Graham P. Martin

Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant literature

Background Formal evaluations of programmes are an important source of learning about the challenges faced in improving quality in healthcare and how they can be addressed. The authors aimed to integrate lessons from evaluations of the Health Foundations improvement programmes with relevant literature. Methods The authors analysed evaluation reports relating to five Health Foundation improvement programmes using a form of ‘best fit’ synthesis, where a pre-existing framework was used for initial coding and then updated in response to the emerging analysis. A rapid narrative review of relevant literature was also undertaken. Results The authors identified ten key challenges: convincing people that there is a problem that is relevant to them; convincing them that the solution chosen is the right one; getting data collection and monitoring systems right; excess ambitions and ‘projectness’; organisational cultures, capacities and contexts; tribalism and lack of staff engagement; leadership; incentivising participation and ‘hard edges’; securing sustainability; and risk of unintended consequences. The authors identified a range of tactics that may be used to respond to these challenges. Discussion Securing improvement may be hard and slow and faces many challenges. Formal evaluations assist in recognising the nature of these challenges and help in addressing them.

Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study

Background Problems of quality and safety persist in health systems worldwide. We conducted a large research programme to examine culture and behaviour in the English National Health Service (NHS). Methods Mixed-methods study involving collection and triangulation of data from multiple sources, including interviews, surveys, ethnographic case studies, board minutes and publicly available datasets. We narratively synthesised data across the studies to produce a holistic picture and in this paper present a high-level summary. Results We found an almost universal desire to provide the best quality of care. We identified many ‘bright spots’ of excellent caring and practice and high-quality innovation across the NHS, but also considerable inconsistency. Consistent achievement of high-quality care was challenged by unclear goals, overlapping priorities that distracted attention, and compliance-oriented bureaucratised management. The institutional and regulatory environment was populated by multiple external bodies serving different but overlapping functions. Some organisations found it difficult to obtain valid insights into the quality of the care they provided. Poor organisational and information systems sometimes left staff struggling to deliver care effectively and disempowered them from initiating improvement. Good staff support and management were also highly variable, though they were fundamental to culture and were directly related to patient experience, safety and quality of care. Conclusions Our results highlight the importance of clear, challenging goals for high-quality care. Organisations need to put the patient at the centre of all they do, get smart intelligence, focus on improving organisational systems, and nurture caring cultures by ensuring that staff feel valued, respected, engaged and supported.

Institutional Work to Maintain Professional Power: Recreating the Model of Medical Professionalism

The creation of new roles commonly threatens the power and status of elite professionals through the substitution of their labour. In this paper we examine the institutional work carried out by elite professionals to maintain their professional dominance when threatened. Drawing on 11 case sites from the English National Health Service (NHS) where new nursing or medical roles have been introduced, threatening the power and status of specialist doctors, we observed the following. First, the professional elite respond through institutional work to supplant threat of substitution with the opportunity for them to delegate routine tasks to other actors and maintain existing resource and control arrangements over the delivery of services in a way that enhances elite professionals’ status. Second, other professionals outside the professional elite, but relatively powerful within their own professional group, are co-opted by the professional elite to engage in institutional work to maintain existing arrangements. Our work extends Lawrence and Suddaby’s typology of institutional work in three ways. First, we reveal how different types of institutional work interact, and how different types of institutional work cross categories of creating or maintaining institutions. Second, we show how an actor’s social position or status, both intra-professionally as well as inter-professionally, in the institutional field frame the institutional work they engage in. Third, the institutional work of ‘theorizing’ by professional elites appears particularly significant, specifically the focus of the institutional work to invoke the concept of ‘risk’ associated with any change in service delivery, which maintains the model of medical professionalism.

Representativeness, legitimacy and power in public involvement in health-service management☆

Public participation in health-service management is an increasingly prominent policy internationally. Frequently, though, academic studies have found it marginalized by health professionals who, keen to retain control over decision-making, undermine the legitimacy of involved members of the public, in particular by questioning their representativeness. This paper examines this negotiation of representative legitimacy between staff and involved users by drawing on a qualitative study of service-user involvement in pilot cancer-genetics services recently introduced in England, using interviews, participant observation and documentary analysis. In contrast to the findings of much of the literature, health professionals identified some degree of representative legitimacy in the contributions made by users. However, the ways in which staff and users constructed representativeness diverged significantly. Where staff valued the identities of users as biomedical and lay subjects, users themselves described the legitimacy of their contribution in more expansive terms of knowledge and citizenship. My analysis seeks to show how disputes over representativeness relate not just to a struggle for power according to contrasting group interests, but also to a substantive divergence in understanding of the nature of representativeness in the context of state-orchestrated efforts to increase public participation. This divergence might suggest problems with the enactment of such aspirations in practice; alternatively, however, contestation of representative legitimacy might be understood as reflecting ambiguities in policy-level objectives for participation, which secure implementation by accommodating the divergent constructions of those charged with putting initiatives into practice.

Role Transition and the Interaction of Relational and Social Identity: New Nursing Roles in the English NHS:

Our study provides an analysis of role transition, examining how macro-level influences and micro-level practice interact in framing role transition, with a focus upon professional identity. Empirically, we examine the case of nurses in the English NHS, for whom government ‘modernization’ policy has opened up a new occupational position in the delivery of genetics services within a professional bureaucracy. We track the experiences of the nurses through their recruitment to, enactment of, and progress on from, the new genetics role over two years. Our qualitative interview-based study encompasses six comparative cases. Analysis draws upon two linked literatures — role and identity, and sociology of professions — to examine the tension between the identity expected by the profession and the role expected by government policy-makers. While policy encourages reconfiguration of roles and relationships to support the new, less-bounded role, concerns aligned to professional identity mean that inter-professional competition between doctors and nurses, and intra-professional competition within nursing itself, constrain the enactment of the new role. Through our empirical study, we develop literature on role transition through its application to a professionalized context, and sociology of professions literature, within which issues of identity are relatively neglected. Our study demonstrates that the emphasis of identity within a professional bureaucracy lies at the collective level.

Professional competition and modernizing the clinical workforce in the NHS

Located within a debate about changing organizational forms and new workforce roles this article provides an analysis of policy attempts to modernize the healthcare workforce. Theoretically, the article draws upon sociology of professions literature to focus upon competition within and between professions that impacts upon new roles in the NHS for doctors, designed to combine specialist and generalist knowledge and cross organizational and professional boundaries. The article highlights that attempts by policy-makers to reconfigure the clinical workforce may be constrained due to attempts at occupational closure by more powerful professional groups and by associated concerns about professional identities.

Optimizing patient involvement in quality improvement

Patient and public involvement in healthcare planning, service development and health‐related research has received significant attention. However, evidence about the role of patient involvement in quality improvement work is more limited. We aimed to characterize patient involvement in three improvement projects and to identify strengths and weaknesses of contrasting approaches.

Accounting for the `dark side' of new organizational forms: The case of healthcare professionals

Our study responds to a call for research to integrate institutional, organizational and individual levels of analysis in examining the implications for work and employment relations of new organizational forms. We empirically examine the implementation of network forms of genetics healthcare delivery that cross organizational and professional boundaries. We highlight that less powerful professional groups may find difficulty in enacting boundary-spanning roles associated with new organizational forms. This is due, first, to inconsistency of government policy, which fragments organizations. Second, professional institutions sustain professional hierarchy and power differentials.

Team Work in Context: Institutional Mediation in the Public-service Professional Bureaucracy

This paper examines how context shapes team work within the public-service professional bureaucracy. We examine the effects of an interaction between both macro-institutional and local-organizational context upon the micro-negotiation of team work. Specifically, we consider how features of local context mediate professional-institutional effects. Drawing upon neo-institutionalism (Lawrence and Suddaby 2006; Powell and DiMaggio 1991), we view team members as ‘institutional agents’ (Scott 2008), shaping team work in ways that either reproduce or transform professional structures within particular local conditions. Exemplary of international government transformative efforts for public-service enhancement (Newman 2001; Osborne and Gaebler 1992), we focus upon a UK government initiative to reconfigure professional relationships through introducing team work in National Health Service genetic care. Findings from two qualitative, comparative case studies reveal contrasting outcomes: reproduction or transformation of the professional institution, respectively. Specific local conditions — organizational, and human and social in particular — combine to produce these divergent mediating effects towards inertia or change. This highlights the importance of antecedents to team work and taking a historical perspective to understand the influence of context. While the challenges of reconfiguring professional structures through team work are shown, our analysis also suggests optimism regarding possibilities for change, albeit within certain local conditions. The challenge for management and policy-makers becomes the extent to which — and indeed, if at all — such facilitative local environments might be supported.

Beyond metrics? Utilizing ‘soft intelligence’ for healthcare quality and safety

Formal metrics for monitoring the quality and safety of healthcare have a valuable role, but may not, by themselves, yield full insight into the range of fallibilities in organizations. ‘Soft intelligence’ is usefully understood as the processes and behaviours associated with seeking and interpreting soft data—of the kind that evade easy capture, straightforward classification and simple quantification—to produce forms of knowledge that can provide the basis for intervention. With the aim of examining current and potential practice in relation to soft intelligence, we conducted and analysed 107 in-depth qualitative interviews with senior leaders, including managers and clinicians, involved in healthcare quality and safety in the English National Health Service. We found that participants were in little doubt about the value of softer forms of data, especially for their role in revealing troubling issues that might be obscured by conventional metrics. Their struggles lay in how to access softer data and turn them into a useful form of knowing. Some of the dominant approaches they used risked replicating the limitations of hard, quantitative data. They relied on processes of aggregation and triangulation that prioritised reliability, or on instrumental use of soft data to animate the metrics. The unpredictable, untameable, spontaneous quality of soft data could be lost in efforts to systematize their collection and interpretation to render them more tractable. A more challenging but potentially rewarding approach involved processes and behaviours aimed at disrupting taken-for-granted assumptions about quality, safety, and organizational performance. This approach, which explicitly values the seeking out and the hearing of multiple voices, is consistent with conceptual frameworks of organizational sensemaking and dialogical understandings of knowledge. Using soft intelligence this way can be challenging and discomfiting, but may offer a critical defence against the complacency that can precede crisis.