 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, or doing something about slippery hallways or empty soap-dispensers.
• However, focus on technology can lead to overly mechanistic approaches, and create
workarounds & exhaustion (te groot aspect van je werk). Geen technologie is ook
vermoeiend en kan minder efficiëntie betekenen (related to structural challenge).
Emotional challenge
Challenge of inspiring, energizing, and mobilizing people by linking QI (quality improvement) to
inner sentiments and deeper commitments (Bate et al.). Often overlooked but important!
• 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 activists
• However, focus on emotions can lead to uncertainty, or laissez-faire policies (dat je als leider
het laat gaan en niet aan het leiden bent). Helemaal geen focus op emoties leidt tot
desintresse (sluit aan bij cultural challenge).
In short
• Systemic and processual focus on the work of doing quality improvement (QI)
• One specific challenge will be addressed 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
Further elaboration of the structural challenge:
Decoupling = gap between policies and implementation
Not a bad thing, can serve as a buffer between external demands (f.e. from governments), where
the expectations do not match with situations in daily lives.
Also, leads to flexibility in organizations, to safeguard their internal processes from external
pressure like national policies/guidelines.
Can make organizations more effective/efficient in terms of QoC.
Two forms of decoupling:
, 1. Policy-practice decoupling: policy sluit niet aan bij daily practice
2. Means-ends decoupling: policy wordt uitgevoerd maar leidt niet tot intended outcomes,
omdat het bv. veel extra papierwerk oplevert
See: Bromley & Powell (2012)
*Structuring is a way of ordering in chaos; it is needed in case of quality improvement. But too much
focus on structuring is not good, leads to f.e. bureaucratization.
Policy-practice decoupling:
• Institutional adoption of rules and policies is largely symbolic and inconsequential
• ‘Ceremonial window dressing’ – it is done for the stage (organization saying they have
implemented policy while they did not)
• Rules are systematically violated and unimplemented
• Formal policies are disconnected from daily practices
• Daily practices may or may not be linked to intended outcomes
This is the classical explanation of decoupling
See: Bromley & Powell (2012)
Example: workarounds
“A way of dealing with a problem or making something work despite the problem, without
completely solving it” (Cambridge Dictionary)
“In computing, a method for overcoming a problem or limitation in a program or system (Concise
Oxford English Dictionary)
• Workarounds are inherent to organizing; necessary to ‘get the job done’ (this is done very
often)
• Workarounds often build on each other and create organizational ‘drift’
à This calls for reflection on actual practices:
o Workarounds as feedback on structure (think of decoupling!)
o Feedback can lead to organizational learning
Means-ends decoupling:
• Rules and policies are implemented in 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
See: Bromley & Powell (2012)
Example: indicators and rankings
Using performance indicators and rankings to improve hospital care
However, in practice we often see:
• Excessive focus on measurable outcomes & parameters (≠ intended outcomes!)
• Increasing pressure on registration
• Registration comes to define quality, strengthens top-down management approach
This calls for reflection on (qualitative interpretation of) numerical data
Indicators can be useful as ‘entrance to reflection process’
