Table 4 Examples of vignettes representative of each second-order theme

Tensions between different QI conceptualizations

Strategies to reconcile divergent views about QI

What became apparent throughout the study period is a clear disconnect or tension between the publicly celebrated concept of quality, and the implicit, operational definition. There are several areas in which this contradiction appears apparent. Firstly, a tension appears to exist between finances and quality. Staff report how the quality issue quickly slipped off the agenda in the face of financial crises. This was despite the pressures exerted by the CQC to make immediate improvements. Although, the public narrative stresses that quality was at the forefront of the organisation, staff describe how tens of thousands of pounds are spent using a multitude of external consultants to assist the organisation in making financial savings. In contrast, only one external consultant was recruited to help the organisation improve upon its quality. At the same time staff describe how the organisation focused on improving upon the shortcomings flagged up by the CQC inspectors, but then suddenly lost this focus in the face of necessary financial savings (England B).

The informants often refer to the “quality puzzle” or more correctly “Safe Health Care – every time, all the time” which is another basic concept for quality improvement including patient safety. It is expressed as a puzzle with 14 pieces, where each piece contributes to the development of quality and patient safety and it illustrates the endeavour that good quality and safe care should permeate all treatment and care of patients. The project leader coordinating patient safety work follows up the clinical results in using the 14 pieces in the puzzle by using a matrix on the intranet. There she can follow to what extent each clinic works with the 14 issues which the clinics themselves are asked to judge. Clinical outcomes are measured, followed and visualized regularly on the intranet. (Sweden A).

Pressures for independent work

Boundary spanners and multi-professional work

While medical communities like the orthopaedic surgeons seem to learn from each other at daily meetings, a marketing and communication manager feels that ward managers are largely isolated from each other: “Well, I find it scandalous, how little we learn from each other. I’m trying to break down the walls, so that we can learn from each other. I want to be honest here, it’s crazy when you look at the wards. They don’t look any further than their own ward …because…sometimes, they might have thought up a good solution to a disturbing problem. If they shared that, everyone could do something with it (communications manager)” (The Netherlands A).

In the various meetings we have attended as observers with the quality team members and departmental directors and head nurses, it was mentioned several times that the quality team was always available to go to departments, that directors and head nurses could phone and ask a question or even appear in their office. Many times they arranged quality team visits to departments. At the same time it was emphasized that quality had to be part of every professional’s life “as naturally as putting on your gown in the morning when you start work.” (Portugal B).

General templates used to give sense to QI

Multiple and local organizational elements implementing QI

The letter of assignment from the regional health authority (RHA) stipulates the following strategic areas related to quality improvement: 1) reduction of waiting lists, patient pathways, and deadlines, 2) user involvement 3) patient safety, and 4) quality measurements. The letter of assignment states that the health trust is responsible for taking part in the strategic regional quality effort; to participate in the steering group, the quality forum and the quality conference. Moreover the health trust should promote project proposals for strategic QI projects funded by the RHA; conduct patient experience surveys at the local level; report adverse events and use inspection reports for learning purposes; organize regular meetings across units to assess adverse events and use them for learning.. As such, the quality and patient safety targets set by the RHA generate learning arenas and learning activities within the hospital. (Norway A).

Productive Ward is construed as a bottom-up project, as it allows teams to choose locally relevant improvement objectives and tools. This is experienced as greatly motivating. Many participate because they feel finally able to regain control and ‘do’ quality improvement that goes beyond externally driven indicators. Nevertheless, the project is steered hierarchically: a steering group sets the overall agenda and decides on project continuation. The ward managers, who run the local working groups, are not part of the steering group. Contact between the steering group and ward managers is largely facilitated through the project leader, who communicates important outcomes of the steering group to the working groups. The executive director and the middle manager maintain contact with the ward-based work through site visits, when they hear about developments and bottlenecks. These visits are designed to demonstrate the relevance of the project work and also serve as qualitative mini-evaluations. These site visits link nurses and executive managers (not ward managers). The bottom-up project, while steered in a top-down fashion, tries to build on the motivational aspects of bottom-up work. (The Netherlands A).

Indicators, targets and rules guide QI

Local judgment guides QI

Some senior leaders and the vast majority of staff at middle management and frontline levels argue that their organisation had lost sight of the patients they care for. They saw the strong focus on efficiency measures, analysis of quantitative quality data and the commitment to meet national targets rather as a means to an end than the optimal approach to improve patient care. A senior leader reflected on this as follows: So demand from the general public and also demand from organisations. Endless streams of targets to try and achieve, which again, they are there for quality, so we have measuring incident rates of thrombosis, pressure sores, all these sorts of things, which is good, and nutrition analysis on the ward, but sometimes these things are … almost the analysis is the means to an end and I think we’re trying to do these things to ensure quality, not just to ensure that we’ve met the targets, and there seems to be a focus on that. And how do you get the balance when people have scorecards and they measure quality. I’m not sure the balance is right’. Most criticism of the hospital board came from clinical leaders at middle-management level. They were cynical about the obsession of senior leaders with assurance as they felt the hospital board denied recognising real problems. (England A).

Besides national quality norms, the hospital handles local quality norms aimed at positioning the hospital on the care market, as the local norms usually exceed the national ones. Some of these norms are being criticized as being too ambiguous, and at times, this leads to the official reduction of a local set norm, and elsewhere it results in local norms being ignored. Usually one tries to adhere to the hospital norm through a process that sometimes requires a little ‘tweaking’, as the case of bed occupancy highlights. The local norm states that all patients admitted with acute health problems remain on the acute entry ward for a maximum stay of 48 h and a ratio of 50% discharge to reduce the average duration of stay. The bed occupancy meeting is supposed to support compliance with this norm. The meeting takes place daily at 9.30 a.m. chaired by the admission manager, and all ward managers participate. All present ward managers focus their attention on a large wall screen that shows a matrix with numbers. All patients on the acute ward are discussed with regard to their diagnosis and preliminary therapeutic plans, and successively all those who have to undergo further hospital treatment are distributed to relevant wards. However two patients remain unplaced. Both are scheduled for surgery, but all surgical wards are fully booked. The paediatric ward has five vacant beds and the admission manager proposes placing them there until other beds become vacant. The manager of the surgery ward remarks that this would throw up serious questions about quality and safety, as these patients demand particular pre- and post-surgical treatment, such as adequate pain medication. Such care protocols, however, are not routinely used on paediatric wards. All ward managers present agree that this is an unsafe option. Thus, patient placement continues…(The Netherlands A).

Centrality of patients in QI

Peripheral place of patients in QI

There are a number of forums and activities regarding involvement of patients in the QI work, e.g. patient involvement in deciding on new treatment equipment, “learning cafés” where patients and related persons meet and discuss issues linked to their illness with other patients and relatives with the support of a resource person. There are also patient associations taking part in regular meetings regarding quality and patient safety at the hospital etc. The hospital performs patient surveys to get to know about the patients’ experiences. An example of concrete patient involvement is the rebuilding of the dialysis pavilion where patients participated in the choice of dialysis equipment and where the patients by now manage their own treatment assisted by care personnel only when needed (Sweden A).

The hospital had an internal policy which set out to employ 12 patient advisors to provide a critical view on service. Since two of them had left and had not been replaced, the hospital had only ten patient representatives at the time of our fieldwork. From an interview with a patient advisor, it was suggested that the senior management team had brought them under strict control, so that they had practically little impact, but were rather used as mediators between the hospital and the public. A patient advisor referred to this as: ‘Previously we could give an external view, an outsider’s view to the inside of here, now the change is that there is a temptation to ask us to reflect to the outside as the internal view, in other words we are more likely to be required to see things the hospital way than the patient way so I think this is actually a weakness of the system now’. (England A).

Efforts to maintain systems´ integrity

Attempts to generate change from learning

The informants talk positively about the team training activities in the maternity section, valuing interprofessional training activities as important QI learning arenas. Other important learning arenas are the morning meetings on the ward and different forums within the professional groups, both informal in form. During our observations we attended an informal lunch meeting among the paediatricians in which the experienced physicians contributed their experience and competence in the discussions about current challenges on the wards. The midwives can furthermore attend guidance offered by the Counselling Centre for mother and child in the maternity section. A midwife trained as a coach leads the group, and the attendees are coached about their performance and how to handle situations. Another learning arena is the weekly meeting about interpretation of STAN results (a type of monitoring of the infant during the birth process). The physicians bring cases or examples that have been difficult to monitor during delivery. In the meeting, physicians and midwives discuss the case, evaluate their performance and evaluate how they could improve performance. Our observations showed how the midwife room constitutes an important learning arena and an arena for experience transfer between professional disciplines and within the midwife group. In sum, the results show that the staff in the maternity section uses results from their practice for learning purposes and to improve their practical skills. (Norway B).

As part of a training session related with the subject of quality, the head nurse in the Intensive Medicine ward got together with three nurses and designed a monitoring project for intra-hospital and secondary transport of critical patients. The aim of the project was “to promote/ensure the safety of the patient/professionals in the transport of the critical patient, based on the premise that the level of care during transport should not be inferior to that in the original service, with the possibility of a higher level of care foreseen”. The project group created a formal document, presenting it to all the important internal stakeholders showing that the project contains all the information for the implementation including: evidence-based principles and practices to ensure the safety of this type of transport; an analysis of the most common type of incidents in this type of transport and a detailed description of the procedures used in the different phases; a description of the responsibilities of doctors/nurses/others; a detailed description of the equipment, medication and other support materials required for intra-hospital and secondary transport; three forms for recording each specific transport; procedural norms to be adopted by all nurses in the hospital cluster; guideline for the internal audit of the process. (Portugal A).