Talking about quality: exploring how ‘quality’ is conceptualized in European hospitals and healthcare systems

Abstract

BackgroundConceptualization of quality of care – in terms of what individuals, groups and organizations include in their meaning of quality, is an unexplored research area. It is important to understand how quality is conceptualised as a means to successfully implement improvement efforts and bridge potential disconnect in language about quality between system levels, professions, and clinical services. The aim is therefore to explore and compare conceptualization of quality among national bodies (macro level), senior hospital managers (meso level), and professional groups within clinical micro systems (micro level) in a cross-national study.MethodsThis cross-national multi-level case study combines analysis of national policy documents and regulations at the macro level with semi-structured interviews (383) and non-participant observation (803 hours) of key meetings and shadowing of staff at the meso and micro levels in ten purposively sampled European hospitals (England, the Netherlands, Portugal, Sweden, and Norway). Fieldwork at the meso and micro levels was undertaken over a 12-month period (2011–2012) and different types of micro systems were included (maternity, oncology, orthopaedics, elderly care, intensive care, and geriatrics).ResultsThe three quality dimensions clinical effectiveness, patient safety, and patient experience were incorporated in macro level policies in all countries. Senior hospital managers adopted a similar conceptualization, but also included efficiency and costs in their conceptualization of quality. ‘Quality’ in the forms of measuring indicators and performance management were dominant among senior hospital managers (with clinical and non-clinical background). The differential emphasis on the three quality dimensions was strongly linked to professional roles, personal ideas, and beliefs at the micro level. Clinical effectiveness was dominant among physicians (evidence-based approach), while patient experience was dominant among nurses (patient-centered care, enough time to talk with patients). Conceptualization varied between micro systems depending on the type of services provided.ConclusionThe quality conceptualization differed across system levels (macro-meso-micro), among professional groups (nurses, doctors, managers), and between the studied micro systems in our ten sampled European hospitals. This entails a managerial alignment challenge translating macro level quality definitions into different local contexts.

Quality conceptualization in the era of measurement: A qualitative study of primary care physicians in Medicare’s Merit-Based Incentive Payment System

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“…(17,18) Thus in a contemporary clinical practice environment characterized by both physician ambivalence to measurement and an expansion of quality measurement activities, there is a need to examine physician conceptualizations of the quality of healthcare so that quality measurement program administrators can align future measurement programs to optimize physician engagement. (19,20) Thus, our objective was to describe how PCPs characterize the nature of quality in healthcare by performing interviews with PCPs reporting under MIPS.…”

Janusian, anomic, agent, and steward: How employees perceive the identity of healthcare organizations

“…Doctors have a more anomic view while nurses have a more janusian or agent view. Although professional differentiation regarding critical organizational features is widely recognised amongst HCOs 45,4,46 , the role of leadership in successfully achieving intergroup collaboration has been neglected.…”

Investigation of the degree of organisational influence on patient experience scores in acute medical admission units in all acute hospitals in England using multilevel hierarchical regression modelling

“…Patient experience is regarded as a key aspect of quality at macro (policy), meso (hospital management) and micro (clinical staff interacting with patients) levels 1. Surveys are used in several national programmes to collect data on patient experience and to compare hospitals and healthcare organisations, with the implicit assumption that interorganisational differences in scores reflect meaningful differences in local care delivery 2.…”