Enacting quality improvement in ten European hospitals: a dualities approach

Abstract

Background: Hospitals undertake numerous initiatives searching to improve the quality of care they provide, but these efforts are often disappointing. Current models guiding improvement tend to undervalue the tensional nature of hospitals. Applying a dualities approach that is sensitive to tensions inherent to hospitals' quest for improved quality, this article aims to identify which organizational dualities managers should particularly pay attention to. Methods: A set of cross-national, multi-level case studies was conducted involving 383 semi-structured interviews and 803 h of non-participant observation of key meetings and shadowing of staff in ten purposively sampled hospitals in five European countries (England, the Netherlands, Portugal, Sweden, and Norway). Results: Six dualities that describe the quest for improved quality, each embracing a seemingly contradictory feature were identified: plural consensus, distributed connectedness, orchestrated emergence, formalized fluidity, patient coreness, and cautious generativeness. Conclusions: We advocate for a move from the usual sequential and project-based and systemic thinking about quality improvement to the development of meta-capabilities to balance the simultaneous operation of opposing ideas or concepts. Doing so will help hospital managers to deal with major challenges of change inherent to quality improvement initiatives.

Talking about quality: how ‘quality’ is conceptualized in nursing homes and homecare

“…Since “quality in healthcare” has become a powerful driver of health policy with a set of measurable indicators in several countries, it is important to illuminate the complexity of this concept which includes several softer dimensions (dignity, professional pride), identified in our study. This is consistent with previous research in hospitals [ 5 , 8 ], nursing homes and homecare [ 7 ]. Among the quality challenges that service providers need to address to improve the quality of care [ 24 , 36 ], our findings fit most with the soft dimensions: “engagement,” “competence” and “culture” [ 25 , 37 , 40 ] in the Organizing for Quality framework.…”

“…There is a growing knowledge about conceptualization of quality in the hospital setting (e.g. [ 5 ],), but there is less research on the topic from the nursing homes and home care settings However, a notable exception, the UK-based study by Farr and Cassey [ 7 ], concluded that nursing homes and homecare staff’s notion of quality was influenced by their personal and professional values and standards.…”

Balancing adaptation and innovation for resilience in healthcare – a metasynthesis of narratives

“…Findings from this research show that long-term adaptations also provide flexibility to healthcare professionals, a balance which is described as valuable for ambidextrous organizations, like healthcare [ 51 ]. Additionally, innovative solutions should be sought, as the acquisition of new perspectives and knowledge may provide novel ways for solving challenges.…”

Governance Tensions in the Healthcare Sector: A Contrasting Case Study in France

“…They are generating particularly acute tensions among the employees and managers of the public services concerned [1,2]. These tensions result from the coexistence of opposing demands, or dualities, such as exibility and control, differentiation and integration, stability and change [3]. Seen in isolation, each element in tension makes perfect sense, but when both elements appear at the same time, their coexistence may seem illogical.…”

“…The practices that result from these reforms, which according to health professionals are rooted in values from the market sphere [12], sometimes appear incompatible with the public service mission of healthcare institutions [13]. Nunes et al [3] in analysing their causes, have shown that these incompatibilities are expressed in the form of dualities requiring meta-capabilities to manage them (Plural consensus, orchestrated emergence, distributed connectedness, patient coreness, formalized uidity, cautious generativness). However, beyond an analysis of their causes, these incompatibilities can also be analysed through their consequences on the personnel and production of health services.…”