Summary of literature Quality and Safety 2020-2021
Week 1 ‘Structural challenge’.............................................................................................................2
Bate, P. Mendel, P. et al. Organizing for quality : the improvement journeys of leading hospitals
in Europe and the United States.....................................................................................................3
Bromley, P and Powell W.W. From Smoke and Mirrors to Walking the Talk: Decoupling in the
Contemporary World......................................................................................................................7
Dixon-Woods, M., Bosk, C.L., et al. Explaining Michigan: Developing an Ex Post Theory of a
Quality Improvement Program.....................................................................................................13
Week 2 ‘Cultural challenge’..............................................................................................................19
Levay, Charlotta, Waks, Caroline. (2009). Professions and the Pursuit of Transparency in
Healthcare: Two cases of Soft Autonomy.....................................................................................20
Van Loon, Esther, Zuiderent-Jerak, et al. (2013). Diagnostic work through Evidence-Based
Guidelines: avoiding gaps between development and implementation of a guideline for problem
behaviour in elderly care..............................................................................................................23
Week 3 ‘Educational challenge’........................................................................................................26
Clegg, S.R., et al. (2005). Learning/Becoming/Organizing.............................................................27
Carel, Havi, Kidd, Ian James (2014). Epistemic injustice in healthcare: a philosophical analysis...32
Fitzsimons, Bev, Cornwell, Jocelyn (2018). What can we learn from patients’ perspectives on the
quality and safety of hospital care?..............................................................................................35
Week 4 ‘Political challenge’..............................................................................................................36
Allen, D. (2017). Translational Mobilisation Theory: A new paradigm for understanding the
organisational elements of nursing work.....................................................................................37
Week 5 ‘Technological challenge’.....................................................................................................41
Ash, J. S., M. Berg, et al. (2004). Some Unintended consequences of information technology in
Healthcare: The Nature of Patient Care Information-related Errors.............................................41
Smits, Martijntje (2006). Taming monsters: The cultural domestication of new technology.......44
Week 6 ‘Emotional challenge’..........................................................................................................47
Mann, Sandi (2005). A healthcare model of emotional labour: an evaluation of the literature and
development of a model..............................................................................................................48
Sharp, Cathy, et al. (2017). How being appreciative creates change – theory in practice from
health and social care in Scotland (recommended!)....................................................................51
1
,Week 1 ‘Structural challenge’
Questions for reading the literature:
As a reading guide for the literature, please answer the following questions for yourself:
1. Why is this literature relevant for this problem and for the course as a whole?
The literature talks about achieving better quality and safety and that this is not as easy as it
seems You have to take context into consideration (colour maps by Bate), and not every
solution is great for another organisation. In the first lecture it also became clear that
creating quality and safety it not as simple as it looks
Decoupling also talks about taking the context into consideration, because we act on it.
2. Bromley & Powell make a distinction between two kinds of ‘decoupling’.
a. What is ‘decoupling’?
It’s the gap between policies and implementation. The gap between the work as
imagined and the work being done. It’s not necessary a bad thing, because it can also be
seen as a buffer between external demands (governments for example). It allows
organisations some flexibility to keep their internal process in tact when the external
policy is changing.
b. Which two types of decoupling do the authors distinguish and which do they find more
important?
Policy – practice gap (symbolic adoption) – classical approach to decoupling The
organisations says they implemented policies, but in practice there isn’t much going on.
So the policy strategy doesn’t really fit into practice.
Means – ends (symbolic implementation) it’s about preferred effects, about gaming
the situation. The policy is more implemented but it slowly moves away from the original
ends (look at Q&A). E.g. performance indicators not just being a means to improve
quality but also an end itself as it rates your ranking.
This means that a strategy is implemented, but is the goal really achieved? E.g. the
rankings and university, we focus a lot on rankings but are those strategies really related
to the ultimate goal; better knowledge?
c. Why does this last kind of decoupling occur in organizations?
Because we tend to focus more on measure how we do it, which deviates from the
ultimate goal
d. How does the notion of decoupling relate to the structural challenge of Bate et al.?
As the structural challenge you have the understand the structures, so you have to
understand the decoupling which can happen in organisations:
o Policy/practice: work-arounds
o Means/end: perverse effects
Learning from structures: Reflect on QI (Quality Improvement) as complex social
interventions.
Just as Bate et al. mentions to take the environment into consideration, this article mentions
this. We act to the institutional environment. We have to understand this environment and
why and how we react to it.
3. Dixon-Woods et al. argue for ‘ex post theory’ to assess the implementation of quality
improvement efforts.
2
, a. What do Dixon-Woods et al. mean with ‘ex post theory’ and how is this notion related to
the ‘cargo cult’ that they describe as one of the problems of quality improvement?
The authors relate this theory to the Bayesian analyses: The analogue we propose is that
prospectively defined program theory and the program leaders’ experience can be
regarded as “the prior” and can be synthesized with the contribution of social sciences to
produce a new ex post theory that can be used and tested in future implementations of
the program.
Updating program theory after the program has been carried out is critically important,
and combining the program leaders’ experience of implementing the program and the
expertise of social scientists may offer a valuable way of achieving this.
You need to this to understand the social processes and mechanisms which lead to the outcomes of
the programme.
Not understanding how programs work when they are complex social interventions is
likely to result in non-transferability, a limited ability to improve the program and its
outcomes, and disappointment.
b. Which are the explanations the authors give for the success of the Michigan program?
The Michigan project achieved its effects by..
Generating isomorphic pressures for ICUs to join the program and conform to its
requirements
Creating a densely networked community with strong horizontal links that
exerted normative pressures on members
Reframing CVC-BSIs as a social problem and addressing it through a professional
movement combining “grassroots” features with a vertically integrating program
structure
Using several interventions that functioned in different ways to shape a culture
of commitment to doing better in practice
Harnessing data on infection rates as a disciplinary force
Using “hard edges’’
c. How do these explanations relate to the different challenges posed by Bate et al.?
Bate also talks how not every intervention of 1 organisations will lead to the same
outcome in another organisation. There are lots of social processes and mechanism at
play, also environmental factors; you need to understand this and take it into
consideration!
Bate, P. Mendel, P. et al. Organizing for quality : the improvement journeys
of leading hospitals in Europe and the United States
Chapter 9
This chapter has the following aim: identify for practitioners what the common core challenges and
practical solutions are (or may be) for QI efforts in healthcare organizations generally.
It became clear, through stories, that these high-performing healthcare organizations has all
encountered similar kinds of challenges when seeking to develop their improvement systems and
processes. The chapter talk about the ‘the universal but variable’ thesis; the idea of a set of common
challenges with different solutions across several contexts.
Only a limited basic human problems to which all people to all times and on all places must
find an solution, however the number of possible solutions is almost unlimited.
Hence the co-existence of similarities (common problems) and difference (varied solutions)
between all human systems, social or organizational.
3
, The chapter continues with 6 common challenges, which if not solved will lead to disappointment
and failure in the quality arena. These challenges are:
There is no one best way of reaching one’ goals; because local conditions and contexts vary so much,
particular solutions also need to vary, and therefore be locally cultivated, home-grown and situation-
specific
There is a need to factor in the effect of the wider institutional and social environment (key
interactions and pressures with parties or influences external); without this contextualist and
institutionalist framework, any attempt at making sense of the stories would risk overlooking
or misattributing critical sources or organizational behaviour and change.
External conditions be tuff or enabling
The internal-external divide was also important in most cases; this case study approach tries to show
how these internal-external dynamics play out around QI in healthcare.
The chapter uses a ‘color-codebook’ for quality and service improvement. It’s the same idea as
Vermaak and the Caluwé’s scheme to look at quality improvements:
However they added the colours grey (for the wider ‘inner’ (organizational) and black (for
‘outer’ (external) context)
1. Blue
Represents the structural challenges; the cold, hard steel and structural and strategic support for the
QI effort, acting like metal hoops to pull various quality activities together. Example are the
development and organization-wide implementation of integrated care pathways.
If it fails: it leads to fragmentation; and general lack of synergy and joined-upness between different
parts of the organization
2. Yellow
Related to the power and politics of organization; represents the frictional ‘heat’ of politics and the
search for a common ground between stakeholders, sufficient appeal for ‘what’s in it for me?’
Second challenge issues clinical engagement, staff and patient empowerment, and
partnerships working with external stakeholders
If it fails: it leads to disillusionment; people are resisting change etc.
3. Red
4
